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.
Each participant in the Plan must select a Primary Care Physician (PCP) when they enroll. When choosing a PCP, use the aetna.com website to select an individual physician. You may not select a physician group as your PCP. Your PCP serves as your guide to care in today's complex medical system and will coordinate and monitor your overall care.
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 or investigational procedures, drugs, devices or biological products not proven by long-term clinical studies are generally not covered. See Exclusions for limited exceptions.
When determining medical necessity, Clinical Policy Bulletins (CPBs) published by Aetna, the claims administrator may be used. CPBs are based on established, nationally accepted governmental and/or professional society recommendations, as well as other recognized sources. These CPBs may be found on the Aetna website at www.aetna.com.
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, see the National Precertification List on the Aetna member website. To find a list of mental health treatments requiring precertification, including inpatient and intensive outpatient services, visit the Magellan website.
The Primary Care Physician
As a participant in the Plan, you will become a partner with your 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 will refer you to other doctors or facilities for treatment. Even if your PCP provides services in a facility as the attending physician, a referral for the facility is required for services rendered at the facility to be covered. The referral is important because it is how your PCP arranges for you to receive necessary, appropriate care and follow up treatment. Except for PCP, Obstetricians/Gynecologists, and emergency services, you must have a prior written or electronic referral from your PCP to receive coverage for all services and any necessary follow up treatment.
Participating specialists are required to send reports back to your PCP to keep your PCP informed of any treatment plans ordered by the specialist.
Primary and preventive care
Your 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 routine vision exams and gynecological exams from participating providers without a referral from your PCP. 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
Your PCP may refer you to a specialist or facility for treatment or for covered preventive care services, when medically necessary. Except for those benefits described in this guide as direct access benefits and emergency care, you must have a prior written or electronic referral submitted to Aetna from your PCP prior to services being rendered in order to receive coverage for any services the specialist or facility provides.
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:
- Consult your PCP first when you need routine medical care. If your PCP deems it medically necessary, you will get a written or electronic referral to a participating specialist or facility. You have one year from the date the referral is issued to complete your visit, unless a different timeframe is specified, as long as you remain an eligible participant in the Plan. Your referral is also valid for the number of services your PCP has approved. For direct access benefits, you may contact the participating provider directly, without a referral.
- Certain services require both a referral from your PCP and prior authorization from Aetna. Your PCP is responsible for obtaining authorization from Aetna for in-network covered services.
- All services provided by a non-participating provider require prior authorization by Aetna.
- Review the referral with your PCP. Understand what specialist services are being recommended and why.
- Present the referral to the participating provider. Except for direct access benefits, any additional treatments or tests that are covered benefits require another referral from your PCP. The referral is necessary to have these services approved for payment. Without the referral, you are responsible for payment for these services.
- If it is not an emergency and you go to a doctor or facility without your PCP’s prior written or electronic referral, you must pay the bill yourself.
- Your PCP may refer you to a nonparticipating provider for covered services that are not available within the network. Services from nonparticipating providers require prior by Aetna. When properly authorized, these services are covered after the applicable out-of-pocket expenses.
- Reciprocity applies. See Key Terms.
Remember, you cannot request referrals after you visit a specialist or hospital. Therefore, to receive maximum coverage, you need to contact your PCP and get authorization from Aetna (when applicable) before seeking specialty or hospital care.
Some PCPs are affiliated with integrated delivery systems (IDS) or other provider groups (such as Independent Practice Associations and Physician-Hospital Associations). If your PCP participates in such an arrangement, you will usually be referred to specialists and hospitals within that system or group. However, if your medical needs extend beyond the scope of the participating providers, you may ask to have services provided by out-of-network physicians or facilities. Services provided by out-of-network providers may require prior authorization from Aetna and/or the IDS or other provider group. Check with your PCP or call the Member Services number that appears on your ID card to find out if prior authorization is necessary.
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.
To find Magellan network providers in your area, use the search tool on the Magellan website or call Magellan Member Services.
Your ID cards
When you join the Plan, you and each enrolled member of your family receive a member ID card from Aetna for the Medical Plan. Your ID card lists the name of the Aetna PCP you have chosen. New enrollees in the Plan should select their PCP as soon as possible, as Aetna Select ID cards will not be sent until a PCP has been selected. If you change your PCP, you automatically will receive a new card displaying the change. Temporary ID cards can be requested by contacting Aetna Member Services. You will also receive separate Express Scripts ID cards - ESI will send one member ID card for single coverage, and two 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 www.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 or Medco). Your cards identify you as a plan participant when you receive services from participating 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.