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Aetna Medicare PinnacleHealth Prime (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare PinnacleHealth Prime (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Aetna Medicare PinnacleHealth Prime (PPO) in 2026, please refer to our full plan details page.
Aetna Medicare PinnacleHealth Prime (PPO) is a PPO plan offered by CVS Health Corporation available for enrollment in 2025 to people living in South Central Pennsylvania. This plan received an overall rating of 4.5 out of 5 stars in 2026.
It's important to know that Aetna Medicare PinnacleHealth Prime (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 PinnacleHealth Prime (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 PinnacleHealth Prime (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. 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 $11300.00 (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 $11300.00 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 PinnacleHealth Prime (PPO) plan features an annual drug deductible of $615. For Tier 1 preferred generic and Tier 2 generic drugs, you will pay no copay when using preferred pharmacies or preferred mail order services. Standard pharmacies and standard mail order options for these tiers require copays, starting at $2.00 for Tier 1 and $12.00 for Tier 2 for a one-month supply. For brand-name and specialty drugs, you will pay a coinsurance percentage instead of a flat copay. Tier 3 preferred brand drugs carry a 24% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs require a 25% coinsurance. These coinsurance rates apply across all preferred and standard pharmacy and mail order services, with specialty tier drugs limited to a one-month supply.
Additional Benefits
The Aetna Medicare PinnacleHealth Prime (PPO) offers comprehensive medical coverage with no copays for primary care physician visits, annual preventive exams, and home health services. Specialist visits range from no copay up to a $35 copay, while inpatient acute hospital stays require a flat $425 copay. Emergency room visits carry a $115 copay, which is waived if you are admitted within 24 hours, and urgent care visits require a $40 copay. For supplemental care, this plan features no copays for routine hearing exams, annual eye exams, and preventive dental services, plus up to $1,000 in comprehensive dental coverage with 20% to 50% coinsurance. Prescription hearing aids are covered up to $500 per ear annually, and eyewear is covered up to a $150 annual limit, both with no copays. Additionally, medical equipment and diagnostic lab tests are highly accessible, featuring no copays and coinsurance ranging up to 20%.
Inpatient Hospital See details
Aetna Medicare PinnacleHealth Prime (PPO) partially covers inpatient hospital services with no coinsurance, though prior authorization is required. Acute care stays require a $425 copay per stay, while psychiatric stays incur a $350 daily copay for days 1 through 5 and no copay for days 6 through 90; however, upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Aetna Medicare PinnacleHealth Prime (PPO) covers outpatient services with no coinsurance, featuring no copays for ambulatory surgical center and blood services. Outpatient hospital services require a copay of $0 to $275, observation services carry a $275 copay per stay, and outpatient substance abuse sessions have a $35 copay.
Partial Hospitalization See details
Aetna Medicare PinnacleHealth Prime (PPO) covers partial hospitalization services with no coinsurance, though prior authorization is required. Depending on the service, you will pay either no copay or a $110 copay.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are partially covered by Aetna Medicare PinnacleHealth Prime (PPO), with prior authorization required for all ambulance services. Ground ambulance services require a $300 copay and no coinsurance, while air ambulance services require a 20% coinsurance and no copay. Transportation services to plan-approved or other health-related locations are not covered.
Emergency Services See details
Aetna Medicare PinnacleHealth Prime (PPO) covers emergency services with a $115 copay, which is waived if admitted to the hospital within 24 hours, and urgently needed services with a $40 copay, both with no coinsurance. Worldwide emergency, urgent, and transportation services are also covered with no coinsurance up to a $250,000 maximum limit, requiring a $115 copay for emergency or urgent care and a $300 copay for emergency transportation.
Primary Care See details
Primary care benefits under the Aetna Medicare PinnacleHealth Prime (PPO) feature primary care physician visits with no copay and no coinsurance, and specialist visits with a $0 to $35 copay and no coinsurance. Other covered services like physical, occupational, speech, mental health, psychiatric, and opioid treatment require a $35 copay and no coinsurance, while telehealth has a $0 to $40 copay and 20% coinsurance, but chiropractic and podiatry services are not covered.
Preventive Services See details
Aetna Medicare PinnacleHealth Prime (PPO) partially covers preventive services with no copay and no coinsurance for annual exams, health education, and fitness benefits, though kidney disease education carries a 20% coinsurance and no copay. Uncovered sub-services include in-home safety assessments, PERS, medical nutrition therapy, medication reconciliation, re-admission prevention, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, palliative care, in-home support, caregiver support, enhanced disease management, telemonitoring, home safety devices, and counseling.
Hearing Services See details
Aetna Medicare PinnacleHealth Prime (PPO) covers Medicare-covered hearing exams for a $35 copay and no coinsurance, while annual routine exams and fitting evaluations have no copay and no coinsurance. Prescription hearing aids are partially covered with no copay or coinsurance up to a $500 annual maximum per ear, but inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
Aetna Medicare PinnacleHealth Prime (PPO) covers vision services, featuring eye exams with a $0 to $35 copay, no coinsurance, and a $50 annual maximum limit. Eyewear is also covered with no copay and no coinsurance, up to a combined $150 annual maximum for both in-network and out-of-network benefits.
Dental Services See details
Dental services are partially covered by Aetna Medicare PinnacleHealth Prime (PPO), offering preventive care with no copay and no coinsurance, and Medicare-covered services for a $35 copay and no coinsurance. Comprehensive care is covered up to a $1,000 yearly limit with no copay and 20% to 50% coinsurance, though fluoride, implants, orthodontics, maxillofacial prosthetics, and other diagnostic or preventive services are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Aetna Medicare PinnacleHealth Prime (PPO) with no copay, though prior authorization is required. Under this benefit, Medicare Part B insulin has a $35 copay and no coinsurance, while other Part B drugs, including chemotherapy and radiation, carry a coinsurance ranging from no coinsurance up to 20%.
Dialysis Services See details
Dialysis services are covered by Aetna Medicare PinnacleHealth Prime (PPO) with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
Aetna Medicare PinnacleHealth Prime (PPO) covers medical equipment, including durable medical equipment, prosthetics, medical supplies, and diabetic equipment with no copays. Coinsurance for these covered benefits ranges from no coinsurance up to 20%, and prior authorization is required.
Diagnostic and Radiological Services See details
Aetna Medicare PinnacleHealth Prime (PPO) covers diagnostic and radiological services, featuring no copay and no coinsurance for diagnostic procedures, lab tests, and diagnostic radiology. Outpatient X-ray services require a $15 copay with coinsurance, while therapeutic radiology has a 20% coinsurance and a copay, and prior authorization is required for all services.
Home Health Services See details
Home Health Services are covered under the Aetna Medicare PinnacleHealth Prime (PPO) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Aetna Medicare PinnacleHealth Prime (PPO) does not cover Cardiac Rehabilitation Services. This exclusion applies to cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) services.
Skilled Nursing Facility (SNF) See details
Aetna Medicare PinnacleHealth Prime (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day inpatient hospital stay. There is no copay for days 1 through 20, a $218 daily copay for days 21 through 100, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Aetna Medicare PinnacleHealth Prime (PPO) partially covers other services, providing an annual wellness exam, screening mammography, and additional gFOBT and FIT screenings with no copay and no coinsurance. Acupuncture, over-the-counter (OTC) items, and meal benefits are not covered under this plan.
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