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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 2026 to people living in IL Northern and Chicago. 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 $60.00. 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 $10100.00 (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 $10100.00 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 generics and Tier 2 generics, you will pay no copay when using a preferred pharmacy or preferred mail-order service. If you choose standard pharmacies or standard mail-order services, Tier 1 drugs carry a copay starting at $2.00, while Tier 2 drugs start at a $12.00 copay for a one-month supply. For higher-tier medications, costs shift to 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 both carry a 25% coinsurance. Note that Tier 5 specialty tier coverage is limited to a one-month supply.
Additional Benefits
The Aetna Medicare Enhanced (PPO) plan offers robust coverage with predictable out-of-pocket costs, featuring no copays or coinsurance for primary care visits and routine preventive services. Specialist visits require a $40 copay, while inpatient hospital stays incur a daily copay of $375 for the first seven days of acute care with no coinsurance. Emergency room visits are covered with a $130 copay, which is waived if you are admitted. For dental, vision, and hearing needs, the plan provides routine exams with no copay, alongside allowances for prescription eyewear and hearing aids. Dental care includes routine cleanings at no cost and comprehensive services up to a $1,000 annual limit with 20% to 50% coinsurance. Additionally, members benefit from home health services with no copay and a quarterly over-the-counter item allowance of up to $30.
Inpatient Hospital See details
Inpatient hospital care is partially covered by Aetna Medicare Enhanced (PPO) with no coinsurance, requiring prior authorization and a daily copay of $375 for days 1-7 of acute stays and $325 for days 1-7 of psychiatric stays, with no copay for subsequent days. While acute care includes unlimited additional days at no copay, this plan does not cover upgrades, non-Medicare-covered stays, or additional psychiatric days.
Outpatient Services See details
Aetna Medicare Enhanced (PPO) covers outpatient services with no coinsurance, including outpatient hospital visits with a $0 to $375 copay and observation services with a $375 copay per stay. Ambulatory surgical center and outpatient blood services have no copay and no coinsurance, while outpatient substance abuse services require a $40 copay per session with no coinsurance.
Partial Hospitalization See details
Aetna Medicare Enhanced (PPO) covers partial hospitalization services with a copay of either $65.00 or $145.00 and no coinsurance. Prior authorization is required for these covered services.
Ambulance and Transportation Services See details
Aetna Medicare Enhanced (PPO) covers ground ambulance services with a $295 copay and no coinsurance, and air ambulance services with a 20% coinsurance and no copay, with prior authorization required. While some transportation services are covered, transportation to plan-approved or any health-related locations is not covered.
Emergency Services See details
Aetna Medicare Enhanced (PPO) covers emergency services with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $45 copay with no coinsurance, and worldwide emergency services are covered up to a $250,000 limit with no coinsurance and copays ranging from $130 to $295.
Primary Care See details
Aetna Medicare Enhanced (PPO) provides primary care physician services with no copay and no coinsurance, and specialist visits with a $40 copay and no coinsurance. Occupational, physical, and speech-language therapy require a $35 copay and no coinsurance, while mental health, psychiatric, and opioid treatment services require a $40 copay and no coinsurance. Telehealth benefits are available with a $0 to $45 copay and 20% coinsurance, whereas chiropractic and podiatry services are not covered.
Preventive Services See details
Aetna Medicare Enhanced (PPO) offers partially covered preventive services with no copay and no coinsurance for annual physicals, fitness benefits, and various screenings, while kidney disease education requires no copay and 20% coinsurance. Non-covered services include in-home safety assessments, PERS, 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, disease management, telemonitoring, home and bathroom safety devices, and counseling.
Hearing Services See details
Aetna Medicare Enhanced (PPO) covers Medicare-covered hearing exams for a $40 copay and no coinsurance, while routine hearing exams and fitting evaluations are fully covered with no copay and no coinsurance. Prescription hearing aids are partially covered with no copay and no coinsurance up to a $750 maximum per ear annually, but OTC hearing aids as well as inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
Aetna Medicare Enhanced (PPO) covers vision services with no deductibles and no coinsurance, offering routine eye exams and eyewear with no copay. Medicare-covered eye exams have a copay of up to $40, and the plan features an annual maximum benefit of $50 for exams and $150 for combined eyewear.
Dental Services See details
Dental services are partially covered by Aetna Medicare Enhanced (PPO), featuring no copay and no coinsurance for routine exams and cleanings, and no copay with 20% to 50% coinsurance for comprehensive services up to a $1,000 annual maximum. Medicare-covered dental requires a $40 copay and no coinsurance, 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. Medicare Part B insulin drugs are covered with a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs feature no copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by Aetna Medicare Enhanced (PPO) with no copay and a 20% coinsurance, and prior authorization is required.
Medical Equipment See details
Medical Equipment is covered by Aetna Medicare Enhanced (PPO) with no copays for durable medical equipment (DME), prosthetics, medical supplies, and diabetic therapeutic shoes. Coinsurance ranges from no coinsurance to 20% for DME, medical supplies, and diabetic supplies, while prosthetic devices require a 20% coinsurance, and prior authorization is required.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under the Aetna Medicare Enhanced (PPO) plan, with prior authorization required for all services. Lab services feature no copay or coinsurance, diagnostic tests carry a $0 to $75 copay with no coinsurance, and radiological services require varying copays and coinsurance, including a $10 copay for x-rays 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
Aetna Medicare Enhanced (PPO) covers Cardiac Rehabilitation Services with no coinsurance, meaning some services are covered, but cardiac rehabilitation ($20 copay), intensive cardiac rehabilitation ($20 copay), pulmonary rehabilitation ($15 copay), and supervised exercise therapy for peripheral artery disease ($25 copay) are not covered.
Skilled Nursing Facility (SNF) See details
Aetna Medicare Enhanced (PPO) covers Skilled Nursing Facility (SNF) services 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, and while a prior three-day hospital stay is not necessary, additional days beyond the Medicare-covered 100 days are not covered.
Other Services See details
Other Services are partially covered by Aetna Medicare Enhanced (PPO) with no copays and no coinsurance for covered benefits, though acupuncture is not covered. Covered services include a meal benefit for chronic illness, annual wellness exams, additional cancer screenings, and up to $30 every three months for over-the-counter items.
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