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Aetna Medicare Prime (HMO-POS)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare Prime (HMO-POS). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Aetna Medicare Prime (HMO-POS) in 2025, please refer to our full plan details page.
Aetna Medicare Prime (HMO-POS) is a HMO-POS plan offered by CVS Health Corporation available for enrollment in 2025 to people living in Northern Rhode Island. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Aetna Medicare Prime (HMO-POS) 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 Prime (HMO-POS).
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 Prime (HMO-POS), 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 no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $4500.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
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 Prime (HMO-POS) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you'll pay a copay or coinsurance depending on the drug tier and pharmacy. For example, preferred generic drugs have a $5 copay at preferred pharmacies. After your total drug costs reach $2,000, you enter the catastrophic coverage phase and pay nothing for Part D covered drugs. If you qualify for the low-income subsidy, you may have a reduced premium. Check the plan's formulary for specific drugs covered.
Additional Benefits
The Aetna Medicare Prime (HMO-POS) plan offers a wide range of benefits with varying costs. Inpatient hospital stays have copays, while outpatient services may have copays depending on the specific service. The plan also includes no copay for many services, such as primary care visits, preventive services like annual physical exams, and certain dental services. This plan also provides coverage for ambulance services, with no copay for ground ambulance, and a 20% coinsurance for air ambulance. Other benefits include coverage for hearing and vision services, with copays for exams and allowances for eyewear. Additionally, the plan covers home health services with no copay, and offers other services with no copay like over-the-counter items and meal benefits.
Inpatient Hospital See details
Inpatient hospital services are covered, with a copay of $200 for days 1-4 and no copay for days 5-90 for Inpatient Hospital-Acute, and a copay of $250 for days 1-5 and no copay for days 6-90 for Inpatient Hospital Psychiatric. Additional days for Inpatient Hospital-Acute are covered with no copay, while Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute, and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient services, including all outpatient hospital services, are covered by the Aetna Medicare Prime (HMO-POS) plan. Outpatient Hospital Services have a copay between $0 and $200, Observation Services have a $250 copay, Ambulatory Surgical Center (ASC) Services have no copay, and Outpatient Blood Services have no copay. Individual and Group Sessions for Outpatient Substance Abuse have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered with prior authorization, and there is no copay.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by Aetna Medicare Prime (HMO-POS), including ground and air ambulance services, and transportation services to plan-approved health-related locations. Ground ambulance services have no copay, and air ambulance services have a 20% coinsurance; transportation services to plan-approved health-related locations have no copay, and allow up to 48 one-way trips every year via rideshare services, bus/subway, and medical transport. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the Aetna Medicare Prime (HMO-POS) plan. Emergency Services and Worldwide Emergency Coverage have a $125 copay, while Urgently Needed Services and Worldwide Emergency Transportation have no copay.
Primary Care See details
The Aetna Medicare Prime (HMO-POS) plan covers primary care physician services and chiropractic services with no copay. The plan also covers physician specialist services with a copay of $10-$30, and occupational therapy, physical therapy, and speech-language pathology services with no copay. Mental health and psychiatric services have a $5 copay for individual and group sessions. Additional telehealth benefits have a 20% coinsurance and a $0-$30 copay, while podiatry services and other health care professional services have a $15 and a $0-$30 copay respectively. Routine Chiropractic Care is not covered.
Preventive Services See details
The Aetna Medicare Prime (HMO-POS) plan covers preventive services, including an annual physical exam with no copay. It also covers additional preventive services, with no copay for services like Health Education, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit. Additionally, there is no copay for Wigs for Hair Loss Related to Chemotherapy, and a 20% coinsurance for Kidney Disease Education Services.
Hearing Services See details
Hearing services with the Aetna Medicare Prime (HMO-POS) plan include hearing exams with a $30 copay, routine hearing exams with no copay, fitting/evaluation for hearing aids with no copay, and prescription hearing aids with a maximum copay of $1700; however, inner ear, outer ear, and over-the-ear prescription hearing aids, as well as OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams and eyewear. Eye exams have a copay of $0-$30, and eyewear has a combined maximum benefit of $365 per year with no copay for contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a $30 copay, and other services with a $1,500 annual maximum benefit. Oral exams, dental x-rays, other diagnostic dental services, cleaning, fluoride treatments, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are covered with no copay. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Aetna Medicare Prime (HMO-POS) plan, but require prior authorization. You will pay 20% coinsurance.
Medical Equipment See details
Medical Equipment is covered under the Aetna Medicare Prime (HMO-POS) plan. Durable Medical Equipment has no copay and a coinsurance between 0% and 20%, while Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies have no copay and a coinsurance, with Medicare-covered Prosthetic Devices and Medical Supplies being covered. Diabetic Equipment has no copay for Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including Diagnostic Procedures/Tests with a copay between $0 and $5, Lab Services with no copay, Diagnostic Radiological Services with a copay up to $50, Therapeutic Radiological Services with 20% coinsurance, and Outpatient X-Ray Services with no copay. All services require prior authorization.
Home Health Services See details
Home Health Services are covered by the Aetna Medicare Prime (HMO-POS) plan with no copay and no coinsurance; however, additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Aetna Medicare Prime (HMO-POS) plan. Although the plan covers this benefit, it does not cover any of the sub-services offered under this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Aetna Medicare Prime (HMO-POS) plan, but require prior authorization. For days 1-20, there is no copay, for days 21-56 there is a $125 copay, and for days 57-100, there is no copay.
Other Services See details
The Aetna Medicare Prime (HMO-POS) plan covers Over-the-Counter (OTC) Items and Meal Benefits with no copay. The plan also covers other services such as annual wellness exams, screening mammography, and gFOBT/FIT, all with no copay. Acupuncture, Dual Eligible SNPs, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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