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Aetna – PPO Value 2500 – ALABAMA
A comparison of the PPO Value 2500 offered by Aetna is detailed out below for both Network and Non-Network coverage.
| Network | Non-Network | |
|---|---|---|
|
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| Network | See Provider | See Provider |
| Application | PPO Value 2500 Application | PPO Value 2500 Application |
| Brochure | PPO Value 2500 Brochure | PPO Value 2500 Brochure |
| Copay | Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): Visits 1-5 $50 copay, deductible waived; Visit 5+ member is responsible for 100% but Aetna discount applies; Aetna will pay 100% after out-of-pocket maximum is satisfied (Unlimited visits); Specialist Visit: Visits 1-5 $50 copay, deductible waived; Visit 5+ member is responsible for 100% but Aetna discount applies; Aetna will pay 100% after out-of-pocket maximum is satisfied (Unlimited visits, Specialist and Non-Specialist will share visit max.) | Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): Visits 1-5 $50 copay plus 80% coinsurance, deductible applies; Visit 5+ member is responsible for 100% but Aetna discount applies; Aetna will pay 100% after out-of-pocket maximum is satisfied (Unlimited visits); Specialist Visit: Visits 1-5 $50 copay plus 80% coinsurance, deductible applies; Visit 5+ member is responsible for 100% but Aetna discount applies; Aetna will pay 100% after out-of-pocket maximum is satisfied (Unlimited visits, Specialist and Non-Specialist will share visit max.) |
| Office Visit | Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): Visits 1-5 $50 copay, deductible waived; Visit 5+ member is responsible for 100% but Aetna discount applies; Aetna will pay 100% after out-of-pocket maximum is satisfied (Unlimited visits); Specialist Visit: Visits 1-5 $50 copay, deductible waived; Visit 5+ member is responsible for 100% but Aetna discount applies; Aetna will pay 100% after out-of-pocket maximum is satisfied (Unlimited visits, Specialist and Non-Specialist will share visit max.) | Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): Visits 1-5 $50 copay plus 80% coinsurance, deductible applies; Visit 5+ member is responsible for 100% but Aetna discount applies; Aetna will pay 100% after out-of-pocket maximum is satisfied (Unlimited visits); Specialist Visit: Visits 1-5 $50 copay plus 80% coinsurance, deductible applies; Visit 5+ member is responsible for 100% but Aetna discount applies; Aetna will pay 100% after out-of-pocket maximum is satisfied (Unlimited visits, Specialist and Non-Specialist will share visit max.) |
| Deductible | Individual: $2,500, Family: $5,000 | Individual: $5,000, Family: $10,000 |
| Coinsurance | 80% after deductible up to out-of-pocket max. ($0 once out-of-pocket max. is satisfied) | 65% after deductible up to out-of-pocket max. ($0 once out-of-pocket max. is satisfied) |
| Coinsurance Limit | Individual: $2,500, Family: $5,000 | Individual: $5,000, Family: $10,000 |
| Out-of-Pocket Maximum | Individual: $5,000, Family: $10,000 (Includes deductible) | Individual: $10,000, Family: $20,000 (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: $500 per individual (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 (Maximum applies to combined in and out-of-network benefits): $5,000 per individual | Pharmacy Deductible: $500 per individual (Does not apply to generic); Generic (Oral Contraceptives Included): $15 copay plus 80%, deductible waived; Preferred Brand (Oral Contraceptives Included): $40 copay plus 80% after deductible; Non-Preferred Brand (Oral Contraceptives Included): $60 copay plus 80% after deductible; Calendar Year Maximum (Maximum applies to combined in and out-of-network benefits): $5,000 per individual |
| Emergency Room | $100 copay (waived if admitted), 80% coinsurance after deductible | $100 copay (waived if admitted), 80% coinsurance after deductible |
| Adult Preventative Care | Annual Routine Gyn Exam (No waiting period, no calendar year max., Annual Pap): $0 copay, deductible waived; Mammogram: $30 copay, deductible waived; 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): $50 copay, deductible waived (Includes lab work and X-rays) | $50 copay plus 80% after deductible (Age limitations apply) |
| Child Preventative Care | $30 copay (Age limitations apply) | $50 copay plus 80% after deductible (Age limitations apply) |
| Lab / X-Ray | 80% after deductible | 65% after deductible |
| Maternity | Maternity - Inpatient Facility Services: 60% Inpatient Facility Services coverage after deductible for the mother and the newborn for a minimum of 48 hours for an uncomplicated vaginal delivery and 96 hours for an uncomplicated cesarean birth; Maternity - Professional Services: Coverage for complications of pregnancy | Maternity - Inpatient Facility Services: 50% Inpatient Facility Services coverage after deductible for the mother and the newborn for a minimum of 48 hours for an uncomplicated vaginal delivery and 96 hours for an uncomplicated cesarean birth; Maternity - Professional Services: Coverage for complications of pregnancy |
| Physical Therapy | Physical/Occupational Therapy and Chiropractic Care (24 visits per calendar year, Maximum applies to combined in and out-of-network benefits): 80% after deductible (Aetna will pay a max. of $25 per visit) | Physical/Occupational Therapy and Chiropractic Care (24 visits per calendar year, Maximum applies to combined in and out-of-network benefits): 65% after deductible (Aetna will pay a max. of $25 per visit) |
| 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 | 80% after deductible (in lieu of hospital, 40 visits per calendar year, Maximum applies to combined in and out-of-network benefits) | 65% after deductible (in lieu of hospital, 40 visits per calendar year, Maximum applies to combined in and out-of-network benefits) |
| Mental Health | 60 days partial hospitalization; Outpatient: not less than 80% first 5 visits (CYM); 65% 6th-30th visit; 50% 31st visit on. Benefits cover mental illness, emotional, drug and alcohol abuse. Treat same as physical illness, no separate LTM. | 60 days partial hospitalization; Outpatient: not less than 80% first 5 visits (CYM); 65% 6th-30th visit; 50% 31st visit on. Benefits cover mental illness, emotional, drug and alcohol abuse. Treat same as physical illness, no separate LTM. |
| Hospital Care | Hospital Admission (Includes complications of pregnancy): 60% after deductible; Outpatient Surgery: 80% after deductible; Urgent Care Facility: $50 copay, deductible waived | Hospital Admission (Includes complications of pregnancy): 50% after deductible; Outpatient Surgery: 65% after deductible; Urgent Care Facility: $50 copay; 80% coinsurance after deductible |
| Optional Benefits | Individual Dental PPO Max Plan | Individual Dental PPO Max Plan |