Medical & Prescription Benefits

Medical Plan Summaries

Important Links

ID Cards

Important Phone #s

Aetna: 1-800-370-4526
Aetna Precertification (for Providers): 1-888-632-3862
Express Scripts: 1-800-467-2006
Express Scripts Home Delivery: 1-800-698-3757
Express Scripts Prior Authorization (for Providers): 1-800-753-2851
Accredo Specialty Pharmacy: 1-800-803-2523
SaveOn SP: 1-800-683-1074
Teladoc: 1-855-835-2362
Guardian Nurses: 609-472-3273 or 609-472-1797

Now What?

I need help finding an in-network Doctor or Hospital.

Aetna’s provider directory is available online 24/7/365 at www.aetna.com. Members can log in and locate participating providers under your plan. If a member is having issues they may contact Aetna member services at 1-800-370-4526 or AssuredPartners at lgbenefits@assuredpartners.com for further assistance.

My upcoming procedure has been denied.

Only your provider can prove medical necessity and provide the necessary details to back up why you need a certain procedure. The letter received from Aetna showing the procedure has been denied will include detailed information as to why. This information will be helpful in assisting your provider in working with Aetna. Your provider will need to speak to Aetna’s Prior Authorization Department at 1-888-632-3862. Approvals may take up to 14 business days but are typically responded to within 3 business days. If you are having trouble with an approval, please reach out to AssuredPartners at lgbenefits@assuredpartners.com. AP will not be able to get the procedure approved or expedited but we can check on the status, confirm reason for denial, and assist in providing your doctor with what would be needed to get this approved.

I got a bill from the provider, I thought I was covered 100%.

There can be a number of things that go wrong between your date of service and receiving an invoice. The first thing you want to do is compare your invoice to the Explanation of Benefits (EOB) received from Aetna. It will include information on the claim including the member’s responsibility.

If the Invoice and EOB do not match: You can call Aetna member services at 1-800-370-4526 for claims assistance. If you are not able to resolve your issue directly with Aetna, please reach out to lgbenefits@assuredpartners.com for assistance.

If there is no EOB: Check to make sure the provider has your insurance information by calling the billing number on the invoice. It is possible that they did not submit it at all due to missing this information. If they confirm they have the insurance and it was submitted it is possible Aetna is still processing the claim. You can contact Aetna member services at 1-800-370-4526 to confirm they have the claim and current status. If there are further issues, please reach out to lgbenefits@assuredpartners.com for assistance.

If the Invoice and the EOB match but you do not agree with the outcome: Please reach out to lgbenefits@assuredpartners.com for assistance.

I’m at the pharmacy and they said my prescription was not covered.

9 times out of 10 a pharmacy will advise a medication was not covered and will provide no context as to why which leaves the member feeling frustrated and confused. A member does have the ability to pay for the prescription out of pocket and return to the point of sale within 10 days to get a full refund, minus any applicable copays.

Some drugs do require prior authorization. Only your prescribing doctor can get a drug approved. Please ask your provider to call Express Scripts Prior Authorization line at 1-800-753-2851 for assistance. Please note authorizations are only good for one year and a new authorization will be need to be obtained annually if it is part of your continued treatment plan.

Sometimes the issue can be as small as user error. Confirm personal information like ID # and date of birth are accurate.

If you are still having an issue with a prescription please reach out to AssuredPartners at lgbenefits@assuredpartners.com. Remember: We cannot get a drug that requires approval approved but we can look further into the issue and help guide a prescribing doctor to approval.

How do my out-of-network benefits work?

Always remember if you go out-of-network you can be balance billed. We will always encourage members to go in-network whenever possible but understand sometimes you have to venture outside of the network.

When you go out-of-network you first have to meet the out-of-network deductible. Once you have satisfied your deductible for the calendar year, the plan will pay a portion and you will be responsible for the remaining balance. The portion the plan pays is called coinsurance. For specific plan deductible and coinsurance information please refer to your plan’s summary linked above.

Out-of-network benefits do have an annual maximum. Once that maximum is hit, the plan will pay 100% for the remaining calendar year. Refer to your plan summary for plan maximum specifics.

Please keep in mind, Aetna will process the out-of-network claim based on the allowed amount and depending on the amount the provider charges, this may be less than billed. The difference between the allowed amount and billed amount is considered non-reimbursable.

The Allowed Amount is the maximum amount a plan will pay for a covered health care service. For Non-Network Providers, the claims administrator may use different sources to calculate the reimbursement for services including industry resources provided by entities such as FAIR Health, the Centers for Medicare & Medicare Services (CMS) and other databases. The plan administrator uses these fee schedules to calculate a reimbursement allowance that corresponds to your plan’s non-network benefits, taking into account your coinsurance, copayment, non-network deductible or any other member out of pocket costs that apply to the claim.

Typically when you see an out-of-network provider, you will be required to submit the claim manually to Aetna. You can do this right on you Aetna Member portal by logging in at http://www.aetna.com. Please include a copy of the completed claim form and a copy of your itemized claim. If you already paid, you can also include the paid receipt. Claim payment will be sent directly to you via check from Aetna. You can then use this to pay the provider or reimburse your wallet.

Aetna Medical Claim Form

I don’t feel well but I cannot get an appointment with my doctor and it’s not pressing enough for an urgent care or emergency room visit.

Why not try telemedicine? You can reach out to Teladoc at 1-855-835-2362 or online at www.teladoc.com/Aetna. You can easily setup a virtual appointment and chat live with a doctor via video from the comfort of your own home.

I am looking for additional support and guidance but would prefer it came from a medical professional.

Guardian Nurses are available to members and their covered dependents free of charge. They can be reached at 609-472-3273 or 609-472-1797. Guardian Nurses can help with:

Visit you at home or in the hospital to assess your care needs.
Be your guide, coach, and advocate for any healthcare issue.
Make appointments so you can be seen as quickly as possible.
Go with you to see doctors, to ask questions, and to get answers.
Identify providers for all care needs and second opinions.
Get things you need such as healthcare equipment.
Provide decision support when considering treatments or surgery.
Explain a new diagnosis to help you make informed decisions.

Does our plan offer any gym discounts?

Aetna’s offers gym discounts through Husk Wellness (formerly known as GlobalFit).
Husk Wellness: 800-294-1500
https://marketplace.huskwellness.com
Participation in Husk Wellness is for new gym members only. Membership to a gym of which members are already signed up for, or were recently members of, may not be available.
Members may also log in to the Aetna Portal and click on Health Programs for more information on what Aetna offers.