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Aetna – PPO Value 1500 with Dental – NEBRASKA
A comparison of the PPO Value 1500 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 Value 1500 with Dental Application | PPO Value 1500 with Dental Application |
| Brochure | PPO Value 1500 with Dental Brochure | PPO Value 1500 with Dental Brochure |
| Copay | Visit 1-2: $30 copay, deductible waived. Visits 3+: 70% after deductible. Specialist and Non- Specialist share visit max. | Non-Specialist Office Visit: 50% after deductible, Specialist: 50% after deductible |
| Office Visit | Visit 1-2: $30 copay, deductible waived. Visits 3+: 70% after deductible. Specialist and Non- Specialist share visit max. | Non-Specialist Office Visit: 50% after deductible, Specialist: 50% after deductible |
| Deductible | Individual: $1,500, Family: $3,000 | Individual: $3,000, Family: $6,000 |
| Coinsurance | 70% 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: $3,000, Family: $6,000 | Individual: $7,000, Family: $14,000 |
| Out-of-Pocket Maximum | Individual: $4,500, Family: $9,000 (Deductible included) | Individual: $10,000, Family: $20,000 (Deductible included) |
| 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: $500 (Does not apply to generic); Generic (Oral Contraceptives Included): $20 copay, deductible waived; Preferred Brand (Oral Contraceptives Included): $40 copay after deductible; Non-Preferred Brand (Oral Contraceptives Included): Not covered (Aetna discount applies); Calendar Year Maximum (per individual, Maximum applies to combined in and out-of-network benefits): $5,000 per individual | Pharmacy Deductible per Individual: $500 (Does not apply to generic); Generic (Oral Contraceptives Included): $20 copay plus 50%, deductible waived; Preferred Brand (Oral Contraceptives Included): $40 copay plus 50% after deductible; Non-Preferred Brand (Oral Contraceptives Included): Not covered; Calendar Year Maximum (per individual, Maximum applies to combined in and out-of-network benefits): $5,000 per individual |
| Emergency Room | $100 copay (waived if admitted), 70% coinsurance after deductible | $100 copay (waived if admitted), 70% 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): $50 copay, deductible waived (Includes lab and X-rays) | 50% after deductible (Age and frequency limits apply) |
| Child Preventative Care | $50 copay (Age and frequency limits apply) | 50% after deductible (Age and frequency limits apply) |
| Lab / X-Ray | 70% after deductible | 50% after deductible |
| Maternity | Not covered (Except for pregnancy complications) | Not covered (Except for pregnancy complications) |
| Physical Therapy | Physical/Occupational Therapy & Chiropractic Care- 70% after deductible ($25 Max per visit- 24 visits per calendar year, Maximum applies to combined in and out of network benefits). | Physical/Occupational Therapy & Chiropractic Care- 50% after deductible ($25 Max per visit- 24 visits per calendar year, Maximum applies to combined in and out of network benefits). |
| Skilled Nursing | 70% 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 | 70% 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: 70% after deductible, Outpatient Surgery: 70% 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 Value 1500 with Dental | PPO Value 1500 with Dental |