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Aetna – PPO 2500 with Dental – VIRGINIA
A comparison of the PPO 2500 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 2500 with Dental Application | PPO 2500 with Dental Application |
| Brochure | PPO 2500 with Dental Brochure | PPO 2500 with Dental Brochure |
| Copay | Non-specialist Office Visit: $30 copay deductible waived (unlimited visits), Specialist Visit: $40 copay deductible waived (unlimited visits). | Non-specialist Office Visit: $30 copay deductible waived (unlimited visits), Specialist Visit: $40 copay deductible waived (unlimited visits). |
| Office Visit | Non-specialist Office Visit: $30 copay deductible waived (unlimited visits), Specialist Visit: $40 copay deductible waived (unlimited visits). | Non-specialist Office Visit: $30 copay deductible waived (unlimited visits), Specialist Visit: $40 copay deductible waived (unlimited visits). |
| Deductible | Individual: $2,500, Family: $5,000 | Individual: $5,000, Family: $10,000 |
| Coinsurance | 80% after deductible | Non Facility Services: 80% after deductible, Facility Services: 50% after deductible |
| Coinsurance Limit | Individual: $2,500, Family: $5,000 | Individual: $5,000, Family: $10,000 |
| Out-of-Pocket Maximum | Individual: $5,000, Family: $10,000 (Includes deductible) | Individual: $10,000, Family: $20,000 (Includes deductible) |
| 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: $500 (does not apply to generic), Generic (Oral Contraceptives Included): $15 copay deductible waived, Preferred Brand Name (Oral Contraceptives Included): $25 copay after deductible, Non-Preferred Brand Name (Oral Contraceptives Included): $40 copay after deductible, Calendar Year Maximum per individual (Maximum applies to combined in and out of network benefits): Unlimited. | Pharmacy Deductible per individual: $500 (does not apply to generic), Generic (Oral Contraceptives Included): $15 copay deductible waived, Preferred Brand Name (Oral Contraceptives Included): $25 copay after deductible, Non-Preferred Brand Name (Oral Contraceptives Included): $40 copay 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): $0 copay deductible waived, Routine Physical: $30 copay deductible waived, Aetna will pay up to $200 per exam (includes lab work and X-rays). | $30 copay (Age and frequency limits apply). |
| Child Preventative Care | $30 copay (Age and frequency limits apply). | $30 copay (Age and frequency limits apply). |
| Lab / X-Ray | 80% after deductible | 80% 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 maximum (24 visits per calendar year, maximum applies to combined in and out of network benefits). | Physical/Occupational Therapy and Chiropractic Care: 80% after deductible, Aetna will pay up to $25 per visit maximum (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. | 80% 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. | 80% 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; Urgent Care Facility: $50 copay deductible waived | Hospital Admission: 50% after deductible; Outpatient Surgery: 50% after deductible; Urgent Care Facility: 50% after deductible |
| Optional Benefits | PPO 2500 with Dental | PPO 2500 with Dental |