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Aetna – PPO 5000 with Maternity and Dental – DELAWARE
A comparison of the PPO 5000 with Maternity and Dental offered by Aetna is detailed out below for both Network and Non-Network coverage.
| Network | Non-Network | |
|---|---|---|
|
||
| Network | See Provider | See Provider |
| Application | PPO 5000 with Maternity and Dental Application | PPO 5000 with Maternity and Dental Application |
| Brochure | PPO 5000 with Maternity and Dental Brochure | PPO 5000 with Maternity and Dental Brochure |
| Copay | Non-Specialist Office Visit: $40, Specialist Visit: $50. | 50% after deductible |
| Office Visit | Non-Specialist Office Visit: $40 copay deductible waived (unlimited visits), Specialist Visit: $50 copay deductible waived (unlimited visits). | Non-Specialist Office Visit: 50% after deductible (unlimited visits), Specialist Visits: 50% after deductible (unlimited visits). |
| Deductible | Individual: $5,000, Family: $10,000 | Individual: $10,000, Family: $20,000 |
| Coinsurance | 80% after deductible 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: $2,500, Family: $5,000 | Individual: $2,500, Family: $5,000 |
| 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): $35 copay after deductible, Non-Preferred Brand (Oral Contraceptives Included): $50 copay after deductible, Calendar Year Maximum per individual (maximum applies to combined in and out-of-network benefits): $5,000. | Pharmacy Deductible per individual: $500 (does not apply to generic), Generic (Oral Contraceptives Included): $125 copay plus 50% deductible waived, Preferred Brand (Oral Contraceptives Included): $35 copay plus 50% after deductible, Non-Preferred Brand (Oral Contraceptives Included): $50 copay plus 50% after deductible, Calendar Year Maximum per individual (maximum applies to combined in and out-of-network benefits): $5,000. |
| 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 (Annual Pap/Mammogram): $0 copay deductible waived, Routine Physical: $40 copay deductible waived Aetna will pay up to $200 per exam (includes lab work and X-rays). | 100% after deductible (Age and frequency schedule apply). |
| Child Preventative Care | $40 copay (Age and frequency schedule apply). | 100% after deductible (Age and frequency schedule apply). |
| Lab / X-Ray | 80% after deductible | 50% after deductible |
| Maternity | Maternity Obstetrician Visits: $50 copay deductible waived, Maternity Hospital - $2,000 Copayment: 80% after deductible. | Maternity Obstetrician Visits: 50% after deductible, Maternity Hospital - $2,000 Copayment: 50% after deductible. |
| Physical Therapy | Physical/Occupational Therapy and Chiropractic Care: 80% after deductible Aetna will pay up to $25 per visit max (24 visits per calendar year, maximum applies to combined in and out-of-network benefits. | |
| Skilled Nursing | 80% 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) 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: 80% after deductible, Outpatient Surgery: 80% after deductible. | Hospital Admission: 50% after deductible, Outpatient Surgery: 50% after deductible. |
| Optional Benefits | PPO 5000 with Maternity and Dental | PPO 5000 with Maternity and Dental |