AETNA – PPO First Dollar 30 – ARIZONA

A comparison of the PPO First Dollar 30 offered by AETNA is detailed out below for both Network and Non-Network coverage.

• Compare to other AETNA plans.

• Compare to all carriers in ARIZONA.

	Network	Non-Network
Network	See Provider	See Provider
Application	PPO First Dollar 30 Application	PPO First Dollar 30 Application
Brochure	PPO First Dollar 30 Brochure	PPO First Dollar 30 Brochure
Copay	Non-specialist Office Visit: $30 Copay, Specialist Visit: $40 Copay	Non-specialist Office Visit: 50% after deductible, Specialist Visit: 50% after deductible
Office Visit	Non-specialist Office Visit: $30 Copay, Specialist Visit: $40 Copay	Non-specialist Office Visit: 50% after deductible, Specialist Visit: 50% after deductible
Deductible	Individual: $0, Family: $0	Individual: $5,000, Family: $10,000
Coinsurance	70% up to out of pocket max. $0 once out of pocket max is satisfied.	50% after deductible up to out of pocket max. $0 once out of pocket max is satisfied.
Coinsurance Limit	Individual: $7,500, Family: $15,000	Individual: $7,500, Family: $15,000
Out-of-Pocket Maximum	(Deductible included) Individual: $7,500, Family: $15,000	(Deductible included) Individual: $12,500, Family: $25,000
Lifetime Maximum	$5,000,000 (Maximum applies to combined in and out of network benefits)	$5,000,000 (Maximum applies to combined in and out of network benefits)
Prescription Drugs	Pharmacy Deductible per individual: $500 (does not apply to generic), Generic (Oral Contraceptives Included): $15 copay deductible waived, Preferred Brand (Oral Contraceptives Included): $40 copay after deductible, Non-Preferred Brand (Oral Contraceptives Included): $60 copay after deductible, Calendar Year Maximum per individual (Maximum applies to combined in and out-of-network benefits): Unlimited.	Pharmacy Deductible per Individual (does not apply to generic): $500, Generic (Oral Contraceptives included): $15 copay plus 50% deductible waived, Preferred Brand Name (Oral Contraceptives included): $40 copay plus 50% after deductible, Non-Preferred Brand (Oral Contraceptives included): $60 copay plus 50% after deductible, Calendar Year Maximum per individual (Maximum applies to combined in and out-of-network benefits): Unlimited.
Emergency Room	$100 copay (waived if admitted) 70% coinsurance after deductible	$100 copay (waived if admitted) 70% coinsurance after deductible
Adult Preventative Care	Annual Routine Gyn Exam (Annual Pap/Mammogram): $0 copay, Routine Physical: $30 copay Aetna will pay up to $200 per exam (includes lab work and X-rays).	50% after deductible (Age and frequency schedule apply).
Child Preventative Care	$30 copay (Age and frequency schedule apply).	50% after deductible (Age and frequency schedule apply).
Lab / X-Ray	70%	50% after deductible
Maternity	Not covered (except for pregnancy complications)	Not covered (except for pregnancy complications)
Physical Therapy	Physical/Occupational Therapy and Chiropractic Care: 70% (24 visits per calendar year, Aetna will pay up to $25 per visit max) maximum applies to combined in and out-of-network benefits.	Physical/Occupational Therapy and Chiropractic Care: 50% after deductible (24 visits per calendar year, Aetna will pay up to $25 per visits max) maximum applies to combined in and out-of-network benefits.
Skilled Nursing	70% (in lieu of hospital) 30 days per calendar year maximum applies to combined in and out-of-network benefits.	50% after deductible (in lieu of hospital) 30 days per calendar year maximum applies to combined in and out-of-network benefits.
Home Health Care	70% (in lieu of hospital) 30 visits per calendar year maximum applies to combined in and out-of-network benefits.	50% after deductible (in lieu of hospital) 30 visits per calendar year maximum applies to combined in and out-of-network benefits.
Mental Health	Not covered except for severe, biologically based mental or nervous disorders and associated treatment of drug and alcohol dependencies.	Not covered except for severe, biologically based mental or nervous disorders and associated treatment of drug and alcohol dependencies.
Hospital Care	Hospital Admission: 70%, Outpatient Surgery: 70%	Hospital Admission: 50% after deductible, Outpatient Surgery: 50% after deductible
Optional Benefits	Individual Dental PPO Max Plan	Individual Dental PPO Max Plan