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Aetna – Preventive and Hospital Care 1250 with Dental – NEBRASKA
A comparison of the Preventive and Hospital Care 1250 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 | Preventive and Hospital Care 1250 with Dental Application | Preventive and Hospital Care 1250 with Dental Application |
| Brochure | Preventive and Hospital Care 1250 with Dental Brochure | Preventive and Hospital Care 1250 with Dental Brochure |
| Copay | Not covered | Not covered |
| Office Visit | Not covered | Not covered |
| Deductible | Individual: $1,250, Family: $2,500 | Individual: $2,500, Family: $5,000 |
| 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: $3,000, Family: $6,000 | Individual: $7,500, Family: $15,000 |
| Out-of-Pocket Maximum | (Deductible included) Individual: $4,250, Family: $8,500 | (Deductible included) Individual: $10,000, Family: $20,000 |
| Lifetime Maximum | $1,000,000 (Maximum applies to combined in and out of network benefits) | $1,000,000 (Maximum applies to combined in and out of network benefits) |
| Prescription Drugs | Pharmacy Deductible per individual: Not applicable, Generic (Oral Contraceptives Included): $15 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 per individual (Maximum applies to combined in and out-of-network benefits): Unlimited | Pharmacy Deductible per individual: Not Applicable, Generic (Oral Contraceptives Included): $15 copay plus 50%, Preferred Brand (Oral Contraceptives Included): Not covered, Non-Preferred Brand (Oral Contraceptives Included): Not covered, Calendar Year Maximum per individual (Maximum applies to combined in and out-of-network benefits): 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 (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). | 50% after deductible (Age and frequency schedule apply) |
| Child Preventative Care | $25 copay (Age and frequency schedule apply) | 50% after deductible (Age and frequency schedule apply) |
| Lab / X-Ray | Not covered (Except for pregnancy complications) | Not covered (Except for pregnancy complications) |
| Maternity | Not covered (Except for pregnancy complications) | Not covered (Except for pregnancy complications) |
| Physical Therapy | Not covered | Not covered |
| 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 | Preventive and Hospital Care 1250 with Dental | Preventive and Hospital Care 1250 with Dental |