FLORIDA HMO Plan FAQs

What is an HMO?
A Health Maintenance Organization (HMO) is a health plan that requires a participant to have a primary care physician (PCP) from which all services are received. To see a specialist, you will need to obtain a referral from your PCP.

How do I find a primary care physician?
To find a primary care physician (PCP) you can call Aetna at (877) 402-8742 or visit www.aetna.com. On Aetna's website, select Find a Doctor; enter your search criteria; under Provider Type select Primary Care Physician; under Plan select HMO under Aetna Standard Plans .

How do I access the mental health and prescription benefits through Aetna?
To access a mental health provider through Aetna you will need to contact Aetna at (800) 424-5928. To locate network pharmacies you can either call Aetna at (877) 402-8742 or visit their website at www.aetna.com. On Aetna's website, select Find a Doctor; enter your search criteria; under Provider Category select Pharmacy/Vision/Hearing; on the Provider Type drop down menu select Pharmacy Locations ; under Plan select General Card Programs.

How do I designate a primary care physician?
You will have a chance to designate a primary care physician when you first enroll in the HMO plan during Benefits Enrollment as a new hire or during Open Enrollment.

Can Aetna auto assign me a primary care physician?
No. You have to choose a Primary Care Physician upon enrolling in the HMO Medical Plan.

Can each member of my family have a different primary care physician?
Yes, each member of your family may have a different primary care physician in a different medical group.

How often can I change primary care physicians?
You may change your Primary Care Physician as often as you like. The change goes into effect immediately which allows you to see your new Primary Care Physician right away. You will need to notify Aetna of the change by calling their member services line at: 1-877-402-8742 or by going on their website at: www.aetna.com

How do I access a specialist under the HMO plan? 
Your PCP will refer you to someone they always refer to who they have developed a relationship with or may refer you to someone upon your requests. You can only be referred to a specialist that is within the Aetna HMO network. Make sure that your PCP is referring you to a specialist that is within the Aetna HMO network.

For mental health and substance abuse treatment, you do not need a referral from your PCP. Contact Aetna directly for a referral to a therapist who has contracted with Aetna Health Plans. The telephone number is (800) 424-5928. It also will be on your ID card.

In Addition, dermatology, podiatry and chiropractic treatment you do not need a referral from your PCP. However, the provider must be a participant of the Aetna HMO network.

Can I self refer to an OB-GYN of my choice for my annual well woman exam?
You do not need a referral from your PCP for your annual well-woman exam or for any obstetrical or gynecological care. The provider does not need to be within the same medical group as your PCP but make sure the provider is a participant of the Aetna HMO Network.

Do I have to see a provider with Aetna?
Yes. No benefits will be received if you go outside of the HMO network.

Is there a deductible with the HMO plan?
No, you do not have to meet a deductible before services will be covered through the HMO plan.

Is there a co-pay?
Yes, most services received through the HMO plan require a $15 co-pay at the time of the service. Outpatient surgery and inpatient hospital services are covered at 100%; emergency room visits cost $100 per visit. Unlike the PPO plan, you should not receive any bills with the HMO plan.

What should I do if I need emergency service?
If you have a life threatening injury or condition, proceed to the nearest emergency facility or call 911. If a delay would not be detrimental to your health, call your PCP or notify your PCP as soon as possible after receiving treatment. If you are admitted to an inpatient facility, you or a family member or friend on your behalf should notify your PCP or Aetna as soon as possible. For urgent care, you need to go to an urgent care facility in your PCP's participating medical group or call your PCP for a referral. Any follow up care after an emergency or urgent care visit must be coordinated by your PCP.

What is considered an emergency vs. urgent care?
An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the heath of the individual in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. Examples of an emergency illness or injury are: serious breathing difficulties, unconsciousness, uncontrollable bleeding, sudden onset of chest pain, major burns, seizures, etc. When you are in need of emergency care, go to the nearest emergency facility or call 911.

An urgent medical condition is one for which care is medically necessary and immediately required because of unforeseen illness, injury, or condition, and it is not reasonable, given the circumstances, to delay care in order to obtain the services through the member's PCP.

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When will I receive my medical card, and will it be in my name?
You should expect to receive your medical card within two weeks. Your medical card will include your name and the name of any dependents covered under your plan if they are in the same medical group as you. If you have dependents who have a PCP in a different medical group than you, they will receive their own cards.

Your card is to be used for medical, mental health, and prescription services only. To obtain a card for Delta Dental you will need to log onto their website to print a card. You will not need a card for VSP.

How do I order extra/replacement insurance cards?
To order extra or replacement cards you can contact Aetna at (877) 402-8742 or log onto their website and print out a card.

Do I use the ID number on the medical card or my Social Security number?
You will use the ID number on your medical card for medical, mental health, or prescription services. This ID number is generated by Aetna and is different than your TSRI ID number.

How can I find out what services are covered?
To find out what services are covered you can contact Aetna at (877) 402-8742 or contact your Primary Care Physician. You may also consult Aetna's Evidence of Coverage for more information.

I currently see a private practice therapist for my mental health.  Will I be able to continue to see this provider under the HMO?
Aetna has Transition of Coverage Request forms which you should submit directly to Aetna to apply for continuation of treatment with your existing therapist within the first 90 days of coverage through the Aetna HMO. Aetna commonly approves a temporary continuation of treatment with your existing therapist, provided the therapist agrees to accept Aetna’s normal level of reimbursement. 

Transition of Care is also available for completion of covered services for pregnancy, acute conditions, terminal illnesses and chronic medical conditions.

What is the prescription drug formulary?
A preferred drug list or formulary is a list of prescription medications generally covered under the pharmacy benefit plans subject to applicable limits and conditions. Aetna’s formulary includes brand-name and generic drugs that have been approved by the FDA as safe and effective.

A preferred drug list or formulary helps provide access to quality, affordable prescription drug benefits. Drugs chosen for the formulary have gone through an extensive review process. The formulary selection process is structured so that there are internal and external physicians and pharmacists offering clinical input about the medications under consideration. The drugs listed on the preferred drug list either represent an important therapeutic advance, or are clinically equivalent and possibly more cost-effective than other drugs not on the preferred drug list.

How do I determine what tier copay my prescriptions will be covered under?
You may look up your particular medications to see what copay will apply by going to www.aetna.com.  Under Shortcuts, click on “Look up a drug”.  This will bring you to a screen called Plan Selection. Click on the box labeled Non-Medicare Plans. Then use the drop down box under number 1 and select Three Tier Open Formulary and click submit.  A screen called Preferred Drug (Formulary) List Information will open.  You may then click on Medication search.  On the next page you will be able to type in the name of the medication and click on Submit Search.

The search will bring you to information on your particular medication.  Your copay will be based on what tier your medication falls.  Tier one is a $10 copay, tier two is a $25 copay and tier three is a $50 copay.  This screen will also tell you if your particular medication requires precertification, step therapy or quantity limits.  It will also provide generic alternatives if the medication is a brand name.

How can I save money on my prescriptions?
You can save money by using generic drugs when available and by utilizing those that are on the formulary. You can also save money by using the mail order program. For more information regarding the mail order program visit www.aetna.com or call Aetna at (877) 402-8742.

Who can I add to my medical plan?
Employees eligible for any medical plan can add their spouse or domestic partner (Affidavit of Domestic partnership must be completed) and child(ren). Grandparents, parents and siblings are not eligible to be covered on the plan.

When can I add/drop a dependent from my insurance?
You may add or drop a dependent within 31 days of your date of hire or date you become benefit eligible; within 31 days of a qualified status change such as a birth of a child, marriage, divorce, dependent gaining or losing other coverage, etc.; or during Open Enrollment.

To add or drop a dependent from your medical and/or dental insurance due to a qualified status change, you need to complete and submit a Benefits Coverage Change Form along with proof of dependency and/or proof of status change. The form needs to be turned into Benefits within 31 days of a status change. If the form is received after 31 days, you will have to wait until Open Enrollment to make your change.