View Coverage & Benefits

See a list of covered drugs for your plan

Looking for referral and pre-approval requirements?
Check your plan’s Evidence of Coverage.

Review your claim and payment status

Protect yourself from the flu.
Learn about your flu shot benefit

The Centers for Medicare & Medicaid Services periodically issus National Coverage Determinations. They issue these when a service’s or drug’s coverage rules change.

View a list of coverage determinations

We want to make sure you can access your benefits even during urgent situations - like a public health emergency or state of disaster.

Finding care during a disaster or emergency

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:

• Base our decisions on appropriateness of care, service and plan coverage
• Use nationally recognized guidelines and resources to make changes
• Don’t pay or reward providers, employees or others for denying coverage or care
• Focus on reviewing the risks of members who aren’t fully using certain services

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:

• Carefully review the latest information and ask experts for their opinions
• Compare the information with well-known standards
• Base all of our decisions on making sure you have the right care and services

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:

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

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:

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