Select your state, county and plan name below to find your:
The plan name is listed on your member ID card.
Choose your state, county and plan name to view documents for your plan.
Get coverage from an employer or group health plan? Review the plan benefit information you received from them.
Medicare Advantage members, you can request a copy of your Evidence of Coverage or Formulary if you need one.
Prescription drug plan members (SilverScript Choice, Plus, or SmartRx), you can request a copy of your Evidence of Coverage, formulary and pharmacy directory.
Email us or call Member Services at the number on your ID card.
Sometimes you need a referral or prior authorization before you can get care. A referral is a kind of preapproval from your primary care doctor to see a specialist. A prior authorization or precertification is when your doctor has to get approval from us before we cover an item or service. Prior authorizations are often used for things like MRIs or CT scans. Your doctor is in charge of sending us prior authorization requests for medical care.
Each plan has rules on whether a referral or prior authorization is needed. Check your plan’s Evidence of Coverage (EOC) to see if or how these rules apply.
Tip: If you’re viewing an EOC online, you can simply press Ctrl + F to search for an item. You can find most rules for referrals or prior authorizations in Chapter 4 — Benefits Chart — of the EOC.
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The Centers for Medicare & Medicaid Services periodically issues National Coverage Determinations. They issue these when a service’s or drug’s coverage rules change.
We want to make sure you can access your benefits even during urgent situations - like a public health emergency or state of disaster.
We help you get medically necessary health care services in the most cost-effective way under your health plan. And we work with you and doctors to evaluate services for medical appropriateness, timeliness and cost.
Specifically, we:
Doctors and health care companies continuously develop new technologies. This can include anything from a new procedure to a new way to use a device.
When we learn about a new technology, we:
If you’re enrolled in a standard Aetna Medicare Plan (HMO)
If you get coverage from an out‐of‐network provider, your plan won’t cover their charges. Medicare and Aetna Medicare won’t be responsible either.
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 Aetna 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:
If you get routine care from out‐of‐network providers, Medicare and Aetna Medicare won’t be responsible for the costs.
If you’re enrolled in Aetna 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 Aetna 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:
Telehealth – or telemedicine – means virtual care you can get at home or away. These visits are live, video conferences between you and a doctor over a computer or smart phone. Consider using telehealth when you have a time sensitive medical need or can’t get to the doctor in person.
Your plan covers certain telehealth visits with in-network primary care doctors, nationally contracted walk-in-clinics and urgent care facilities.
Your plan may also cover some telehealth visits with in-network mental health providers. Take a look at your Evidence of Coverage to see if your plan covers this service.
Not all provider visits can be handled through telehealth. You can view and download a list of potentially covered telehealth services here. Ask your doctor whether they offer these services via telehealth and how to schedule a visit.
Telehealth visits with out-of-network providers are not covered unless you’re enrolled in a Medicare Advantage ESA or PPO plan through your employer.
Please refer to your provider directory to find an in-network provider. The list also includes including a list of nationally contracted walk-in clinics across the country.
Note: Certain services may require a referral or prior authorization (pre-approval). See your Evidence of Coverage for details.
See Evidence of Coverage for a complete description of plan benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by service area.
Aetna handles premium payments through InstaMed, a trusted payment service. Your InstaMed log-in may be different from your Caremark.com secure member site log-in.
Aetna handles premium payments through Payer Express, a trusted payment service. Your Payer Express log-in may be different from your Aetna secure member site log-in.
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