Components of Your Medical Plan
Please look through the tabs below for more information on different aspects of the medical plan and Aetna.
Are you switching plans and want to know if your your doctor is covered?
Use Aetna’s DocFind tool to search for your doctor under the desired plan:
Click here to view Aetna's online tool for viewing claims, printing out temporary ID cards, and lots of other great resources!
- Aetna Memorial Hermann ACO = Aetna Whole Health Plans, (TX) Aetna Whole Health – Memorial Hermann Accountable Care Network
- Aetna Select HMO = Aetna Standard Plans, Aetna Select
- Aetna Choice POS II (Open Access) = Aetna Open Access Plans, Aetna Choice POS II (Open Access)
- Aetna Consumer Driven Health Plan (also known as the High Deductible Plan) = Aetna Open Access Plans, Aetna Choice POS II (Open Access)
Please note the for the Aetna Choice POS II (Open Access), you only receive the $35 primary care physician (PCP) copayment for your selected PCP. Any other in-network physician, even if a non-designated PCP, will have the $45 copayment applied. Want your network to go? If you have an iPhone or other wireless device, you can download Aetna's mobile website for access wherever you go!
The emergency room copayments for the ACO, HMO, and POS plans are $175 and our urgent care center copayments are $50. This differential exists in an effort to help you think about what is appropriate care and where the appropriate location to take care of your situation is.
If you go to the emergency room for a problem that is not a true emergency:
- It will cost a lot more than it would at your doctor's office or a walk-in clinic. A trip to the emergency room for an earache, for example, may cost three to four times as much as it would at your doctor's office.
- You will probably spend a lot more time there than you would at a walk-in clinic or doctor's office.
- You will get care from a doctor who has probably never seen you before. It's always best to get as much of your care as you can from a doctor who knows and understands your particular needs.
How Do You Know if You Have an Emergency?
Technically, an emergency is "fear of loss of life or limb." It is usually clear if you are having a heart attack or are in a car wreck and you need immediate medical assistance, but it is not always clear if you cut yourself and are bleeding or have a high fever.
If You Have a Clear Emergency Situation
So, if it is a clear-cut emergency, go to the closest or most appropriate emergency room. Let the ambulance driver assist you in that decision. Some times when you should go to the emergency room include:
- chest pain that could be a heart attack,
- not being able to breathe,
- severe and uncontrolled bleeding, and
- stroke symptoms.
If You are Uncertain that You Have an Emergency
You may want to take care of the problem right away because you feel sick or uncomfortable, but if nothing bad is going to happen to you if you wait awhile, then you probably don't have a true emergency. Then again, you don't always know that for sure. Some problems that seem minor can become serious if you ignore them. And it may be even harder to know what to do when a child is sick.
If you are not certain if it is a real emergency, follow these steps:
- Consider calling your doctor. Most primary care physicians and pediatricians have answering services that will get in touch with your doctor and your doctor will call you back relatively quickly. This is a great way to get a second opinion as to what you should do given your situation.
- Consider using the Baylor Express Care Center.
- Consider a network urgent care center. Urgent care centers are for minor emergencies, and they can treat you much quicker and for a lot less money than at an emergency room. If it turns out you are having a true medical emergency, a walk-in clinic will send you to the ER.
- When you have an urgent situation, you often won't have time to look for the closest urgent care facility. Know ahead of time which facilities near you (home or work) are in Aetna's network.
- Take a "wait and see" approach. This often works with a fever or a viral infection. If you are ill for more than two weeks, or have a fever and have other complications, consider calling your doctor. In most cases, the illness that caused the fever will clear up in a few days. You likely can treat the fever at home if you are in good health and do not have any medical problems or significant symptoms with the fever. It is easy to become dehydrated when you have a fever. Make sure that you are taking enough foods and fluids and urinating in normal amounts.
Clinical Source: WebMD
When enrolled in the medical plan, one routine eye exam is covered at 100% every 12 months with participating providers. You will need to provide your Aetna medical ID card at the time of service. You also have access to vision discounts (including frames, lenses, contact lenses and Lasik) at participating providers. Please read the Aetna brochure for more information about this program.
The vision discount program does not apply to the KelseyCare Advantage plan that is available to retirees.
Occasionally, you may need to submit a claim directly to Aetna for reimbursement. Please use the following forms:
Be sure to send the claim with documentation to the address listed on the form. Also, keep a copy for your records. You should receive an explanation of benefits for all claims. You can also review your claims history and claims status online at Aetna Navigator.
Your ID card should arrive within 10-15 business days of your enrollment. If you have not received an ID card, or need to order a replacement ID card, please contact Aetna.
Need an ID Card now? Aetna Navigator Can Help!
Did you know that you can print a temporary ID from Aetna's secure member website, Aetna Navigator? Anytime, anywhere — simply log into Aetna Navigator and select "ID Card" under the Requests & Changes menu. A temporary ID lets you visit your doctor and fill a prescription when you haven't yet received your permanent ID card. Use your permanent ID card once you receive it. If you ever need to replace your ID card, you can order one online too. Your replacement ID card should arrive within 10 business days.
Your prescription drug information is on the BACK of your Aetna ID card. Please see more about the prescription drug program and the information on your ID card on the Benefits Prescription Drug Information page.
Confused by all of the health insurance jargon? Let this dictionary help you sort it out.
Please use the Aetna Concierge telephone number, 1-800-905-7670, to contact Aetna for medical issues or log into Aetna Navigator online. The Concierge Service should be able to assist you with any Aetna-related medical issue you have.
To reach Envision Rx Options regarding your pharmacy information, please call 1-800-361-4542.