Aetna Plan Overview
Aetna is a major health insurer serving over 23 million members across the United States. In 2018, CVS Health acquired Aetna, creating one of the largest healthcare companies in America. This merger affects how pharmacy benefits and medical coverage work together for Aetna members.
For joint pain patients, Aetna offers coverage through several plan types:
- Employer-sponsored plans (PPO, HMO, POS)
- Individual marketplace plans (ACA/Obamacare)
- Medicare Advantage plans (for those 65+)
- Medicaid managed care (in select states)
Coverage for knee injections and joint treatments varies by plan. This guide explains what Aetna covers, what you will pay, and how to get approved.
What Treatments Does Aetna Cover?
Quick Coverage Summary
| Treatment | Covered? | Prior Authorization |
|---|---|---|
| Hyaluronic acid (gel shots) | Yes | Required |
| Cortisone injections | Yes | Usually not required |
| Physical therapy | Yes | Varies by plan |
| PRP injections | No | N/A |
| Stem cell therapy | No | N/A |
Hyaluronic Acid Injections (Gel Shots)
Aetna covers most FDA-approved hyaluronic acid products for knee osteoarthritis. Popular brands include Synvisc-One, Euflexxa, Gel-One, and Supartz. Your provider must get approval before treatment.
Coverage requirements:
- X-ray or MRI confirming knee osteoarthritis
- At least 3 months of failed conservative care (PT, medications)
- Documented pain and functional limitation
- You are not ready for or want to avoid knee replacement
Learn more: Hyaluronic Acid Injections Guide
Cortisone Injections
Aetna covers cortisone (corticosteroid) injections for joint pain and inflammation. These shots typically do not require prior authorization. Your doctor can provide them during a regular office visit.
Coverage requirements:
- Medical necessity documented
- Appropriate diagnosis (arthritis, bursitis, tendinitis)
Physical Therapy
Physical therapy is covered under most Aetna plans. However, visit limits vary significantly:
- Some plans cover 20-30 visits per year
- Other plans have no set limit if medically necessary
- In-network providers cost less than out-of-network
Check your specific plan documents or call member services to confirm your PT benefits.
What Aetna Does NOT Cover
- PRP (Platelet-Rich Plasma): Aetna considers PRP experimental and investigational
- Stem cell injections: Not covered under standard policies
- Prolotherapy: Considered experimental
These treatments require full out-of-pocket payment.
The Precertification Process
Aetna calls prior authorization “precertification.” For hyaluronic acid injections, your provider must get approval before your treatment.
How Precertification Works
Includes your diagnosis, imaging results, and treatment history
Checks if you meet their clinical policy criteria
Urgent requests may be processed faster
Authorization is valid for a specific time period
Documentation Your Doctor Needs
- Imaging reports: X-rays showing joint space narrowing or bone spurs
- Treatment records: Dates and outcomes of PT, medications, and other treatments
- Pain assessment: Scores and descriptions of how pain affects your daily life
- Medical necessity letter: Statement explaining why HA injections are appropriate
For detailed guidance, read our Prior Authorization Guide for Gel Injections.
Step Therapy Requirements
Aetna may require you to try other treatments before approving hyaluronic acid injections. This is called “step therapy.”
Typical Step Therapy Progression
Step 1: Conservative Care (3+ months)
- Over-the-counter pain relievers (acetaminophen, ibuprofen)
- Physical therapy
- Weight management
- Activity modification
Step 2: Prescription Options
- Stronger NSAIDs
- Topical treatments
- Cortisone injection(s)
Step 3: Viscosupplementation
- Hyaluronic acid injections approved after steps 1-2 fail
Important: Keep records of all treatments you have tried. Aetna will want to see proof that conservative care did not provide adequate relief.
Understanding Your Costs
What You Will Pay
Your out-of-pocket costs depend on your specific Aetna plan. Here are typical ranges:
| Cost Type | Typical Amount |
|---|---|
| Office visit copay | $30-$75 |
| Specialist copay | $40-$100 |
| Coinsurance | 20-40% after deductible |
| Annual deductible | $500-$3,000+ |
| Out-of-pocket maximum | $3,000-$9,100 |
Factors That Affect Your Cost
- Plan type: PPO, HMO, and high-deductible plans have different cost structures
- Network status: In-network providers have negotiated lower rates
- Deductible status: Services before meeting your deductible cost more
- Specific HA product: Some plans have preferred brands
In-Network vs. Out-of-Network
Using an in-network provider can save you hundreds of dollars:
- In-network: Lower copay, negotiated rates, no balance billing
- Out-of-network: Higher costs, separate deductible, balance billing possible
Tip: Always verify a provider is in your Aetna network before scheduling treatment.
CVS Health and Pharmacy Benefits
Since the CVS-Aetna merger, your pharmacy benefits may be managed through CVS Caremark. For injectable medications like hyaluronic acid:
- Some plans require the HA product to come from a specialty pharmacy
- CVS specialty pharmacy may provide the medication to your doctor
- This can affect which HA brands are covered or preferred
Ask your Aetna plan about any specialty pharmacy requirements.
The Appeals Process
If Aetna denies your request for coverage, you have the right to appeal.
Common Denial Reasons
How to File an Appeal
Step 1: Review Your Denial Letter
- Understand the specific reason for denial
- Note the deadline for filing an appeal (usually 60-180 days)
Step 2: Gather Supporting Documents
- Complete medical records
- All imaging reports
- Records of every treatment tried
- Letter from your doctor explaining medical necessity
Step 3: Submit Your Appeal
- Mail or fax to the address on your denial letter
- Include a clear explanation of why you believe coverage should be approved
- Attach all supporting documents
Step 4: Request Peer-to-Peer Review
- Your doctor can speak directly with an Aetna medical director
- This often resolves issues faster than written appeals
Step 5: External Review (If Needed)
- If Aetna denies your internal appeals, you can request an independent external review
- Contact your state insurance commissioner if you need additional help
Tips for a Successful Appeal
Key Takeaways
Aetna Coverage Summary
What Aetna covers:
- Hyaluronic acid injections (with precertification)
- Cortisone shots
- Physical therapy
What you need for approval:
- Imaging confirming osteoarthritis
- 3+ months of failed conservative treatment
- Documentation of pain and functional limitation
What to do next:
- Call Aetna member services to verify your specific benefits
- Confirm your provider is in-network
- Make sure precertification is obtained before treatment
- Keep records of all treatments you have tried
- Appeal if denied (many denials are overturned)
Find Providers Who Accept Aetna
Locate in-network specialists who can help with knee injections and joint pain treatment.
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We've received your request. A provider specialist will contact you within 1-2 business days to help you find the right care.
What happens next?
- 1 We'll verify your insurance coverage
- 2 Match you with quality providers in your area
- 3 Contact you to discuss your options
Questions? Browse our guides:
How to Choose a ProviderHelpful Resources
Contact Aetna
- Member Services: Call the number on your Aetna ID card
- Online: Log in at aetna.com to check benefits
- Mobile App: Download the Aetna Health app for benefit details
Related Guides
- Hyaluronic Acid Injections: Complete Guide
- Prior Authorization for Gel Injections
- Medicare Coverage for Knee Injections
- UnitedHealthcare Coverage Guide
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This guide provides general information about Aetna coverage policies. Your specific benefits may vary based on your plan. Always verify coverage with Aetna before receiving treatment.