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Aetna – PPO 1500 with Dental – TENNESSEE
A comparison of the PPO 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 1500 with Dental Application | PPO 1500 with Dental Application |
| Brochure | PPO 1500 with Dental Brochure | PPO 1500 with Dental Brochure |
| Copay | Non-Specialist Office Visit: $25 copay deductible waived (unlimited visits), Specialist Visit: $35 copay deductible waived (unlimited visits) | Specialist and Non-Specialist Office Visit: 50% after deductible (unlimited visits). |
| Office Visit | Non-Specialist Office Visit: $25 copay deductible waived (unlimited visits), Specialist Visit: $35 copay deductible waived (unlimited visits) | Specialist and Non-Specialist Office Visit: 50% after deductible (unlimited visits). |
| Deductible | Individual: $1,500, Family: $3,000 | Individual: $3,000, Family: $6,000 |
| 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: $1,500, Family: $3,000 | Individual: $7,000, Family: $14,000 |
| Out-of-Pocket Maximum | (Deductible included) Individual: $3,000, Family: $6,000 | (Deductible included) Individual: $10,000, Family: $20,000 |
| Lifetime Maximum | $5,000,000 (Maximum applies to combined in and out of network benefits) | $5,000,000 (Maximum applies to combined in and out of network benefits) |
| Prescription Drugs | Pharmacy Deductible per individual: $250 (does not apply to generic), Generic (Oral Contraceptives Included): $15 copay deductible waived, Preferred Brand (Oral Contraceptives Included): $35 copay after deductible, Non-Preferred Brand (Oral Contraceptives Included): $50 copay after deductible, Calendar Year Maximum per individual (Maximum applies to combined in and out-of-network benefits): Unlimited. | Pharmacy Deductible per Individual (does not apply to generic): $250, Generic (Oral Contraceptives included): $15 copay plus 50% deductible waived, Preferred Brand (Oral Contraceptives included): $35 copay plus 50% after deductible, Non-Preferred Brand (Oral Contraceptives included): $50 copay plus 50% after deductible, 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 | 80% after deductible | 50% after deductible |
| Maternity | Not covered (Except for pregnancy complications) | Not covered (Except for pregnancy complications) |
| Physical Therapy | 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)- 80% after deductible. | 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)- 50% after deductible. |
| 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 | PPO 1500 with Dental | PPO 1500 with Dental |