Coverage, Benefits & Star Ratings

Find your plan information

2021 Plan: Coming Soon
2020 Plan: Plan Name

Evidence of Coverage (EOC)

Review your Evidence of Coverage (EOC) to learn about comprehensive plan details, and your rights and responsibilities.

Manage your prescription

Our prescription drug list (formulary) shows:

The drugs we cover
The tier a drug is on
Any limits or requirements before we cover the drug
Mail order availability

Review the Formulary

Other coverage information

Prescription drug coverage

See a list of covered drugs for your plan

Referrals & prior authorizations

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

Check your claims

Review your claim and payment status

Flu shot coverage

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

Medicare coverage changes

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

Coverage during a disaster or emergency

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

How we decide which health care services to cover

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

How we review new technologies

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

Using an out-of-network for an HMO plan

If you’re enrolled in an 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).

Typically, referrals aren't required, however some states may require it. For some services, your PCP is required to obtain prior authorization from Aetna Medicare.

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.

Using an out-of-network provider for a PPO ESA plan

If you’re enrolled in Aetna Medicare Plan (PPO) with ESA

A PPO is a preferred provider organization plan. 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. 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.

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

Using an out-of-network provider PPO plan

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

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Coverage, Benefits & Star Ratings

Find your plan information

2021 Plan

2020 Plan

Evidence of Coverage (EOC)

Manage your prescription

Other coverage information

Prescription drug coverage

Referrals & prior authorizations

Check your claims

Flu shot coverage

Medicare coverage changes

Coverage during a disaster or emergency

How we decide which health care services to cover

How we review new technologies

Using an out-of-network for an HMO plan

If you’re enrolled in an Aetna Medicare Plan (HMO)

Using an out-of-network provider for a PPO ESA plan

If you’re enrolled in Aetna Medicare Plan (PPO) with ESA

Using an out-of-network provider PPO plan

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