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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 San Mateo and Santa Clara 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 $204.00. 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 $8900.00 (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 $8900.00 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 offers an Enhanced Alternative drug benefit with an annual prescription drug deductible of $615.00. The standard Part D premium is $22.80, which lowers to $10.80 for members who qualify for the full Low-Income Subsidy (LIS). Once your yearly out-of-pocket drug costs reach $2,100.00, you enter the catastrophic coverage phase and pay nothing for covered Part D prescriptions. During the initial coverage phase, Tier 1 preferred generics have no copay at preferred pharmacies or through preferred mail order, though standard options carry a $12.00 copay. For other tiers, you will pay a 24% coinsurance for Tier 2 standard generics and a 25% coinsurance for Tier 3 preferred brand and Tier 4 non-preferred drugs.
Additional Benefits
The Aetna Medicare Enhanced (PPO) plan offers comprehensive coverage for essential medical needs, featuring primary care visits, annual physicals, and home health services with no copay or coinsurance. Specialist visits and urgent care require a budget-friendly $30 to $40 copay, while emergency room visits have a $130 copay that is waived upon hospital admission. For inpatient hospital stays, members pay a $300 daily copay for the first seven days, followed by no copay for days 8 through 90. This plan also includes valuable supplemental benefits, such as routine dental, vision, and hearing exams with no copay, alongside allowances for eyewear and hearing aids. Outpatient diagnostic tests and lab services are covered with no copay, while durable medical equipment and dialysis services generally carry a 0% to 20% coinsurance. Additionally, skilled nursing facility stays are covered with daily copays starting at $10 for the first 20 days.
Inpatient Hospital See details
Inpatient hospital benefits are partially covered by Aetna Medicare Enhanced (PPO), featuring a $300 daily copay for days 1 through 7, no copay for days 8 through 90, and no coinsurance for acute and psychiatric stays. Upgrades, non-Medicare-covered stays, and additional days for psychiatric care are not covered.
Outpatient Services See details
Outpatient services are covered by Aetna Medicare Enhanced (PPO) with no coinsurance and copays ranging from $0 to $300. There is no copay for ambulatory surgical center or blood services, a $40 copay for outpatient substance abuse services, and up to a $300 copay for outpatient hospital and observation services.
Partial Hospitalization See details
Aetna Medicare Enhanced (PPO) covers partial hospitalization benefits, though prior authorization is required. Covered services feature a copay ranging from $70.00 to $145.00 and no coinsurance.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are partially covered by Aetna Medicare Enhanced (PPO), with ground ambulance services requiring a $285 copay and no coinsurance, and air ambulance services requiring a 20% coinsurance and no copay. 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 $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, urgent, and transportation services are covered up to a $250,000 maximum limit with copays ranging from $130 to $285 and no coinsurance.
Primary Care See details
Aetna Medicare Enhanced (PPO) covers primary care physician services with no copay and no coinsurance, while specialist visits and therapy services require a $30 copay and no coinsurance. Chiropractic services are partially covered with a $15 copay and no coinsurance, excluding routine chiropractic care, and podiatry is not covered. Mental health, psychiatric, and opioid treatments have a $40 copay and no coinsurance, while telehealth benefits require a 20% coinsurance and a $0 to $40 copay.
Preventive Services See details
Preventive services are partially covered by Aetna Medicare Enhanced (PPO), offering no copay and no coinsurance for annual physicals, vaccinations, and fitness benefits. Kidney disease education requires a 20% coinsurance and no copay, while several supplemental services, such as weight management, therapeutic massage, and in-home safety assessments, are not covered.
Hearing Services See details
Hearing Services are partially covered by Aetna Medicare Enhanced (PPO), which offers routine hearing exams and fitting evaluations with no copay and no coinsurance. Prescription hearing aids are covered up to $1,250 per ear annually with no copay and no coinsurance, but OTC hearing aids and prescription hearing aids for the inner ear, outer ear, and over the ear are not covered.
Vision Services See details
Aetna Medicare Enhanced (PPO) covers vision services with no copay and no coinsurance for both eye exams and eyewear. The plan includes a $50 annual maximum for eye exams, including one routine exam per year, and a $200 yearly limit for eyewear like contact lenses, eyeglasses, and upgrades.
Dental Services See details
Dental services are partially covered by Aetna Medicare Enhanced (PPO), offering preventive care like exams and cleanings with no copay and Medicare-covered dental services for a $30 copay. Other covered services require a 20% to 50% coinsurance up to a $1,000 annual limit, while fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Aetna Medicare Enhanced (PPO) with prior authorization, requiring a $35 copay and no coinsurance for Part B insulin. Other covered Part B chemotherapy, radiation, and miscellaneous drugs require no copay and carry a coinsurance ranging from no coinsurance up to 20%.
Dialysis Services See details
Dialysis services are covered under Aetna Medicare Enhanced (PPO) with a 20% coinsurance and no copay. Prior authorization is required to receive these covered services.
Medical Equipment See details
Medical equipment is covered by Aetna Medicare Enhanced (PPO), with durable medical equipment, diabetic supplies, and medical supplies requiring 0% to 20% coinsurance and no copay. Prosthetic devices require a 20% coinsurance with no copay, while diabetic therapeutic shoes and inserts are covered with no copay and no coinsurance.
Diagnostic and Radiological Services See details
Aetna Medicare Enhanced (PPO) covers diagnostic and radiological services, with prior authorization required. Diagnostic tests, lab services, and outpatient X-rays have no copay or coinsurance, while diagnostic radiological services require a copay of up to $250 with no coinsurance, and therapeutic radiological services have a 20% coinsurance with no copay.
Home Health Services See details
Home health services are covered by Aetna Medicare Enhanced (PPO) with no copay and no coinsurance, though prior authorization is required for these services.
Cardiac Rehabilitation Services See details
Aetna Medicare Enhanced (PPO) does not cover Cardiac Rehabilitation Services, as none of the sub-services—including intensive cardiac, pulmonary, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD)—are covered under this plan.
Skilled Nursing Facility (SNF) See details
Aetna Medicare Enhanced (PPO) partially covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring a $10 daily copay for days 1 to 20 and a $218 daily copay for days 21 to 100. Prior authorization is required, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other Services are partially covered by Aetna Medicare Enhanced (PPO), featuring no copay and no coinsurance for covered benefits like Over-the-Counter (OTC) items up to $30 every three months, annual wellness exams, screening mammographies, and additional gFOBT and FIT. Acupuncture, meal benefits, and Dual Eligible SNPs with Highly Integrated Services are not covered.
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