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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 2025 to people living in Lehigh Valley Pennsylvania. 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 $66.00. 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 Enhanced (PPO) plan features an annual drug deductible of $615. For Tier 1 preferred generic and Tier 2 generic medications, members pay no copay when using a preferred pharmacy or preferred mail-order service for up to a three-month supply. If standard pharmacies or standard mail-order services are used instead, copays range from $2 to $6 for Tier 1 and $12 to $36 for Tier 2. For higher-tier medications, cost sharing transitions to a percentage-based coinsurance across all pharmacy and mail-order options. Tier 3 preferred brand drugs require a 24% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs incur a 25% coinsurance. This structure provides predictable cost-sharing rates for brand-name and specialty prescriptions under the plan.
Additional Benefits
The Aetna Medicare Enhanced (PPO) plan offers robust medical coverage with no copays for primary care visits, preventive screenings, and home health services. Specialist visits, urgent care, and outpatient therapies require a copay of $35 to $40, while emergency room services carry a $115 copay. For hospital stays, members pay a daily copay for the first several days of inpatient care, with no additional coinsurance required. This plan also includes valuable supplemental benefits, featuring no copays for routine dental, vision, and hearing exams, alongside allowances for eyewear and hearing aids. Diagnostic lab tests are covered with no copay, while dialysis and durable medical equipment feature no copay and up to 20% coinsurance. Additionally, members receive a $75 quarterly over-the-counter item reimbursement to help lower everyday out-of-pocket health costs.
Inpatient Hospital See details
Aetna Medicare Enhanced (PPO) partially covers inpatient hospital services with no coinsurance, requiring a $325 daily copay for days 1 through 7 of acute stays and a $350 daily copay for days 1 through 5 of psychiatric stays, with no copay for remaining days. Prior authorization is required, and 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, including ambulatory surgical center and blood services which feature no copays. Outpatient hospital services carry a copay of $0 to $325, observation services cost $325 per stay, and outpatient substance abuse sessions require a $40 copay.
Partial Hospitalization See details
Partial hospitalization is covered by Aetna Medicare Enhanced (PPO) 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 services under the Aetna Medicare Enhanced (PPO) plan require prior authorization, featuring a $300 copay and no coinsurance for ground transport, alongside a 20% coinsurance and no copay for air transport. Routine transportation services to health-related or plan-approved locations are not covered.
Emergency Services See details
Aetna Medicare Enhanced (PPO) covers emergency services with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours, and urgently needed services with a $40 copay and no coinsurance. Worldwide emergency services are also covered up to a $250,000 maximum with no coinsurance, featuring 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 Enhanced (PPO) feature no copay and no coinsurance for primary care physician visits, while specialist, mental health, podiatry, and psychiatric services require a $40 copay and no coinsurance. Physical, occupational, and speech therapies have a $35 copay and no coinsurance, telehealth features a $0 to $40 copay with 20% coinsurance, and chiropractic services are not covered.
Preventive Services See details
Preventive Services under the Aetna Medicare Enhanced (PPO) are generally covered with no copay and no coinsurance, including annual physical exams, glaucoma screenings, and diabetes self-management training. Additional preventive services are partially covered, excluding options like in-home safety assessments and weight management programs, while covered kidney disease education services require no copay and a 20% coinsurance.
Hearing Services See details
Aetna Medicare Enhanced (PPO) covers hearing exams with a $40 copay and no coinsurance, while routine exams and fitting evaluations have no copay and no coinsurance. Prescription hearing aids are partially covered with no copay or coinsurance up to $500 per ear annually, but inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
Vision services are covered by Aetna Medicare Enhanced (PPO) with no deductibles and no coinsurance, featuring no copay for routine eye exams (up to a $50 annual limit) and up to a $40 copay for Medicare-covered exams. Eyewear, including contacts and eyeglasses, is covered with no copay and no coinsurance up to a combined annual limit of $250.
Dental Services See details
Aetna Medicare Enhanced (PPO) provides partial dental coverage, featuring no copay and no coinsurance for preventive services like cleanings and exams, and a $40 copay with no coinsurance for Medicare-covered dental. Comprehensive services like restorative care and periodontics require no copay and 20% to 50% coinsurance up to a $1,500 annual maximum, while 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 Enhanced (PPO) with no copay, though prior authorization is required. Under this benefit, Medicare Part B chemotherapy, radiation, and other Part B drugs require a 0% to 20% coinsurance, 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, though prior authorization is required.
Medical Equipment See details
Aetna Medicare Enhanced (PPO) covers medical equipment, including durable medical equipment, diabetic supplies, and prosthetics, with no copayment. Coinsurance ranges from no coinsurance up to 20% depending on the equipment, and prior authorization is required for these covered services.
Diagnostic and Radiological Services See details
Aetna Medicare Enhanced (PPO) covers diagnostic procedures and lab services with no copay and no coinsurance, subject to prior authorization. Covered radiological services, which also require prior authorization, feature no copay and no coinsurance for diagnostic radiology, a $30 copay and coinsurance for outpatient X-rays, and a copay plus a minimum 20% coinsurance for therapeutic radiology.
Home Health Services See details
Home Health Services are covered under the Aetna Medicare Enhanced (PPO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Aetna Medicare Enhanced (PPO) covers some Cardiac Rehabilitation Services with no copay and no coinsurance, but standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
Aetna Medicare Enhanced (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring no copay for days 1 through 20 and a $210 daily copay for days 21 through 100. Prior authorization is required and less than a 3-day inpatient hospital stay is allowed before admission, but additional days beyond the standard 100 days are not covered.
Other Services See details
Aetna Medicare Enhanced (PPO) provides partially covered other services with no copay and no coinsurance, which includes annual wellness exams, screening mammography, additional gFOBT and FIT, and a $75 quarterly over-the-counter (OTC) item reimbursement. Acupuncture and meal benefits are not covered under this plan.
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