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Note: The plan names listed here are generic. Your employer may have custom names for these plans. If you don't see your plan listed, contact your employer to obtain the generic plan names.

Medical Families of Products    |     HMO    |     PPO    |     Indemnity Plan    |     POS    |    
Consumer-Directed Plan    |     Medicare Advantage Plans

Medical Families of Products

Aetna Standard Family of Products
Aetna Standard products encompass the core health benefit plans Aetna offers. These benefit plans offer a range of coverage, from the Open Choice® PPO plan, which does not require any referrals or PCP selection, to our HMO and exclusive provider plans, where the member chooses a primary care physician, who provides guidance when specialist care is required.

Aetna Open Access® Family of Products
Aetna Open Access products offer the benefits similar to our standard suite of products, and encourage, but do not require members to select a primary care physician. Members can go directly to network specialists, without needing to obtain a referral from their PCP.

Aetna HealthFund® Family of Products
Aetna HealthFund offers consumers an innovative health plan alternative that broadens consumer choice. Aetna HealthFund combines the protection of a deductible-based medical plan with an employer-established health fund. Within the plan, consumers have freedom to choose referral-free access to Aetna's expansive network of physicians and hospitals, as well as the ability to seek out-of-network care. With Aetna HealthFund, members are encouraged to become more involved in their own health care decisions, including how and when their health fund dollars are used.

Aetna Aexcel®/Aexcel® Plus Designation
Aexcel is a physician designation within Aetna's Performance Network that includes specialists who have demonstrated effectiveness in the delivery of care based on a balance of measures of clinical performance and efficiency.

Aetna Medicare Advantage Plans
Medicare Advantage Plans are health plans options made available under the guidance of the Centers for Medicare and Medicaid Services (CMS). These plans cover the benefits under Part A and Part B (Original Medicare) and may also provide additional features such as eyewear and prescription drug benefits. The types of Medicare Advantage plans that Aetna offers includes:

  • Aetna MedicareSM Plan(HMO) is an HMO plan.
  • Aetna MedicareSM Plan(PPO) is a PPO plan.
  • Aetna Medicare OpenSM Plan is a Private-Fee-For-Service plan.

National Advantage™ Program (NAP)
The National Advantage™ Program (NAP) offers access to contracted rates for many medical claims that would otherwise be paid as billed under many indemnity plans, the out-of-network portion of managed care plans, or for emergency/medically necessary services not provided within the standard network. The NAP Network consists of many of Aetna's directly-contracted hospitals, ancillary providers, and physicians. The Network also includes hospitals, ancillary providers, and physicians accessed through vendor arrangements where Aetna does not have direct contractual arrangements. Aetna does not credential, monitor or oversee those providers who participate through third party contracts. Since there are a number of factors that determine whether a discount will be given, Aetna is unable to guarantee any level of discount under this program.

Behavioral Healthcare Program
The Aetna Behavioral Health Program offers members access to covered behavioral health services provided by a comprehensive network of psychiatrists, psychologists, therapists and other clinical professionals. Covered benefit options may include access to both inpatient and outpatient services. Members can access covered services directly, without referrals from a PCP.

Employee Assistance Program (EAP)
An employee assistance program (EAP) is a worksite-based program designed to assist (1) work organizations in addressing productivity issues and (2) "employee clients" in identifying and resolving personal concerns, including, but not limited to, health, marital, family, financial, alcohol, drug, legal, emotional, stress, or other personal issues that may affect job performance.

Health Maintenance Organization (HMO) Our Exclusive Provider Plans
HMO**
  • Member chooses primary care physician (PCP) from the network of participating providers. (Use 6 digit Primary Office #)
  • Member visits PCP for routine care or for injury or illness.
  • PCP referral is generally required for specialist care, except OB/GYN.
  • Deductible, copays and/or percentage copays may apply.
  • No claim forms or balance bills.
  • Except for emergency or out-of-area urgent care, benefits are not covered outside the network.
  • Wellness and preventive programs included.
**In Washington, the product referred to as HMO is called Primary Choice(SM) and is offered by Aetna Health Inc., a licensed Health Care Service Contractor.
Aetna Open Access® Elect Choice (EPO)
  • Member encouraged to choose a primary care physician (PCP) from the network of participating providers. (Use 7 digit Provider ID #)
  • Member can go directly to network specialists — referrals not required.
  • Deductible, copays and/or percentage copays may apply.
  • No claim forms or balance bills.
  • Except for emergency or out-of-area urgent care, benefits are not covered outside the network.
  • Some wellness and preventive programs included.
  • Preventive care required by federal health care reform covered at 100% without cost share.
Aetna Open Access® HMO
  • Member encouraged to choose a primary care physician (PCP) from the network of participating providers. (Use 6 digit Primary Office #)
  • Member can go directly to network specialists — referrals not required.
  • Deductible, copays and/or percentage copays may apply.
  • No claim forms or balance bills.
  • Except for emergency or out-of-area urgent care, benefits are not covered outside the network.
  • Wellness and preventive programs included.
Aetna Health Network OnlySM(Open Access)
  • Member encouraged to choose a primary care physician (PCP) from the network of participating providers. (Use 6 digit Primary Office #)
  • Member can go directly to network specialists — referrals not required.
  • Deductible, copays and/or percentage copays may apply.
  • No claim forms or balance bills.
  • Except for emergency or out-of-area urgent care, benefits are not covered outside the network.
  • Wellness and preventive programs included.
Aetna SelectSM
  • Member chooses primary care physician (PCP) from the network of participating providers. (Use 7 digit Provider ID #)
  • Member visits PCP for routine care or for injury or illness.
  • PCP referral is generally required for specialist care, except OB/GYN.
  • Deductible, copays and/or percentage copays may apply.
  • No claim forms or balance bills.
  • Except for emergency or out-of-area urgent care, benefits are not covered outside the network.
  • Some wellness and preventive programs included.
  • Preventive care required by federal health care reform covered at 100% without cost share.
Aetna Value NetworkSM HMO (available in California and Nevada only)
  • Member chooses primary care physician (PCP) from the participating providers within the Aetna Value NetworkSM. (Use 6 digit Primary Office #)
  • Member visits PCP for routine care or for injury or illness.
  • PCP referral is generally required for specialist care, except OB/GYN.
  • Copays and/or percentage copays may apply.
  • No claim forms or balance bills.
  • Except for emergency or out-of-area urgent care, benefits are not covered outside the network.
  • Wellness and preventive programs included.
HMO Deductible Plan (California members only)
  • HMO medical plan with deductible. Deductible applies to certain services according to the member's benefit plan. (Use 6 digit Primary Office #)
  • Member chooses a primary care physician (PCP) from the CA providers participating in the network that supports this plan.
  • Member visits PCP for routine care or for injury or illness.
  • PCP referral is generally required for specialist care, except OB/GYN.
  • Deductible, copays and/or percentage copays may apply.
  • No claim forms or balance bills.
  • Except for emergency or out-of-area urgent care, benefits are not covered outside the network.
  • Wellness and preventive programs included.
Elect Choice® (EPO)
  • Member chooses primary care physician (PCP) from the network of participating providers. (Use 7 digit Provider ID #)
  • Member visits PCP for routine care or for injury or illness.
  • PCP referral is generally required for specialist care, except OB/GYN.
  • Deductible, copays and/or percentage copays may apply.
  • No claim forms or balance bills.
  • Except for emergency or out-of-area urgent care, benefits are not covered outside the network.
  • Some wellness and preventive programs included.
  • Preventive care required by federal health care reform covered at 100% without cost share.
NYC Community PlanSM Tier 1/Referred (available in NYC only)
  • Member chooses primary care physician (PCP) from the participating providers within the tier 1 / referred NYC Community Network. (Use 6 digit Primary Office #)
  • Member visits selected PCP for routine care or for injury or illness.
  • PCP referrals are required for specialist care within the tier 1 / referred NYC Community Network, except OB/GYN. Copay only applies.
  • Self-referral to tier 1 / referred provider not covered.
  • No claim forms or balance bills.
  • Except for emergency or out-of-area urgent care, out-of-network care is not covered.
  • Wellness and preventive programs included.
NYC Community PlanSM Tier 2/Self-Referred (available in NYC only)
  • Member can not choose primary care physician (PCP) from the tier 2 / self-referred NYC Community Network.
  • Member visits to tier 2 / self-referred PCP covered at self-referred benefit level.
  • Referrals are not required for specialist care within the tier 2 / self-referred NYC Community Network.
  • Deductible and coinsurance apply.
  • No claim forms or balance bills.
  • Except for emergency or out-of-area urgent care, out-of-network care is not covered.
  • Wellness and preventive programs included.
Open Access Aetna SelectSM
  • Member encouraged to choose a primary care physician (PCP) from the network of participating providers. (Use 7 digit Provider ID #)
  • Member can go directly to network specialists — referrals not required.
  • Deductible, copays and/or percentage copays may apply.
  • No claim forms or balance bills.
  • Except for emergency or out-of-area urgent care, benefits are not covered outside the network.
  • Some wellness and preventive programs included.
  • Preventive care required by federal health care reform covered at 100% without cost share.
Preferred Provider Organization (PPO) Plan
Open Choice® (PPO)
  • No primary care physician (PCP) required.
  • No referrals required.
  • Member can access any recognized provider for covered services (in or out of network).
    • If participating provider, member pays lower out-of-pocket costs, including deductible, copays and/or coinsurance.
    • If nonparticipating provider, member pays higher out-of-pocket costs, including deductible, coinsurance, and balance bills (provider charge in excess of the amount Aetna determines is allowable under the terms of the plan).
  • Some wellness and preventive programs may be included.
  • Preventive care required by federal health care reform covered at 100% without cost share.
Indemnity Plan
Traditional Choice® Indemnity
  • Indemnity health insurance product.
  • No provider network.
  • Member free to choose any recognized provider for covered benefits.
  • Discounted rates may be available through our National Advantage® program for covered services at many hospitals, facilities and physician offices.
  • Member pays deductible and coinsurance, and is responsible for balance bills (provider charge in excess of the amount Aetna determines is allowable under the terms of the plan).
  • Member submits claim forms for care received.
  • Some wellness and preventive programs may be included.
  • Preventive care required by federal health care reform covered at 100% without cost share.
Point-of-Service (POS) Plans
Aetna Choice® POS
  • Member encouraged to choose a primary care physician (PCP) from the network of participating providers. (Use 6 digit Provider ID #)
  • Member can go directly to network specialists — referrals not required.
  • Deductible, copays and/or percentage copays may apply when accessing care from network providers.
  • Member may visit any out-of-network, licensed provider for a covered benefit. Member will typically be subject to higher out-of-pocket costs, including deductible, coinsurance and balance bills (provider charge in excess of the amount Aetna determines is allowable under the terms of the plan)
  • Wellness and preventive programs included.
Aetna Health Network OptionSM(Open Access)
  • Member encouraged to choose a primary care physician (PCP) from the network of participating providers. (Use 6 digit Primary Office #)
  • Member can go directly to network specialists — referrals not required.
  • Deductible, copays and/or percentage copays may apply when accessing care from network providers.
  • Member may visit any out-of-network, licensed provider for a covered benefit. Member will typically be subject to higher out-of-pocket costs, including deductible, coinsurance and balance bills (provider charge in excess of the amount Aetna determines is allowable under the terms of the plan).
  • Wellness and preventive programs included.
Aetna Choice® POS II
  • Member encouraged to choose a primary care physician (PCP) from the network of participating providers. (Use 7 digit Provider ID #)
  • Member can go directly to network specialists — referrals not required.
  • Deductible, copays and/or percentage copays may apply when accessing care from network providers.
  • Member may visit any out-of-network, licensed provider for a covered benefit. Member will typically be subject to higher out-of-pocket costs, including deductible, coinsurance and balance bills (provider charge in excess of the amount Aetna determines is allowable under the terms of the plan)
  • Some wellness and preventive programs included.
  • Preventive care required by federal health care reform covered at 100% without cost share.
Aetna Open Access® Managed Choice® (POS)
  • Member encouraged to choose a primary care physician (PCP) from the network of participating providers. (Use 7 digit Provider ID #)
  • Member can go directly to network specialists — referrals not required.
  • Deductible, copays and/or percentage copays may apply when accessing care from network providers.
  • Member may visit any out-of-network, licensed provider for a covered benefit. Member will typically be subject to higher out-of-pocket costs, including deductible, coinsurance and balance bills (provider charge in excess of the amount Aetna determines is allowable under the terms of the plan).
  • Some wellness and preventive programs included.
  • Preventive care required by federal health care reform covered at 100% without cost share.
Managed Choice® (POS)
  • Member chooses primary care physician (PCP) from the network of participating providers. (Use 7 digit Provider ID #)
  • Member visits PCP for routine care or for injury or illness.
  • PCP referral is generally required for specialist care, except OB/GYN.
  • Deductible, copays and/or percentage copays may apply when accessing care from network providers.
  • Member may visit any licensed provider without PCP referral for a covered benefit, except in case of OB/GYN. Member will typically be subject to higher out-of-pocket costs, including deductible, coinsurance and balance bills (provider charge in excess of the amount Aetna determines is allowable under the terms of the plan).
  • Some wellness and preventive programs included.
  • Preventive care required by federal health care reform covered at 100% without cost share.
Quality Point-of-Service® (QPOS®)
  • Member chooses primary care physician (PCP) from the network of participating providers. (Use 6 digit Primary Office #)
  • Member visits PCP for routine care or for injury or illness.
  • PCP referral is generally required for specialist care, except OB/GYN.
  • Deductible, copays and/or percentage copays may apply when accessing care from network providers.
  • Member may visit any licensed provider without PCP referral for a covered benefit, except in the case of OB/GYN. Member will typically be subject to higher out-of-pocket costs, including deductible, coinsurance and balance bills (provider charge in excess of the amount Aetna determines is allowable under the terms of the plan).
  • Wellness and preventive programs included.
Vitalidad Mexico Con AetnaSM
  • Member chooses a Vitalidad Mexico doctor as their primary care physician (PCP). (Use 6 digit Primary Office #)
  • Vitalidad network providers are located in Mexico (Mexicali, Tecate, or Tijuana).
  • Member can visit any Vitalidad (SIMNSA) primary care physician (PCP) or clinic for routine care or for an injury or illness.
  • PCP referrals are generally required for specialist care, except OB/GYN.
  • Member pays copay at time of service.
  • No claim forms or balance bills.
  • Except for emergency or out-of-area urgent care, benefits are not covered outside the Vitalidad Mexico network.
  • Wellness and preventive programs included.
Vitalidad PlusSM California con Aetna
  • Vitalidad PlusSM California con Aetna network includes providers located in both the US and Mexico.
  • Member chooses a primary care physician (PCP) from the participating providers within the Vitalidad PlusSM network. (Use 6 digit Primary Office #)
  • Members visit their PCPs for routine care or for an injury or illness.
  • PCP referrals are generally required for specialist care, except OB/GYN.
  • Member pays copay at time of service.
  • No claim forms or balance bills.
  • Except for emergency or out-of-area urgent care, benefits are not covered outside the Vitalidad PlusSM network.
  • Wellness and preventive programs included.
Consumer-Directed Plans
Aetna HealthFund® Aetna Choice® POS
  • Employer paid health fund.
  • Medical plan with deductible.
  • Unused health fund dollars roll over to the next year if member remains in plan with current employer.
  • Member encouraged to choose a primary care physician (PCP) from the network of participating providers. (Use 6 digit Provider ID #)
  • Member can go directly to network specialists — referrals not required.
  • Deductible, copays and/or percentage copays may apply when accessing care from network providers.
  • Member may visit any out-of-network, licensed provider for a covered benefit. Member will typically be subject to higher out-of-pocket costs, including deductible, coinsurance and balance bills (provider charge in excess of the amount Aetna determines is allowable under the terms of the plan).
  • Aetna Navigator®, access to personalized tools and reliable consumer health care information.
  • Wellness and preventive programs included
Aetna HealthFund® Aetna Health Network OnlySM(Open Access)
  • Employer paid health fund.
  • Medical plan with deductible.
  • Unused health fund dollars roll over to the next year if member remains in plan and with current employer.
  • Member encouraged to choose a primary care physician (PCP) from the network of participating providers. (Use 6 digit Primary Office #)
  • Member can go directly to network specialists — referrals not required.
  • Deductible, copays and/or percentage copays may apply.
  • No claim forms or balance bills.
  • Except for emergency or out-of-area urgent care, benefits are not covered outside the network.
  • Aetna Navigator®, access to personalized tools and reliable consumer health care information.
  • Wellness and preventive programs included.
Aetna HealthFund® Aetna Health Network OptionSM(Open Access)
  • Employer paid health fund.
  • Medical plan with deductible.
  • Unused health fund dollars roll over to the next year if member remains in plan with current employer.
  • Member encouraged to choose a primary care physician (PCP) from the network of participating providers. (Use 6 digit Primary Office #)
  • Member can go directly to network specialists — referrals not required.
  • Deductible, copays and/or percentage copays may apply when accessing care from network providers.
  • Member may visit any out-of-network, licensed provider for a covered benefit. Member will typically be subject to higher out-of-pocket costs, including deductible, coinsurance and balance bills (provider charge in excess of the amount Aetna determines is allowable under the terms of the plan).
  • Aetna Navigator®, access to personalized tools and reliable consumer health care information.
  • Wellness and preventive programs included
Aetna HealthFund® HMO (available in CA only)
  • Employer paid health fund.
  • Medical plan with deductible.
  • Unused health fund dollars roll over to the next year if member remains in plan and with current employer.
  • Member chooses a primary care physician (PCP) from the CA providers participating in the network that supports this plan. (Use 6 digit Primary Office #)
  • Member visits PCP for routine care or for injury or illness.
  • PCP referral is generally required for specialist care, except OB/GYN.
  • Deductible, copays and/or percentage copays may apply.
  • No claim forms or balance bills.
  • Except for emergency or out-of-area urgent care, benefits are not covered outside the network.
  • Aetna Navigator®, access to personalized tools and reliable consumer health care information.
  • Wellness and preventive programs included
Aetna HealthFund® Open Access Aetna SelectSM
  • Employer paid health fund.
  • Medical plan with deductible.
  • Unused health fund dollars roll over to the next year if member remains in plan and with current employer.
  • Member encouraged to choose a primary care physician (PCP) from the network of participating providers. (Use 7 digit Provider ID #)
  • Member can go directly to network specialists — referrals not required.
  • Deductible, copays and/or percentage copays may apply.
  • No claim forms or balance bills.
  • Except for emergency or out-of-area urgent care, benefits are not covered outside the network.
  • Aetna Navigator®, access to personalized tools and reliable consumer health care information.
  • Some wellness and preventive programs included.
  • Preventive care required by federal health care reform covered at 100% without cost share.
Aetna HealthFund® Open Access Elect Choice® EPO
  • Employer paid health fund.
  • Medical plan with deductible.
  • Unused health fund dollars roll over to the next year if member remains in plan and with current employer.
  • Member encouraged to choose a primary care physician (PCP) from the network of participating providers. (Use 7 digit Provider ID #)
  • Member can go directly to network specialists — referrals not required.
  • Deductible, copays and/or percentage copays may apply.
  • No claim forms or balance bills.
  • Except for emergency or out-of-area urgent care, benefits are not covered outside the network.
  • Aetna Navigator®, access to personalized tools and reliable consumer health care information.
  • Some wellness and preventive programs included.
  • Preventive care required by federal health care reform covered at 100% without cost share.
Aetna HealthFund® Open Access Managed Choice® POS
  • Employer paid health fund.
  • Medical plan with deductible.
  • Unused health fund dollars roll over to the next year if member remains in plan with current employer.
  • Member encouraged to choose a primary care physician (PCP) from the network of participating providers. (Use 7 digit Provider ID #)
  • Member can go directly to network specialists — referrals not required.
  • Deductible, copays and/or percentage copays may apply when accessing care from network providers.
  • Member may visit any out-of-network, licensed provider for a covered benefit. Member will typically be subject to higher out-of-pocket costs, including deductible, coinsurance and balance bills (provider charge in excess of the amount Aetna determines is allowable under the terms of the plan).
  • Aetna Navigator®, access to personalized tools and reliable consumer health care information.
  • Some wellness and preventive programs included.
  • Preventive care required by federal health care reform covered at 100% without cost share.
Aetna HealthFund® Open Access Choice POS II
  • Employer paid health fund.
  • Medical plan with deductible.
  • Unused health fund dollars roll over to the next year if member remains in plan with current employer.
  • Member encouraged to choose a primary care physician (PCP) from the network of participating providers. (Use 7 digit Provider ID #)
  • Member can go directly to network specialists — referrals not required.
  • Deductible, copays and/or percentage copays may apply when accessing care from network providers.
  • Member may visit any out-of-network, licensed provider for a covered benefit. Member will typically be subject to higher out-of-pocket costs, including deductible, coinsurance and balance bills (provider charge in excess of the amount Aetna determines is allowable under the terms of the plan).
  • Aetna Navigator®, access to personalized tools and reliable consumer health care information.
  • Some wellness and preventive programs included.
  • Preventive care required by federal health care reform covered at 100% without cost share.
Aetna HealthFund® Open Choice® PPO
  • Employer paid health fund.
  • Medical plan with deductible.
  • Unused health fund dollars roll over to the next year if member remains in plan with current employer.
  • No PCP required.
  • No referrals required.
  • Member can access any recognized provider for covered services (in or out of network).
    • If participating provider, member pays lower out-of-pocket costs, including deductible, copays and/or coinsurance.
    • If nonparticipating provider, member pays higher out-of-pocket costs, including deductible, coinsurance, and balance bills (provider charge in excess of the amount Aetna determines is allowable under the terms of the plan).
  • Some wellness and preventive programs may be included.
  • Preventive care required by federal health care reform covered at 100% without cost share.
Medicare Advantage Plans
Aetna MedicareSM Plan (HMO)
  • Member chooses primary care physician (PCP) from the network of participating providers. (Use 6 digit Primary Office #)
  • Member visits PCP for routine care or for injury or illness.
  • PCP referral is generally required for specialist care.
  • Copays and/or percentage copays may apply.
  • No claim forms or balance bills for covered services.
  • No out of network coverage, except for emergency or out-of-area urgent care.
  • Wellness and preventive programs included.
Aetna MedicareSM Plan (Open Access HMO)
  • Member encouraged to choose a primary care physician (PCP) from the network of participating providers. (Use 6 digit Primary Office #)
  • Member can go directly to network specialists — referrals not required.
  • Copays and/or percentage copays may apply.
  • No claim forms or balance bills for covered services.
  • No out of network coverage, except for emergency or out-of-area urgent care.
  • Wellness and preventive programs included.
Aetna MedicareSM Plan (PPO)
  • No primary care physician (PCP) selection required. However; when accessing care thru a PCP other than your selected PCP, higher cost sharing may apply.
  • No referrals required.
  • Member can access covered services from any licensed provider that is eligible to receive payment from Medicare.
    • If network provider, member pays lower out-of-pocket costs, including copay and/or coinsurance.
    • If non-network provider, member pays higher out-of-pocket costs, including deductible and coinsurance.
  • Wellness and preventive programs included.
Aetna Medicare OpenSM Plan (PFFS)
  • No primary care physician (PCP) required.
  • No referrals required.
  • Member can access covered services from any licensed provider that is eligible to receive payment from Medicare, agrees to treat them and accepts the Aetna Medicare Open Plan terms and conditions of payment.
  • Deductible, copays or coinsurance may apply.
  • No balance bills unless the provider does not take assignment under Original Medicare.
  • Wellness and preventive programs included.
If you're an Aetna Medicare OpenSM Plan member or a prospective enrollee interested in enrolling in this plan, please note that the Aetna Medicare Open Plan is a non-network based Medicare Advantage Private-Fee-For-Service plan that allows you to receive covered services from any licensed provider who: (i) is eligible to receive payment from Medicare, (ii) agrees to provide covered services to you, and (iii) has reasonable access to the Aetna Medicare Open Plan Terms and Conditions of Payment. This means that the Aetna Medicare Open Plan does not offer a provider network. Provided below are links to Medicare's website, where you can locate providers and hospitals that participate with Medicare and are located in your service area ("Medicare participating providers"). These Medicare participating providers must meet all of the conditions above to provide you with covered services under the Aetna Medicare Open Plan.


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