| Copay |
Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): Visits 1-5 $30 copay, deductible waived; Visit 5+ member is responsible for 100% but Aetna discount applies; Aetna will pay 100% after out-of-pocket maximum is satisfied (Specialist and Non-Specialist share visit max.); Specialist Visit: Visits 1-5 $50 copay, deductible waived; Visit 5+ member is responsible for 100% but Aetna discount applies; Aetna will pay 100% after out-of-pocket maximum is satisfied (Specialist and Non-Specialist will share visit max.) |
Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): Visits 1-5 $30 copay plus 20% coinsurance, deductible applies; Visit 5+ member is responsible for 100% but Aetna will pay 100% after out-of-pocket maximum is satisfied (Specialist and Non-Specialist share visit max.); Specialist Visit: Visits 1-5 $50 copay plus 20% coinsurance, deductible applies; Visit 5+ member is responsible for 100% but Aetna will pay 100% after out-of-pocket maximum is satisfied (Specialist and Non-Specialist will share visit max.) |
| OfficeVisit |
Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): Visits 1-5 $30 copay, deductible waived; Visit 5+ member is responsible for 100% but Aetna discount applies; Aetna will pay 100% after out-of-pocket maximum is satisfied (Specialist and Non-Specialist share visit max.); Specialist Visit: Visits 1-5 $50 copay, deductible waived; Visit 5+ member is responsible for 100% but Aetna discount applies; Aetna will pay 100% after out-of-pocket maximum is satisfied (Specialist and Non-Specialist will share visit max.) |
Non-Specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist): Visits 1-5 $30 copay plus 20% coinsurance, deductible applies; Visit 5+ member is responsible for 100% but Aetna will pay 100% after out-of-pocket maximum is satisfied (Specialist and Non-Specialist share visit max.); Specialist Visit: Visits 1-5 $50 copay plus 20% coinsurance, deductible applies; Visit 5+ member is responsible for 100% but Aetna will pay 100% after out-of-pocket maximum is satisfied (Specialist and Non-Specialist will share visit max.) |
| Deductible |
|
|
| Coinsurance |
20% after deductible up to out-of-pocket max. ($0 once out-of-pocket max. is satisfied) |
35% after deductible up to out-of-pocket max. ($0 once out-of-pocket max. is satisfied) |
| Coinsurance Limit |
Individual: $2,500, Family: $5,000 |
|
| Out-of-Pocket Maximum |
N/A |
N/A |
| Lifetime Maximum |
Unlimited |
Unlimited |
| Prescription Drugs |
Pharmacy Deductible (per individual): $500 (Does not apply to generic); Generic (Oral Contraceptives Included): $15 copay, deductible waived; Preferred Brand (Oral Contraceptives Included): $40 copay after deductible; Non-Preferred Brand (Oral Contraceptives Included): $60 copay after deductible |
Pharmacy Deductible (per individual): $500 (Does not apply to generic); Generic (Oral Contraceptives Included): $15 copay plus 20%, deductible waived; Preferred Brand (Oral Contraceptives Included): $40 copay plus 20% after deductible; Non-Preferred Brand (Oral Contraceptives Included): $60 copay plus 20% after deductible |
| Emergency Room |
$100 copay (waived if admitted), 20% coinsurance after deductible |
$100 copay (waived if admitted), 20% coinsurance after deductible |
| Adult Preventative Care |
Annual Routine Gyn Exam (No waiting period, no calendar year max., Annual Pap/Mammogram): $0 copay, deductible waived; Mammogram: $0 copay, deductible waived; Preventive Health - Routine Physical (No waiting period): $0 copay, deductible waived (Includes lab work and X-rays) |
Annual Routine Gyn Exam (No waiting period, no calendar year max., Annual Pap/Mammogram): 20% coinsurance after deductible; Mammogram: 20% coinsurance after deductible; Preventive Health - Routine Physical (No waiting period): 20% coinsurance after deductible (Includes lab work and X-rays) |
| Child Preventative Care |
$0 copay (Age limitations apply); No charge for immunizations up to the age of 18 |
20% after deductible (Age limitations apply); No charge for immunizations up to the age of 18 |
| Lab / X-Ray |
20% after deductible (Non-Preventive) |
35% after deductible (Non-Preventive) |
| Maternity |
Maternity (Inpatient Facility Services): 40% Inpatient Facility Services coverage after deductible for the mother and the newborn for a minimum of 48 hours for an uncomplicated vaginal delivery and 96 hours for an uncomplicated cesarean birth; Maternity (Professional Services): Coverage for complications of pregnancy |
Maternity (Inpatient Facility Services): 50% Inpatient Facility Services coverage after deductible for the mother and the newborn for a minimum of 48 hours for an uncomplicated vaginal delivery and 96 hours for an uncomplicated cesarean birth; Maternity (Professional Services): Coverage for complications of pregnancy |
| Physical Therapy |
Physical/Occupational Therapy (24 visits per calendar year, Maximum applies to combined in and out-of-network benefits): 20% after deductible |
Physical/Occupational Therapy (24 visits per calendar year, Maximum applies to combined in and out-of-network benefits): 35% after deductible |
| Home Health Care |
20% after deductible (instead of hospital, 40 visits per calendar year, Maximum applies to combined in and out-of-network benefits) |
35% after deductible (instead of hospital, 40 visits per calendar year, Maximum applies to combined in and out-of-network benefits) |
| Mental Health |
Inpatient and Outpatient: Coverage is provided for treatment of mental illness (Deductible and coinsurance/copay apply - Day and/or visit limits apply) |
Inpatient and Outpatient: Coverage is provided for treatment of mental illness (Deductible and coinsurance/copay apply - Day and/or visit limits apply) |
| Hospital Care |
Hospital Admission (Includes complications of pregnancy): 40% after deductible; Outpatient Surgery: 20% after deductible; Urgent Care Facility: $50 copay, deductible waived |
Hospital Admission (Includes complications of pregnancy): 50% after deductible; Outpatient Surgery: 35% after deductible; Urgent Care Facility: $50 copay; 20% coinsurance after deductible |
