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Frequently asked questions

Managing my costs

To submit a claim for reimbursement, please download, complete and submit the forms below. You will find submission instructions and when you can expect to receive reimbursement within each form.

 

Prescription drug claim form


Prescription drug claim form (Spanish)


Fitness claim form


Fitness claim form (Spanish)


Medical, dental, hearing, vision and vaccine claim form


Medical, dental, hearing, vision and vaccine claim form (Spanish)

To request coverage for a medical service or prescription drug, you must follow a few steps. For example, the process to request a coverage decision for medical services can be different than the process for prescription drugs. You can learn more about coverage decisions by selecting this link.
 

Learn about coverage decisions

An appeal is a formal way of asking us to review and change a coverage decision we made. The appeals process can differ depending on what type of medical service you’re trying to appeal. You can learn more about how to appeal a coverage decision for medical coverage or prescription drugs at our appeals and grievances center.

 

Learn about appeals

The Medicare Extra Help program is for those with limited income and resources. It helps pay for Medicare Prescription drug costs if you qualify.

 

Learn more about Extra Help

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

 

View a list of coverage determinations

Managing my plan

If you’re moving to a new address or getting a new phone number, please let us know right away. Just call Member Services at the number on your ID card. Based on where you move, you may need to enroll in a new plan.

 

If you get Aetna Medicare coverage through an employer, union, or retiree plan, you may need to contact your benefits administrator to update your address or phone number. 

If you need a new or additional ID card, you can view and print one within your secure member website. A digital or printed card is identical to a plastic ID card. If you’re unable to log in or do not have an account, please call Member Services to log in or replace a lost card.

 

Log in to replace your ID card

 

Call Member Services

There are two main time periods when you can change or leave your Medicare Advantage (Part C) or prescription drug (Part D) plan.

 

During Medicare's annual election period: 10/15 – 12/7

 

From October 15 through December 7 each year, you can decide to keep your current plan or select a new plan. Your coverage will begin on January 1 of the following year, if we get your request during the annual election period.

 

Medicare beneficiaries may also enroll in an Aetna Medicare plan through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.

 

During a special enrollment period granted to you for certain situations

 

In certain situations, you can change your Medicare plan outside of Medicare’s annual election period. Some examples include if you:

 

  • Move out of your plan’s service area
  • Lose other creditable prescription drug coverage (prescription drug coverage that pays out, on average, at least as much as a Medicare Part D plan)
  • Live in a long-term care facility (like a nursing home)
  • Have Medicaid

 

If you get coverage from an employer or group health plan, review the information they provided to see what options are available to you.

 

Generally, your membership on your current plan will end on the last day of the month after we get your request to switch to Original Medicare or another plan.

We’re so sorry for your loss. And we're here to help and support you during this challenging time.
 

Have you already notified the Social Security Administration, or SSA, of your loved one’s death? If not, you should do so right away by calling 1-800-772-1213 (TTY: 1-800-325-0778). Connecting with the SSA is the only way to officially close your loved one's account. You may still receive premium bills from us until the account is closed.
 

If you have questions about their plan or premium, call us.
 

  • For Aetna Medicare Advantage and prescription drug plans call 1-844-826-5296 ${tty}. We're here 7 days a week, 8 AM to 8 PM.
  • For Aetna Medicare Supplement plans call at 1-800-264-4000 ${tty}. We're here ${medsupphours}.

Managing my care

Aetna plans have a home delivery option through the CVS Caremark Mail Service Pharmacy. To get started with home delivery, please visit the CVS Caremark Mail Service Pharmacy page. Not all benefits and services are available in all plans.

 

If you qualify, you may complete the forms below to enroll.

 

Mail Service Order Form


Mail Service Order Form (Spanish)

 

Please mail the forms to:
 

CVS Caremark

PO BOX 659541

SAN ANTONIO, TX 78265-9541

If you need help just once, you can give us your permission by phone. We can speak with that person during the call.

 

If you want to appoint someone to act as a long-term care manager or authorized representative, you’ll need to mail us an Authorization for Release of Protected Health Information (PHI) form. It lets this person access your personal health information. They can also speak with us on your behalf about benefits, coverage, claims, bills and more.

 

Open and print the PHI form


Open and print the PHI form (Spanish)

 

Return the completed form to us at the address or fax number shown on the form.

 

It’s important to know:

 

The PHI form doesn’t override Medicare Power of Attorney documents. You don’t need to complete the PHI form if you have a Power of Attorney (POA).

 

The PHI form is only good for one year. You need to complete a new form each year for a representative to continue to assist you.

 

You need to complete a separate form (see below), if you need help filing an initial request for coverage, a grievance or an appeal.

 

Appointment of Representative CMS Form


Appointment of Representative CMS Form (Spanish)

You have a few options when filing a complaint. You can:

 

 

We’ll get back to you within 30 days (24 hours if you request a faster response). To send a complaint to Medicare, complete the Medicare Electronic Complaint form

You can select or change your PCP online through the secure member site. Or you can call us at the number on your member ID card. You may need to choose your PCP from your plan’s network.

 

Log in to change your provide (PCP)

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 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, nonemergency 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 (EOC) for more information, including the cost share for out‐of‐network services.

 

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  

Aetna provides a directory for providers in Spanish.

 

For Spanish, you can search all directories here

Sometimes you need a referral or prior authorization before you can get care. A referral is a kind of preapproval from your primary care provider to see a specialist. A prior authorization or precertification is when your provider 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 provider 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.
 

Read more on the criteria Aetna uses to make decisions on your care
 

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.

 

You’ll need a prescription from your provider to use your DME benefit. Read more about DME, what kinds of DME are covered and how to use your DME benefit on our DME page.

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

Aetna Medication Therapy Management (MTM) programs help you and your doctor manage your medications safely. Visit our MTM information page to learn more about these programs and see if you qualify.


More about Medication Therapy Management (MTM) programs

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

Aetna® and CVS Caremark® Mail Service Pharmacy are part of the CVS Health® family of companies.

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