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Aetna Medicare Essential (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare Essential (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Aetna Medicare Essential (PPO) in 2025, please refer to our full plan details page.
Aetna Medicare Essential (PPO) is a PPO plan offered by CVS Health Corporation available for enrollment in 2025 to people living in Central/Southern Illinois. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Aetna Medicare Essential (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 Essential (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 Essential (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 $590.00 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 $14000.00 (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 $14000.00 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 Essential (PPO) plan has a $590 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance for your prescriptions depending on the drug tier and where you fill your prescription. For preferred generic drugs, there is no copay at preferred pharmacies and mail order, but a $12 copay at standard pharmacies. Standard generic drugs have 22% coinsurance, while preferred and non-preferred brand drugs have 25% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Aetna Medicare Essential (PPO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a $325 copay for the first six days, while outpatient services have copays ranging from $0 to $350. Many services, including primary care, preventive services, and dental services, have no copay. This plan covers hearing and vision services, including hearing exams and prescription hearing aids, and eye exams and eyewear. Additionally, the plan covers ambulance services, emergency services, and home health services, with specific copays and coinsurance amounts depending on the service.
Inpatient Hospital See details
Inpatient Hospital services are covered under the Aetna Medicare Essential (PPO) plan. For Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, you will pay a $325 copay for days 1-6, and no copay for days 7-90.
Outpatient Services See details
The Aetna Medicare Essential (PPO) plan covers outpatient hospital services with a copay between $0 and $350, observation services with a $395 copay, and ambulatory surgical center (ASC) services with no copay. Individual and group sessions for outpatient substance abuse have copays of $40 and $30, respectively, and outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered, but requires prior authorization. You will pay a $70 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Aetna Medicare Essential (PPO) plan, with prior authorization required for all ambulance services. Ground ambulance services have a $295 copay, while air ambulance services have a 20% coinsurance. 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 by the Aetna Medicare Essential (PPO) plan. Emergency Services and Worldwide Emergency Coverage have a $110 copay, Urgently Needed Services has a $45 copay, and Worldwide Emergency Transportation has a $295 copay; all services have no coinsurance.
Primary Care See details
Primary Care Physician Services, Physician Specialist Services, and Other Health Care Professional services have no copay. Chiropractic Services have a $15 copay, Occupational Therapy Services have a $30 copay, and Physical Therapy and Speech-Language Pathology Services have a $30 copay. Mental Health Specialty Services (Individual Sessions) and Psychiatric Services (Individual Sessions) have a $40 copay, and Mental Health Specialty Services (Group Sessions) and Psychiatric Services (Group Sessions) have a $30 copay. Additional Telehealth Benefits have a 20% coinsurance and a copay between $0 and $40. Opioid Treatment Program Services have a $40 copay.
Preventive Services See details
The Aetna Medicare Essential (PPO) plan covers preventive services, including an annual physical exam with no copay. This plan also covers other preventive services, such as Health Education, Nutritional/Dietary Benefit, Additional Sessions of Smoking and Tobacco Cessation Counseling, Fitness Benefit, and Remote Access Technologies, with a $0 copay. Additionally, the plan covers Kidney Disease Education Services with 20% coinsurance.
Hearing Services See details
Hearing exams are covered with a $40 copay, while routine hearing exams and fitting/evaluation for hearing aids have no copay. Prescription hearing aids are covered up to $1500 per year, and other hearing aid services are not covered.
Vision Services See details
Vision services include eye exams and eyewear. Eye exams, including routine eye exams and other eye exam services, have no copay. Eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades, also have no copay, with a combined maximum benefit of $185 per year.
Dental Services See details
The Aetna Medicare Essential (PPO) plan covers a variety of dental services. Medicare Dental Services have a $40 copay and require prior authorization, while Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), Fluoride Treatment, Other Preventive Dental Services, Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics (removable & fixed), and Oral and Maxillofacial Surgery have no copay. Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered. This plan has a maximum benefit of $750 per year for both in-network and out-of-network services.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Aetna Medicare Essential (PPO) plan, but require prior authorization. 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 Essential (PPO) plan and require prior authorization. You will pay 20% coinsurance for this service.
Medical Equipment See details
Medical Equipment is covered, with Durable Medical Equipment (DME) subject to a 0-20% coinsurance and Prosthetic Devices covered with 20% coinsurance. Diabetic Supplies have a 0-20% coinsurance, and Diabetic Therapeutic Shoes/Inserts have a $10 copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Aetna Medicare Essential (PPO) plan. Diagnostic Procedures/Tests have a copay between $0 and $40, and Lab Services have no copay. Diagnostic Radiological Services have a copay up to $110, while Therapeutic Radiological Services have a coinsurance of at least 20%. Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by Aetna Medicare Essential (PPO) 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 Essential (PPO) plan. The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Aetna Medicare Essential (PPO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214.
Other Services See details
The Aetna Medicare Essential (PPO) plan's "Other Services" benefit covers over-the-counter items and meal benefits with no copay. Acupuncture, Dual Eligible SNPs with Highly Integrated Services, 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. The plan offers a maximum of $30 for over-the-counter items every three months.
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