The Plan generally covers only Medically necessary care and services.
Plan participants have access to a network of participating Primary Care Physicians (PCPs), specialists and hospitals that meet Aetna’s requirements for quality and service. These providers are independent physicians and facilities that are monitored for quality of care, patient satisfaction, cost-effectiveness of treatment, office standards and ongoing training.
Although not required, each participant in the Plan is encouraged to select a network Primary Care Physician (PCP) when they enroll. When choosing a PCP, use the aetna.com website to select an individual physician. Your PCP serves as your guide to care in today's complex medical system and will coordinate and monitor your overall care or may provide treatment. They may also refer you to other network providers.
Participants may update their PCP by calling Member Services or through aetna.com.
Expenses are covered under these options only if they are medically necessary. Care is medically necessary if it is a therapeutic procedure, service or supply used in the medical treatment of an injury, disease, or pregnancy, which is generally recognized by the United States medical community as appropriate. Claims are reviewed as submitted, and some or all of any claim or series of services could be denied as not being medically necessary. It also means that Experimental procedures, drugs, devices or biological products not proven by long-term clinical studies are generally not covered. See Exclusions: What your plan doesn’t cover for limited exceptions.
When determining medical necessity, Clinical Policy Bulletins (CPBs) published by Aetna, the claims administrator may be used.
CPBs are based on objective, credible sources, such as the scientific literature, guidelines, consensus statements and expert opinions. These CPBs may be found on the Aetna website at https://www.aetna.com/health-care-professionals/clinical-policy-bulletins.html
Precertification or preauthorization is a mandatory review of inpatient admissions and select ambulatory procedures or services in advance of treatment, to confirm medical necessity based on clinical criteria and benefits eligible under the Plan. If you are using a network provider, the provider will perform the precertification process on your behalf.
For more information on precertification for medical/surgical procedures and services and mental health and substance use disorder services, see the Precertification Lists on the Aetna member website.
The Primary Care Physician
As a participant in the Plan, you will become a partner with participating PCP in preventive medicine. The following physicians are considered PCPs: Internists, General Practitioners, Pediatricians and Family Practitioners. Consult your PCP whenever you have questions about your health. Your PCP will provide your primary care and, when medically necessary, your PCP may refer you to other doctors or facilities for treatment.
Primary and preventive care
A PCP can provide preventive care and treat you for illnesses and injuries. The Plan covers routine physical exams, well-baby care, immunizations and allergy shots provided by your PCP.
You may also obtain gynecological exams from in-network providers. You are responsible for the copayment stated in the Benefits summary.
Some immunizations can also be obtained or administered at participating retail pharmacies, using the Aetna ID card at an Aetna network pharmacy, or the Express Scripts ID card at an Express Scripts network pharmacy.
Specialty and facility care
While your plan does not require a referral from a participating PCP to see specialty doctors, you will want to coordinate such care with your PCP. Your PCP may refer you to a specialist or facility for treatment or for covered preventive care services, when medically necessary. When your PCP refers you to a participating specialist or facility for covered services, you will be responsible for the copayment shown in the Benefits summary.
To avoid costly and unnecessary bills, follow these steps:
- You are encouraged to consult your PCP first when you need routine medical care.
- Certain services require prior authorization from Aetna.
- All services provided by a non-network provider require prior authorization by Aetna.
To find Aetna network providers in your area, choose “Find a Doctor” on the Aetna website or mobile app. If you need further assistance, you can call Aetna Member Services.
Your ID cards
Show your ID card each time you get covered services from a provider. Only members on your plan can use your ID card. We will mail you your ID card. If you haven’t received it before you need covered services, or if you lose it, you can print a temporary one using the Aetna website.
You will also receive separate Express Scripts ID card(s).
ESI will send 1 member ID card for single coverage, and 2 member ID cards for family coverage (any coverage for more than employee only). Temporary ID cards can be requested by logging into Express Scripts customer website at express-scripts.com, or call Express Scripts member services at 800 695-4116.
Always carry your ID cards with you, including your prescription drug card (Express Scripts ). Your cards identify you as a plan participant when you receive services from in-network providers or when you receive emergency services at non-participating facilities. If your cards are lost or stolen, please notify Aetna and Express Scripts immediately.
Effective January 1, 2024 Instead of receiving printed ID cards for the medical, dental and vision plans in the mail, they will be available on each plan’s website and apps so you can view them on your phone. You can download them and easily save, share, print or email them directly to providers. You can also request a physical version any time via customer service, as well as through the Aetna, Cigna, Express Scripts or UHC Vision app or member website.