Your Health Benefits
Aetna SelectSM EPO
About Aetna SelectSM EPO Plan
With the Aetna Select EPO plan, you receive care from primary care physicians (PCPs), specialists, hospitals and other health care providers who belong to Aetna's network. These network providers are independent physicians and facilities that must meet strict requirements for quality and service.
When you enroll in the plan, you choose a primary care physician (PCP). When your PCP provides your care or refers you to network providers, the plan pays benefits. When you seek care on your own, you pay the entire cost of your care.
How the Plan Works
You choose a PCP.
When you enroll in Aetna Select, you must choose a primary care physician (PCP) for yourself and each family member covered under the plan. Your PCP provides routine and basic care and, when needed, referrals to specialists within Aetna's network.
A PCP can be a general practitioner, family practitioner, internist or pediatrician. Family members can share a PCP or each may have a different PCP.
To find network providers, use DocFind®, Aetna's online provider directory. When you are asked to "select a plan," click on Aetna Standard Plans, then choose Aetna SelectSM. You can search the online directory for a specific doctor, type of doctor or all the doctors in a given zip code and/or travel distance.
The plan pays benefits when you visit your PCP first.
Benefits are paid only when your care is provided or coordinated by your PCP, except in an emergency. You pay a low flat fee, or copay, for most services. Some preventive care services (such as health screenings) are covered at 100% with no copay required at all. For other types of services, such as hospital stays, the services would be subject to the calendar year deductible, then covered at 90% after copay (if applicable). The Summary of Benefits (PDF) chart shows how the plan pays benefits for a variety of medical services.
You don't need to file claims for benefits.
With Aetna Select, there is no need to file a claim for benefits. When you visit your PCP or PCP-referred specialist, just show your Aetna ID card and pay the required copay. For hospital care and other inpatient care that requires a copay, you may pay the copay before you are admitted or wait until you are billed for the amount of the copay. Hospital care and other inpatient care are subject to the deductible.
Coverage for Pre-existing Conditions
The plan has a "pre-existing condition" rule that limits coverage for expenses incurred for a condition you had before the plan's effective date. A "pre-existing condition" is a condition for which you:
" Received treatment or services; or
" Took prescribed drugs or medicines;
. . . during the 90 days right before your coverage under this plan went into effect.
The rule is: For the first 365 days after this plan takes effect, expenses for treatment of a pre-existing condition are not covered. There may be an exception to this rule in the case of a child whom you adopt or for whose health coverage you are responsible because of a child support order. Also, under certain circumstances, the 365-day exclusion period may be reduced by your "prior creditable coverage," if applicable. For details about the pre-existing condition rule and any exceptions or modifications to it, refer to the Summary Plan Description (coming soon). The "pre-existing condition" rule does not apply to your dependents under age 19.
Aetna Select Q&A
Can I make an appointment with a network specialist directly?
In order to receive benefits from the plan for specialty care, your PCP must make a referral to a network specialist. If you visit any specialist – even a network doctor – without a referral from your PCP, you must pay the entire cost of your care.
How do I change my PCP?
You can change your PCP at any time, for any reason. Just go to DocFind and select your new PCP. Then call Aetna Member Services at the number on the back of your ID care and let them know whom you've selected.
What happens if I need emergency care and I can't reach my PCP?
The plan covers care for a true emergency no matter who provides it. In the event of an emergency, dial 911 or visit the nearest hospital emergency room. After you've received care, you or a family member should call your PCP so he or she can coordinate other services for you.
What if my dependents live away from home?
If your dependent lives in an area where Aetna offers a network, they should select a PCP based where they are living not necessarily where the employee resides. This means your dependent must receive all routine medical care where they reside. Your dependent will only have coverage for emergency and urgent care when visiting where the employee resides. Failure to select a PCP may significantly reduce the benefits paid by this plan.
Are prescription drug expenses covered as part of this plan?
No. Prescription drug expenses are covered through Express Scripts for this plan.