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Aetna Medicare Prime (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare Prime (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Aetna Medicare Prime (HMO) in 2026, please refer to our full plan details page.
Aetna Medicare Prime (HMO) is a HMO plan offered by CVS Health Corporation available for enrollment in 2025 to people living in El Paso County. This plan received an overall rating of 4 out of 5 stars in 2026.
It's important to know that Aetna Medicare Prime (HMO) 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 (HMO).
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 (HMO), 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 $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 Maximum Out-Of-Pocket cost of $4200.00 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 (HMO) plan features an annual drug deductible of $615. You can save on generic medications, as there is no copay for Tier 1 preferred generics and Tier 2 generics when using a preferred pharmacy or preferred mail-order service. Standard pharmacies and standard mail-order options charge copays starting at $2 for Tier 1 and $12 for Tier 2. For brand-name and specialty drugs, costs transition to coinsurance percentages. Tier 3 preferred brand drugs require a 24% coinsurance across all pharmacy and mail-order options. Tier 4 non-preferred drugs and Tier 5 specialty tier drugs both carry a 25% coinsurance, with specialty tier coverage limited to a one-month supply.
Additional Benefits
The Aetna Medicare Prime (HMO) plan offers comprehensive coverage for core medical needs, featuring no copay and no coinsurance for primary care doctor visits, annual physicals, and home health services. Specialist consultations and outpatient procedures are covered with low-to-moderate copays and no coinsurance, while inpatient hospital stays require set daily copays. Emergency care is covered with a fixed copay that is waived upon hospital admission, and the plan also provides worldwide emergency coverage. Routine wellness benefits are a key highlight, with vision care requiring no copay, coinsurance, or deductible, including a routine exam and a $100 annual eyewear allowance. Routine dental cleanings and exams also feature no copay, and the plan offers up to $1,500 for comprehensive dental services with 20% to 50% coinsurance. Additionally, hearing care includes no-copay routine exams and up to $500 per ear annually for prescription hearing aids.
Inpatient Hospital See details
Aetna Medicare Prime (HMO) partially covers inpatient hospital stays with no coinsurance, requiring a $425 copay for days 1 to 6 of acute stays and a $375 copay for days 1 to 6 of psychiatric stays, with no copay for days 7 through 90. Hospital upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Aetna Medicare Prime (HMO) covers outpatient services with no coinsurance, featuring no copay for ambulatory surgical center and blood services. Outpatient hospital services require prior authorization with copays ranging from $0 to $300 ($425 per stay for observation), while outpatient substance abuse individual and group sessions carry a $45 copay.
Partial Hospitalization See details
Aetna Medicare Prime (HMO) covers partial hospitalization services with a copayment of either $100.00 or $180.00 and no coinsurance. Prior authorization is required to access these covered services.
Ambulance and Transportation Services See details
Ambulance and transportation services are partially covered by Aetna Medicare Prime (HMO), as transportation services to plan-approved or any health-related locations are not covered. Covered ground ambulance services require a $270 copay and no coinsurance, while air ambulance services require a 20% coinsurance and no copay, with prior authorization required for both.
Emergency Services See details
Aetna Medicare Prime (HMO) covers emergency services with a $150 copay, which is waived if admitted to the hospital within 24 hours, and urgently needed services with a $65 copay, both with no coinsurance. Worldwide emergency and urgent services are covered with a $150 copay, and worldwide emergency transportation has a $270 copay, all featuring no coinsurance up to a $250,000 maximum benefit.
Primary Care See details
Primary care benefits under Aetna Medicare Prime (HMO) feature no copay and no coinsurance for primary care physician services, while specialist visits require a $0 to $45 copay and no coinsurance. Most therapy, psychiatric, and mental health services carry a $45 copay and no coinsurance, whereas podiatry is not covered and chiropractic services are only partially covered.
Preventive Services See details
Preventive Services under Aetna Medicare Prime (HMO) are partially covered, offering no copay and no coinsurance for annual physical exams, health education, fitness benefits, and select screenings. However, kidney disease education requires a 20% coinsurance with no copay, and several services such as in-home safety assessments, personal emergency response systems, and nutritional benefits are not covered.
Hearing Services See details
Hearing services are partially covered by Aetna Medicare Prime (HMO), featuring a $45 copay and no coinsurance for Medicare-covered exams, and no copay or coinsurance for annual routine exams and fittings. Prescription hearing aids are covered up to $500 per ear annually with no copay or coinsurance, but OTC hearing aids and inner ear, outer ear, and over the ear prescription hearing aid types are not covered.
Vision Services See details
Aetna Medicare Prime (HMO) covers vision services with no copay, no coinsurance, and no deductible. This includes one routine eye exam per year, unlimited follow-up diabetic eye exams, and up to a $100 annual maximum benefit for eyewear, including contacts and eyeglasses.
Dental Services See details
Dental services are partially covered by Aetna Medicare Prime (HMO), offering Medicare-covered dental for a $45 copay and no coinsurance, alongside preventive services like exams and cleanings for no copay and no coinsurance. Comprehensive services (up to a $1,500 annual limit) carry no copay and 20% to 50% coinsurance, but fluoride, implants, orthodontics, other diagnostic services, and maxillofacial prosthetics are not covered.
Home Infusion bundled Services See details
Aetna Medicare Prime (HMO) covers home infusion bundled services with no copay, though prior authorization is required. Under this benefit, Medicare Part B chemotherapy, radiation, 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 by Aetna Medicare Prime (HMO) with no copay and a 20% coinsurance. Prior authorization is required to receive this benefit.
Medical Equipment See details
Aetna Medicare Prime (HMO) covers medical equipment, including durable medical equipment (DME), prosthetics, medical supplies, and diabetic equipment, with no copays for these items. Coinsurance ranges from no coinsurance up to 20% depending on the specific service, and prior authorization is required.
Diagnostic and Radiological Services See details
Aetna Medicare Prime (HMO) covers diagnostic and radiological services with prior authorization required. Lab services feature no copay and no coinsurance, diagnostic procedures require a copay of up to $40 with no coinsurance, and therapeutic radiological services carry a minimum 20% coinsurance.
Home Health Services See details
Home health services are covered by Aetna Medicare Prime (HMO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Aetna Medicare Prime (HMO) offers no coinsurance for Cardiac Rehabilitation Services and states some services are covered, though in practice, standard cardiac rehabilitation ($20 copay), intensive cardiac rehabilitation ($20 copay), pulmonary rehabilitation ($15 copay), and SET for PAD services ($30 copay) are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Aetna Medicare Prime (HMO) with no coinsurance, requiring a daily copay of $20 for days 1 to 20 and $218 for days 21 to 100. Prior authorization is required, a prior three-day hospital stay is not required, and additional days beyond the standard 100-day limit are not covered.
Other Services See details
Aetna Medicare Prime (HMO) partially covers other services, offering an annual wellness exam, screening mammography, and additional gFOBT and FIT not covered by Medicare with no copay and no coinsurance. However, acupuncture, over-the-counter (OTC) items, and meal benefits are not covered under this plan.
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