View Coverage & Benefits

See a list of covered drugs for your plan

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.

View this list to find out what services and drugs require approval.

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.

Review your claim and payment status

Protect yourself from the flu.

Learn about your flu shot benefit

Medicare Part B:

You can get some diabetic supplies, including durable medical equipment (DME), with your Medicare Advantage (MA) and Medicare Advantage Prescription Drug plans (MAPD). Just check your plan’s Evidence of Coverage (EOC) for details and limitations. Medical benefits, diabetic supplies and equipment coverage may include:

• Insulin infusion pump and most insulins used in the pump
• Therapeutic shoes* and inserts* for diabetics
• Continuous Glucose Monitors (CGM) and supplies, including:
• FreeStyle Libre, Dexcom and Medtronic iPro^®

Download the DME National Provider Listing (PDF) to view potential suppliers.

• Blood Glucose Meters (BGM) and testing supplies — exclusively OneTouch^® by LifeScan
• To avoid rejections on Part B-covered supplies like test strips, ensure they are OneTouch brand
• For more info about your no-cost OneTouch BGM for Aetna^® Medicare plan members, you can visit us online or call 1-877-764-5390 ${tty} without a prescription. Use order code 123AET200.

Medicare Part D:

Individual Medicare Prescription Drug (PDP) and MAPD plans cover diabetic supplies under Part D, including:

• Alcohol swabs and 2x2 gauze
• Insulin needles, pens and syringes (when used for injecting insulin)

*Some items may require prior authorization from your medical benefit.

The Centers for Medicare & Medicaid Services periodically issues 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