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Aetna – PPO 5000 with Dental – ILLINOIS
A comparison of the PPO 5000 with 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 Dental Application | PPO 5000 with Dental Application |
| Brochure | PPO 5000 with Dental Brochure | PPO 5000 with Dental Brochure |
| Copay | Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): $40 copay, deductible waived (Unlimited visits); Specialist Visit: $50 copay, deductible waived (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, deductible waived (Unlimited visits); Specialist Visit: $50 copay, deductible waived (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: $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: $5,000, Family: $10,000 | Individual: $2,500, Family: $5,000 |
| Out-of-Pocket Maximum | Individual: $10,000, Family: $20,000 (Includes deductible) | Individual: $12,500, Family: $25,000 (Includes deductible) |
| 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: $500 per individual (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; Self Injectables: 25% after deductible; Calendar Year Maximum (per individual): Unlimited | Pharmacy Deductible: $500 per individual (Does not apply to generic); Generic (Oral Contraceptives Included): $15 copay plus 50%, deductible waived; Preferred Brand (Oral Contraceptive Included): $35 copay plus 50% after deductible; Non-Preferred Brand (Oral Contraceptives Included): $50 copay plus 50% after deductible; Self Injectables: Not covered; Calendar Year Maximum (per individual): Unlimited |
| 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/Mammogram): $0 copay deductible waived; Preventive Health - Routine Physical (Aetna will pay up to $200 per exam, No waiting period): $40 copay deductible waived (Includes lab and X-rays) | 50% (Age and frequency limits apply) |
| Child Preventative Care | $40 copay (Age and frequency limits apply) | 50% (Age and frequency limits apply) |
| Lab / X-Ray | 80% 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): 80% after deductible (Aetna will pay $25 per visit) | 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 $25 per visit) |
| 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 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) |
| Mental Health | Not covered | Not covered |
| Hospital Care | Hospital Admission: 80% after deductible; Outpatient Surgery: 80% after deductible; Urgent Care Facility: $50 copay deductible waived | Hospital Admission: 50% after deductible; Outpatient Surgery: 50% after deductible; Urgent Care Facility: 50% after deductible |
| Optional Benefits | PPO 5000 with Dental | PPO 5000 with Dental |