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Plan benefits & forms

Medicare plans have many different details and forms, so we’ve organized everything together into one convenient place.

Your Aetna plan benefits & Star Ratings

Knowing more about your plan can help you get the most from your benefits and covered services. Find your plan’s Summary of Benefits, Formulary (list of covered drugs) and other coverage details below. Your member ID card shows your plan’s name. See a word or term you don't know? Check our glossary.

Access your plan documents by selecting your program and plan name below. 

CHOOSE YOUR PLAN YEAR
 

Review your Evidence of Coverage (EOC) to learn about comprehensive plan details, and your rights and responsibilities. You can request a copy of your Evidence of Coverage if you need one.  

 

Schedule a one-on-one appointment with an Aetna representative to talk about the Aetna plan.

Dental plan information

View dental plan benefits and coverage details

Find Medicare forms

 

See below for helpful resources for managing your plan and how to get started with common requests.

 

 

File claims & reimbursement requests

If you were billed directly by a provider, mail us your completed form to request reimbursement. 

 

Reimbursement form - English (PDF) | Español (PDF)

Printer-free reimbursement instructions - English (PDF) | Español (PDF)

Give someone permission to manage your care

Call us with your caregiver or another person on the line to give them permission to speak with us (just one time, while on that call). Or you can mail us a completed Protected Health Information (PHI) form to give them permission on a regular basis.

 

PHI form - English (PDF) | Español (PDF)

You can choose someone to do all of the above. This person is your appointed representative. An appointment is good for one year from the date that you and your representative sign an Appointment of Representative form. 

 

Fill out the form below and mail it to us. Any time your representative makes a request for you, they should send us a signed copy. You'll leave Aetna Medicare and go to the Center for Medicare & Medicaid Services (CMS) website if you link to the form. 

 

Appointment of Representative CMS Form - English (PDF) | Español (PDF)

Exceptions, appeals & grievances

We want to be your first stop when you have a concern about your coverage or care. Call us at the number on your member ID card, or learn more here.

 

See how to get started

Additional information

While you can find these documents online, sometimes you may need a printed version mailed to you.  

 

Request a printed Evidence of Coverage (EOC)

 

Request a printed Provider Directory  - State and Local Government retirees call ${groupPhoneNumberSHBP} ${tty} and Education retirees ${groupPhoneNumberSHBP} ${tty}, ${memberhours}. 

Medicare Helpline & Website - Get general or claims-specific Medicare information, request documents in alternate formats and make changes to your Medicare coverage. Call 1-800-MEDICARE (1-800-633-4227) or TTY: 1-877-486-2048, 7 days a week, 24 hours a day. If you need help in a language other than English or Spanish, say “Agent” to talk to a customer service representative. Or visit the Medicare website

 

Social Security Administration - For questions about Medicare eligibility, Social Security retirement benefits or help paying for prescription drugs. Call 1-800-772-1213 or TTY: 1-800-325-0778, Monday to Friday, 8 AM to 7 PM or visit the Social Security website.

Most health care professionals and organizations that provide Medicare services are honest. Unfortunately, there may be some who are not. If you ever suspect fraud, please contact Member Services at the number on the back of your ID card, or call Medicare toll-free at 1-800-MEDICARE (1-800-633-4227) or TTY: 1-877-486-2048, 7 days a week, 24 hours a day.

Let us know 

 

If you’re moving or getting a new phone number you can update your information by: 
 

  • Visiting the Division of Pensions and Benefits website, where you can log in to access your Member Benefits Online System (MBOS) account. 
  • Calling the Division of Pensions and Benefits at 1-609-292-7524 ${tty}, Monday to Friday, 7 AM to 4:30 PM ET (except on State holidays).
  • Completing  this form on the Division of Pensions and Benefits website. 
  • Mailing or faxing an application or letter to: 

Retiree Health Benefits 
SEHBP or SHBP

PO Box 299 
Trenton, NJ 
08625-0299 
Fax: 609-341-3407


Do you need the Retiree Health Benefit Enrollment and/or Change Form? 

Get form   

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

Your coverage for out-of-network providers depends on the type of plan you have.  

 

If you’re enrolled in an Aetna MedicareSM  (PPO) plan with Extended Service Area (ESA)

 

A PPO plan with an extended service area (ESA) gives you the flexibility to see any provider, in or out of network, at the same cost, according to the costs listed on your plan benefits summary. They just have to be licensed, eligible to receive Medicare payments and willing to accept your plan. 

 

With a PPO plan with ESA, you have the option to choose a primary care physician. But when we know who your doctor is, we can better support your care. 

 

If you’re enrolled in an Aetna MedicareSM HMO plan 

An HMO plan requires you to stay within your network of providers to receive coverage except in urgent or emergency situations. You must also select a primary care provider and receive a referral in order to see a specialist.

 

See if your chosen provider or facility is part of the Aetna network

 

Please call us or see your Evidence of Coverage for more information, including the cost share for out‐of‐network services.

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're here to help

Call us ${memberhours}.

 

SHBP (State and Local Government retirees): ${groupPhoneNumberSHBP} ${tty}

 

SEHBP (Education retirees): ${groupPhoneNumberSEHBP} ${tty}