Aetna Princeton Health Plan

This Aetna Princeton Health Plan (PHP) is not available to you if you are a non - U.S. citizen on a J - 1 Visa.

The Aetna Princeton Health Plan (PHP) has both an in - network and out - of - network component. It has no exclusions for preexisting conditions.
 
The in - network approach allows members to seek care without having to designate a primary care physician (PCP). As a result, it is not necessary to obtain a referral before visiting another physician or specialist. 
 
The out - of - network portion of the plan provides the participant with the ability to see any physician at a greater cost.
 
For a current Physician Directory, visit Aetna's website. Choose "Find a Doctor or Hospital" from the Tools menu at the bottom of the screen. Complete the required sections. Under "Plan," use the drop - down menu and identify the Open Access Plan." Select the name "Aetna Choice II POS (Open Access)" below it and complete the search.
 
For more information about these plan benefits or details on services not listed, call the Aetna Service Center for Princeton University toll free at (800) 535-6689. 

Overview

The chart below provides a brief overview of the benefits offered. Please review the Aetna PHP Plan package, call Aetna for Princeton University toll free at (800) 535-6689 or contact the Benefits Team at  258-3302 for additional  information. 
 
Compare the rates for this and each plan offered. The Prescription Drug Program is included with this plan.
 
Plan Provision
In-Network
Out-of-Network
Deductible
The amount you pay each year before the plan begins covering particular medical expenses. Family deductible is cumulative.
Individual: $200
Family: $400
In-network/out-of-network deductible cross applies1
Individual: $750
Family: $1,500
In-network/out-of-network deductible cross applies1
Coinsurance (Out-of-pocket expense)
The percentage of medical expenses shared by you and the plan after you meet your deductible.
10% after deductible
30% after deductible2
Coinsurance Limit (maximum out-of-pocket expense)
Total amount you pay out–of–pocket in one calendar year before the plan pays 100% of your eligible medical expenses, including your deductible, coinsurance and copayments.
See Salary Band chart 
 
In-network/out-of-network coinsurance limit cross applies1

Individual: $4,500
Family: $9,000

In-network/out-of-network coinsurance limit cross applies1
Non-Notification/Non-Compliance Penalty
The amount you must pay if you do not call Medical Management at (800) 535-6689 before hospitalization and certain types of surgery, or fail to follow concurrent review procedures.
$200 per procedure and/or admission
$200 per procedure and/or admission
Lifetime Maximum
Medical/surgical/mental health
Unlimited
Unlimited
Feature/Service
In-Network Service: You Pay
Out-of-Network Service: You Pay
Physician Services Performed in an Office Setting
Office visits for routine care; diagnosis and treatment of an illness or injury and initial maternity visit pre- and post-partum care inclusive to the surgical charge for delivery
$20 copayment per office visit
 
$30 copayment per specialist visit
30% after deductible2
Physician Services Performed in a Hospital/Ambulatory Setting
10% after deductible
30% after deductible2 (surgical fees subject to R&C limits)
Preventive Care
Preventive physicals, well-child care (including scheduled immunizations)
 
Plan pays for up to seven visits during first year for well-child care, PSA, and tests and well–woman care office visits
$0 copayment per office visit
30% after deductible2
 
 
Scheduled immunizations
$0 copayment per office visit
30% after deductible2
Inpatient Hospital Services3
Medical/surgical care (includes maternity)
10% after deductible
30% after deductible2
Urgent Care Facility
$30 copayment per office visit
30% after deductible2
Emergency Room Care
Services administered for conditions meeting the definition of an emergency. 
 
You must follow the instructions on your member ID card.
$60 copayment per emergency visit. If you are admitted, copayment is waived.
 
No coverage for non-emergencies
Surgery (Inpatient3
/Outpatient)
Anesthesia and use of an operating room or related facility in a hospital or authorized institution.
10% after deductible
30% after deductible2
Outpatient Lab and X-Ray Services for Diagnosis or Treatment
$0 copayment per office visit
30% after deductible2
Outpatient Mental Health and Substance Abuse
Outpatient treatment; crisis intervention; detoxification.
$30 copayment per office visit
30% (no deductible required)2
Inpatient Mental Health and Substance Abuse3 
10% after deductible
30% after deductible2
Outpatient Physical Rehabilitation
Short-term physical, speech, occupational or pulmonary and cardio rehabilitation therapies.
 
Maximum of 50 visits per therapy per calendar year (combined in-network/out-of-network)
10% after deductible
30% after deductible2
Chiropractic Services
20 visits per calendar year limit, (combined in-network/out-of-network)
$30 copayment per office visit
30% after deductible2
Home Health Care
Services provided in the home by an RN, LPN or contract therapist
 
60 visits per calendar year limit (combined in-network/out-of-network)
10% after deductible
30% after deductible2
Skilled Nursing Facility/Inpatient Physical Rehabilitation
Confinement and skilled nursing services in a hospital or specialized facility
 
60 days per calendar year limit (combined in-network/out-of-network)
10% after deductible
30% after deductible2
Dialysis, Chemo, and Radiation Services
$0 after deductible
30% after deductible2
Hospice Care
Room and board in a licensed facility or in your home; services of medical personnel; others services and supplies
 
180 day maximum (combined in-network/out-of-network)
Inpatient: 10% after deductible
 
Outpatient: 10% after deductible
Inpatient: 30% after deductible2
 
Outpatient: 30% after deductible2
Durable Medical Equipment Purchase or Rental
Splints, braces, nonsurgically implanted prostheses, specified medical equipment for use in the home
10% after deductible
30% after deductible2
Nutritional Counseling
Limited to 12 visits per calendar year with referral and/or script by your physician; coinsurance, deductible or copayment applies
$30 copayment per office visit
30% after deductible2
Hearing Exam
1 exam per calendar year; coinsurance, deductible or copayment applies
$30 copayment per office visit
30% after deductible2
Hearing Aids
Combined in-network/out-of-network limit of $1,500 reimbursement every 3 years
Covered at 100% up to $1,500
Covered at 100% up to $1,500
Routine Eye Exam/Prescription Glasses or Contact Lenses
Not covered
Not covered
1 The term "cross applies" means that in – network payments count toward your out - of - network payment limits if you decide to use out - of - network services. Likewise, out - of - network payments count toward your in-network payment limits if you decide to use in – network services.
2 You pay 30% after you meet the required deductible and any amounts over reasonable and customary; the plan will pay 70% of reasonable and customary after you meet the required deductible.
3These services require pre-certification through Aetna. You must call Aetna at (800) 535-6689 at least 14 days in advance of nonemergency treatment to request precertification or you will have to pay a $200 penalty per procedure and/or admission.

Salary Band Chart

Find the salary range below which includes your January 1 (or salary at date of hire, if later) base salary to determine your in –network and/or out –of –network coinsurance limit.

Base Salary Range

In-Network Coinsurance Limit

From
To
Individual
Family
$75,000
  or under
$1,550
  $3,100
$75,001
$150,000
$2,350
  $4,700
$150,001
or over
$3,100
  $6,200
 
If you are a participating retiree, the salary used is your salary at the time of retirement.
 
Only medically necessary services are covered.
 
For information about these plan benefits please call Aetna Customer Service toll free at (800) 535 - 6689. 

PHP Plan Member Information

Aetna provides a family ID card. Rather than each Aetna member receiving an ID card, the family will receive two cards with all of the members information listed on it. If you would like additional cards, you must contact Aetna directly.
 
The Aetna ID card should be used to access medical care. You will receive a separate ID card for the Prescription Drug Program, administered through Express Scripts.
 
If a doctor's office and/or hospital needs to verify coverage, they can call the Benefits Team at 258 - 3302. 
Group number
811281
Member ID #
Will be system generated
Phone number
(800) 535 - 6689
 
You can count on support from knowledgeable and responsive HR staff when you have a benefits question or problem. Just call or e-mail us. We’re here to help!
 
 
While the University intends to continue each of the benefit plans, the University reserves the right to terminate or amend any plan, at any time, and for any reason.