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Aetna – PPO Value 1500 with Dental – WEST VIRGINIA
A comparison of the PPO Value 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 Value 1500 with Dental Application | PPO Value 1500 with Dental Application |
| Brochure | PPO Value 1500 with Dental Brochure | PPO Value 1500 with Dental Brochure |
| Copay | Non-Specialist and Specialist Office Visits 1-2: $30 copay, deductible waived; thereafter 70% coinsurance after deductible (Unlimited visits) | Non-Specialist and Specialist Office Visits 1-2: $30 copay, deductible waived; thereafter 70% coinsurance after deductible (Unlimited visits) |
| Office Visit | Non-Specialist and Specialist Office Visits 1-2: $30 copay, deductible waived; thereafter 70% coinsurance after deductible (Unlimited visits) | Non-Specialist and Specialist Office Visits 1-2: $30 copay, deductible waived; thereafter 70% coinsurance after deductible (Unlimited visits) |
| Deductible | Individual: $1,500, Family: $3,000 | Individual: $3,000, Family: $6,000 |
| Coinsurance | 70% after deductible | Non Facility Services: 70% after deductible, Facility Services: 50% after deductible |
| Coinsurance Limit | Individual: $1,500, Family: $3,000 | Individual: $4,500, Family: $9,000 |
| Out-of-Pocket Maximum | Individual: $3,000, Family: $6,000 (Deductible included) | Individual: $7,500, Family: $15,000 (Deductible included) |
| Lifetime Maximum | $3,000,000 (Maximum applies to combined in and out of network benefits) | $3,000,000 (Maximum applies to combined in and out of network benefits) |
| Prescription Drugs | Pharmacy Deductible per Individual: Not applicable, Generic (Oral Contraceptives Included): $20 copay, Preferred Brand Name (Oral Contraceptives Included): Not covered; Non-Preferred Brand (Oral Contraceptives Included): Not covered; Calendar Year Maximum per Individual (Maximum applies to combined in and out of network benefits): $5,000. | Pharmacy Deductible per Individual: Not applicable, Generic (Oral Contraceptives Included): $20 copay, Preferred Brand Name (Oral Contraceptives Included): Not covered; Non-Preferred Brand (Oral Contraceptives Included): Not covered; Calendar Year Maximum per Individual (Maximum applies to combined in and out of network benefits): $5,000. |
| Emergency Room | $100 copay (waived if admitted), 70% coinsurance after deductible | $100 copay (waived if admitted), 70% coinsurance after deductible |
| Adult Preventative Care | Annual Routine Gyn Exam (Annual Pap/Mammogram): $0 copay deductible waived, Routine Physical: $50 copay deductible waived, Aetna will pay up to $200 per exam (includes lab work and X-rays). | $50 copay (Age and frequency limits apply) |
| Child Preventative Care | $50 copay (Age and frequency limits apply) | $50 copay (Age and frequency limits apply) |
| Lab / X-Ray | 70% after deductible | 70% after deductible |
| Maternity | Not covered (Except for pregnancy complications) | Not covered (Except for pregnancy complications) |
| Physical Therapy | Physical/Occupational Therapy and Chiropractic Care: 70% 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: 70% 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 | 70% after deductible (in lieu of Hospital) 30 days per calendar year, Maximum applies to combined in and out of network benefits. | 70% after deductible (in lieu of Hospital) 30 days per calendar year, Maximum applies to combined in and out of network benefits. |
| Home Health Care | 70% after deductible (in lieu of Hospital) 30 visits per calendar year, maximum applies to combined in and out of network benefits. | 70% 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 | Not covered |
| Hospital Care | Hospital Admission: 70% after deductible; Outpatient Surgery: 70% 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 Value 1500 with Dental | PPO Value 1500 with Dental |