Step 1 of 2: Medical profile   Gender Date of birth Height Weight Smoker? Applicant* M F / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Spouse -- M F / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children 0  1 2 3 4 5 6         Children -- M F   / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children -- M F   / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children -- M F   / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children -- M F / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children -- M F   / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children -- M F   / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Currently Insured?* Yes No Have conditions?* yes   no Please specify  Take medications?* yes   no Please specify  Step 2 of 2: Tell us about yourself First Name* Last Name* Address* City* State* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip* Day Phone* Evening Phone* Contact Time* Morning Afternoon Evening Email* By submitting this form, you agree to be legally bound to, and abide by, the Privacy Policy.

Small Group POS Providers

Quality Point-of-Service(QPOS®)
QPOS gives your employees the option to access care with or without a referral. To access care with a referral, your employees will be charged a copayment when their PCP provides care or makes referrals to specialists or hospitals if necessary. To access care without a referral, your employees can go to any licensed provider for covered benefits but will pay more of the cost through deductibles and coinsurance.

Aetna Choice™POS
Aetna Choice POS gives your employees a little more freedom than the QPOS plan by eliminating referrals. Members are not required to use a PCP to coordinate their care and have the freedom to access care from any network physician without a referral. Higher copay for office visits may apply for members who do not have a PCP or go directly to another network provider. If your employees go to an out-of-network provider, they will pay more of the cost through deductibles and coinsurance, just as in the QPOS plan.

Managed Choice®
Managed Choice members select a PCP to coordinate care. Your employees will pay a copayment when they receive care from their PCP or when referrals are made for covered services. They can also go directly to any licensed provider for covered benefits without a referral, but will have to pay more of the cost through deductibles and coinsurance.

Open Access Managed Choice
Open Access Managed Choice is just like the Managed Choice plan but without referrals. Members are not required to use a PCP to coordinate their care and have the freedom to access care from any network physician without a referral. Members pay a specialist copay when going directly to another network provider. If your employees go to an out-of-network provider, they will pay more of the cost through deductibles and coinsurance, just as in the Managed Choice plan.

USAccess®
The USAccess plan combines freedom of choice and cost control for your employees. For lower out-of-pocket costs, members can receive care within the network under the coordination of their PCP and pay a copay for each office visit. In addition, they can go directly to specialists or hospitals within the network without a referral and pay a higher copay. Finally, they can visit an out-of-network provider and pay more of the cost through deductibles, coinsurance, and benefit limitations.

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