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Aetna – PPO First Dollar 40 – LOUISIANA
A comparison of the PPO First Dollar 40 offered by Aetna is detailed out below for both Network and Non-Network coverage.
| 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 (Includes Chiropractic Care Visits) | Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 50% after deductible (Unlimited visits); Specialist Visit: 50% after deductible (Includes Chiropractic Care Visits) |
| Office Visit | Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): $40 copay (Unlimited visits); Specialist Visit: $50 copay (Includes Chiropractic Care Visits) | Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 50% after deductible (Unlimited visits); Specialist Visit: 50% after deductible (Includes Chiropractic Care 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% 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 | 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 |
| 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% (Age and frequency limits apply) |
| Child Preventative Care | $40 copay (Age and frequency limits apply) | 50% (Age and frequency limits 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 (24 visits per calendar year, Maximum applies to combined in and out-of-network benefits): 60% (Aetna will pay up to $25 per visit max.) | Physical/Occupational Therapy (24 visits per calendar year, Maximum applies to combined in and out-of-network benefits): 50% after deductible (Aetna will pay up to $25 per visit max.) |
| 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 | Mental Health (Outpatient) - Serious, Biologically Based: Not covered; Mental Health (Outpatient) - Non-Serious, Non-Biologically Based: 60% | Mental Health (Outpatient) - Serious, Biologically Based: Not covered; Mental Health (Outpatient) - Non-Serious, Non-Biologically Based: 50% |
| 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 |