Aetna MedicareSM Plan (HMO) (PPO)

Section 1 – Introduction
This directory provides a list of Aetna Medicare (HMO)
(PPO) plan providers. To get detailed information
about your health care coverage, please see your
Evidence of Coverage.
With the standard Aetna Medicare Health
Maintenance Organization (HMO) plan you will
have to choose one of our plan providers that are
listed in this directory to be your Primary Care
Physician (PCP). The term “PCP” will be used
throughout this directory. Generally, you must get your
health care coverage from your PCP.
The “plan providers” listed in this directory have
agreed to provide you with your health care coverage.
You may go to any of our plan providers listed in this
directory, however some services may require a
referral. If you have been going to one plan provider,
you are not required to continue going to that same
provider. In some cases, you may get covered services
from non-plan providers. In cases where noncontracting
providers submit a bill directly you, you
should not pay the bill, but submit it to Aetna
Medicare for processing and determination of your
financial liability, if any. 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. You must use
network providers except for urgent care or out-of
area urgent care/renal dialysis. Except for those
benefits described in your plan documents as directaccess
benefits, or in an emergency, you will need to
obtain a referral from your PCP before seeking covered
non-emergency specialty or hospital care. Check your
Evidence of Coverage for details.
With the Aetna Medicare Open Access (HMO)
plans, you are not required to choose a primary care
physician (PCP) and are free to visit network providers
without a referral to receive covered services.
Although selecting a PCP is not required, you will
benefit by receiving care from a doctor that has a
deeper understanding of your health care needs and
may be able to assist with important medical
decisions.
With the Aetna Medicare Preferred Provider
Organization (PPO) Plan, you have the flexibility to
choose either network providers at lower out-ofpocket
costs, or out-of-network providers at a higher
cost sharing level. If you select a PCP from our
network, you must notify us of your selection in order
to have the lower primary doctor visit copay. By having
a PCP coordinate your care, you’ll also benefit by
receiving care from a doctor that has a deeper
understanding of your health care needs and may be
able to assist with important medical decisions. Note:
If you do not select a PCP, you’ll be responsible for the
higher specialist copay when receiving services from a
PCP.
Certain healthcare services, such as hospitalization or
outpatient surgery, require precertification with Aetna.
This means the service must be approved by Aetna
before it will be covered under the plan. Check your
Evidence of Coverage for a complete list of services
that require this approval. When you are to obtain
services requiring precertification from a participating
provider, the provider is responsible to precertify those
services prior to treatment. If your plan covers out-ofnetwork
benefits and you may self-refer for covered
services, it is your responsibility to contact Aetna to
precertify those services which require precertification.
If you need emergency care, you are covered 24 hours
a day, 7 days a week, anywhere in the world. Whether
you are in or out of an Aetna Medicare service area,
we simply ask that you follow the guidelines below
when you believe you need emergency care.
■ Call the local emergency hotline (ex. 911) or go to
the nearest emergency facility. If a delay would not
be detrimental to your health, call your PCP. Notify
your PCP as soon as possible after receiving
treatment.
■ If you are admitted to an inpatient facility, you or a
family member or friend on your behalf should
notify your PCP or Aetna as soon as possible.
If you are traveling outside of the Aetna Medicare
(HMO) (PPO) plan service area, you are covered for
emergency and urgently-needed care. Urgent care
may be obtained from a private practice physician, a
walk-in clinic, an urgent care center or an emergency
facility. If, after reviewing information submitted to us
www.aetnamedicare.com
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