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Aetna – PPO First Dollar 35 with Dental – PENNSYLVANIA
A comparison of the PPO First Dollar 35 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 First Dollar 35 with Dental Application | PPO First Dollar 35 with Dental Application |
| Brochure | PPO First Dollar 35 with Dental Brochure | PPO First Dollar 35 with Dental Brochure |
| Copay | Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): $35 copay (Unlimited visits); Specialist Visit: $45 copay (Unlimited visits) | Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 50% after deductible (Unlimited visits); Specialist Visit: 50% after deductible (Unlimited visits) |
| Office Visit | Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): $35 copay (Unlimited visits); Specialist Visit: $45 copay (Unlimited visits) | Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 50% after deductible (Unlimited visits); Specialist Visit: 50% after deductible (Unlimited visits) |
| Deductible | Individual: $0, Family: $0 | Individual: $7,000, Family: $14,000 |
| Coinsurance | 65% up to out-of-pocket max. ($0 once out-of-pocket max. is satisfied) | 50% after deductible ($0 once out-of-pocket max. is satisfied) |
| Coinsurance Limit | Individual: $7,500, Family: $15,000 | Individual: $5,500, Family: $11,000 |
| Out-of-Pocket Maximum | Individual: $7,500, Family: $15,000 (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 (Does not apply to generic): $500 per individual; Generic (Oral Contraceptives Included): $15 copay deductible waived; Preferred Band (Oral Contraceptives Included): $35 copay after deductible; Non-Preferred Brand (oral Contraceptives Included): $50 copay after deductible; Calendar Year Maximum (Maximum applies to combined in and out-of-network benefits): $5,000 per individual | Pharmacy Deductible (Does not apply to generic): $500 per individual; Generic (Oral Contraceptives Included): $15 copay plus 50% deductible waived; Preferred Band (Oral Contraceptives Included): $35 copay plus 50% after deductible; Non-Preferred Brand (oral Contraceptives Included): $60 copay plus 50% after deductible; Calendar Year Maximum (Maximum applies to combined in and out-of-network benefits): $5,000 per individual |
| Emergency Room | $100 copay (waived if admitted), 65% coinsurance | $100 copay (waived if admitted), 65% coinsurance |
| 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): $35 copay, deductible waived (Includes lab work and X-rays) | 50% after deductible (Age and frequency schedule apply) |
| Child Preventative Care | $35 copay (Age and frequency schedule apply) | 50% after deductible (Age and frequency schedule apply) |
| Lab / X-Ray | 65% | 50% after deductible |
| Maternity | Not covered (except for pregnancy complications) | Not covered (except for pregnancy complications) |
| Physical Therapy | Physical/Occupational Therapy and Chiropractic Care (24 visits per calendar year, Maximum applies to combined in and out-of-network benefits): 65% after deductible (Aetna will pay a max. of $25 per visit) | Physical/Occupational Therapy and Chiropractic Care (24 visits per calendar year, Maximum applies to combined in and out-of-network benefits): 50% after deductible (Aetna will pay a max. of $25 per visit) |
| Skilled Nursing | 65% (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 | 65% (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: 65%; Outpatient Surgery: 65%; Urgent Care Facility: $50 copay | Hospital Admission: 50% after deductible; Outpatient Surgery: 50% after deductible; Urgent Care Facility: 50% after deductible |
| Optional Benefits | PPO First Dollar 35 with Dental | PPO First Dollar 35 with Dental |