The Aetna Quality Point-of-Service Program (QPOS) offers all of
the comprehensive benefits of the Aetna HMO plan with the added freedom to
"self-refer" -- choose to use out-of-network providers or visit network doctors
without a Primary Care Physician (PCP) referral.
Aetna QPOS is available to City of New York employees and non-Medicare
retirees residing in:
New York (the five boroughs and the following counties: Dutchess, Nassau,
Orange, Putnam, Rockland, Suffolk, Sullivan, Ulster, and Westchester)
The entire states of Connecticut, Delaware, and New Jersey
A number of counties in Georgia, Maryland, Massachussetts, North
Carolina, Pennsylvania, and Washington, DC
You can keep your out-of-pocket expense to a minimum when you
see your PCP for routine care, and when he or she refers necessary specialty or
hospital care. Preventative care exams such as routine Adult Physical
Exams/Immunizations, Well-Child Exams/Immunizations are covered at
You also have the freedom to go directly to a PCP, specialist
or hospital for medically necessary care any time you wish, even out-of-network
providers. If you choose that route, you will be responsible for a coinsurance
amount of 20% of the customary and reasonable fee; and a deductible -- $250 for
those with the Individual plan; $750 for those with the Family plan.
Aetna will reimburse you the coinsurance amount of 80% of the customary and
reasonable fee. Once you have paid $2,500 in coinsurance on the Individual plan
or $7,500 on the Family plan, you will be reimbursed 100% of the customary and
reasonable fee for covered charges up to the annual maximum benefit of $250,000.
You are responsible for amounts charged in excess of customary and reasonable
Self-referred outpatient mental health care is covered at 50%
of the customary and reasonable fee.
Several benefits require that Aetna's precertification program
(phone number found on your Aetna ID card) be contacted in order to avoid a
substantial reduction in benefits for self-referred care. For example,
self-referred Durable Medical Equipment costs exceeding $1,500 must be
precertified; a planned self-referred hospital admission must be precertified at
least five days in advance.
Certain benefits are covered in-network only: routine
physicals; routine pediatric dental; routine GYN exams; infertility services;
and the special medical programs listed below.
Additionally, members have access to:
Aetna NavigatorTM, Aetna’s
member and consumer self-service website that provides a single source for
online health and benefits information 24 hours a day, 7 days a week at
www.aetna.com. Through Aetna Navigator, members can change their primary care
physician, replace an ID card, research Aetna’s products and programs, contact
Aetna directly and access a vast amount of health and wellness information.
Aetna Navigator also includes secure, personalized features for members who
register on the site including access to claim and benefit status. Additionally,
members can contact their designated member services team and customize their
home page to meet their individual health needs.
DocFind®, an online provider list located at
www.aetna.com; InteliHealth®, an online consumer health information network
located at www.intelihealth.com; and Informed Health® Line,a telephonic nurse
line available 24 hours a day, 7 days a week.
Aetna Special Medical Programs
Management -- Specific programs are aimed at slowing or avoiding
complications of certain diseases through early detection and treatment to help
improve outcomes and quality of life. The programs include Low Back Pain,
Asthma, Heart Failure and Diabetes.
The Moms-to-Babies™ Maternity Management Program -- A
management program to help identify at-risk pregnancies, which are given special
attention from nurse case managers.
Natural Alternatives™-- A discount program
that offers contracted discounted rates for alternative types of health care
(e.g., chiropractors [for chiropractic care not covered under the medical plan],
acupuncturists, massage therapists and nutritional counselors), all available
without a referral or precertification.
Vision One®Discount Program -- A program that
offers significant discounts on eye care needs, such as prescription eyeglasses,
contact lenses, non-prescription sunglasses, contact lens solutions and eye care
accessories. Members can call 1-800-793-8618 to find the Vision One® locations
nearest to them. This benefit is in addition to, not in place of, members’ union
welfare fund vision benefits.
An Optional Rider benefit is available
for prescription drug coverage with a three-tier copay structure: $10 for
generic drugs/30% for formulary drugs/50% for non-formulary drugs, mandatory
generic, 30-day supply, available at retail pharmacy. Mail Order Delivery
for prescription drugs is $20/30%/50% for a 31-90 day supply.
Maximum out-of-pocket expense of $3,000 individual/$9,000 family. Once
maximum is met there are no copays or coinsurance.
Please see rate chart for payroll and pension
See the rate page
For More Information
For more details,
refer to the City of New York/Aetna Commercial packet. To speak to a customer
service representative, call (800) 445-8742, 8:00 am - 6:00 pm, Monday through
Friday. You can send your questions in writing to:
99 Park Avenue
New York, NY 10016
Attention: City of New York
Visit the Plan Web site
Updated to reflect health plan changes effective January 1,