Aetna Medicare Essential (PPO)
North Carolina Medicare Advantage Plan (2025 Plan)
Additional Coverage
HearingVisionDental
Overall Government Star Rating
4.5
out of 5 stars
Plan Name
Aetna Medicare Essential (PPO)
Plan Type
Medicare Advantage Plan With Part D Prescription Drug Coverage
Aetna Medicare Essential (PPO) is a Medicare Advantage Plan With Part D Prescription Drug Coverage, which is available in North Carolina and offered by the health insurance company Aetna Medicare. This plan’s network type is PPO which determines in-network doctors who accept the health plan and whether a referral is needed.
Primary doctor visit
$0 copay
Specialist visit
$0-45 copay per visit
ER visit
$110 copay per visit (always covered)
Aetna Medicare Essential (PPO) has a monthly premium cost of $0 per month, with an annual deductible of $0 and a maximum out of pocket cost sharing of $8,500 In and Out-of-network
$7,500 In-network. The most common benefit costs which people evaluate when choosing a plan are costs for a primary doctor visit, specialist doctor visit, emergency room visit, and ambulance. These costs are listed in this summary section and a full list of benefit costs for Aetna Medicare Essential (PPO) are defined below.
Yes
Part D Prescription Drug Coverage
Aetna Medicare Essential (PPO) is a Medicare Advantage plan which does include Medicare Part D Prescription Drug coverage. Other common benefits included with Medicare Advantage plans are coverage for dental, vision, and hearing. Aetna Medicare Essential (PPO) includes coverage for hearing, vision, dental.
Medicare Advantage health plans can offer even more additional benefits. Aetna Medicare Essential (PPO) includes coverage for the following additional benefits:
Other benefits
Over the counter drug benefits
Home and bathroom safety devices
Each year the federal government evaluates the quality of Medicare Advantage and Part D Prescription Drug plans based on a 5-star scoring system. For 2025, Aetna Medicare Essential (PPO) received an overall government quality rating of 4.5 stars out of 5 stars.
Aetna Medicare Essential (PPO) performed better than North Carolina’s State average overall quality score of 4.0 stars.
This Plan’s 5-star Gov’t Quality Score
North Carolina State Average Score
Overall Government 5 Star Quality Rating
4.5
4.0
Summary rating of health plan quality
Staying healthy: screenings, tests, & vaccines
Managing chronic (long term) conditions
Member experience with health plan
Member complaints & changes in the health plan's performance
Health plan customer service
Summary rating of drug plan quality
Drug plan customer service
Member complaints & changes in the drug plan's performance
Member experience with the drug plan
Drug safety & accuracy of drug pricing
The government calculates an “Overall star rating” based on ratings for sub components including “Health plan star rating” and “Drug plan star rating”, which includes further subcomponents of each.
Aetna Medicare Essential (PPO) received 4 stars for its health plan quality score which is the same as the North Carolina State average health plan quality score of 4.0 stars.
Aetna Medicare Essential (PPO) received 4.5 stars for its drug plan quality score which is better than the North Carolina State average drug plan quality score of 3.7 stars.
Health Portion of Premium
Health Plan Max Out-of-Pocket
$8,500 In and Out-of-network
$7,500 In-network
Nationwide Coverage included
Hearing Coverage included
Doctor Services
Primary doctor visit
In-network: $0 copay
Out-of-network: $10 copay per visit
Specialist visit
In-network: $0-45 copay per visit
Out-of-network: $55 copay per visit
Tests, labs, & imaging
Diagnostic tests & procedures
In-network: $0-100 copay
Out-of-network: 20% coinsurance
Lab services
In-network: $0 copay
Out-of-network: 20% coinsurance
Diagnostic radiology services (like MRI)
In-network: $0-300 copay
Out-of-network: 20% coinsurance
Outpatient x-rays
In-network: $14 copay
Out-of-network: 20% coinsurance
Emergency care
$110 copay per visit (always covered)
Urgent care
$45 copay per visit (always covered)
Hospital Services
Inpatient hospital coverage
In-network: $332 per day for days 1 through 8
$0 per day for days 9 through 90
Out-of-network: $432 per day for days 1 through 8
$0 per day for days 9 through 90
Outpatient hospital coverage
In-network: $0-332 copay per visit
Out-of-network: $432 copay per visit
Skilled nursing facility
Skilled nursing facility
In-network: $0 per day for days 1 through 20
$214 per day for days 21 through 100
Out-of-network: 20% per stay
Preventive services
Preventive services
In-network: $0 copay
Out-of-network: $0 copay
Ambulance
Ground ambulance
In-network: $275 copay
Out-of-network: $275 copay
Therapy services
Occupational therapy visit
In-network: $30 copay
Out-of-network: $40 copay
Physical therapy & speech & language therapy visit
In-network: $30 copay
Out-of-network: $40 copay
Mental health services
Outpatient group therapy with a psychiatrist
In-network: $40 copay
Out-of-network: 20% coinsurance
Outpatient individual therapy with a psychiatrist
In-network: $40 copay
Out-of-network: 20% coinsurance
Outpatient group therapy visit
In-network: $40 copay
Out-of-network: 20% coinsurance
Outpatient individual therapy visit
In-network: $40 copay
Out-of-network: 20% coinsurance
Opioid treatment services
Opioid treatment services
Other services
Durable medical equipment (like wheelchairs & oxygen)
In-network: 0-20% coinsurance per item
Out-of-network: 20% coinsurance per item
Prosthetics (like braces, artificial limbs)
In-network: 20% coinsurance per item
Out-of-network: 20% coinsurance per item
Diabetes supplies
In-network: 0-20% coinsurance per item
Out-of-network: 0-20% coinsurance per item
Tier drug costs for: Standard retail pharmacy drug cost for 1-month
| Tiers | Initial coverage phase | Catastrophic coverage phase |
|---|
| Preferred Generic | $2.00 copay | $0 copay |
| Generic | $12.00 copay | $0 copay |
| Preferred Brand | 24% coinsurance | $0 copay |
| Non-Preferred Drug | 25% coinsurance | $0 copay |
| Specialty Tier | 25% coinsurance | $0 copay |
Part B Drugs
Chemotherapy drugs
In-network: 0-20% coinsurance
Out-of-network: 20% coinsurance
Other Part B drugs
In-network: 0-20% coinsurance
Out-of-network: 20% coinsurance
Hearing
Hearing exam
In-network: $45 copay
Out-of-network: $55 copay
Fitting/evaluation
In-network: $0 copay
Out-of-network: $0 copay
Hearing aids - All types
In-network: $0 copay
Out-of-network: $0 copay
Preventive Dental
Oral exam
In-network: $0 copay
Out-of-network: 50% coinsurance
Cleaning
In-network: $0 copay
Out-of-network: 50% coinsurance
Fluoride treatment
In-network: $0 copay
Out-of-network: 50% coinsurance
Dental x-rays
In-network: $0 copay
Out-of-network: 50% coinsurance
Comprehensive dental
Restorative services
In-network: $0 copay
Out-of-network: 50% coinsurance
Endodontics
In-network: $0 copay
Out-of-network: 50% coinsurance
Periodontics
In-network: $0 copay
Out-of-network: 50% coinsurance
Prosthodontics, removable
In-network: $0 copay
Out-of-network: 50% coinsurance
Prosthodontics, fixed
In-network: $0 copay
Out-of-network: 50% coinsurance
Maxillofacial prosthetics
Oral and maxillofacial surgery
In-network: $0 copay
Out-of-network: 50% coinsurance
Adjunctive general services
In-network: $0 copay
Out-of-network: 50% coinsurance
Vision
Routine eye exam
In-network: $0 copay
Out-of-network: $55 copay
Contact lenses
In-network: $0 copay
Out-of-network: $0 copay
Eyeglasses (frames & lenses)
In-network: $0 copay
Out-of-network: $0 copay
Eyeglass frames (only)
In-network: $0 copay
Out-of-network: $0 copay
Eyeglass lenses (only)
In-network: $0 copay
Out-of-network: $0 copay
Upgrades
In-network: $0 copay
Out-of-network: $0 copay
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