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Aetna – PPO 3500 – TEXAS
A comparison of the PPO 3500 offered by Aetna is detailed out below for both Network and Non-Network coverage.
| Network | Non-Network | |
|---|---|---|
|
||
| Network | See Provider | See Provider |
| Application | PPO 3500 Application | PPO 3500 Application |
| Brochure | PPO 3500 Brochure | PPO 3500 Brochure |
| Copay | Non-specialist: $35 copay deductible waived, Specialist: $45 copay deductible waived | Non-specialist Office Visit: 50% after deductible, Specialist Visit: 50% after deductible |
| Office Visit | Non-specialist: $35 copay deductible waived, Specialist: $45 copay deductible waived | Non-specialist Office Visit: 50% after deductible, Specialist Visit: 50% after deductible |
| Deductible | Individual: $3,500, Family: $7,000 | Individual: $7,000, Family: $14,000 |
| 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: $6,500, Family: $13,000 | Individual: $5,500, Family: $11,000 |
| Out-of-Pocket Maximum | (Deductible included) Individual: $10,000, Family: $20,000 | (Deductible included) Individual: $12,500, Family: $25,000 |
| 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 (does not apply to generic): $500, Generic (Oral Contraceptives Included): $15 copay deductible waived, Preferred Brand Name (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): $500, 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: $35 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 | $35 copay (Age and frequency limits 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: 80% after deductible, Aetna will pay up to $25 per visit max (24 visits per calendar year, maximum applies to combined in and out-of-network benefits) | Physical/Occupational Therapy and Chiropractic: 50% after deductible (Aetna will pay up to $25 per visit max, 24 visits per calendar year, maximum applies to combined in and out-of-network benefits) |
| 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 | Individual Dental PPO Max Plan | Individual Dental PPO Max Plan |