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.
 

The PHP utilizes a three-tier coverage design for certain in-network specialty and laboratory services only.  

Tier 1: In-Network Preferred Providers (Aexcel)

Tier 2: In-Network Non-Preferred Providers

Tier 3: Out-of-Network Providers

Aetna maintains a list of specialist categories with in-network preferred providers. The preferred providers have demonstrated higher quality and efficiency of patient care. You will be charged a higher amount for utilizing an in-network non-preferred or out-of-network provider in these specialty categories. The list of preferred specialty categories, as well as how to search for in-network specialty providers is located on our website.

Quest Diagnostics is the preferred lab for Aetna. If you go to any other in-network lab with Aetna, you will be charged more and will need to meet the plan’s annual deductible.  

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. You can 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

Tier 3

Out-of-Network

Tier 1 Preferred

Tier 2 Non-Preferred

Deductible

The amount you pay each year before the plan begins covering particular medical expenses. Family deductible is cumulative.

Individual: $200

Family: $400

Individual: $750

Family: $1,500

Coinsurance (Out-of-pocket expense)

The percentage of medical expenses shared by you and the plan after you meet your deductible.

10% after deductible

40% after deductible1

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  

 

See Salary Band chart  

Pre-Certification Requirement

No coverage without pre-certification on services so marked

 

 

In-network provider will pre-certify with Aetna

No coverage without pre-certification on services so marked

 

Member must pre-certify with Aetna

Lifetime Maximum

Medical/surgical/mental health

Unlimited

Unlimited

Feature/Service

In-Network Service

Out-of-Network

Tier 1 Preferred: You Pay

Tier 2 Non-Preferred:   You Pay

Tier 3:

You Pay

Physician Services Performed in an Office Setting

 

 

Primary Care Physician (PCP)

$20 copayment per office visit

40% after deductible1

Standard Specialists

$30 copayment per specialist visit

40% after deductible1

Tiered Specialist

$30 copayment per specialist visit

$60 copayment per specialist visit

40% after deductible1

Physician Services Performed in a Hospital/Ambulatory Setting3

10% after deductible

20% after deductible

40% after deductible1 (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

40% after deductible1

 

 

Scheduled immunizations

$0

40% after deductible1

Inpatient Hospital Services2
Medical/surgical care (includes maternity)

10% after deductible

40% after deductible1

Urgent Care Facility

$30 copayment per office visit

40% after deductible1

Emergency Room Care

Services administered for conditions meeting the definition of an emergency. 

 

You must follow the instructions on your member ID card.

$175 copayment per emergency visit. If you are admitted, copayment is waived.

 

No coverage for non-emergencies

Surgery (Inpatient/Outpatient) 2

Anesthesia and use of an operating room or related facility in a hospital or authorized institution.

10% after deductible

40% after deductible1

Outpatient Lab for Diagnosis or Treatment

$0

20% after deductible

50% after deductible1

X-Ray Services for Diagnosis or Treatment

$0

40% after deductible1

Hi-Tech Radiology2

$0

Not Covered

Outpatient Mental Health and Substance Abuse

Outpatient treatment; crisis intervention; detoxification.

$30 copayment per office visit

25% (no deductible required)1

Inpatient Mental Health and Substance Abuse2

10% after deductible

40% after deductible1

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

40% after deductible1

Chiropractic Services

20 visits per calendar year limit, (combined in-network/out-of-network)

$30 copayment per office visit

40% after deductible1

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

40% after deductible1

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

40% after deductible1

Dialysis, Chemo, and Radiation Services

$0 after deductible

40% after deductible1

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: 40% after deductible1

 

Outpatient: 40% after deductible1

Durable Medical Equipment Purchase or Rental

Splints, braces, non-surgically implanted prostheses, specified medical equipment for use in the home

10% after deductible

Not covered

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

40% after deductible1

Hearing Exam

1 exam per calendar year; coinsurance, deductible or copayment applies

$30 copayment per office visit

40% after deductible1

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

 

1You pay 40% for most services after you meet the required deductible and any amounts over reasonable and customary; the plan will pay 60% of reasonable and customary after you meet the required deductible.

2These 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 no coverage for out-of-network services. In-network providers will contact Aetna for pre-certification.

3 Patient costs for tiered specialist fees will correspond to the tier of the specialist utilized to perform the medical or surgical procedure.

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

 

Out-of-Network Coinsurance Limit

From

To

Individual

Family

Individual

Family

$75,000

  or under

$1,550

  $3,100

$4,500

  $9,000

$75,001

$150,000

$2,350

  $4,700

$4,700

  $9,400

$150,001

or over

$3,100

  $6,200

$6,200

  $12,400

 
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 OptumRx.
 
If a doctor's office and/or hospital needs to verify coverage, they can call the Benefits Team at 258-3302. 
Group number
486819
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.