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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 Central/Southern 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 $69.00. 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 $13900.00 (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 $13900.00 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) prescription drug plan features an annual drug deductible of $615. For Tier 1 preferred generic and Tier 2 generic drugs, there is no copay when using preferred retail pharmacies or preferred mail order services. If you use standard pharmacies or standard mail order, Tier 1 copays start at $2 and Tier 2 copays start at $12 for a one-month supply. For higher-tier medications, costs are determined by coinsurance across all pharmacy and mail order channels. 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. This plan offers clear savings opportunities when utilizing preferred network pharmacies and mail-order options.
Additional Benefits
The Aetna Medicare Enhanced (PPO) plan offers robust medical coverage with predictable costs, featuring no copay and no coinsurance for primary care visits, annual physicals, and home health services. For specialist visits, outpatient services, and emergency care, members can expect low to moderate copayments and no coinsurance. Inpatient hospital stays require a daily copay for the first six days of acute or psychiatric stays, after which there is no copay for subsequent days. This plan also includes valuable supplemental benefits, providing routine vision and hearing exams with no copay or coinsurance, alongside allowances for prescription eyewear and hearing aids. Preventive dental care is fully covered with no copay, while comprehensive dental services and medical equipment may require coinsurance up to 50 percent. Additionally, members benefit from a quarterly allowance for over-the-counter items with no copay or coinsurance.
Inpatient Hospital See details
Aetna Medicare Enhanced (PPO) covers inpatient hospital services with no coinsurance, requiring a copay of $375 per day for days 1-6 of acute stays and $345 per day for days 1-6 of psychiatric stays, with no copay for subsequent days. This benefit is partially covered, as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Aetna Medicare Enhanced (PPO) covers outpatient services with no coinsurance, offering no copay for ambulatory surgical center and blood services, and copays ranging from $0 to $375 for outpatient hospital and observation services. Outpatient substance abuse individual and group sessions require a $50 copay, and prior authorization is required for most of these outpatient services.
Partial Hospitalization See details
Partial hospitalization benefits are covered by the Aetna Medicare Enhanced (PPO) plan with a copay of $70 or $110 and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
Aetna Medicare Enhanced (PPO) covers ambulance services with prior authorization, requiring a $295 copay and no coinsurance for ground transport, and a 20% coinsurance and no copay for air transport. Transportation services to plan-approved or health-related locations are not covered under this plan.
Emergency Services See details
Emergency services are covered by Aetna Medicare Enhanced (PPO) with a $115 copay and no coinsurance, which is waived if admitted to the hospital within 24 hours. Urgently needed services require a $40 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with copays ranging from $115 to $295 and no coinsurance up to a $250,000 lifetime limit.
Primary Care See details
Primary care benefits under the Aetna Medicare Enhanced (PPO) include primary care physician visits with no copay and no coinsurance, and specialist visits with a $0 to $50 copay and no coinsurance. Physical, occupational, and speech therapy services carry a $35 copay and no coinsurance, while chiropractic services are not covered. Mental health, psychiatric, podiatry, and opioid treatment services require a $50 copay and no coinsurance, while telehealth services have a $0 to $50 copay and 20% coinsurance.
Preventive Services See details
Aetna Medicare Enhanced (PPO) offers partially covered preventive services, featuring no copay and no coinsurance for annual physicals, screenings, and fitness benefits, though kidney disease education requires a 20% coinsurance and no copay. Excluded sub-services include in-home safety assessments, personal emergency response systems, medical nutrition therapy, medication reconciliation, readmission 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/bathroom safety devices, and counseling.
Hearing Services See details
Hearing services are partially covered by Aetna Medicare Enhanced (PPO), featuring a $50 copay and no coinsurance for Medicare-covered exams, and no copay or coinsurance for annual routine exams and fitting evaluations. Prescription hearing aids are covered with no copay or coinsurance up to $1,250 per ear annually, though OTC, inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
Vision services are covered by Aetna Medicare Enhanced (PPO) with no copay and no coinsurance for both eye exams and eyewear. Patients benefit from a $50 annual maximum for eye exams and a combined $200 annual maximum for prescription eyewear, including contact lenses and eyeglasses.
Dental Services See details
Dental services are partially covered by Aetna Medicare Enhanced (PPO), offering preventive care like exams and cleanings with no copay and no coinsurance, and Medicare-covered dental services for a $50 copay and no coinsurance. Comprehensive services are subject to a $1,000 annual maximum with no copay and 20% to 50% coinsurance, though fluoride, implants, orthodontics, maxillofacial prosthetics, and other diagnostic or preventive services are not covered.
Home Infusion bundled Services See details
Aetna Medicare Enhanced (PPO) covers home infusion bundled services with no copay and no coinsurance, subject to prior authorization. Under this benefit, Medicare Part B chemotherapy and other Part B drugs carry no copay and 0% to 20% coinsurance, while Part B insulin is covered with a $35 copay and no coinsurance.
Dialysis Services See details
Dialysis services are covered under the Aetna Medicare Enhanced (PPO) plan with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
Medical equipment is covered under Aetna Medicare Enhanced (PPO) with no copay and no coinsurance to 20% coinsurance for durable medical equipment (DME) and medical supplies. Prosthetic devices require 20% coinsurance with no copay, while diabetic therapeutic shoes and inserts have a $10 copay, with prior authorization required for most services.
Diagnostic and Radiological Services See details
Aetna Medicare Enhanced (PPO) covers diagnostic and radiological services, with prior authorization required for both. Diagnostic tests have no coinsurance and copays ranging up to $50, lab and outpatient X-ray services feature no copay, and therapeutic radiological services require a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered under the Aetna Medicare Enhanced (PPO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the Aetna Medicare Enhanced (PPO) with no coinsurance, but some services are covered while standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered and carry a $5 copay.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Aetna Medicare Enhanced (PPO) with no coinsurance, requiring prior authorization but no prior three-day hospital stay. The benefit is partially covered, offering no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, while additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Aetna Medicare Enhanced (PPO) partially covers other services with no copay and no coinsurance for over-the-counter items (up to $30 every three months), annual wellness exams, screening mammography, and additional gFOBT and FIT. Acupuncture and meal benefits are not covered under these services.
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