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 DocFind® 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 Navigator.
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, Obstetricians/Gynecologists, 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 followup treatment. Except for PCP, direct access and emergency services, you must have a prior written or electronic referral from your PCP to receive coverage for all services and any necessary followup 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 co-payment stated in the Co-payment schedule.
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 co-payment shown in the Co-payment schedule.
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. 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.
- 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 approval by Aetna in addition to a special nonparticipating referral from your PCP. When properly authorized, these services are covered after the applicable co-payment.
- 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.
Specialist as Principal Physician Direct Access Program
If you have a serious or complex medical condition, you may need ongoing specialty care. A “serious or complex medical condition” is generally a life-threatening, degenerative or disabling condition or disease such as AIDS, cancer, emphysema, an organ failure that may require a transplant, or diabetes with target organ involvement.
The Specialist as Principal Physician Direct Access Program is a voluntary program. Eligibility is based upon the nature of your medical condition, your need for continuing specialty care and a specialist’s willingness to serve as your principal physician for treatment of the condition.
Enrollment in the program must be approved by Aetna. Once you are enrolled, a case manager will be available to answer questions about the features of the program, to assist with any necessary authorizations or pre-certifications and to facilitate communications between your PCP and the specialist treating your condition.
If you are interested in enrolling in the Specialist as Principal Physician Direct Access Program, contact Member Services at the toll-free number shown on your ID card and ask to be transferred to a health management representative.
A listing of network providers is provided automatically. You may also obtain, without charge, this listing of network providers from the Administrator-Benefits, or by calling the toll-free Member Services number on your ID card. To find providers in the Aetna Select network:
- Set browser to Aetna “DocFind” website: www.aetna.com/docfind
- Select geographic location, whether zip code, city, or county
- Follow prompt depending on your prior selection
- In selecting Provider Category, select Medical Providers
- In selecting Provider Type, select either Primary Care Physicians or Specialist
- In selecting Plan, select under Aetna Standard Plans the Aetna Select (SM) option
- After these selections, you can Search by Specialty, Name, and Other Options if you wish to drill down further. If not, a list will be provided after you select the Start Search button.
Your ID cards
When you join the Plan, you and each enrolled member of your family receive a member ID card. 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. You will also receive a separate Express Scripts ID card.
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.