PCP and referral rules for obstetricians and
gynecologists (Ob/Gyn)
A female member can choose an Ob/Gyn as her PCP. Women can
also go to any Ob/Gyn who participates in the Aetna network
without a referral or prior authorization. Visits can be for:
•Checkups, including breast exam
•Mammogram
•Pap smear
•Obstetric or gynecologic problems
Also, an Ob/Gyn can give referrals for covered obstetric or
gynecologic services just like a PCP. Just follow your plan’s normal
rules. Your Ob/Gyn might be part of a larger physician’s group. If
so, any referral will be to a specialist in that larger group. Check
with the Ob/Gyn to see if the group has different referral policies.
Precertification: Getting approvals for services
Sometimes we will pay for care only if we have given an approval
before you get it. We call that “precertification.” You usually only
need precertification for more serious care like surgery or being
admitted to a hospital. When you get care from a doctor in the
Aetna network, your doctor gets precertification from us. But if
you get your care outside our network, you must call us for
precertification when that’s required.
Your plan documents list all the services that require you to get
precertification. If you don’t, you will have to pay for all or a larger
share of the cost for the service. Even with precertification, you
will usually pay more when you use out-of-network doctors.
Call the number shown on your Aetna ID card to begin the process.
You must get the precertification before you receive the care.
You do not have to get precertification for emergency services.
What we look for when reviewing a request
First, we check to see that you are still a member. And we make
sure the service is considered medically necessary for your
condition. We also make sure the service and place requested to
perform the service are cost effective. We may suggest a different
treatment or place of service that is just as effective but costs less.
We also look to see if you qualify for one of our case management
programs. If so, one of our nurses may contact you.
Precertification does not verify if you have reached any plan
dollar limits or visit maximums for the service requested. So,
even if you get approval, the service may not be covered.
Information about specific benefits
Emergency and urgent care and care after
office hours
An emergency medical condition means your symptoms are
sudden and severe. If you don’t get help right away, an average
person with average medical knowledge will expect that you
could die or risk your health. For a pregnant woman, that
includes her unborn child.
Emergency care is covered anytime, anywhere in the world. If
you need emergency care, follow these guidelines:
•Call 911 or go to the nearest emergency room. If you have time,
call your doctor or PCP.
•Tell your doctor or PCP as soon as possible afterward. A friend
or family member may call on your behalf.
•You do not have to get approval for emergency services.
How we cover out-of-network emergency care
You are covered for emergency and urgently needed care. You
have this coverage while you are traveling or if you are near your
home. That includes students who are away at school. When you
need care right away, go to any doctor, walk-in clinic, urgent care
center or emergency room. We’ll review the information when
the claim comes in. If we think the situation was not urgent, we
might ask you for more information and may send you a form to
fill out. Please complete the form, or call Member Services to
give us the information over the phone.
Follow-up care for plans that require a PCP
If you use a PCP to coordinate your health care, your PCP should
also coordinate all follow-up care after your emergency. For
example, you’ll need a doctor to remove stitches or a cast or take
another set of X-rays to see if you’ve healed. Your PCP should
coordinate all follow-up care. You will need a referral for
follow-up care that is not performed by your PCP. You may also
need to get approval if you go outside the network.
After-hours care – available 24/7
Call your doctor when you have medical questions or concerns.
Your doctor should have an answering service if you call after the
office closes. You can also go to an urgent care center, which
may have limited hours. To find a center near you, log in to
www.aetna.com and search our list of doctors and other health
care providers. Check your plan documents to see how much
you must pay for urgent care services.
Prescription drug benefit
Check your plan documents to see if your plan includes
prescription drug benefits.
Some plans encourage generic drugs over brand-name drugs
A generic drug is the same as a brand-name drug in dose, use
and form. They are FDA approved and safe to use. Generic drugs
usually sell for less; so many plans give you incentives to use
generics. That doesn’t mean you can’t use a brand-name drug,
but you’ll pay more for it. You’ll pay your normal share of the
cost, and you’ll also pay the difference in the two prices.
We may also encourage you to use certain drugs
Some plans encourage you to buy certain prescription drugs
over others. The plan may even pay a larger share for those
drugs. We list those drugs in the Aetna Preferred Drug Guide
(also known as a “drug formulary”). This list shows which
prescription drugs are covered on a preferred basis. It also
explains how we choose medications to be on the list.
When you get a drug that is not on the preferred drug list, your
share of the cost will usually be more. Check your plan
documents to see how much you will pay. You can use those
drugs if your plan has an “open formulary,” but you’ll pay the
highest copay under the plan. If your plan has a “closed
formulary,” those drugs are not covered.
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