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Aetna Medicare Elite (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare Elite (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Aetna Medicare Elite (PPO) in 2026, please refer to our full plan details page.
Aetna Medicare Elite (PPO) is a PPO plan offered by CVS Health Corporation available for enrollment in 2025 to people living in North Dakota. This plan received an overall rating of 3 out of 5 stars in 2026.
It's important to know that Aetna Medicare Elite (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 Elite (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 Elite (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 has a $500.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
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 $10000.00 (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 $10000.00 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 Elite (PPO) plan features an annual prescription drug deductible of $615. For Tier 1 preferred generics and Tier 2 generics, members pay no copay when filling prescriptions through preferred pharmacies or preferred mail-order services. If you use standard pharmacies or standard mail-order, copays range from $2 to $12 for a one-month supply depending on the drug tier. For higher-tier medications, the plan utilizes coinsurance rather than flat copayments. Tier 3 preferred brand drugs require a 24% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs incur a 25% coinsurance. These coinsurance rates remain the same whether you use preferred or standard pharmacies and mail-order options.
Additional Benefits
The Aetna Medicare Elite (PPO) plan offers comprehensive medical coverage with no copay for primary care physician visits, annual physical exams, and routine vision, hearing, and dental exams. Specialist visits and Medicare-covered dental services require a $45 copay, while emergency room care features a flat $130 copay. Inpatient hospital stays require a daily copay for the first few days, after which there is no copay for subsequent days. Members also benefit from supplemental allowances, including up to $1,250 per ear annually for prescription hearing aids and a $125 annual limit for eyewear with no copay. Standard services like diagnostic lab tests, home health care, and the first 20 days of a skilled nursing facility stay are covered with no copay. Other essential medical services, including dialysis and durable medical equipment, generally require a twenty percent coinsurance.
Inpatient Hospital See details
Aetna Medicare Elite (PPO) partially covers inpatient hospital services with no coinsurance, requiring a daily copay of $400 for days 1 through 6 of acute stays and $370 for days 1 through 5 of psychiatric stays, with no copay for subsequent covered days. Upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Aetna Medicare Elite (PPO) covers outpatient services with no coinsurance, offering no copay for ambulatory surgical center and outpatient blood services. Outpatient hospital services require a copay of $0 to $400, observation services have a $400 copay per stay, and outpatient substance abuse sessions require a $40 copay, with prior authorization required for most services.
Partial Hospitalization See details
Aetna Medicare Elite (PPO) covers partial hospitalization services with a copayment of either $55.00 or $145.00 and no coinsurance. Prior authorization is required for these covered services.
Ambulance and Transportation Services See details
Ambulance services under the Aetna Medicare Elite (PPO) plan require prior authorization and feature a $350 copay for ground ambulance services and a 20% coinsurance for air ambulance services. While transportation services are listed as a benefit, they are not covered in practice.
Emergency Services See details
Aetna Medicare Elite (PPO) covers emergency services with a $130 copay and urgently needed services with a $50 copay, both with no coinsurance and no deductible. Worldwide emergency services are also covered up to a $250,000 limit with no coinsurance, featuring a $130 copay for emergency and urgent care and a $350 copay for emergency transportation.
Primary Care See details
Aetna Medicare Elite (PPO) offers primary care physician services with no copay and no coinsurance, while specialist visits, physical therapy, and occupational therapy require a $45 copay and no coinsurance. Mental health, psychiatric, and opioid treatment services are covered with a $40 copay and no coinsurance, but podiatry is not covered and only some chiropractic services are covered as routine and other chiropractic care are excluded.
Preventive Services See details
Aetna Medicare Elite (PPO) offers partially covered preventive services with no copay and no coinsurance for annual physical exams, health education, and diabetes training, though kidney disease education requires a 20% coinsurance and no copay. Several sub-services are not covered, including 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 safety modifications, and counseling.
Hearing Services See details
Aetna Medicare Elite (PPO) partially covers hearing services with no copay and no coinsurance for annual routine exams, fitting evaluations, and up to two prescription hearing aids with a $1,250 yearly maximum per ear. 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 Elite (PPO) covers vision services with no copays, no coinsurance, and no deductibles for both eye exams and eyewear. This includes one annual routine eye exam with up to a $50 limit, alongside a combined $125 annual maximum benefit for contact lenses, eyeglasses, frames, lenses, and upgrades.
Dental Services See details
Dental services are partially covered by Aetna Medicare Elite (PPO), which offers Medicare-covered dental services for a $45 copay and no coinsurance, as well as routine exams, cleanings, and x-rays with no copay and no coinsurance. Several sub-services are not covered, including fluoride, other diagnostic or preventive services, restorative care, endodontics, periodontics, prosthodontics, implants, and oral surgery.
Home Infusion bundled Services See details
Aetna Medicare Elite (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Under this benefit, Medicare Part B insulin drugs require a $35 copay and no coinsurance, while chemotherapy and other Part B drugs have a 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Aetna Medicare Elite (PPO) plan with no copay and a 20% coinsurance, although prior authorization is required.
Medical Equipment See details
Aetna Medicare Elite (PPO) covers medical equipment with no copay, though prior authorization is required. Coinsurance ranges from no coinsurance to 20% for durable medical equipment, medical supplies, and diabetic supplies, while prosthetic devices and diabetic therapeutic shoes or inserts require a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Aetna Medicare Elite (PPO) with prior authorization required. Diagnostic tests and procedures have no coinsurance and a copay ranging from $0 to $20, while lab services have no copay. Radiological services feature a $15 copay and coinsurance 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 Elite (PPO) covers home health services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are offered by Aetna Medicare Elite (PPO) with no coinsurance, though only some services are covered. Specifically, standard cardiac rehabilitation ($20 copay), intensive cardiac rehabilitation ($20 copay), pulmonary rehabilitation ($15 copay), and supervised exercise therapy for symptomatic peripheral artery disease ($25 copay) are not covered.
Skilled Nursing Facility (SNF) See details
Aetna Medicare Elite (PPO) covers skilled nursing facility (SNF) services with no coinsurance, featuring no copay for days 1 through 20 and a $202 daily copay for days 21 through 100. Prior authorization is required, a prior three-day inpatient hospital stay is not required, and additional days beyond the 100-day Medicare-covered limit are not covered.
Other Services See details
Aetna Medicare Elite (PPO) partially covers other services, offering a chronic illness meal benefit, annual wellness exams, screening mammographies, and additional gFOBT and FIT screenings with no copay and no coinsurance. Acupuncture, over-the-counter (OTC) items, and Dual Eligible SNPs with Highly Integrated Services are not covered.
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