The Platinum Plan is a network plan that gives you the freedom to select any licensed provider when you need care. It provides the highest level of benefits. This plan offers both in-network and out-of-network benefits; however, the plan’s reimbursement is higher when you use an in-network provider.
Under the Platinum Plan, you may receive care from any licensed health care provider. You are not required to select a primary care physician (PCP) and no referrals are required for specialty care. When you need care, simply choose the appropriate doctor and make an appointment.
The Platinum Plan has two levels of benefits:
- In-Network Benefits - When you use in-network providers, you pay a fixed dollar amount, called a copayment (or copay), for doctor’s office visits and routine exams. For other services, you pay a lower deductible and the plan pays a larger share of your expenses. In addition, the in-network provider files claims for you and takes care of the plan’s precertification requirement(s) for hospital admissions.
- Out-of-Network Benefits - If you use an out-of-network provider, you will receive a lower level of benefits and you must meet a higher deductible. The plan pays a smaller share of your expenses. In addition, you must file your own claims and call Aetna when your doctor recommends care that must be precertified.
While you are free to use any provider, you save money when you use in-network providers. If your doctor refers you to another provider (such as a specialist), be sure to ASK if the provider belongs to the network. If he or she doesn’t, benefits will be paid at the lower, out-of-network level AND only up to what Aetna determines to be the reasonable charge for the service. You’ll be billed for any amount that exceeds the reasonable charge.
The Aetna Network
The Aetna Choice network is large and comprehensive. It consists of primary care physicians and specialists ranging from cardiologists, podiatrists, and OB/GYNs to oncologists, ophthalmologists, and orthopedists. Facilities such as hospitals, urgent care centers, and labs also belong to the network. To find preferred providers near you, visit www.aetna.com.
Prescription Drug Benefits - Express Scripts
When you enroll in one of the Aetna medical plan options, you’ll automatically have prescription drug coverage through Express Scripts. This program includes a Formulary Management Program that uses a “four-tier” copayment approach to covered drugs and is designed to control cost for you and the plan. Click here to learn more about prescription benefits.
Female and male fertility treatment and care will be covered subject to the deductible and coinsurance in all three medical plans. There is a limitation of 3 attempts/live birth up to a lifetime maximum benefit of $50,000.
Is the Platinum Plan Right for Me?
You should choose the Platinum Plan if:
- You want great protection but do not want to pay the highest monthly premium.
- Are willing to pay modest copays for most services
- Are willing to pay the deductible and coinsurance for more expensive services like hospitalization and MRI's
- You need open access to any licensed health care provider.
- You are open to controlling your health care costs by using in-network providers and receiving higher benefits.
- You want to be able to visit specialists without getting referrals from a PCP.
Review your claims and expenses for the previous year at www.aetna.com. (login required). Reviewing your medical expenses may help you determine the coverage that is best for you and your family.
Platinum Plan Resources
- Aetna Platinum Plan - Summary of Benefits and Coverage - 2022
- Aetna Platinum Plan - Summary of Benefits and Coverage - 2023
- Benefit Summary
- Platinum SPD
- Platinum Schedule of Benefits
Federal Transparency in Coverage Rule
The link below leads to the machine readable files that are made available in response to the federal Transparency in Coverage Rule and includes negotiated service rates and out-of-network allowed amounts between health plans and healthcare providers. The machine-readable files are formatted to allow researchers, regulators, and application developers to more easily access and analyze data.