Important information about our provider directory

This online directory lists ${ProviderDirectoryPlanName} network providers. For detailed information about your health care coverage, please see your Evidence of Coverage.

How to find providers in your area

The directory tool lets you search for:
 

• A provider, by entering a ZIP code, county or city
• A provider’s name, facility, specialty or condition
• A hospital or urgent care center

You may have to select a product or plan name to complete the search.

About the providers in this directory

The ${planType} network providers in this directory have agreed to provide you with your health care services. You may go to any of these network providers. However, some services may require a referral.

If you’ve been going to one network provider, you don’t have to continue to go to that same provider. In some cases, you may get covered services from out-of-network providers.

For some plans, you may have to choose one of our network providers to be your primary care physician (PCP). (We’ll often use the term "PCP" throughout this directory.)

You can also find a list of pharmacies that offer Part B and Part D drugs in your pharmacy directory. Check with your pharmacy to see if they offer the services you need to fill a prescription.

We update provider information regularly

We make updates ${dirUpdates}. Updates may also be affected by interruptions due to system maintenance, upgrades or unplanned outages.

This information is subject to change at any time

Please contact your provider before you schedule an appointment or receive services. Confirm that they still participate in our network.

For more information

For information on ${ProviderDirectoryPlanName} network providers in your area, just call us toll-free at 1-800-282-5366 (TTY: 711), ${hours}. You can also visit us on ${website}.

What to do if you get a bill from an out-of-network provider 

If an out-of-network provider sends you a bill, don’t pay it. Instead, send it to ${company} Medicare to process it. We’ll determine your cost-sharing amount, if any. Our claims/billing address is on your member ID card.

What is prior authorization and when do you need it?

Certain network health care services, such as hospitalization or outpatient surgery, require prior authorization from ${company} Medicare. This means that ${company} Medicare must approve the service before the plan will cover it. Check your Evidence of Coverage for a list of services that require prior authorization.

If you need services that require prior authorization, have the network provider contact us. The provider is responsible for getting prior authorization from ${company} Medicare before treating you.

Some plans include an out-of-network benefit. If yours does and you decide to receive covered services from an out-of-network provider, ask the provider to contact us for prior authorization for those services.

When you need emergency care

If you need emergency care, you’re covered 24 hours a day, 7 days a week, anywhere in the world. Whether you’re in or out of an ${company} Medicare service area, please follow these guidelines when you think you need emergency care:

• Call the local emergency hotline (for example, 911) or go to the nearest emergency facility.
• Notify your PCP as soon as possible after you get treatment.
• Call your PCP if a delay in treatment would not be harmful to your health.
• Notify your PCP or ${company} Medicare as soon as possible if you’re admitted to an inpatient facility.

If you travel outside of the ${ProviderDirectoryPlanName} service area

You’re covered for emergency and urgently needed care. You can always get emergency care from the closest available provider, in or out of the service area. HMO plan members must use providers in their network service area for urgent care, unless these providers aren’t available. When you’re out of the service area, you can get urgent care from the first available provider.

You can get urgent care from:

• A private practice physician
• A walk-in clinic
• An urgent care center or an emergency facility

We’ll review the information that the provider who supplied your care submits to us. We may need more information if the nature of the urgent or emergency issue doesn’t qualify for coverage.

Follow-up care after an emergency

Your PCP should coordinate all follow-up care. For HMO plans, we may cover follow-up care with out-of-network providers if you meet these two requirements:

1. Your PCP’s referral
2. ${company}’s prior authorization

If your plan requires a referral, you must get one before we’ll cover any follow-up care. This applies whether you were treated inside or outside your ${company} Medicare service area. If your HMO plan doesn’t require a referral, you should call us toll-free at 1-800-282-5366 (TTY: 711), ${hours} before you get follow-up care at out-of-network facilities. You can also visit us at ${website}.

Examples of follow-up care include:

• Suture removal
• Cast removal
• X-rays
• Clinic and emergency room revisits

We’ll cover in-network and out-of-network follow-up care after emergencies for PPO plans, under the terms and conditions of your plan.

Information for California members only

${company} contracts with provider organizations called an Independent Practice Association (IPA) or a Physician-Hospital Organization (PHO). An IPA/PHO is an association of independent providers. It may include hospitals, primary care doctors and specialist doctors, who together provide health care services.

${company} uses several IPAs to provide you with health care services. If you choose a primary care physician (PCP) associated with an IPA/PHO, they’ll refer you for health care services and specialist care within their IPA/PHO.

If you’re enrolled in our ${company} Medicare Prime Plan (HMO) or (PPO)

You’ll need to use our dedicated network of local providers. We work closely with them to coordinate your care. If you have the Prime HMO plan, you’ll have to pay for out-of-network care.

With the Prime PPO plan, we’ll pay for part of your out-of-network care, but you may pay more out of pocket. If you need urgent or emergency care, or get out-of-area kidney dialysis, we’ll cover it even if the provider isn’t part of the Prime network.

If you’re enrolled in a standard ${company} Medicare Plan (HMO)

You’ll have to choose a primary care physician (PCP). You can find a network doctor in this directory.

Generally, you must get your health care coverage from your primary care physician (PCP)

Your PCP will issue referrals to participating specialists and facilities for certain services. For some services, your PCP is required to obtain prior authorization from ${company} Medicare.

You’ll need to get a referral from your PCP for covered, non-emergency specialty or hospital care, except in an emergency and for certain direct-access service. There are exceptions for certain direct-access services.

You must use network providers, except for:

• Emergency or urgent care situations
• Out-of-area renal dialysis

If you get routine care from out-of-network providers, Medicare and ${company} Medicare won’t be responsible for the costs.

If you’re enrolled in ${anCompany} Medicare Plan (HMO) Open Access 

You’re not required to choose a primary care physician (PCP). You don’t need a referral to visit network providers to receive covered services. Although you’re not required to select a PCP, we encourage you to do so.

You must use network providers, except for:

• Emergency or urgent-care situations
• Out-of-area renal dialysis

If you get care from an out-of-network provider, your plan won’t cover their charges. Medicare and Aetna Medicare won’t be responsible either.

If you’re enrolled in an ${company} Medicare Plan (PPO)

You have the flexibility to receive covered services from network providers or out-of-network providers. Out-of-network/non-contracted providers are under no obligation to treat ${company} Medicare members, except in emergency situations. For a decision about whether we’ll cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call us or see your Evidence of Coverage for more information, including the cost share for out-of-network services.

Although you don’t have to choose a primary care physician, we encourage you to do so. If you receive covered services from an out-of-network doctor, it’s important to confirm that they:

• Accept your PPO plan
• Are eligible to receive Medicare payment

The service area for the ${company} Medicare Plan (HMO) or (PPO)

Please see your Evidence of Coverage for the most up-to-date service area listing.

If you have questions

For questions about your ${ProviderDirectoryPlanName} or if you need help selecting a PCP, call us toll-free at 1-800-282-5366 (TTY: 711), ${hours}. You can also visit us at ${website}.

Prime plan members only

Other pharmacies, physicians and providers are available in our network.

Medicare Advantage plan members only

Members who get “Extra Help” are not required to fill prescriptions at preferred network pharmacies in order to get Low Income Subsidy (LIS) copays.

Accreditation by the National Committee for Quality Assurance

${company} is committed to accreditation by the National Committee for Quality Assurance (NCQA). It demonstrates our commitment to continuous quality improvement and meeting customer expectations. You can find a complete listing of health plans and their NCQA status at ncqa.org. See the “Report Cards” tab to search on “Health Plans.”

To refine your search, go to “Clinicians” or “Other Healthcare Organizations.” The link for “Clinicians” includes doctors recognized by NCQA in the areas of:

• Heart/stroke care
• Diabetes care
• Patient-centered medical home and patient-centered specialty practice

The recognition programs are built on evidence-based, nationally recognized clinical standards of care. Therefore, NCQA provider recognition is subject to change. You can find the official NCQA directory of recognized clinicians at recognition.ncqa.org.

The link for “Other Healthcare Organizations” includes “Managed Behavioral Healthcare Organizations” for behavioral health accreditation and “Credentials Verifications Organizations” for credentialing certification.

Terms of use

By using the provider search directory, you acknowledge and agree that all of the data contained within belongs exclusively to ${company} Inc. and is protected by copyright and other law. The directory search is provided solely for the personal, non‐commercial use of current and prospective ${company} members and providers. Use of any robot, spider or other intelligent agent to copy content from the provider search, extract any portion of it or otherwise cause the provider search to be burdened with unwarranted high access or transaction activity is strictly prohibited. ${company} reserves all rights to take appropriate civil, criminal or injunctive action to enforce these terms of use.