Aetna PPO Plan
The Aetna PPO Plan (also known as Aetna Choice POS II) provides comprehensive medical coverage through in-network providers who are affiliated with the Plan or through out-of-network providers who do not participate in the Plan's network. In-network preventive care is paid at 100%, with no coinsurance, no deductible and no copayment. Most other services are subject to the deductible first then coinsurance or copay. It is important to note that the deductible applies to prescription drugs as well. There is no separate out-of-pocket maximum for prescription drugs under the Aetna PPO. Once you reach the out-of-pocket maximum, the plan pays 100% of covered expenses for the remainder of the calendar year. The coinsurance, deductible, and out-of-pocket maximum amounts are higher for out-of-network services.
With the Aetna PPO Plan, you can visit any doctor you choose, and you don't need a referral to see a specialist. Nor do you have to choose a primary care physician (PCP).
Provider Network. The Aetna PPO uses the Aetna Choice® POS II (Open Access) provider network.
The Aetna PPO includes a variety of transition assistance transgender services*, such as:
- Behavioral health services. Your mental well-being is important and talking to a behavioral health provider before your gender affirmation surgery is a requirement for your transition planning.
- Hormone therapy and medications (covered under OptumRx). Used to make you more masculine or more feminine.
- Gender affirmation surgery and gender support services. Aetna Concierge Services can help you find an appropriate surgeon and work with your surgeon to get all the precertifications needed.
- Reproductive services. You may be covered for in vitro fertilization services (note that ART reproductive services are only covered under the Aetna HDHP, not under the Aetna PPO).
- Staying healthy after your surgery. You’re covered for preventive health services based on your birth anatomy, including certain cancer screenings.
*Coverage for gender transition services depends on certain federal laws.
The Aetna PPO Transform Oncology program includes resources and support you may need to manage your cancer care, understand your benefits and locate the right providers.
- Personal Navigator. Your dedicated advocate who will provide you and your caretaker with personalized support.
- Guided Genetic Health® program. Genetic counseling and testing can help guide your treatment and assess your risk of developing other forms of cancer.
- Aetna Cancer Support Center. Providing resources to your fingertips, serving as your trusted source for information and guidance on what to expect while managing cancer treatment and care.
You have access to the Aetna Back and Joint Care Services Partnership with Hinge Health.
- Manage chronic back and joint pain with digital exercise therapy.
- Engage with a physical therapist virtually for more recent musculoskeletal issues.
- Avoid common musculoskeletal conditions through the wellness program.
- The Aetna Back and Joint Care program is included on your member website, with a direct connection to the Hinge Health online screener.
The Aetna PPO plan does not cover Advanced Reproductive Technology (ART), unlike the Aetna HDHP with HSA.
View the Aetna PPO Summary of Benefits and Coverage and the Aetna PPO Summary of Benefits.
View the 2023 Aetna PPO Booklet Certificate and the Aetna PPO Schedule of Benefits for the details of your 2023 healthcare benefits, your share of the costs and which services are covered. The 2024 editions are coming soon.
Prescription drug coverage is provided through OptumRx, the prescription drug plan administrator for the Aetna medical plans (except the HMO).
Under the Aetna PPO, prescription drugs are grouped into preventive and non-preventive medications.
- Preventive prescription medications are used to prevent conditions such as asthma.
- The Affordable Care Act (ACA) lists preventive drugs that are covered at 100% and are not subject to the deductible.
- OptumRx lists preventive drugs that require a copay (for generic drugs) or coinsurance (for brand-name and specialty drugs). The copay and coinsurance are not subject to the deductible.
- For non-preventive medications, you pay the full cost of the drug (after OptumRx discounts are applied) at the time of purchase. Non-preventive medication expenses do apply to the deductible. Go to the OptumRx website to search for all covered drugs under the Plan and see how much they cost.
- Once you meet your annual deductible, you pay the applicable copay or coinsurance.
There is no separate out-of-pocket maximum for prescription drugs under the PPO.
When obtaining your non-specialty prescriptions, you can receive reimbursement for up to a 30-day supply at a retail Participating Pharmacy or up to a 90-day supply at OptumRx mail order or at Walgreens and Duane Reade local pharmacies. You obtain specialty prescriptions through Optum Specialty.
Learn more about prescription drug benefits.