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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 Nassau and Suffolk Counties. 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 $134.00. 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 $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 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 retail pharmacy or preferred mail-order service. Standard pharmacies and standard mail-order options are also available, with copays starting at $2.00 for Tier 1 and $12.00 for Tier 2 drugs. Brand-name and specialty medications under this plan are subject to coinsurance. You will pay a 24% coinsurance for Tier 3 preferred brand drugs and a 25% coinsurance for Tier 4 non-preferred drugs, regardless of your pharmacy choice. Tier 5 specialty drugs also require a 25% coinsurance for a one-month supply.
Additional Benefits
The Aetna Medicare Enhanced (PPO) plan offers robust medical coverage featuring no copay for primary care visits and a $45 copay for specialist visits, with no coinsurance for either. Inpatient hospital stays require daily copays for the first six days before transitioning to no copay, while emergency room visits carry a $130 copay that is waived if you are admitted. Outpatient hospital services and home health care are also covered with no coinsurance, with home health services requiring no copay. Routine dental cleanings, yearly vision exams, and hearing evaluations are provided with no copay and no coinsurance, though coverage limits apply for eyewear and prescription hearing aids. Skilled nursing facility stays feature no copay for the first 20 days, followed by a daily copay of $218 for days 21 through 100. Most preventive screenings and annual wellness exams are also fully covered with no copay or coinsurance to help keep your healthcare affordable.
Inpatient Hospital See details
Inpatient hospital care is partially covered by Aetna Medicare Enhanced (PPO) with no coinsurance, featuring a $399 daily copay for days 1 through 6 of acute stays and a $346 daily copay for days 1 through 6 of psychiatric stays, with no copay for days 7 through 90. While unlimited additional acute days are covered at no copay, non-Medicare-covered stays, upgrades, and additional psychiatric days are not covered.
Outpatient Services See details
Aetna Medicare Enhanced (PPO) covers outpatient services with no coinsurance, featuring outpatient hospital services with copays ranging from $0 to $399 and ambulatory surgical center services with no copay. Outpatient substance abuse services require a $45 copay per individual or group session, while outpatient blood services are covered with no copay and no deductible.
Partial Hospitalization See details
Partial hospitalization is covered by Aetna Medicare Enhanced (PPO) with a copay of $105.00 or $145.00 and no coinsurance. Prior authorization is required to access these services.
Ambulance and Transportation Services See details
Aetna Medicare Enhanced (PPO) covers ground and air ambulance services with a $280 copay and no coinsurance, though prior authorization is required. Transportation services to plan-approved or health-related locations are not covered.
Emergency Services See details
Aetna Medicare Enhanced (PPO) covers emergency services with a $130 copay—which is waived if admitted to the hospital within 24 hours—and urgent care with a $50 copay, both featuring no coinsurance. Worldwide emergency, urgent, and transportation services are also covered with no coinsurance and copays ranging from $130 to $280, up to a $250,000 maximum benefit limit.
Primary Care See details
Aetna Medicare Enhanced (PPO) offers partially covered primary care benefits, excluding chiropractic and podiatry services. Covered services include primary care physician visits with no copay and no coinsurance, specialist and mental health visits for a $45 copay with no coinsurance, and physical and occupational therapy for a $40 copay with no coinsurance.
Preventive Services See details
Preventive Services are partially covered by Aetna Medicare Enhanced (PPO), offering most covered services like annual exams, health education, and screenings with no copay and no coinsurance, though kidney disease education requires a 20% coinsurance and no copay. Non-covered 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, home-based palliative care, in-home support, caregiver support, enhanced disease management, telemonitoring, home/bathroom safety devices, and counseling.
Hearing Services See details
Hearing services are partially covered by Aetna Medicare Enhanced (PPO), featuring Medicare-covered exams for a $45 copay and no coinsurance, and annual routine exams and fitting evaluations with no copay and no coinsurance. Prescription hearing aids are covered with no coinsurance and a copay between $0 and $1,700, though OTC hearing aids as well as inner ear, outer ear, and over the ear prescription models are not covered.
Vision Services See details
Vision services are covered by Aetna Medicare Enhanced (PPO) with no coinsurance, offering eye exams with copays ranging from no copay to $45 and a $50 annual maximum, including one routine exam yearly at no copay. Eyewear is also covered with no copay and no coinsurance up to a combined annual limit of $100 for contacts, eyeglasses, lenses, frames, and upgrades.
Dental Services See details
Aetna Medicare Enhanced (PPO) dental services are partially covered, featuring a $45 copay and no coinsurance for Medicare-covered dental, and no copay or coinsurance for preventive oral exams, cleanings, and x-rays. Major services such as fluoride, restorative, endodontic, periodontic, prosthodontic, implant, and orthodontic treatments are not covered.
Home Infusion bundled Services See details
Aetna Medicare Enhanced (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Under this benefit, Medicare Part B insulin has a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs have no copay and 0% to 20% coinsurance.
Dialysis Services See details
Aetna Medicare Enhanced (PPO) covers dialysis services with no copay and a 20% coinsurance, though 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. Coinsurance ranges from no coinsurance to 20% depending on the item, and prior authorization is required.
Diagnostic and Radiological Services See details
Aetna Medicare Enhanced (PPO) covers diagnostic and radiological services with prior authorization required. Diagnostic services feature no coinsurance, with no copay for lab tests and a $0 to $45 copay for other procedures, while radiological services include a $45 copay for X-rays, a minimum 20% coinsurance and copay for therapeutic services, and no coinsurance with copays starting at $0 for diagnostic radiology.
Home Health Services See details
Home health services are covered under the Aetna Medicare Enhanced (PPO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under Aetna Medicare Enhanced (PPO) with no coinsurance, though only some services are covered. Standard Cardiac Rehabilitation ($20 copay), Intensive Cardiac Rehabilitation ($20 copay), Pulmonary Rehabilitation ($15 copay), and SET for PAD services ($25 copay) are not covered by the plan.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Aetna Medicare Enhanced (PPO) plan with no coinsurance and do not require a prior three-day inpatient hospital stay. There is no copay for days 1 through 20 and a daily copay of $218 for days 21 through 100, though prior authorization is required and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Other Services under the Aetna Medicare Enhanced (PPO) are partially covered, offering a meal benefit for chronic illness, annual wellness exams, screening mammographies, and additional gFOBT and FIT screenings with no copay and no coinsurance. Acupuncture and over-the-counter (OTC) items are not covered under these benefits.
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