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Aetna Medicare Enhanced (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare Enhanced (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Aetna Medicare Enhanced (PPO) in 2026, please refer to our full plan details page.
Aetna Medicare Enhanced (PPO) is a PPO plan offered by CVS Health Corporation available for enrollment in 2026 to people living in Metro Area: Manhattan. This plan received an overall rating of 4.5 out of 5 stars in 2026.
It's important to know that Aetna Medicare Enhanced (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 Enhanced (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 Enhanced (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $124.00. 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 does not have a health deductible. Your insurance coverage on covered health services will start immediately.
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 $13900.00 (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 $13900.00 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 Enhanced (PPO) plan features an annual drug deductible of $615. For Tier 1 preferred generics and Tier 2 generics, you will pay no copay when using a preferred pharmacy or preferred mail-order service. Standard pharmacies and standard mail-order services carry low copays, starting at $2.00 for Tier 1 and $12.00 for Tier 2 medications for a 1-month supply. For brand-name and specialty medications under this plan, your costs are based on coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 24% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs require a 25% coinsurance across all pharmacy options. Note that Tier 5 specialty drugs are limited to a 1-month supply.
Additional Benefits
The Aetna Medicare Enhanced (PPO) plan offers comprehensive healthcare coverage with no copay and no coinsurance for primary care doctor visits, routine physicals, and fitness benefits. Specialist office visits require a $45 copay, while outpatient hospital services range from no copay up to a $399 copay. Emergency care is covered with a $115 copay, which is waived if you are admitted to the hospital within 24 hours. For inpatient hospital stays, members pay a $399 daily copay for the first six days, followed by no copay for additional days. Skilled nursing facility stays feature no copay for the first 20 days, before transitioning to a $218 daily copay. Additionally, routine dental, vision, and hearing exams are covered with no copay, helping you easily manage your everyday wellness costs.
Inpatient Hospital See details
Aetna Medicare Enhanced (PPO) partially covers inpatient hospital services with no coinsurance, excluding upgrades, non-Medicare-covered stays, and additional psychiatric days. For covered acute stays, you pay a $399 copay per day for days 1 through 6 and no copay thereafter, while psychiatric stays require a $346 copay per day for days 1 through 6 and no copay for days 7 through 90.
Outpatient Services See details
Aetna Medicare Enhanced (PPO) covers outpatient services with no coinsurance, featuring a $0 to $399 copay for outpatient hospital services and a $399 copay per stay for observation services. Ambulatory surgical center and outpatient blood services are covered with no copay and no coinsurance, while outpatient substance abuse individual and group sessions carry a $45 copay.
Partial Hospitalization See details
Partial hospitalization is covered under the Aetna Medicare Enhanced (PPO) plan with a copayment of $105.00 or $110.00 and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
Aetna Medicare Enhanced (PPO) covers ground and air ambulance services with a $290 copay and no coinsurance, though prior authorization is required. Transportation services to health-related locations are not covered.
Emergency Services See details
Aetna Medicare Enhanced (PPO) covers emergency services with a $115 copay (waived if admitted within 24 hours) and urgently needed services with a $40 copay, both with no coinsurance. Worldwide emergency and urgent care are covered with a $115 copay, and worldwide emergency transportation has a $290 copay, with no coinsurance up to a $250,000 maximum plan benefit.
Primary Care See details
Primary care benefits under Aetna Medicare Enhanced (PPO) feature no copay and no coinsurance for primary care provider visits, while specialist visits require a $45 copay and no coinsurance. Physical and occupational therapy services require a $35 copay and no coinsurance, whereas podiatry and chiropractic services are not covered.
Preventive Services See details
Preventive Services are partially covered by Aetna Medicare Enhanced (PPO), with most covered services—such as annual physicals, fitness benefits, and various screenings—offered with no copay and no coinsurance, though kidney disease education requires a 20% coinsurance and no copay. This plan does not cover several sub-services, including 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, home-palliative care, in-home support, caregiver support, enhanced disease management, telemonitoring, home safety devices, and counseling.
Hearing Services See details
Aetna Medicare Enhanced (PPO) covers hearing services with no deductible, including Medicare-covered exams for a $45 copay and no coinsurance, alongside annual routine exams and fitting evaluations with no copay or coinsurance. Prescription hearing aids are partially covered with no coinsurance and copays ranging from $0 to $1,700, though inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
Aetna Medicare Enhanced (PPO) covers vision services with no coinsurance, featuring no copay for routine eye exams and eyewear up to annual limits of $50 and $100, respectively. Medicare-covered eye exams are also covered with copays ranging up to $45.
Dental Services See details
Aetna Medicare Enhanced (PPO) partially covers dental services, offering Medicare-covered dental care for a $45 copay and no coinsurance, alongside select preventive services like cleanings, exams, and X-rays with no copay and no coinsurance. However, other dental sub-services, including fluoride, restorative care, endodontics, periodontics, prosthodontics, implants, and oral surgery, are not covered.
Home Infusion bundled Services See details
Aetna Medicare Enhanced (PPO) covers home infusion bundled services with no copay, though prior authorization and step therapy are required. Under this benefit, Medicare Part B insulin drugs have a $35 copay and no coinsurance, while chemotherapy and other Part B drugs require 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Aetna Medicare Enhanced (PPO) plan with no copay and a 20% coinsurance, although prior authorization is required.
Medical Equipment See details
Aetna Medicare Enhanced (PPO) covers medical equipment, including durable medical equipment, prosthetics, and diabetic supplies, with no copay and 0% to 20% coinsurance. Prior authorization is required for these benefits, and diabetic supplies are limited to specified manufacturers.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Aetna Medicare Enhanced (PPO) with prior authorization required. Diagnostic tests feature no coinsurance and a $0 to $45 copay, lab services have no copay, and radiological services require a $45 copay for X-rays, a $0 minimum copay for diagnostic radiology, and a minimum 20% coinsurance for therapeutic radiology.
Home Health Services See details
Home Health Services are covered under the Aetna Medicare Enhanced (PPO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by Aetna Medicare Enhanced (PPO) with no coinsurance, but only some services are covered in practice. Specifically, standard cardiac rehabilitation ($20 copay), intensive cardiac rehabilitation ($20 copay), pulmonary rehabilitation ($15 copay), and supervised exercise therapy for peripheral artery disease ($20 copay) are not covered.
Skilled Nursing Facility (SNF) See details
Aetna Medicare Enhanced (PPO) covers Skilled Nursing Facility (SNF) care with no coinsurance, requiring prior authorization but allowing admission without a prior three-day hospital stay. Patients pay no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, though additional days beyond the standard Medicare benefit are not covered.
Other Services See details
Aetna Medicare Enhanced (PPO) covers acupuncture with a $45 copay and no coinsurance for up to 12 treatments yearly, while chronic illness meal benefits, annual wellness exams, and additional colorectal screenings are available with no copay and no coinsurance. Over-the-counter (OTC) items are not covered under this plan.
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