State Specific Information

Covid 19 Therapeutics

Aetna provides coverage for COVID-19 therapeutics without prior authorization. Please call your doctor if you have tested positive for COVID-19 and need access to treatment. Access to COVID-19 therapeutics is considered an urgently needed service and you should receive an appointment within 48 hours of receiving your request. If you are not able to receive a timely appointment, please call the phone number on the back of your ID card for assistance.

Your telehealth options

Telehealth services may be available through your PCP or Specialist. Please call your PCP or Specialist for more information. Telehealth services are also available with third-party corporate telehealth providers, such as Teladoc^®. Log in to the member portal or refer to your member documents for additional information.

What this means for you

If you choose to receive telehealth services through a third-party corporate telehealth provider, you are notified of the following information:

Your telehealth visit records may be shared with your PCP to ensure coordination of care. Please notify the third-party corporate telehealth provider if you do not want your medical records shared with your PCP.
All services received through a third-party corporate telehealth provider is subject to the in-network cost sharing and will accrue to your plan’s deductibles and/out-of-pocket maximum. This means that your copayment or coinsurance will never be greater than your in-network copayment or coinsurance.

We can help

If you have any additional questions, please call the phone number on your member ID card.

Transition of care coverage

California HMO transition of care coverage policy - English (PDF)

California HMO transition of care coverage policy - Spanish (PDF)

California traditional transition of care coverage - English (PDF)

California traditional transition of care coverage - Spanish (PDF)

Enrollee transfer notices

California hospital and facility enrollee transfer notice (PDF)

California new primary care physician and independent physician association enrollee transfer notice - 002 (PDF)

California same primary care physician and new independent physician association enrollee transfer notice – 012 (PDF)

Cost estimator for Connecticut members

If a service or procedure is not listed in the cost estimator in the Aetna member website, a Connecticut member can obtain an estimated cost by completing the appropriate Member Request for Estimate Form.

Aetna member (PDF)

Aetna voluntary member (PDF)

Boon member (PDF)

Aetna student health member (PDF)

How we build our networks

Our online provider directory gives details on our provider networks, including the factors and standards we use to build them.

Help with a surprise bill

Connecticut members who received a surprise bill from a nonparticipating provider can get help. Find more information here:

Surprise billing member notification (PDF)

Important information: Network provider not reasonably available

If you are enrolled in a plan that uses a comprehensive provider network, you can get covered health services from an out-of-network provider at your in network cost share if an appropriate network provider is not reasonably available. You must request access to the out-of-network provider in advance and we must agree. Contact Member Services at the toll-free number on your ID card for help starting the process.

Access to ASAM criteria for members

Read the Introduction to ASAM criteria for members (PDF)

If you received a denial letter based on American Society of Addiction Medicine (ASAM) criteria that says a link to the ASAM criteria we used for the review is available online, you can access the ASAM criteria through the form below. Follow these steps:

Enter the ASAM Guideline Code from your denial letter in the box below and submit.
Read and accept the terms and conditions.
View the criteria on the results page.

Access to MCG criteria for members

If you received a denial letter based on Milliman Care Guidelines (MCG) criteria that says a link to MCG criteria is available online, you can access the MCG criteria at the link below. To access the MCG criteria, enter the following information from your denial letter:

Date of letter
Member’s last name
MCG Guideline Code (stated in the letter)
Password (stated in the letter)

Access the MCG criteria

Massachusetts - Behavioral health child and adolescent services

For Massachusetts members seeking information on behavioral health care services for children and adolescents (BHCA)

Massachusetts - Behavioral health and substance use disorder precertification

Massachusetts precertification information for Fully-Insured plans (PDF)

Massachusetts residents must have health care coverage

Are you a Massachusetts resident? Are you age 18 or older? Can you afford health insurance? If you answered yes to all of these, you must have health coverage for the entire year according to Massachusetts Health Care Reform.

Cost estimator for Massachusetts members

If a service or procedure is not listed in the cost estimator in the Aetna member website, a Massachusetts member can obtain an estimated cost by completing the appropriate Member Request for Estimate Form.

Aetna member (PDF)

Aetna voluntary member (PDF)

Boon member (PDF)

Aetna student health member (PDF)

Savings Plus network

Helpful information on the Savings Plus plan. Savings Plus doctors and hospitals are noted in our online directory.

How can I change the way Aetna communicates with me?

You have the right to ask us to communicate with you in a certain way or at a certain location.

If you are on someone else’s insurance and would like us to send your Explanation of Benefits statements and other claim information to an address that’s different from the primary subscriber’s, please call Member Services at the number on your ID card.

To stop paper mailings of Explanation of Benefits and claim information, log in to your Aetna member website and use the “Profile” link in the upper right corner to change your paper-saving preferences. Your Explanation of Benefits and claim information will still be available in your secure account.

Massachusetts voluntary and involuntary disenrollment rates

The voluntary and involuntary disenrollment rates for insureds are 0 percent. If you need a printed copy of this notice, call the number on your ID card.

For the purposes of 211 CMR 52.14(1)(c), the term “voluntary disenrollment” means that an insured has terminated coverage with the carrier for nonpayment of premium.

For the purposes of 211 CMR 52.14(1)(c), the term “involuntary disenrollment” means that a carrier has terminated the coverage of the insured due to any of the reasons contained in 211 CMR 52.13(3)(j) 2 and 3:

Misrepresentation or fraud on the part of the insured
Commission of acts of physical or verbal abuse by the insured which pose a threat to providers or other insureds of the carrier and which are unrelated to the physical or mental condition of the insured, provided that the commissioner prescribes or approves the procedures for the implementation of the provisions of 211 CMR 52.13(3)(i)3.

If you have any questions concerning the data disclosed above, please contact the Massachusetts Office of Patient Protection by:

Calling them toll free at 1-800-436-7757
Faxing your question to 1-617-624-5046

Visiting Office of Patient Protection.

New Jersey prior authorization statistics

New Jersey pharmacy prior authorization statistics (ALIC & AHI) – 2024 (XLSX)

Price estimates

Price estimates can be made in the Aetna member website.

If a service or procedure is not found on the Aetna member website, New Jersey members can obtain an estimated cost for out-of-network services by completing the appropriate Member Request for Estimate Form or by visiting the FAIR Health, Inc.* website. The estimates provided on this site will not take into account whether or not the member’s coinsurance and other plan cost-share limits when the estimate is provided.

Estimate costs of out-of-network services

Aetna member (PDF)

Aetna Voluntary member (PDF)

Boon member (PDF)

Aetna student health member (PDF)

*FAIR Health Marks and the FAIR Heath Logo are trademarks or registered trademarks of FAIR Health, Inc.

If you would prefer a printed copy of this information, or a printed list of providers, contact Member Services at the toll-free number on your ID card.

Learn more about managing your health care costs

Important information about your out-of-network benefits

Refer to this document for Important Information on Out of Network Claims.

It covers some details on voluntary and involuntary uses of out of network providers. The information on voluntary out-of-network benefits only applies if your plan has voluntary out-of-network benefits.

Out-of-network disclosures (PDF)

How we compensate your health care providers

Health care providers are independent practicing professionals that are neither employed nor exclusively contracted with Aetna. Individual physicians and other providers are in the network by either contracting with us directly or by affiliating with a group or organization that contracts with us.

We compensate these health care providers:

Per individual service or case (fee for service at contracted rates).
Per hospital day (per diem contracted rates).
Through capitation (a prepaid amount per member, per month).
Through Integrated Delivery Systems (IDS), Independent Practice Associations (IPA), Physician Hospital Organizations (PHO), Physician Medical Groups (PMG), behavioral health organizations and similar provider organizations or groups. Aetna pays these organizations, which in turn may reimburse the physician, provider organization or facility directly or indirectly for covered services. In such arrangements, the group or organization has a financial incentive to control the cost of care.

One of the purposes of managed care is to manage the cost of health care. Incentives in compensation arrangements with physicians and health care providers are one method by which Aetna attempts to achieve this goal.

Producer Transparency

Disclosure of a Financial Interest in the Sale of Health Insurance Policies (PDF)

Claim reimbursement examples

The claim reimbursement examples (PDF) has examples of average submitted charges and allowances for commonly billed voluntary out-of-network services. Actual charges and costs may vary. Follow the steps on this page to obtain a price estimate for any planned out-of-network covered services.

Out-of-network exceptions

You can ask for an exception to have an out-of-network service treated as a network benefit when:

a network provider with the needed training or expertise is not available for your condition; or
a participating provider is not accessible.

You or your provider must get pre-approval (pre-cert) from Aetna for the services to be covered. You or your provider can call the precert number on your identification card to start the process.

Note: Doctors, chiropractors and podiatrists must inform you of certain financial interests.

The laws of the State of New Jersey, at N.J.S.A 45:9-22.4 et seq., mandate that a physician, chiropractor or podiatrist who is permitted to make referrals to other health care providers in which she/he has a significant financial interest inform his or her patients of any significant financial interest he or she may have in a health care provider or facility when making a referral to that health care provider or facility. If you want more information about this, contact your physician, chiropractor or podiatrist. If you believe that you are not receiving the information to which you are entitled, contact the Division of Consumer Affairs in the New Jersey Department of Law and Public Safety at 1-973-504-6200 OR 1-800-242-5846.

Extension of benefits

A subscriber or dependent may be eligible for continued coverage under the Aetna benefits plan if the subscriber's plan would otherwise terminate but the plan includes a provision for continued coverage for total disability and the subscriber or dependent initiates a request for continued coverage by contacting Aetna Member Services.

The individual who is totally disabled must meet the extension eligibility requirements on the date that coverage would otherwise end.

If the request for continued coverage is approved, the continued coverage applies only to the individual who is disabled and not to other family members. In addition, the terms of coverage at the time of the approved extension remain in effect and the continued coverage would be subject to all plan provisions and limitations.

The following forms must be completed and submitted to Aetna Member Services for consideration. The mailing address appears on the forms.

Request for extension of benefits due to total disability (PDF) — This form requires a statement from the treating practitioner(s) supporting the request.

Handicapped child/behavioral health attending physician's statement (PDF) — For behavioral health conditions in children and adults, and medical conditions in dependents age 18 and younger.

Adult medical attending physician's statement (PDF) — For medical conditions in adults.

Present on Admission indicator code

Effective 10/1/2008, Present on Admission (POA) indicator codes will be required for determining appropriate DRG (Diagnosis Related Grouping) assignment and thus pricing. The code is required for both Commercial and Medicare lines of business. A POA code is a code used to indicate if the corresponding diagnosis was present at the time of admission. A POA code is required for all primary and secondary diagnosis codes; however a POA code is not needed for the admitting diagnosis code. Refer to the below for a list of POA indicator codes.

Value in the POA - Field Meaning

Y - Diagnosis was present at the time of inpatient admission.
N - Diagnosis was not present at the time of the inpatient admission.
U - Documentation insufficient to determine if condition was present at the time of inpatient admission.
W - Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of the inpatient admission.
1 or Spaces Unreported/not used - Exempt from POA reporting.

Health insurance carriers must inform subscribers about organ and tissue donation and registration

Health insurance carriers are now required to provide subscribers written informational materials about organ and tissue donation and registration at each contract renewal. These materials must:

Be developed or approved by a federally designated organ procurement organization; and
Inform subscribers on how to make an anatomical gift, including information on the registration of a gift in the Donate Life New Jersey registry.

Organ and tissue donation and registration – English (PDF)

Organ and tissue donation and registration – Spanish (PDF)

State-specific information about your insurance plan

Legal notices

Also of interest: