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Aetna – PPO High Deductible 5000 (HSA Compatible) – NEBRASKA
A comparison of the PPO High Deductible 5000 (HSA Compatible) offered by Aetna is detailed out below for both Network and Non-Network coverage.
| Network | Non-Network | |
|---|---|---|
|
||
| Network | See Provider | See Provider |
| Application | PPO High Deductible 5000 (HSA Compatible) Application | PPO High Deductible 5000 (HSA Compatible) Application |
| Brochure | PPO High Deductible 5000 (HSA Compatible) Brochure | PPO High Deductible 5000 (HSA Compatible) Brochure |
| Copay | N/A | N/A |
| Office Visit | PPO High Deductible 5000 (HSA Compatible) | PPO High Deductible 5000 (HSA Compatible) |
| Deductible | Individual: $5,000, Family: $10,000 | Individual: $10,000, Family: $20,000 |
| Coinsurance | 100% after deductible up to out of pocket max. $0 once out of pocket max. is satisfied. | 75% after deductible |
| Coinsurance Limit | Individual: $0, Family: $0 | Individual: $2,500, Family: $5,000 |
| Out-of-Pocket Maximum | Individual: $5,000, Family: $10,000 (Includes deductible) | Individual: $12,500, Family: $25,000 (Includes deductible) |
| Lifetime Maximum | $3,000,000 (Maximum applies to combined in and out of network benefits) | $3,000,000 (Maximum applies to combined in and out of network benefits) |
| Prescription Drugs | Pharmacy Deductible per Individual: Integrated Medical/Rx Deductible, Generic (Oral Contraceptives Included): 100% after Medical/Rx deductible, Preferred Brand (Oral Contraceptives Included): 100% after Medical/Rx deductible, Non-Preferred Brand (Oral Contraceptives Included): 100% after Medical/Rx deductible, Calendar Year Maximum per individual (Maximum applies to combined in and out-of-network benefits): $5,000. | Pharmacy Deductible per Individual- Integrated Medical/Rx Deductible. Generic (Oral Contraceptives included)- 75% after Medical/Rx Deductible. Preferred Brand Name (Oral Contraceptives included)- 75% after Medical/Rx Deductible. Non-Preferred Brand (Oral Contraceptives included)- 75% after Medical/Rx Deductible. Calendar Year Maximum per Individual (Maximum applies to combined in and out of network benefits)- $5,000. |
| Emergency Room | $0 after deductible | $0 after deductible |
| Adult Preventative Care | Annual Routine Gyn Exam (Annual Pap/Mammogram, no waiting period, no calendar year max.): $0 copay deductible waived, Preventive Health - Routine Physical: $25 copay deductible waived (Aetna will pay up to $200 per exam, includes lab work and X-rays). | 75% after deductible (Age and frequency limits apply). |
| Child Preventative Care | $25 copay (Age and frequency limits apply) | 75% after deductible (Age and frequency limits apply). |
| Lab / X-Ray | 100% after deductible | 75% after deductible |
| Maternity | Not covered (Except for pregnancy complications) | Not covered (Except for pregnancy complications) |
| Physical Therapy | Physical/Occupational Therapy and Chiropractic Care- 100% after deductible ($25 Max per visit- 24 visits per calendar year, Maximum applies to combined in and out-of-network benefits). | Physical/Occupational Therapy and Chiropractic Care ($25 Max per visit- 24 visits per calendar year, Maximum applies to combined in and out-of-network benefits): 75% after deductible. |
| Skilled Nursing | 100% after deductible (in lieu of Hospital) (30 days per calendar year, Maximum applies to combined in and out of network benefits). | 75% after deductible (in lieu of Hospital) (30 days per calendar year, Maximum applies to combined in and out of network benefits). |
| Home Health Care | 100% after deductible (in lieu of Hospital) (30 visits per calendar year, Maximum applies to combined in and out of network benefits). | 75% 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: 100% after deductible, Outpatient Surgery: 100% after deductible | Hospital Admission: 75% after deductible, Outpatient Surgery: 75% after deductible |
| Optional Benefits | Individual Dental PPO Max Plan | Individual Dental PPO Max Plan |