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Aetna – PPO High Deductible 3000 (HSA Compatible) with Dental – VIRGINIA
A comparison of the PPO High Deductible 3000 (HSA Compatible) 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 High Deductible 3000 (HSA Compatible) with Dental Application | PPO High Deductible 3000 (HSA Compatible) with Dental Application |
| Brochure | PPO High Deductible 3000 (HSA Compatible) with Dental Brochure | PPO High Deductible 3000 (HSA Compatible) with Dental Brochure |
| Copay | Non-Specialist Office Visit: 100% after deductible (unlimited visits), Specialist Visit: 100% after deductible (unlimited visits). | Non-Specialist Office Visit: 50% after deductible (unlimited visits), Specialist Visit: 50% after deductible (unlimited visits). |
| Office Visit | Non-Specialist Office Visit: 100% after deductible (unlimited visits), Specialist Visit: 100% after deductible (unlimited visits). | Non-Specialist Office Visit: 50% after deductible (unlimited visits), Specialist Visit: 50% after deductible (unlimited visits). |
| Deductible | Individual: $3,000, Family: $6,000 | Individual: $6,000, Family: $12,000 |
| Coinsurance | 100% 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: $0, Family: $0 | Individual: $6,500, Family: $13,000 |
| Out-of-Pocket Maximum | Individual: $3,000, Family: $6,000 (Includes deductible) | Individual: $12,500, Family: $25,000 (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: Integrated Medical/Rx Deductible, Generic (Oral Contraceptives Included): 100% after Medical/Rx deductible, Preferred Brand (Oral Contraceptives Included): 100% after Medical/Rx deductible, Non-Preferred Brand (Oral Contraceptives Included): 100% after Medical/Rx deductible, Calendar Year Maximum per individual (Maximum applies to combined in and out-of-network benefits): Unlimited. | Pharmacy Deductible per Individual: Integrated Medical/Rx Deductible, Generic (Oral Contraceptives Included): 50% after Medical/Rx deductible, Preferred Brand (Oral Contraceptives Included): 50% after Medical/Rx deductible, Non-Preferred Brand (Oral Contraceptives Included): 50% after Medical/Rx deductible, Calendar Year Maximum per individual (Maximum applies to combined in and out-of-network benefits): Unlimited. |
| Emergency Room | $0 copay after deductible | $0 copay 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: $20 copay deductible waived (Aetna will pay up to $200 per exam, maximum applies to combined in and out-of network benefits, includes lab work and X-rays). | 50% after deductible (Age and frequency schedule apply) |
| Child Preventative Care | $20 copay (Age and frequency schedule apply) | 50% after deductible (Age and frequency schedule apply) |
| Lab / X-Ray | 100% 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: 100% 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 Care: 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 | 100% 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 | 100% 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: 100% after deductible, Outpatient Surgery: 100% after deductible | Hospital Admission: 50% after deductible, Outpatient Surgery: 50% after deductible |
| Optional Benefits | PPO High Deductible 3000 (HSA Compatible) with Dental | PPO High Deductible 3000 (HSA Compatible) with Dental |