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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.
| 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 (does not apply to generic)- $500. Generic (Oral Contraceptives included)- $15 copay deductible waived. Preferred Brand Name (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. Preventive Health (Routine Physical)(Aetna will pay up to $200 per exam)- $30 copay. | 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- 70% ($25 Max per visit- 24 visits per calendar year, Maximum applies to combined in and out of network benefits). | Physical/Occupational Therapy and Chiropractic- 50% after deductible ($25 Max per visit- 24 visits per calendar year, 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 |
