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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 Capital Region and Hudson Valley Area. 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 $109.00. 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 filling prescriptions through preferred pharmacies or preferred mail-order services. If you choose standard pharmacies or standard mail-order options, Tier 1 copays range from $2 to $6, while Tier 2 copays range from $12 to $36. For brand-name and specialty medications, costs are structured as coinsurance. Tier 3 preferred brand drugs require a 24% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs both carry a 25% coinsurance. These coinsurance rates remain the same whether you use preferred or standard pharmacies or mail-order services.
Additional Benefits
The Aetna Medicare Enhanced (PPO) plan offers robust medical coverage with no copay for primary care visits, home health services, and routine laboratory work. For specialized care, members pay a $40 copay for specialist visits and urgent care, while emergency room visits require a $115 copay. Inpatient hospital stays carry a daily copay of $399 for the first six days, with no copay required for acute care days seven and beyond. Ancillary benefits such as routine dental, vision, and hearing exams are covered with no copay or coinsurance, though annual benefit limits apply to eyewear and dental care. For specialized medical needs, members are responsible for a 20% coinsurance on dialysis, durable medical equipment, and prosthetics. Overall, this plan helps manage out-of-pocket costs by utilizing predictable flat copays and eliminating coinsurance for the majority of everyday healthcare services.
Inpatient Hospital See details
Aetna Medicare Enhanced (PPO) covers inpatient acute stays with no coinsurance and a $399 copay per day for days 1 to 6, and psychiatric stays with no coinsurance and a $346 copay per day for days 1 to 6, both requiring prior authorization. There is no copay for acute days 7 and beyond, but upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Aetna Medicare Enhanced (PPO) covers outpatient services with no coinsurance, featuring no copay for ambulatory surgical center and blood services, and a $40 copay for outpatient substance abuse sessions. Outpatient hospital services carry a copay of $0 to $399, while observation services require a $399 copay per stay.
Partial Hospitalization See details
Aetna Medicare Enhanced (PPO) covers partial hospitalization with a copay 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 $300 copay and no coinsurance, though prior authorization is required. Transportation services to plan-approved or any other health-related locations are not covered.
Emergency Services See details
Aetna Medicare Enhanced (PPO) covers emergency services with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services are covered with a $40 copay and no coinsurance, and worldwide emergency services are covered up to a $250,000 limit with no coinsurance and copays ranging from $115 to $300.
Primary Care See details
Primary Care benefits under the Aetna Medicare Enhanced (PPO) are partially covered, as podiatry and chiropractic services are not covered. Covered services feature no coinsurance, with no copay for primary care visits, a $40 copay for specialists and mental health, and a $25 to $30 copay for physical and occupational therapy.
Preventive Services See details
Preventive Services are partially covered by Aetna Medicare Enhanced (PPO), featuring no copay and no coinsurance for annual exams, health education, fitness, and select screenings, while kidney disease education requires a 20% coinsurance and no copay. Sub-services not covered under this benefit include in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, readmission 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 and bathroom safety devices, and counseling.
Hearing Services See details
Aetna Medicare Enhanced (PPO) partially covers hearing services, offering annual routine exams and fittings with no copay or coinsurance, and Medicare-covered exams for a $40 copay and no coinsurance. Up to two prescription hearing aids are covered annually with no coinsurance and copays ranging from $0 to $1,700, while OTC, inner ear, outer ear, and over-the-ear hearing aids are not covered.
Vision Services See details
Vision services are covered by Aetna Medicare Enhanced (PPO) with no deductibles and no coinsurance. Eye exams carry a $0 to $40 copay with a $50 annual limit, while routine eye exams and eyewear—such as contact lenses and eyeglasses—have no copay, with eyewear subject to a $100 yearly maximum.
Dental Services See details
Dental services are partially covered by Aetna Medicare Enhanced (PPO), offering no copay and no coinsurance for most preventive and comprehensive services up to a $1,000 annual maximum, while Medicare-covered dental services require a $40 copay and no coinsurance. However, maxillofacial prosthetics, implant services, and orthodontics are not covered under this plan.
Home Infusion bundled Services See details
Aetna Medicare Enhanced (PPO) covers home infusion bundled services with no copay, subject to prior authorization. Under this benefit, Medicare Part B chemotherapy and other Part B drugs have no copay and 0% to 20% coinsurance, while Part B insulin is covered with a $35 copay and no coinsurance.
Dialysis Services See details
Aetna Medicare Enhanced (PPO) covers Dialysis Services with no copay and a 20% coinsurance, although prior authorization is required.
Medical Equipment See details
Aetna Medicare Enhanced (PPO) covers medical equipment with no copays, though prior authorization is required for all categories. Durable medical equipment, medical supplies, and diabetic supplies range from no coinsurance up to 20% coinsurance, while prosthetic devices and diabetic shoes or inserts require a flat 20% coinsurance.
Diagnostic and Radiological Services See details
Aetna Medicare Enhanced (PPO) covers diagnostic and radiological services with prior authorization required. Diagnostic services require no coinsurance, featuring no copay for lab work and a copay of up to $40 for tests, while radiological services involve a $40 copay for X-rays, a minimum 20% coinsurance for therapeutic services, and no minimum copay for diagnostic radiology.
Home Health Services See details
Home health services are covered by the Aetna Medicare Enhanced (PPO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered in practice under the Aetna Medicare Enhanced (PPO) plan, as cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are listed as not covered. For these services, members pay no coinsurance but are responsible for copayments ranging from $15 to $20.
Skilled Nursing Facility (SNF) See details
Aetna Medicare Enhanced (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, featuring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Aetna Medicare Enhanced (PPO) partially covers Other Services, providing a meal benefit, annual wellness exams, screening mammography, and additional gFOBT and FIT screenings with no copay and no coinsurance. Acupuncture and over-the-counter (OTC) items are not covered under this plan benefit.
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