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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 Puget Sound 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 $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 a $500 annual drug deductible. For Tier 1 preferred generic and Tier 2 generic medications, you will pay no copay when using a preferred pharmacy or preferred mail-order service for any supply up to three months. If you choose a standard pharmacy or standard mail-order service, copays range from $2 to $6 for Tier 1 and $12 to $36 for Tier 2 depending on the supply duration. For higher-tier prescription medications, your costs transition to coinsurance percentages regardless of the pharmacy type you select. You will pay a 22% coinsurance for Tier 3 preferred brand drugs and a 25% coinsurance for Tier 4 non-preferred drugs. Tier 5 specialty drugs require a 27% coinsurance for a one-month supply across all preferred and standard pharmacy options.
Additional Benefits
The Aetna Medicare Enhanced (PPO) plan offers strong coverage with no copay for primary care visits, home health services, and annual preventive care. For inpatient hospital stays, members pay no coinsurance, though a daily copay applies for the first five days of stays before dropping to no copay for subsequent days. Emergency care is covered with a $115 copay, while specialist visits range from no copay to a $50 copay. Routine vision, dental, and hearing services are widely covered, featuring no copay and no coinsurance for preventive care, annual exams, and select hardware. Comprehensive dental and durable medical equipment require no copay but do carry coinsurance, while dialysis services require a 20% coinsurance with no copay. Additionally, skilled nursing facility stays require no coinsurance and no copay for the first 20 days of care.
Inpatient Hospital See details
Aetna Medicare Enhanced (PPO) inpatient hospital services are partially covered with no coinsurance, though prior authorization is required. Medicare-covered acute stays require a $425 copay for days 1 to 5 and no copay for days 6 and beyond, while psychiatric stays require a $415 copay for days 1 to 5 and no copay for days 6 to 90. Hospital 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 a $0 to $375 copay for outpatient hospital services and a $425 copay 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 services are covered under the Aetna Medicare Enhanced (PPO) plan 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 ambulance services with prior authorization, requiring a $300 copay for ground ambulance services and a 20% coinsurance for air ambulance services. For transportation, some services are covered, but transportation to plan-approved health-related locations and any 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 are covered with a $40 copay and no coinsurance, while worldwide emergency and urgent care require a $115 copay ($300 for worldwide emergency transportation) and no coinsurance, up to a $250,000 maximum benefit limit.
Primary Care See details
Aetna Medicare Enhanced (PPO) covers primary care physician services with no copay and no coinsurance, and specialist visits with a $0 to $50 copay and no coinsurance. Physical, speech, and occupational therapies require a $25 copay and no coinsurance, while mental health and psychiatric services require a $40 copay and no coinsurance. Telehealth is covered with a $0 to $50 copay and 20% coinsurance, while chiropractic and podiatry services are not covered.
Preventive Services See details
Aetna Medicare Enhanced (PPO) partially covers preventive services, offering annual physicals, fitness benefits, and health screenings with no copay and no coinsurance, though kidney disease education requires a 20% coinsurance with no copay. Several supplemental services are not covered, including weight management, nutritional/dietary benefits, alternative therapies, and in-home safety assessments.
Hearing Services See details
Hearing services are partially covered by Aetna Medicare Enhanced (PPO), offering Medicare-covered exams, annual routine hearing exams, fitting evaluations, and up to two prescription hearing aids per year with no copay and no coinsurance. While there is a $1,250 annual maximum benefit per ear for prescription hearing aids, OTC hearing aids as well as inner ear, outer ear, and over-the-ear prescription hearing aids are not covered.
Vision Services See details
Vision services are covered by Aetna Medicare Enhanced (PPO) with no copay, no coinsurance, and no deductible for both eye exams and eyewear. This coverage includes one routine eye exam per year up to a $50 maximum benefit, as well as a $175 annual combined maximum allowance for contacts, eyeglasses, and upgrades.
Dental Services See details
Dental Services are partially covered by Aetna Medicare Enhanced (PPO), offering preventive care with no copay and no coinsurance, and Medicare-covered dental services for a $50 copay and no coinsurance. Covered comprehensive services require no copay and 20% to 50% coinsurance up to a $1,250 annual limit, while fluoride, implants, orthodontics, maxillofacial prosthetics, and other diagnostic or preventive services 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 may be required. Under this benefit, Medicare Part B chemotherapy, radiation, and other Part B drugs have a coinsurance ranging from 0% to 20%, while Part B insulin is covered with a $35 copay and no coinsurance.
Dialysis Services See details
Dialysis services are covered by Aetna Medicare Enhanced (PPO) with no copay and a 20% coinsurance. Prior authorization is required to receive these services.
Medical Equipment See details
Aetna Medicare Enhanced (PPO) covers durable medical equipment, prosthetics, and medical supplies with no copay and 20% coinsurance. Diabetic equipment and supplies are also covered with coinsurance ranging from 0% to 20% and no copay for therapeutic shoes or inserts, with prior authorization required for these services.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by the Aetna Medicare Enhanced (PPO) plan, with prior authorization required. Diagnostic tests and procedures have no coinsurance and a copay of $0 to $20, lab services have no copay and no coinsurance, and outpatient X-rays have no copay but require coinsurance. Diagnostic radiological services have a copay starting at $0, while therapeutic radiological services require a copay and a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered under the Aetna Medicare Enhanced (PPO) plan with no copay and no coinsurance. Prior authorization is required to receive these services.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under Aetna Medicare Enhanced (PPO) with no copay and no coinsurance. However, only some services are covered in practice, as Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) care is covered by Aetna Medicare Enhanced (PPO) with no coinsurance, featuring no copay for days 1 through 20 and a $218 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 with no copay and no coinsurance, including over-the-counter items up to $25 every three months, annual wellness exams, screening mammography, and additional gFOBT and FIT. Acupuncture and meal benefits are not covered.
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