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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.
This summary reflects 2026 plan information. Where this plan continues in 2027, the full plan details page links to its 2027 benefits and costs.
Aetna Medicare Enhanced (PPO) is a PPO plan offered by Coventry Health Care of Illinois, Inc. available for the 2026 plan year to people living in Central Illinois. This plan received an overall rating of 3.5 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 $37.00. 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 that applies only to drugs in certain tiers. You pay this amount toward covered prescriptions in those tiers before the plan's cost sharing begins; drugs in the other tiers are not subject to the deductible. See the full plan details page for the tier table.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $4700.00 for in-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $4700.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
This plan has a Maximum Out-Of-Pocket cost of $10100.00 (in-network and out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $10100.00 for covered services, the plan will pay 100% of 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 Enhanced (PPO) plan features an annual drug deductible of $615 before coverage begins. For Tier 1 preferred generic and Tier 2 generic medications, you will pay no copay when using a preferred pharmacy or preferred mail order service. If you use a standard pharmacy or standard mail order, Tier 1 copays start at $2.00 and Tier 2 copays start at $12.00 for a one-month supply. For brand-name and specialty medications, costs are structured as coinsurance across all pharmacy options. Tier 3 preferred brand drugs require a 24% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs both carry a 25% coinsurance. Please note that Tier 5 specialty tier prescriptions are limited to a one-month supply.
Additional Benefits
The Aetna Medicare Enhanced (PPO) plan offers robust coverage with no copay for primary care visits and most preventive services. Specialist visits, outpatient care, and diagnostic tests feature low copays up to $40, while inpatient hospital stays require a $275 daily copay for the first six days followed by no copay. Emergency room visits carry a $130 copay, which is waived if you are admitted to the hospital. This plan also includes valuable supplemental benefits, such as routine dental, vision, and hearing care with no copay. You receive up to $400 annually for eyewear, up to $1,250 per ear for prescription hearing aids, and up to $1,500 for comprehensive dental services with 20% to 50% coinsurance. Additionally, the plan provides a quarterly $45 over-the-counter allowance with no copay or coinsurance.
Inpatient Hospital See details
Aetna Medicare Enhanced (PPO) partially covers inpatient hospital services with no coinsurance and a $275 daily copay for days 1 through 6, followed by no copay for days 7 through 90. Prior authorization is required, and exclusions include upgrades, non-Medicare-covered stays, and additional psychiatric days.
Outpatient Services See details
Aetna Medicare Enhanced (PPO) covers outpatient services with no coinsurance, including ambulatory surgical center and blood services with no copay. Patients will pay a copay of $0 to $250 for outpatient hospital services, $275 per stay for observation services, and $40 per session for outpatient substance abuse treatment.
Partial Hospitalization See details
Partial hospitalization is covered by Aetna Medicare Enhanced (PPO) with a copay of either $70.00 or $145.00 and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
Aetna Medicare Enhanced (PPO) covers ground ambulance services with a $325 copay and no coinsurance, and air ambulance services with a 20% coinsurance and no copay, with prior authorization required for both. Transportation services to plan-approved or any other health-related locations are not covered under this plan.
Emergency Services See details
Emergency services are covered by the Aetna Medicare Enhanced (PPO) with a $130 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $40 copay with no coinsurance, while worldwide emergency services are covered up to a $250,000 maximum with no coinsurance and copays of $130 for emergency or urgent care and $325 for emergency transportation.
Primary Care See details
Aetna Medicare Enhanced (PPO) covers primary care physician services with no copay and no coinsurance, and specialist, therapy, and mental health services with copays ranging from $0 to $40 and no coinsurance. Telehealth benefits are also available with a $0 to $40 copay and 20% coinsurance, while chiropractic services are not covered.
Preventive Services See details
Preventive services are partially covered by the Aetna Medicare Enhanced (PPO) with no copay and no coinsurance for most benefits, except for kidney disease education which has 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 services.
Hearing Services See details
Hearing services are partially covered by Aetna Medicare Enhanced (PPO), offering Medicare-covered exams for a $40 copay and no coinsurance, alongside annual routine exams and fitting evaluations with no copay or coinsurance. Prescription hearing aids are covered with no copay or coinsurance up to a $1,250 annual maximum per ear, but OTC hearing aids and inner-ear, outer-ear, or over-the-ear prescription models are not covered.
Vision Services See details
Vision services are covered by Aetna Medicare Enhanced (PPO) with no copay, no coinsurance, and no deductible for eye exams and eyewear. This includes one routine eye exam per year with a $50 annual maximum, and a $400 annual combined maximum for contacts, eyeglasses, frames, and upgrades.
Dental Services See details
Aetna Medicare Enhanced (PPO) dental services are partially covered, offering preventive care like cleanings and exams with no copay and no coinsurance, and Medicare-covered dental services for a $40 copay and no coinsurance. Comprehensive services such as restorative and endodontic care are covered with no copay and 20% to 50% coinsurance up to a $1,500 annual limit, though fluoride, implants, orthodontics, maxillofacial prosthetics, and other diagnostic services are not covered.
Home Infusion bundled Services See details
Aetna Medicare Enhanced (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Medicare Part B insulin drugs require a $35 copay and no coinsurance, while chemotherapy, radiation, 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 Enhanced (PPO) plan with no copay and a 20% coinsurance, although prior authorization is required.
Medical Equipment See details
Medical equipment is covered by Aetna Medicare Enhanced (PPO), with durable medical equipment, prosthetics, and medical supplies featuring no copay and up to 20% coinsurance. Diabetic supplies carry 0% to 20% coinsurance, while diabetic therapeutic shoes and inserts require a $10 copay, with prior authorization required for these services.
Diagnostic and Radiological Services See details
Aetna Medicare Enhanced (PPO) covers diagnostic and radiological services with prior authorization required. Diagnostic services have no coinsurance, offering lab services with no copay and diagnostic tests with a $0 to $40 copay, while radiological services feature no copay for X-rays, copays starting at $0 for diagnostic radiology, and a minimum 20% coinsurance for therapeutic radiology.
Home Health Services See details
Aetna Medicare Enhanced (PPO) covers home health services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered in practice under the Aetna Medicare Enhanced (PPO) plan, as all sub-services—including cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation—are not covered, despite having a $5 copay and no coinsurance.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Aetna Medicare Enhanced (PPO) 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 three-day prior hospital stay is not required, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Other services are partially covered by Aetna Medicare Enhanced (PPO) with no copay and no coinsurance, including a chronic illness meal benefit, annual wellness exams, and select screenings, while acupuncture is not covered. Over-the-counter (OTC) items are also covered with no copay or coinsurance up to a maximum of $45 every three months via reimbursement.
Plan Providers
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, Health Care Service Corporation, HealthSpringSM, HealthSun, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
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1-877-649-2073 / TTY 711. Call-center hours (ET): Mon-Fri 8am-10pm; Sat 9am-8pm; Sun closed.
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