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Aetna Medicare Elite (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare Elite (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Aetna Medicare Elite (PPO) in 2026, please refer to our full plan details page.
Aetna Medicare Elite (PPO) is a PPO plan offered by CVS Health Corporation available for enrollment in 2026 to people living in Northern Virginia. This plan received an overall rating of 4.5 out of 5 stars in 2026.
It's important to know that Aetna Medicare Elite (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Aetna Medicare Elite (PPO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Aetna Medicare Elite (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $90.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan has a $750.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $615.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $10100.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $10100.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Aetna Medicare Elite (PPO) plan features an annual drug deductible of $615. For Tier 1 preferred generics and Tier 2 generics, members pay no copay when using preferred pharmacies or preferred mail order services. If you choose standard pharmacies or mail order, Tier 1 drugs carry a copay starting at $2.00, while Tier 2 drugs start at a $12.00 copay for a one-month supply. Higher tier medications under this plan require coinsurance rather than flat copayments. Tier 3 preferred brands require a 24% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs both require 25% coinsurance across all pharmacy types. These coinsurance rates apply to one-month, two-month, and three-month supplies, except for Tier 5 specialty drugs which are limited to a one-month supply.
Additional Benefits
The Aetna Medicare Elite (PPO) plan offers robust medical coverage with no copay for primary care physician visits, home health services, and preventive care. For specialist visits, patients can expect a copay of up to $45, while inpatient hospital stays require a $382 daily copay for the first seven days and no copay thereafter. Emergency care is accessible with a $130 copay, which is waived if admitted, and urgent care visits require a $40 copay. This plan also includes valuable supplemental benefits, featuring no copay for routine eye and hearing exams, along with annual allowances of $200 for eyewear and $1,500 for prescription hearing aids. Preventive dental care is covered with no copay, while comprehensive dental services require a 20% to 50% coinsurance up to a $750 annual limit. Additionally, members receive a $30 quarterly allowance for over-the-counter items and no copay for routine physicals.
Inpatient Hospital See details
Aetna Medicare Elite (PPO) covers inpatient acute hospital stays with no coinsurance, a $382 daily copay for days 1 through 7, and no copay for days 8 and beyond. Inpatient psychiatric care is covered with no coinsurance, requiring a $292 daily copay for days 1 through 7 and no copay for days 8 through 90. Prior authorization is required for both benefits, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient services covered by Aetna Medicare Elite (PPO) feature no coinsurance, with copays varying depending on the specific service. Patients pay no copay and no coinsurance for ambulatory surgical center and blood services, while outpatient hospital services require a $0 to $382 copay, observation services cost a $382 copay per stay, and outpatient substance abuse sessions have a $40 copay.
Partial Hospitalization See details
Partial hospitalization is covered by Aetna Medicare Elite (PPO) with a copay of either $105.00 or $145.00 and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
Aetna Medicare Elite (PPO) covers ground ambulance services with a $275 copay and no coinsurance, and air ambulance services with a 20% coinsurance and no copay, with prior authorization required for both. For transportation benefits, some services are covered, but transportation to plan-approved health-related locations and any health-related locations are not covered in practice.
Emergency Services See details
Aetna Medicare Elite (PPO) covers emergency services with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $40 copay with no coinsurance, while worldwide emergency services are covered up to a $250,000 maximum with no coinsurance and copays of $130 for emergency or urgent care and $275 for emergency transportation.
Primary Care See details
Aetna Medicare Elite (PPO) provides primary care physician services with no copay and no coinsurance, while specialist visits require a copay of up to $45 and no coinsurance. Physical, occupational, and speech therapy services feature a $30 copay and no coinsurance, though podiatry and routine chiropractic services are not covered.
Preventive Services See details
Aetna Medicare Elite (PPO) offers partially covered preventive services with no copay and no coinsurance for annual physicals, screenings, and fitness benefits, though kidney disease education requires a 20% coinsurance and no copay. Uncovered sub-services include in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, palliative care, in-home support, caregiver support, enhanced disease management, telemonitoring, home safety devices, and counseling.
Hearing Services See details
Hearing services are partially covered by Aetna Medicare Elite (PPO), with Medicare-covered exams requiring a $45 copay and no coinsurance, while annual routine exams and fitting evaluations have no copay and no coinsurance. Up to two prescription hearing aids are covered per year with no copay and no coinsurance up to a $1,500 limit, but OTC, inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
Aetna Medicare Elite (PPO) covers vision services with no deductibles and no coinsurance, including routine eye exams with no copay and Medicare-covered exams with a copay of $0 to $45. Eyewear, including contacts and eyeglasses, is covered with no copay up to a combined maximum benefit of $200 per year.
Dental Services See details
Aetna Medicare Elite (PPO) partially covers dental services, offering Medicare-covered dental with a $45 copay and no coinsurance, and preventive care like cleanings and exams with no copay and no coinsurance. Comprehensive services, such as restorative care and endodontics, are covered with no copay and 20% to 50% coinsurance up to a $750 annual limit, though fluoride, implants, maxillofacial prosthetics, and orthodontics are not covered.
Home Infusion bundled Services See details
Aetna Medicare Elite (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Under this benefit, Medicare Part B insulin drugs require a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs have a coinsurance ranging from 0% to 20%.
Dialysis Services See details
Dialysis services are covered by Aetna Medicare Elite (PPO) with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
Aetna Medicare Elite (PPO) covers Medical Equipment with no copay for durable medical equipment (DME), prosthetics, and diabetic therapeutic shoes. Coinsurance ranges from no coinsurance to 20% for DME, medical supplies, and diabetic supplies, while prosthetic devices require a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Aetna Medicare Elite (PPO) with prior authorization, offering lab services and outpatient X-rays with no copay. Diagnostic procedures and tests carry a copay of $0 to $100 with no coinsurance, while diagnostic radiological services have a copay starting at $0 and therapeutic radiological services require a minimum 20% coinsurance.
Home Health Services See details
Aetna Medicare Elite (PPO) covers Home Health Services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Aetna Medicare Elite (PPO) offers cardiac rehabilitation services with no copay and no coinsurance, though only some services are covered because standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy for peripheral artery disease are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Aetna Medicare Elite (PPO) with no coinsurance and no prior three-day hospital stay required, though prior authorization is necessary. There is no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, while additional days beyond the Medicare limit are not covered.
Other Services See details
Aetna Medicare Elite (PPO) partially covers other services with no copay and no coinsurance, including chronic illness meal benefits, annual wellness exams, screening mammographies, and a $30 quarterly over-the-counter item allowance. Acupuncture is not covered under these services.
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