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Aetna Medicare Prime Care (HMO-POS)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare Prime Care (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 Care (HMO-POS) in 2026, please refer to our full plan details page.
Aetna Medicare Prime Care (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 3.5 out of 5 stars in 2026.
It's important to know that Aetna Medicare Prime Care (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 Care (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 Care (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 a $200.00 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 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 Care (HMO-POS) plan features an annual drug deductible of $200 and offers significant savings on generic medications. Tier 1 preferred generics and Tier 2 generics have no copay when filled through a preferred pharmacy or preferred mail order service. For standard pharmacies and standard mail order, Tier 1 drugs require a copay starting at $2.00, while Tier 2 drugs have a copay starting at $12.00 for a one-month supply. For brand-name and specialty medications, your costs are based on coinsurance rather than a flat copay. Tier 3 preferred brands require a 25% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs require a 30% coinsurance across all pharmacy options. Specialty drugs in Tier 5 are limited to a one-month supply.
Additional Benefits
The Aetna Medicare Prime Care (HMO-POS) plan offers comprehensive medical coverage with no copays for primary care visits, routine vision and hearing exams, and home health services. For specialized care, members can expect predictable copays, such as $40 for urgent care and specialist visits, and a $130 copay for emergency room visits which is waived upon admission. Inpatient hospital stays require a daily copay of $240 for days one through four, while outpatient services generally feature no coinsurance. Additional benefits include a $1,000 annual dental allowance and a $250 annual eyewear allowance with no copays or coinsurance. The plan also features a $75 quarterly over-the-counter item reimbursement and no copays for routine hearing exams, though prescription hearing aids carry a copay of up to $1,700. For durable medical equipment and Part B drugs, coinsurance ranges from 0% to 20% with no copays required.
Inpatient Hospital See details
Aetna Medicare Prime Care (HMO-POS) covers inpatient hospital services with no coinsurance, requiring a $240 daily copay for days 1 through 4 of acute stays and a $300 daily copay for days 1 through 5 of psychiatric stays, with no copay for remaining covered days. Prior authorization is required for these services, and upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Aetna Medicare Prime Care (HMO-POS) covers outpatient services with no coinsurance, offering ambulatory surgical center and blood services with no copay. Outpatient hospital services have a copay of $0 to $300, observation services carry a $225 copay per stay, and outpatient substance abuse sessions require a $40 copay.
Partial Hospitalization See details
Aetna Medicare Prime Care (HMO-POS) covers partial hospitalization with copays ranging from no copay to $145 and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
Aetna Medicare Prime Care (HMO-POS) covers ground ambulance services with a $200 copay and no coinsurance, and air ambulance services with a 20% coinsurance and no copay, with prior authorization required for both. Routine transportation services to health-related locations are not covered.
Emergency Services See details
Aetna Medicare Prime Care (HMO-POS) covers emergency services for a $130 copay, which is waived if admitted to the hospital within 24 hours, and urgently needed services for a $40 copay, with no coinsurance required for either service. Worldwide emergency, urgent, and transportation services are also covered up to a $250,000 maximum limit with no coinsurance and copays ranging from $130 to $200.
Primary Care See details
Primary Care benefits under Aetna Medicare Prime Care (HMO-POS) include primary care physician visits with no copay and no coinsurance, though chiropractic services are not covered in practice. Most other outpatient and specialist services feature no coinsurance with copays ranging from $0 to $40, while telehealth benefits require a 20% coinsurance and a $0 to $40 copay.
Preventive Services See details
Aetna Medicare Prime Care (HMO-POS) offers partially covered preventive services, featuring annual physicals, fitness benefits, and health education with no copay and no coinsurance, though kidney disease education requires a 20% coinsurance and no copay. Sub-services not covered under this plan include in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, home-based palliative care, in-home support, caregiver support, enhanced disease management, telemonitoring, home and bathroom safety devices, and counseling.
Hearing Services See details
Aetna Medicare Prime Care (HMO-POS) hearing services are partially covered, offering routine exams and fitting evaluations with no copay and no coinsurance, and Medicare-covered exams for a $40 copay and no coinsurance. Covered prescription hearing aids carry a copay of up to $1,700 and no coinsurance, but OTC hearing aids and inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
Aetna Medicare Prime Care (HMO-POS) covers vision services with no coinsurance, offering routine eye exams and follow-up diabetic exams with no copay, while Medicare-covered exams have a $0 to $40 copay. Eyewear, including contacts and eyeglasses, is also covered with no copay and no coinsurance up to a $250 annual maximum benefit.
Dental Services See details
Dental services are partially covered by Aetna Medicare Prime Care (HMO-POS), featuring a $40 copay and no coinsurance for Medicare-covered dental, and no copay and no coinsurance for other covered services up to a $1,000 annual maximum. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Aetna Medicare Prime Care (HMO-POS) covers home infusion bundled services with no copay, though prior authorization is required. Medicare Part B insulin is covered with a $35 copay and no coinsurance, while chemotherapy and other Part B drugs have no copay and a 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Aetna Medicare Prime Care (HMO-POS) plan with no copay and a 20% coinsurance, and prior authorization is required.
Medical Equipment See details
Aetna Medicare Prime Care (HMO-POS) covers medical equipment, including durable medical equipment, prosthetics, and diabetic supplies, with no copays and coinsurance ranging from no coinsurance to 20%. Prior authorization is required for most of these services, and diabetic supplies are limited to specified manufacturers.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Aetna Medicare Prime Care (HMO-POS) with prior authorization required. Diagnostic services feature no coinsurance, offering no copay for lab services and a $0 to $5 copay for procedures, while radiological services include X-rays with no copay (coinsurance applies) and therapeutic services with a copay and a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered by Aetna Medicare Prime Care (HMO-POS) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are covered under the Aetna Medicare Prime Care (HMO-POS) plan with no copay, no coinsurance, and a required referral. While some services are covered, standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
Aetna Medicare Prime Care (HMO-POS) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring a $10 daily copay for days 1 through 20 and a $165 daily copay for days 21 through 100. Prior authorization is required, and additional days beyond the Medicare-covered 100 days are not covered.
Other Services See details
Aetna Medicare Prime Care (HMO-POS) partially covers other services with no copay and no coinsurance, including chronic illness meal benefits, annual wellness exams, screening mammographies, and a $75 quarterly over-the-counter item reimbursement. Acupuncture and Dual Eligible SNP services are not covered under this benefit.
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