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Aetna – PPO Value 2500 – WEST VIRGINIA
A comparison of the PPO Value 2500 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 2500 Application | PPO Value 2500 Application |
| Brochure | PPO Value 2500 Brochure | PPO Value 2500 Brochure |
| Copay | Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): Visit 1-5 $30 copay, deductible waived; Visit 5+ member pays 100%, but Aetna discount applies specialist and non-specialist share visit max; Specialist Visit: Visit 1-5 $50 copay, deductible waived; Visit 5+ member pays 100%, but Aetna discount applies specialist and non-specialist share visit max. | Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 50% after deductible (Unlimited visits); Specialist Visit: 50% after deductible (Unlimited visits) |
| Office Visit | Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): Visit 1-5 $30 copay, deductible waived; Visit 5+ member pays 100%, but Aetna discount applies specialist and non-specialist share visit max; Specialist Visit: Visit 1-5 $50 copay, deductible waived; Visit 5+ member pays 100%, but Aetna discount applies specialist and non-specialist share visit max. | Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): 50% after deductible (Unlimited visits); Specialist Visit: 50% after deductible (Unlimited visits) |
| Deductible | Individual: $2,500, Family: $5,000 | Individual: $5,000, Family: $10,000 |
| Coinsurance | 80% after deductible up to out-of-pocket max. ($0 once out-of-pocket max. is satisfied) | 50% after deductible ($0 once out-of-pocket max. is satisfied) |
| Coinsurance Limit | Individual: $2,500, Family: $5,000 | Individual: $5,000, Family: $10,000 |
| Out-of-Pocket Maximum | Individual: $5,000, Family: $10,000Individual: $5,000, Family: $10,000 (Includes deductible) | Individual: $10,000, Family: $20,000Individual: $10,000, Family: $20,000 (Includes deductible) |
| Lifetime Maximum | $1,000,000 per insured (Maximum applies to combined in and out-of-network benefits) | $1,000,000 per insured (Maximum applies to combined in and out-of-network benefits) |
| Prescription Drugs | Pharmacy Deductible: Not Applicable; Generic (Oral Contraceptives Included): $15 copay, deductible waived; Preferred Brand (Oral Contraceptives Included): Not covered, Aetna discount applies; Non-Preferred Brand (Oral Contraceptives Included): Not covered, Aetna discount applies; Calendar Year Maximum per Individual: $5,000 (Maximum applies to combined in and out-of-network benefits) | Pharmacy Deductible: N/A; Generic (Oral Contraceptives Included): $15 copay plus 50%, deductible waived; Preferred Brand (Oral Contraceptives Included): Not covered; Non-Preferred Brand (Oral Contraceptives Included): Not covered; Calendar Year Maximum per Individual: $5,000 (Maximum applies to combined in and out-of-network benefits) |
| 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: $50 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 | $50 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 - 80% after deductible (Aetna will pay up to a $25 Max per visit/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 | 60% 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 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) |
| Mental Health | Not covered | Not covered |
| Hospital Care | Hospital Admission: 60% 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 | Individual Dental PPO Max Plan | Individual Dental PPO Max Plan |