Aetna – PPO First Dollar 40 – KANSAS

A comparison of the PPO First Dollar 40 offered by Aetna is detailed out below for both Network and Non-Network coverage.

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	Network	Non-Network

Network	See Provider	See Provider
Application	PPO First Dollar 40 Application	PPO First Dollar 40 Application
Brochure	PPO First Dollar 40 Brochure	PPO First Dollar 40 Brochure
Copay	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): $40 copay (Unlimited visits); Specialist Visit: $50 copay (Unlimited visits)	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 50% after deductible (Unlimited visits); Specialist Visit: 50% after deductible (Unlimited visits)
Office Visit	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): $40 copay (Unlimited visits); Specialist Visit: $50 copay (Unlimited visits)	Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 50% after deductible (Unlimited visits); Specialist Visit: 50% after deductible (Unlimited visits)
Deductible	Individual: $0, Family: $0	Individual: $7,000, Family: $14,000
Coinsurance	60% 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: $12,500, Family: $25,000	Individual: $5,500, Family: $11,000
Out-of-Pocket Maximum	Individual: $12,500, Family: $25,000 (Includes deductible)	Individual: $12,500, Family: $25,000 (Includes deductible)
Lifetime Maximum	$5,000,000 per insured (Maximum applies to combined in and out-of-network benefits)	$5,000,000 per insured (Maximum applies to combined in and out-of-network benefits)
Prescription Drugs	Pharmacy Deductible: Not Applicable; Generic (Oral Contraceptives Included): $20 copay; Preferred Brand (Oral Contraceptives Included): Not covered (Aetna Discount Applies); Non-Preferred Brand (Oral Contraceptives Included): Not covered (Aetna Discount Applies); Calendar Year Maximum (Maximum applies to combined in and out-of-network benefits): Unlimited per individual	Pharmacy Deductible: Not Applicable; Generic (Oral Contraceptives Included): $20 copay plus 50%; Preferred Brand (Oral Contraceptives Included): Not covered; Non-Preferred Brand (Oral Contraceptives Included): Not covered; Calendar Year Maximum (Maximum applies to combined in and out-of-network benefits): Unlimited per individual
Emergency Room	$100 copay (waived if admitted), 60% coinsurance	$100 copay (waived if admitted), 60% coinsurance
Adult Preventative Care	Annual Routine Gyn Exam (No waiting period, no calendar year max., Annual Pap/Mammogram): $0 copay; Preventive Health - Routine Physical (Aetna will pay up to $200 per exam, Maximum applies to combined in and out-of-network benefits, No waiting period): $40 copay (Includes lab work and X-rays)	50% after deductible (Age and frequency schedule apply).
Child Preventative Care	$40 copay (Age and frequency limits apply)	50% after deductible (Age and frequency schedule apply).
Lab / X-Ray	60% after deductible	50% after deductible
Maternity	Not covered (Except for pregnancy complications)	Not covered (Except for pregnancy complications)
Physical Therapy	Physical/Occupational Therapy and Chiropractic Care (24 visits per calendar year, Maximum applies to combined in and out-of-network benefits): 60% (Aetna will pay a max of $25 per visit, Maximum applies to combined in and out-of-network benefits)	Physical/Occupational Therapy and Chiropractic Care (24 visits per calendar year, Maximum applies to combined in and out-of-network benefits): 50% after deductible (Aetna will pay a max of $25 per visit, Maximum applies to combined in and out-of-network benefits)
Skilled Nursing	60% after deductible (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	60% after deductible (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: 60%; Outpatient Surgery: 60%; Urgent Care Facility: $50 copay	Hospital Admission: 50% after deductible; Outpatient Surgery: 50% after deductible: Urgent Care Facility: 50% after deductible
Optional Benefits	Individual Dental PPO Max Plan	Individual Dental PPO Max Plan