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Aetna Medicare Value Plus (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare Value Plus (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Aetna Medicare Value Plus (PPO) in 2026, please refer to our full plan details page.
Aetna Medicare Value Plus (PPO) is a PPO plan offered by CVS Health Corporation available for enrollment in 2025 to people living in Western Pennsylvania. This plan received an overall rating of 4.5 out of 5 stars in 2026.
It's important to know that Aetna Medicare Value Plus (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 Value Plus (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 Value Plus (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $13.00. 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 $9550.00 (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 $9550.00 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 Value Plus (PPO) plan features an annual prescription drug deductible of $615. For Tier 1 preferred generics and Tier 2 generics, you will pay no copay for one-, two-, or three-month supplies when using a preferred pharmacy or preferred mail order. If you choose standard pharmacies or standard mail order, Tier 1 copays range from $2 to $6 and Tier 2 copays range from $12 to $36 depending on the supply duration. For brand-name and specialty medications, the plan utilizes coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 22% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs carry a 25% coinsurance across all pharmacy and mail-order channels. Note that Tier 5 specialty tier medications are limited to a one-month supply.
Additional Benefits
The Aetna Medicare Value Plus (PPO) plan offers comprehensive coverage for essential medical needs, featuring no copay for primary care visits, preventive care, and home health services. Specialist visits require up to a $30 copay, while inpatient hospital stays have a $475 copay per stay and no coinsurance. Emergency room visits carry a $130 copay, and urgent care services have a $50 copay. For supplemental care, the plan provides routine hearing exams with no copay and routine vision exams with up to a $30 copay, alongside a $275 eyewear allowance and coverage for hearing aids. Dental benefits feature no copay for preventive care and 20% to 50% coinsurance for comprehensive services up to a $2,000 annual limit. Additionally, members receive a $45 quarterly over-the-counter allowance, while dialysis services require a 20% coinsurance and no copay.
Inpatient Hospital See details
Aetna Medicare Value Plus (PPO) covers inpatient acute hospital stays with no coinsurance and a $475 copay per stay, while inpatient psychiatric care has no coinsurance and a $350 daily copay for days 1 to 5, with no copay for days 6 to 90. This benefit is partially covered, as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Aetna Medicare Value Plus (PPO) covers outpatient services with no coinsurance, including outpatient hospital services with a $0 to $325 copay and observation services with a $325 copay per stay. Ambulatory surgical center and outpatient blood services have no copay and no coinsurance, while outpatient substance abuse individual and group sessions require a $40 copay and no coinsurance.
Partial Hospitalization See details
Aetna Medicare Value Plus (PPO) covers partial hospitalization services with no coinsurance, though prior authorization is required. Depending on the specific service, you will pay either no copay or a $145.00 copay.
Ambulance and Transportation Services See details
Aetna Medicare Value Plus (PPO) partially covers Ambulance and Transportation Services, though transportation to plan-approved or any health-related locations is not covered. Ground ambulance services require a $225 copay and no coinsurance, while air ambulance services require a 20% coinsurance and no copay, with prior authorization required for all ambulance services.
Emergency Services See details
Emergency Services are covered by the Aetna Medicare Value Plus (PPO) with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services have a $50 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered up to $250,000 with no coinsurance and copays ranging from $130 to $225.
Primary Care See details
Primary care doctor visits under Aetna Medicare Value Plus (PPO) have no copay and no coinsurance, while specialist visits require a $0 to $30 copay and no coinsurance. Physical, occupational, and speech therapies have a $25 copay and no coinsurance, mental health services have a $40 copay and no coinsurance, and telehealth benefits carry a $0 to $50 copay and 20% coinsurance, while chiropractic services are not covered.
Preventive Services See details
Aetna Medicare Value Plus (PPO) covers preventive services, including annual physical exams and most health screenings, with no copay and no coinsurance, though kidney disease education requires no copay and a 20% coinsurance. This benefit is partially covered, as sub-services such as in-home safety assessments, personal emergency response systems, weight management, and nutritional benefits are not covered.
Hearing Services See details
Hearing services covered by the Aetna Medicare Value Plus (PPO) include Medicare-covered exams for a $30 copay and no coinsurance, alongside routine exams and fitting evaluations with no copay and no coinsurance. Prescription hearing aids are partially covered with no copay or coinsurance up to $750 per ear annually, though OTC hearing aids and inner, outer, or over-the-ear prescription models are not covered.
Vision Services See details
Vision services are covered by Aetna Medicare Value Plus (PPO) with no deductibles and no coinsurance, featuring a $0 to $30 copay for eye exams and no copay for eyewear. Benefits include one routine eye exam per year under a $50 annual limit, alongside a $275 yearly allowance for contact lenses and eyeglasses.
Dental Services See details
Aetna Medicare Value Plus (PPO) provides partially covered dental services, featuring Medicare-covered dental for a $30 copay and no coinsurance, plus preventive care like cleanings and exams with no copay and no coinsurance. Covered comprehensive services require no copay and 20% to 50% coinsurance up to a $2,000 annual limit, though fluoride, implants, orthodontics, maxillofacial prosthetics, other diagnostic, and other preventive dental services are not covered.
Home Infusion bundled Services See details
Aetna Medicare Value Plus (PPO) covers home infusion bundled services with no copay, though prior authorization and step therapy may apply. Under this benefit, Medicare Part B insulin is covered with a $35 copay and no coinsurance, while chemotherapy and other Part B drugs require 0% to 20% coinsurance and no copay.
Dialysis Services See details
Dialysis services are covered by Aetna Medicare Value Plus (PPO) with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
Aetna Medicare Value Plus (PPO) covers medical equipment, including durable medical equipment, prosthetics, and diabetic supplies, with no copay and coinsurance ranging from no coinsurance to 20%. Prior authorization is required for these services, and diabetic supplies are limited to specified manufacturers.
Diagnostic and Radiological Services See details
Aetna Medicare Value Plus (PPO) covers diagnostic services with no coinsurance, offering no copay for lab services and a $0 to $5 copay for diagnostic tests. Covered radiological services include diagnostic radiology with copays starting at $0 and no coinsurance, outpatient X-rays with a $25 copay plus coinsurance, and therapeutic radiology with a copay and 20% minimum coinsurance.
Home Health Services See details
Home Health Services are covered under the Aetna Medicare Value Plus (PPO) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Aetna Medicare Value Plus (PPO) plan, as all individual sub-services—including cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for peripheral artery disease (PAD)—are excluded from coverage.
Skilled Nursing Facility (SNF) See details
Aetna Medicare Value Plus (PPO) covers skilled nursing facility (SNF) services with no coinsurance, requiring a $10 daily copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, a prior three-day inpatient hospital stay is not needed, and additional days beyond the standard 100-day limit are not covered.
Other Services See details
Aetna Medicare Value Plus (PPO) provides partial coverage for other services with no copay and no coinsurance, though acupuncture is not covered. Covered benefits include a $45 quarterly over-the-counter item allowance via reimbursement, chronic illness meal benefits, and select wellness exams and screenings.
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