AETNA – Managed Choice Open Access First Dollar 40 with Dental – OKLAHOMA

A comparison of the Managed Choice Open Access First Dollar 40 with Dental offered by AETNA is detailed out below for both Network and Non-Network coverage.

• Compare to other AETNA plans.

• Compare to all carriers in OKLAHOMA.

	Network	Non-Network
Network	See Provider	See Provider
Application	Managed Choice Open Access First Dollar 40 with Dental Application	Managed Choice Open Access First Dollar 40 with Dental Application
Brochure	Managed Choice Open Access First Dollar 40 with Dental Brochure	Managed Choice Open Access First Dollar 40 with Dental Brochure
Copay	Non-specialist Office Visit: $40 Copay, Specialist Visit: $50 Copay	Non-specialist Office Visit: 50% after deductible, Specialist Visit: 50% after deductible
Office Visit	Non-specialist Office Visit: $40 Copay, Specialist Visit: $50 Copay	Non-specialist Office Visit: 50% after deductible, Specialist Visit: 50% after deductible
Deductible	Individual: $0, Family: $0	Individual: $500, Family: $1,000
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: $12,000, Family: $24,000
Out-of-Pocket Maximum	(Deductible included) Individual: $12,500, Family: $25,000	(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)- Not Applicable. Generic (Oral Contraceptives included)- $20 copay. Preferred Brand Name- Not Covered (Aetna Discount Applies). Non-Preferred Brand (Oral Contraceptives included)- Not covered (Aetna Discount Applies). 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)- Not Applicable. Generic (Oral Contraceptives included)- $20 copay plus 50%. Preferred Brand Name- Not Covered. Non-Preferred Brand (Oral Contraceptives included)- Not covered. Calendar Year Maximum per Individual (Maximum applies to combined in and out of network benefits)- Unlimited.
Emergency Room	$100 copay (waived if admitted) 60% coinsurance after deductible	$100 copay (waived if admitted) 60% 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)- $40 copay.	50% after deductible (Age and frequency schedule apply).
Child Preventative Care	$40 copay (Age and frequency schedule apply).	50% after deductible (Age and frequency schedule apply).
Lab / X-Ray	60%	50% after deductible
Maternity	Not covered (except for pregnancy complications)	Not covered (except for pregnancy complications)
Physical Therapy	Physical/Occupational Therapy and Chiropractic- 60% ($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	60% (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% (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%	Hospital Admission: 50% after deductible, Outpatient Surgery: 50% after deductible
Optional Benefits	Managed Choice Open Access First Dollar 40 with Dental	Managed Choice Open Access First Dollar 40 with Dental