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Aetna – Preventive and Hospital Care 1250 with Dental – NORTH CAROLINA
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 | Individual: $4,250, Family: $8,500 (Includes deductible) | Individual: $10,000, Family: $20,000 (Includes deductible) |
| Lifetime Maximum | $1,000,000 per insured (Maximum applies to combined in and out-of-network benefits) | $1,000,000 per insured (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 (Maximum applies to combined in and out-of-network benefits): $5,000 per individual | Pharmacy Deductible per Individual: Not Applicable; Generic (Oral Contraceptives Included): $15 copay plus 50%; Preferred Brand (Oral Contraceptive Included): Not covered; Non-Preferred Brand (Oral Contraceptives Included): Not covered; Calendar Year Maximum (Maximum applies to combined in and out-of-network benefits): $5,000 per individual |
| 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): $25 copay, deductible waived (Includes lab and X-rays) | 50% (Age and frequency limits apply) |
| Child Preventative Care | $25 copay (Age and frequency limits apply) | 50% (Age and frequency limits 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 | Not covered |
| Hospital Care | Hospital Admission: 80% after deductible; Outpatient Surgery: 80% after deductible; Urgent Care Facility: Not covered | Hospital Admission: 50% after deductible; Outpatient Surgery: 50% after deductible; Urgent Care Facility: Not covered |
| Optional Benefits | Preventive and Hospital Care 1250 with Dental | Preventive and Hospital Care 1250 with Dental |