HMO Plan - California


**As of January 2021**    
Aetna HMO Network

P.O. Box 14079
Lexington, KY 40512-4079
Group #: 805400

Member Services - (877) 869-4077
Behavioral Health -    (800) 424-4047 
Pharmacist Services- (800) 238-6279


Prescription Information:                                                                                        RX BIN = 610502                                                                                                  Rx PCN = 00670000                                                                                        Group# = 0805400-017-00001                                                                          www.aetna.com

**NOTE: As of January 2021 Prescription coverage will move from IngenioRx to Aetna Rx. Click here for additional information.


A Health Maintenance Organization (HMO) medical plan is is available to employees, Research Associates, External Graduate Students and their dependents in Florida. TSRI Graduate Students are not eligible for this plan. The network of providers is Aetna Value Network HMO. To search for a primary care physician (PCP), click on Aetna Network of Providers or call Aetna member services at (877) 869-4077.

An HMO plan requires the employee to designate a primary care physician (PCP) who will coordinate all care received including providing referrals to specialists. Prescriptions and Mental Health services are also provided through the HMO plan. Vision services are provided separately through MES Vision.

The chart below outlines the main provisions of the HMO medical plan.

Medical Coverage
Outpatient Services
Annual Deductible: waived for preventive care and office visits $100 per person
$200 per family
Out-of-Pocket Max $2500 per person
$5000 per family
PCP Office Visits/Specialist Office Visit $30 co-pay/$40 co-pay
Outpatient Surgery 90% after deductible
Diagnostic Lab/Diagnostic X-ray 100% covered/$40 co-pay X-Ray/$150 co-pay Complex X-Ray
Inpatient Services
Urgent Care $50 per visit
Emergency Room $100 co-pay after deductible
Inpatient Hospital Charges 90% after deductible
Other Services
Well Baby Care 100% covered
Adult Periodic Exams 100% covered
Well Woman Exams 100% covered
Immunizations 100% covered
Chiropractic Care $15 co-pay; 20 visits/year
Acupuncture None

Prescriptions Retail (30 day supply) Mail Order (90 day supply)
Rx Deductible $100/person, $200/family (applies to brand formulary and non-formulary drugs only)
Generic $10 $20
Brand Name $35 $70
Non-Formulary $60 $120

Mental Health Coverage
Inpatient Care 90% after deductible
Outpatient Care $30 co-pay

Alcohol & Substance Abuse Coverage
Inpatient Hospitalization/ Detoxification 90% after deductible
Outpatient Services $30 co-pay