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Aetna® Medicare provider directory information

This Aetna Medicare provider directory lists Aetna Medicare Plan (HMO) (PPO) network providers. For detailed information about your health care coverage, please see your Evidence of Coverage.

 

How to find providers that accept Aetna Medicare in your area

 

Use the health care provider directory to search for:

 

  • A provider, by entering a ZIP code, county or city
  • A provider’s facility, specialty or condition
  • A hospital or urgent care center

You may have to select a product or plan name to complete the search

 

About the health care providers in this directory

 

The HMO/PPO network providers in this directory have agreed to provide you with your health care services. You may go to any of these in-network providers. However, some services may require a referral.

 

In some cases, you may get covered services from out-of-network providers, but you may pay more out of pocket.

 

For some plans, you may have to choose one of our network providers to be your primary care provider physician (PCP). (We’ll often use the term "PCP" throughout this directory.)

 

You can also find a list of pharmacies that offer Medicare Part B and Part D drug coverage in our pharmacy directory. Check with your pharmacy to see if they offer the services you need to fill a prescription.

 

Aetna updates provider information regularly

 

We make updates six days a week, excluding Sunday. Updates may also be affected by interruptions due to system maintenance, upgrades or unplanned outages.

 

Provider directory information is subject to change at any time

 

Please contact your provider before you schedule an appointment or receive services. Confirm that they still participate in our network.

 

For more information on health care providers near me

 

For information on Aetna Medicare Plan (HMO) (PPO) network providers in your area, just call us toll-free at 1-800-282-5366 ${tty}. We’re available ${hours}. You can also visit us on AetnaMedicare.com.

 

What to do if you get a bill from an out-of-network provider

If an out-of-network provider sends you a bill, don’t pay it. Instead, send it to Aetna® Medicare to process it. We’ll determine your cost-sharing amount, if any. Our claims/billing address is on your member ID card.

 

What is prior authorization and when do you need it?

 

Certain in-network health care services, such as hospitalization or outpatient surgery, may require prior authorization from Aetna Medicare. This means that Aetna Medicare must approve the service before the plan will cover it. Check your Evidence of Coverage for a list of services that require prior authorization.

 

If you need services that require prior authorization, have the network provider contact us. The provider is responsible for getting prior authorization from Aetna Medicare before treating you.

 

If your plan includes an out-of-network benefit and you decide to receive covered services from an out-of-network provider, ask the provider to contact us for prior authorization for those services. Note that not all benefits are available for all plans. Check specific plan details for more information.

 

Find 24/7 emergency care when you need it

If you need emergency care, you’re covered 24 hours a day, 7 days a week, anywhere in the world. Whether you’re in or out of an Aetna Medicare service area, please follow these guidelines when you think you need emergency care:
 

  • Call the local emergency hotline (for example, 911) or go to the nearest emergency facility
  • Notify your PCP as soon as possible after you get treatment.
  • Call your PCP if a delay in treatment would not be harmful to your health.
  • Notify your PCP or Aetna Medicare as soon as possible if you’re admitted to an inpatient facility.

If you travel outside of the Aetna Medicare Plan (HMO) (PPO) service area

 

You’re covered for emergency and urgently needed care. You can always get emergency care from the closest available health care provider, in or out of the service area. HMO plan members must use providers in their network service area for urgent care, unless these providers aren’t available. When you’re out of the service area, you can get urgent care from the first available provider.

 

You can get urgent care from:

 

  • A private practice physician
  • A walk-in clinic
  • An urgent care center or an emergency facility

We’ll review the information that the health care provider who supplied your care submits to us. We may need more information if the nature of the urgent or emergency issue doesn’t qualify for coverage.

 

Plans offer a visitor/traveler benefit. Under our visitor/traveler program you may receive all plan covered services at in-network cost-sharing when you see a network provider. PCP and referral rules still apply. You must select a PCP in the visitor/traveler area in order for your plan to cover those services. Note that not all benefits are available for all plans. Check specific plan details for more information.

 

Follow-up care after an emergency

 

Your PCP should coordinate all follow-up care. For HMO plans, we may cover follow-up care with out-of-network providers if you meet these two requirements:

 

  1. You have a referral from your PCP
  2. You have prior authorization from Aetna

If your plan requires a referral, you must get one before we’ll cover any follow-up care. This applies whether you were treated inside or outside your Aetna Medicare service area. If your HMO plan doesn’t require a referral, you should call us before you get follow-up care at out-of-network facilities. You can reach us toll-free at 1-800-282-5366 ${tty}. We’re available ${hours}. You can also visit us at AetnaMedicare.com.

 

Examples of follow-up care include:

 

  • Suture removal
  • Cast removal
  • X-rays
  • Clinic and emergency room revisits

We’ll cover in-network and out-of-network follow-up care after emergencies for PPO plans, under the terms and conditions of your plan.

 

Information for California members only

 

Aetna contracts with provider organizations called an Independent Practice Association (IPA) or a Physician-Hospital Organization (PHO). An IPA/PHO is an association of independent providers. It may include hospitals, primary care doctors and specialist doctors, who together provide health care services.

 

Aetna uses several IPAs to provide you with health care services. You may choose a primary care physician (PCP) associated with an IPA/PHO. If you do, they’ll refer you for health care services and specialist care within their IPA/PHO.

 

Medicare enrollment and plan-specific information

 

If you’re enrolled in our Aetna Medicare Prime Plan (HMO) or (PPO)

 

You’ll need to use our dedicated network of local providers. We work closely with them to coordinate your care. If you have the Prime HMO plan, you’ll have to pay for out-of-network care.

 

With the Prime PPO plan, we’ll pay for part of your out-of-network care, but you may pay more out of pocket. If you need urgent or emergency care, or get out-of-area kidney dialysis, we’ll cover it even if the provider isn’t part of the Prime network.

 

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

 

You’ll have to choose a primary care provider (PCP). You can find a network provider in this directory.

 

Generally, you must get your health care coverage from your primary care provider (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 an Aetna Medicare Plan (HMO) Open Access

 

You’re not required to choose a primary care provider (PCP). You don’t need a referral to visit network providers to receive covered services.

 

Your plan requires you to use network providers, except for:

 

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

If you get care from an out-of-network provider, your Aetna Medicare plan won’t cover their charges. Medicare won’t be responsible either.

 

If you’re enrolled in an 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.

 

You may want to know if your plan will cover an out-of-network service. If so, you or your provider can ask us for a pre-service organization determination. If you do, we’ll let you know if your plan covers the service. Please call us or see your Evidence of Coverage for more information, including the cost share for out-of-network services.

 

In PPO plans you generally don’t have to choose a primary care provider

In most plans, you don’t have to choose a primary care provider (PCP). However, we encourage you to do so. If you receive covered services from an out-of-network provider, it’s important to confirm that they:

 

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

The service area for the Aetna Medicare Plan (HMO) or (PPO)

 

Please see your Evidence of Coverage for the most up-to-date service area listing.

 

If you have questions about your Aetna Medicare plan

 

For questions about your Aetna Medicare Plan (HMO) (PPO) or if you need help selecting a PCP, call us. You can reach us toll-free at 1-800-282-5366 ${tty}, ${hours}. You can also visit us at AetnaMedicare.com.

 

Aetna Medicare Prime plan members only

 

Other pharmacies, physicians and providers are available in our network.

 

Aetna Medicare Advantage plan members only

 

Members who get “Extra Help” are not required to fill prescriptions at preferred network pharmacies in order to get Low Income Subsidy (LIS) copays.

 

Accreditation by the National Committee for Quality Assurance

 

We are committed to accreditation by the National Committee for Quality Assurance (NCQA). It demonstrates our commitment to continuous quality improvement and meeting customer expectations. You can find a complete listing of health plans and their NCQA status at NCQA.org. See the “Report Cards” tab to search on “Health Plans.”

 

To refine your search, go to “Health Care Providers & Practices” or “Other Health Care Organizations.” The link for “Clinicians” within “Health Care Providers & Practices” includes doctors recognized by NCQA in the areas of:

 

  • Heart/stroke care
  • Diabetes care
  • Patient-centered medical home and patient-centered specialty practice

The recognition programs are built on evidence-based, nationally recognized clinical standards of care. Therefore, NCQA provider recognition is subject to change. You can find the official NCQA directory of recognized clinicians at ReportCards.NCQA.org/clinicians.

 

The link for “Other Health care Organizations” includes:

 

  • “Managed Behavioral Health care Organizations” for behavioral health accreditation
  • “Credentials Verifications Organizations” for credentialing certification

 

Terms of use

 

By using the provider search directory, you acknowledge and agree that all of the data contained within belongs exclusively to Aetna Inc. and is protected by copyright and other law. The directory search is provided solely for the personal, non‐commercial use of current and prospective Aetna members and providers. Use of any robot, spider or other intelligent agent to copy content from the provider search, extract any portion of it or otherwise cause the provider search to be burdened with unwarranted high access or transaction activity is strictly prohibited. Aetna reserves all rights to take appropriate civil, criminal or injunctive action to enforce these terms of use.

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