Aetna Preferred Provider Organization (PPO)

This plan is not available to you if you are a non-U.S. citizen on a J-1 Visa.

 

The Aetna Preferred Provider Organization (PPO) Plan features both an in-network and out-of-network component. 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, but at a greater cost. No preexisting condition exclusion applies.

 

For a current Physician Directory, visit Aetna's website. Choose 'Find a Doctor' from the Tools menu at the bottom of the screen. Complete the required sections. Under “Plan,” use the drop down menu and identify the Aetna Open Access Plan, selecting 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 Aetna Service Center for Princeton University toll free at (800) 535-6689.

 

The chart below provides a brief overview of the benefits offered. Please review the Aetna PPO Plan package, call Aetna for Princeton University toll free at (800) 535-6689, or call the Benefits Team at (609) 258-3302 for more details. 

 

Plan Provision	In-Network Service You Pay	Out-of-Network Service You Pay
Deductible The amount you pay each year before the plan begins covering particular medical expenses.   Family deductible is cumulative.	Individual : $300 Family : $600 In-network/out-of-network deductible cross applies1	Individual : $600 Family : $1,200 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	20% 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 medical expenses.   Includes your deductible and coinsurance, but excludes copayments.	See Salary Band chart 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
Feature/Service	In-Network Service You Pay	Out-of-Network Service You Pay
Lifetime Maximum Medical/Surgical/Mental Health	Unlimited	Unlimited
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 are inclusive to the surgical charge for delivery	$25 copayment per office visit	20% after deductible2
Physician Services Performed in a Hospital/Ambulatory Setting	10% after deductible	20% 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 PAP tests  and well-woman care office visits.	$25 copayment per office visit	20% after deductible2
Scheduled immunizations	$25 copayment per office visit	20% after deductible2
Inpatient Hospital Services Medical/surgical care, including maternity	10% after deductible	20% after deductible2
Urgent Care Facility	$25 copayment per office visit	20% 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; waived if admitted.
Surgery (Inpatient/Outpatient) Anesthesia and use of an operating room or related facility in a hospital or authorized institution	10% after deductible	20% after deductible2
Outpatient Lab and X-Ray Services for Diagnosis or Treatment	10%	20% after deductible2
Outpatient Mental Health and Substance Abuse Outpatient treatment; crisis intervention; detoxification	$25 copayment per office visit	20%   No deductible required
Inpatient Mental Health and Substance Abuse	10% after deductible	20% after deductible2
Outpatient Physical Rehabilitation Short-term physical, speech, occupational or pulmonary and cardio rehabilitation therapies   Maximum of 50 visits combined therapies per calendar year limit, combined in-network/out-of-network	10% after deductible	20% after deductible2
Chiropractic Services 20 visits per calendar year limit, combined in-network/out-of-network	$25 copayment per office visit	20% 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	20% 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	20% 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 : 20% after deductible2    Outpatient : 20% after deductible2
Durable Medical Equipment Purchase or Rental Splints, braces, nonsurgically implanted prostheses, specified medical equipment for use in the home $50,000 lifetime maximum, combined in-network/out-of-network	10% after deductible	20% after deductible2
Nutritional Counseling Limited to three visits per calendar year with referral and/or script by your physician   Coinsurance, deductible or copayment will apply.	$25 copayment per office visit	20% after deductible2
Hearing Exam 1 exam per calendar year   Coinsurance, deductible or copayment will apply.	$25 copayment per office visit	20% after deductible2
Hearing Aids Combined in-network/out-of-network limit of $1,500 reimbursement every three 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 20% after you meet the required deductible and any amounts over reasonable and customary; the plan wil pay 80% of reasonable and customary after you  meet the required deductible. 

Find the range 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		In-Network Coinsurance Limit		Out-of-Network Coinsurance Limit
From	To	Individual	Family	Individual	Family
0 -	$24,999	$ 800	$ 1,600	$ 1,600	$ 3,200
25,000	39,999	1,000	2,000	2,000	4,000
40,000	54,999	1,800	3,600	3,600	7,200
55,000	74,999	2,400	4,800	4,800	9,600
75,000	94,999	3,600	7,200	7,200	14,400
95,000	119,999	4,400	8,800	8,800	17,600
120,000	159,999	5,200	10,400	10,400	20,800
160,000	199,999	5,900	11,800	11,800	23,600
200,000	and Over	7,600	15,200	15,200	30,400

³ 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.

You should receive your Aetna ID card at the end of December 2011. 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 them. If you would like additional cards, you must contact Aetna.

 

The Aetna ID card should be used to access medical care. You will receive a separate ID card for the Prescription Drug Plan, administered through Medco Health. If a doctor's office and/or hospital needs to verify coverage, they can call the Office of Human Resources at (609) 258-3302.

Prescription Drug Program 

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.