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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 Spokane County Inland Empire Washington. 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 $48.00. 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 $500.00 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 prescription drug deductible of $500. For Tier 1 preferred generic and Tier 2 generic drugs, you will pay no copay when using a preferred pharmacy or preferred mail-order service. If you fill these generic prescriptions at standard pharmacies or standard mail-order services, copays start at $2 for Tier 1 and $12 for Tier 2 for a one-month supply. For higher-tier medications, costs are structured as a percentage of the drug cost rather than flat copays. You will pay a 22% coinsurance for Tier 3 preferred brand drugs and a 25% coinsurance for Tier 4 non-preferred drugs across all pharmacy options. Tier 5 specialty drugs require a 27% coinsurance for a one-month supply at both preferred and standard pharmacies.
Additional Benefits
The Aetna Medicare Enhanced (PPO) plan offers robust coverage with no copay for primary care visits, routine preventive services, and annual physicals, while specialist visits require up to a $55 copay. For hospital stays, members pay a $425 daily copay for the first five days of inpatient care, with no copay for day six and beyond. Emergency room visits carry a $115 copay, which is waived if you are admitted, and urgent care is available for a $40 copay. Routine vision and hearing exams feature no copay, with additional allowances of up to $1,250 for prescription hearing aids and $150 for eyewear. Preventive dental care is also covered with no copay, while comprehensive dental treatments and durable medical equipment require a 20% to 50% coinsurance. Additionally, members benefit from no copay on home health services, outpatient lab work, and diagnostic X-rays.
Inpatient Hospital See details
Aetna Medicare Enhanced (PPO) covers inpatient acute hospital stays with no coinsurance and a $425 daily copay for days 1 to 5, followed by no copay for days 6 and beyond. Inpatient psychiatric care is also covered with no coinsurance and a $415 daily copay for days 1 to 5, though this benefit is only partially covered as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services under the Aetna Medicare Enhanced (PPO) are covered with no coinsurance, featuring copays of no copay to $390 for outpatient hospital services and $425 per stay for observation services. Ambulatory surgical center and blood services are covered with no copay and no coinsurance, while outpatient substance abuse sessions require a $40 copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by Aetna Medicare Enhanced (PPO) 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) partially covers Ambulance and Transportation Services, providing ground ambulance services for a $275 copay (no coinsurance) and air ambulance services for a 20% coinsurance (no copay), both requiring prior authorization. Transportation services to plan-approved health-related locations and 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, with the copay 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 ranging from $115 to $275.
Primary Care See details
Primary care benefits under the Aetna Medicare Enhanced (PPO) plan feature no copay and no coinsurance for primary care physician visits, while specialist visits range from no copay to a $55 copay with no coinsurance. Physical, occupational, mental health, and psychiatric therapies are covered with copays ranging from $25 to $40 and no coinsurance, though podiatry is not covered and chiropractic services are only partially covered.
Preventive Services See details
Preventive services are covered by Aetna Medicare Enhanced (PPO) with no copay and no coinsurance for annual physicals, health education, and fitness benefits, though kidney disease education requires no copay and a 20% coinsurance. This benefit is partially covered because sub-services such as 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 safety devices, and counseling are not covered.
Hearing Services See details
Aetna Medicare Enhanced (PPO) provides partially covered hearing services with no copay and no coinsurance for Medicare-covered exams, routine exams, and fitting evaluations. Prescription hearing aids are covered up to $1,250 per ear annually with no copay or coinsurance, but OTC hearing aids and inner ear, outer ear, or over-the-ear prescription models are not covered.
Vision Services See details
Aetna Medicare Enhanced (PPO) covers vision services with no copay, no coinsurance, and no deductible for both eye exams and eyewear. Covered benefits include one routine eye exam per year up to a $50 maximum, and contact lenses, eyeglasses, or upgrades up to a combined annual limit of $150.
Dental Services See details
Dental services are partially covered by Aetna Medicare Enhanced (PPO), featuring a $55 copay and no coinsurance for Medicare-covered dental, and no copay or coinsurance for preventive exams, cleanings, and X-rays. Covered comprehensive services like restorative care, endodontics, periodontics, and prosthodontics require no copay and 20% to 50% coinsurance up to a $1,250 annual limit. Fluoride, implants, orthodontics, maxillofacial prosthetics, other diagnostic dental, and other preventive dental services are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Aetna Medicare Enhanced (PPO) with no copay, though prior authorization is required. Under this benefit, Part B insulin drugs have a $35 copay and no coinsurance, while chemotherapy and other Part B drugs have a 0% to 20% coinsurance.
Dialysis Services See details
Aetna Medicare Enhanced (PPO) covers Dialysis Services with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
Medical Equipment is covered by Aetna Medicare Enhanced (PPO), with prior authorization required for most items. Durable medical equipment, prosthetics, and medical supplies carry no copay and a 20% coinsurance, while diabetic supplies range from no coinsurance to 20% coinsurance and diabetic shoes or inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Aetna Medicare Enhanced (PPO), featuring no copay and no coinsurance for lab services, outpatient X-rays, and diagnostic radiology. Diagnostic procedures and tests have a $0 to $20 copay with no coinsurance, while therapeutic radiological services require a 20% coinsurance, and prior authorization is required for these services.
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
Aetna Medicare Enhanced (PPO) indicates that some services are covered with no copay and no coinsurance, but cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for peripheral artery disease (PAD) are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Aetna Medicare Enhanced (PPO) 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, a prior three-day hospital stay is not required, and additional days beyond the standard 100-day benefit period are not covered.
Other Services See details
Aetna Medicare Enhanced (PPO) partially covers other services with no copay and no coinsurance, though acupuncture, meal benefits, and Dual Eligible SNPs are not covered. Covered services include annual wellness exams, additional colon cancer screenings (gFOBT and FIT), and up to $25 every three months in reimbursed over-the-counter items.
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