Provider and Pharmacy Directory

Getting started in Aetna Better Health Premier Plan MMAI

This section explains key terms you’ll see in our Provider and Pharmacy Directory.

• Providers are health care professionals and support providers such as doctors, nurses, pharmacists, therapists, dental and vision providers, and other people who provide care and services. Services include medical care, long-term services and supports, supplies, prescription drugs, equipment and other services.
  • The term providers also includes facilities such as hospitals, clinics, and other places that provide medical services, medical equipment, and long-term services and supports.
  • Providers that are a part of our plan's network are called network providers.
• Network providers are the providers that have contracted with us to provide services to members in our plan. The providers in our network generally bill us directly for care they give you. When you see a network provider, you usually pay nothing for covered services.
• A Primary Care Provider (PCP) is a general practitioner, internist, family practitioner, women’s health care provider, Federally Qualified Health Centers (FQHC) or nurse practitioner (working with doctors) who gives you routine health care. Your PCP will keep your medical records and get to know your health needs over time.
• Specialists are doctors who provide health care services for a specific disease or part of the body. There are many kinds of specialists. Here are a few examples:
  • Oncologists care for patients with cancer.
  • Cardiologists care for patients with heart conditions.
  • Orthopedists care for patients with certain bone, joint, or muscle conditions.
• You also have access to a Care Team and a Case Manager that you help choose.
• A Case Manager, working closely with you, will lead your Care Team and develop a Care Plan that helps you manage your medical, behavioral health, long term supports and services, and social and functional needs.
• Your Care Team led by your case manager, may include doctors, nurses, counselors, family, caregivers, or other professionals who are there to help you build a care plan and ensure you get the care you need.
• Everyone on the Care Team, led by the Case Manager, works together to make sure your care is coordinated. This means that they make sure your providers are aware of care you get, medicines you take, and that tests and labs are done once and the results are shared with the appropriate providers. Your Care Team will also assess your needs to determine if you need help in other areas besides health, such as physical or social needs. Your Care Team will be in contact with you as often as needed depending on the Care Plan that you help develop.
• A Care Plan will be developed with your help by the Case Manager and Care Team. The Care Plan will list all of your needs, set goals to address those needs, and determine ways to monitor if those needs are being met or if they need to be changed. It will also include a service plan if you are getting Home and Community Based Services.

Choosing a Primary Care Provider (PCP)

You can get services from any provider who is in our network and accepting new members.

First, you will need to choose a Primary Care Provider. You may be able to have a specialist act as your PCP if you are pregnant or have chronic health conditions, disabilities, or special health care needs. You or your providers can request a specialist to be your PCP at any time. If you have a specialist that you want to be your PCP, you must call Aetna Better Health Premier Plan MMAI. Call Member Services at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. If you make a request, you will be contacted to see if you need a specialist as a PCP. Aetna Better Health Premier Plan MMAI Medical Director will approve or deny requests after determining whether you meet the criteria and whether the specialist you have requested is willing to act as a PCP for you.

To choose a PCP, go to the list of providers and choose a provider:

• whose offices are easy for you to get to.
• who has been recommended by someone you trust, or
• that you use now, or
• If you want help in choosing a PCP, please call 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. Or, visit www.aetnabetterhealth.com/illinois/find-provider.
• If you have questions about whether we will pay for any medical service or care that you want or need, call Member Services and ask before you get the service or care.

Getting long-term services and supports

As an Aetna Better Health Premier Plan MMAI member, you may be able to get long-term services and supports (LTSS), such as the services described in the following sentence. Long-term services and supports are help for people who need assistance to do everyday tasks like taking a bath, getting dressed, making food, and taking medicine. Most of these services are provided at your home or in your community but could be provided in a nursing home or hospital.

Identifying Providers in Aetna Better Health Premier Plan MMAI Network

You must get all of your covered services from providers within our network. If you go to providers who are not in Aetna Better Health Premier Plan MMAI network (without prior authorization or approval from us), you will have to pay the bill.

The exceptions to this rule are when you need urgent or emergency care or dialysis and cannot get to a provider in the plan, such as when you are away from home. You can also go outside the plan for other non-emergency services if Aetna Better Health Premier Plan MMAI gives you permission first.

• You may change providers within the network at any time. If you have been going to one network provider, you do not have to keep going to that same provider. You can call Member Services at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week to check if the new PCP is accepting new patients. The change will take effect immediately upon receipt of the request.
• Aetna Better Health Premier Plan MMAI works with all the providers in our network to accommodate the needs of people with disabilities. As applicable, the list of network providers in this Directory includes information about the accommodations they provide. If you need to see a provider and are not sure if they offer the accommodations you need, Aetna Better Health Premier Plan MMAI can help you. Talk to your case manager, for assistance.

Finding Aetna Better Health Premier Plan providers in your area

Finding a provider is easy. You can go to our website at www.aetnabetterhealth.com/illinois/find-provider or call Member Services at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week for assistance.

This directory is arranged by provider type, county and city. Look for the county you live in (or one near you) and find a provider close to where you live. Aetna Better Health Premier Plan MMAI may add or remove plan providers from our provider/pharmacy directory. You can also get current information about Aetna Better Health Premier Plan MMAI providers in your area, on our website www.aetnabetterhealth.com/illinois/find-provider.

List of network providers

This Directory of Aetna Better Health Premier Plan MMAI network providers contains:

• Health care professionals including, for example, primary care physicians, specialists, mental health providers and dental and vision providers;
• Facilities including, for example, hospitals, nursing facilities, mental health facilities, and supportive living; and
• Support providers including, for example, adult day services, consumer-directed services, home-delivered meals, and home health agencies.

Pharmacies

This part of the Directory provides a list of pharmacies in Aetna Better Health Premier Plan MMAI network. These network pharmacies are pharmacies that have agreed to provide prescription drugs to you as a member of the plan.

We also list pharmacies that are in our network but are outside the Aetna Better Health Premier Plan MMAI service area in which you live. You may also fill your prescriptions at these pharmacies. Please contact Aetna Better Health Premier Plan MMAI at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week for additional information.

• Aetna Better Health Premier Plan MMAI members must use network pharmacies to get prescription drugs.
  • You must use network pharmacies except in emergency or urgent care situations. If you go to an out-of-network pharmacy for prescriptions when it is not an emergency, you will have to pay out of pocket for the service. Read the Aetna Better Health Premier Plan MMAI Member Handbook for more information.
• Some network pharmacies may not be listed in this Directory.
  • Some network pharmacies may have been added or removed from our plan after this Directory was published.

For up-to-date information about Aetna Better Health Premier Plan MMAI network pharmacies in your area, please visit our web site at www.aetnabetterhealth.com/illinois/find-provider or call Member Services at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free.

To get a complete description of your prescription coverage, including how to fill your prescriptions, please read the Member Handbook and Aetna Better Health Premier Plan MMAI List of Covered Drugs. You can find the List of Covered Drugs on the Aetna Better Health Premier Plan MMAI website at www.aetnabetterhealth.com/illinois/formulary. You can also search by drug using our online formulary search tool.

Identifying pharmacies in our network

Along with retail pharmacies, your plan’s network of pharmacies includes:

• Mail-Order Pharmacies
• Home infusion pharmacies
• Long-term care (LTC) pharmacies

• You are not required to continue going to the same pharmacy to fill your prescriptions.

Long-term supplies of prescriptions

• Mail-Order Programs. We offer a mail-order program that allows you to get up to a 90-day supply of your prescription drugs sent directly to your home. A 90-day supply has the same copay as a one-month supply.
• 90-Day Retail Pharmacy Programs. Some retail pharmacies may also offer up to
  a 90-day supply of covered prescription drugs. A 90-day supply has the same copay as a one-month supply.

Aetna Better Health Premier Plan MMAI Network Pharmacies

This directory is arranged by pharmacy type, county, city and pharmacy name. Look for the county and city you live in (or one near you) and find a pharmacy close to where you live for your prescription needs.

Retail and mail order pharmacies are available to all members. Home Infusion and Long-Term Care Pharmacies are available to members as long as they are eligible for their services.

You can go to any of the pharmacies in our network. This includes our network pharmacies outside of our service area.

The legend in the front cover of this directory provides information on symbols used in the pharmacy listing.

Mail Order Pharmacy

You can get prescription drugs shipped to your home through our network mail order delivery program which is called CVS Caremark Mail Order Pharmacy. You also have the choice to sign up for automated mail order delivery through our CVS Mail Order Pharmacy. The pharmacy must obtain consent before shipping or delivering any prescriptions you do not personally initiate.

1. New prescriptions the pharmacy gets from you

 The pharmacy will automatically fill and deliver new prescriptions it gets from you.

2. New prescriptions the pharmacy gets directly from your provider’s office

The pharmacy will automatically fill and deliver new prescriptions it gets from health care providers, without checking with you first, if either:

• You used mail order services with this plan in the past, or

• You sign up for automatic delivery of all new prescriptions you get directly from health care providers. You may ask for automatic delivery of all new prescriptions now or at any time by choosing the option on CVS Caremark website at http://www.caremark.com/. If you need help, you can contact Member Services or your case manager.

If you used mail order in the past and do not want the pharmacy to automatically fill and ship each new prescription, please call CVS Caremark Customer Care at 1-800-552-8159 (TTY: 1-800-231-4403) and let them know how you would like  to receive your mail order prescriptions. Or register online with CVS Caremark at www.caremark.com. You can change your mail order preference at any time. 

If you have never used our mail order delivery and/or decide to stop automatic fills of new prescriptions, the pharmacy will contact you each time it gets a new prescription from a health care provider to see if you want the medication filled and shipped immediately. This will give you an opportunity to make sure that the pharmacy is delivering the correct drug (including strength, amount, and form) and, if necessary, allow you to cancel or delay the order before it is shipped. It is important that you respond each time you are contacted by the pharmacy, to let them know what to do with the new prescription and to prevent any delays in shipping. 

To opt out of automatic deliveries of new prescriptions you get directly from your health care provider’s office, please call CVS Caremark Customer Care at 1-800-552-8159 (TTY: 1-800-231-4403).You can also change your preferences by registering online with CVS/Caremark at www.caremark.com.

Typically, you should expect to get your prescription drugs within 10 days from the time that the mail order pharmacy gets the order. If you do not get your prescription drug(s) within this time, if you would like to cancel an automatic order, or if you need to ask for a refund for prescriptions you got that you did not want or need, please contact us at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. To learn more about mail order pharmacies, see Chapter 5 of the Member Handbook.

Home Infusion Pharmacies

Home infusion pharmacies are included in the network. These pharmacies supply drugs that may need to be given to you by an intravenous route or other non-oral routes, such as intra-muscular injections, in your home.

Aetna Better Health Premier Plan MMAI will cover home infusion therapy if:

• Your prescription drug is on the Aetna Better Health Premier Plan MMAI formulary
• We have approved your prescription drug for home infusion therapy
• Your prescription is written by a doctor
• You get your home infusion services from an Aetna Better Health Premier Plan MMAI network pharmacy.

If you have questions about home infusion pharmacies in our network call your case manager or Member Services at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free.

Long-Term Care Pharmacies

Residents of a long-term care facility, such as a nursing home, may access their prescription drugs covered under Aetna Better Health Premier Plan MMAI through the facility’s pharmacy or another network pharmacy. To learn more about drug coverage in special cases, see Chapter 5 of the Member Handbook.

Long-Term Care Pharmacies (LTC) pharmacies are included in the network. These pharmacies offer pharmacy services to patients that live in a type of group home like a nursing home or rehabilitation center. Generally, all LTC pharmacies are in network. LTC pharmacies will fill prescription orders written by medical staff in the group home and deliver the medication directly to the medical staff who will distribute the medication to the members. Generally, each group home will have one or two LTC pharmacies that supply most of the pharmacy services to all of the members residing in the facility.

If you have questions about long-term care pharmacies in our network call your case manager or Member Services at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free.

Real-Time Benefit Tool

You can register on the Caremark.com member portal to use the “Real-Time Benefit Tool”.  With this tool you can search for drugs on the “Drug List” to see an estimate of what you will pay and if there are alternative drugs on the “Drug List” that could treat the same condition.  Once registered, you can access the tool under the Plan & Benefits section and then clicking on the “Check Drug Cost & Coverage” option.