Below is a brief outline of the benefits provided under the Aetna PPO plan. Refer to the official benefits plan booklet for a comprehensive description of plan benefits. Under all circumstances, the plan booklet will take precedence over information contained on this website. Contact Aetna Concierge Services at (800) 836-2824 for questions of coverage.
In-Network | Out-of-Network | |
---|---|---|
Deductible | $500 individual/$1,000 family | |
Annual Out of Pocket Max | $3,350 individual/$6,700 family (includes deductible) | |
Lifetime maximum benefit | Unlimited | |
Office Visits | 100% after $25 copay | Deductible/ Coinsurance |
In-Network | Out-of-Network | |
---|---|---|
Immunizations | 100% | 60% after deductible |
Routine adult physicals | 100% | 60% after deductible |
Well-woman exams/ screenings | 100% | 60% after deductible |
Well-baby exams | 100% | 60% after deductible |
In-Network | Out-of-Network | |
---|---|---|
Emergency Room (copay waived if admitted) |
$100 copay, then deductible/coinsurance | |
Inpatient hospital services | 80% after deductible | 60% after deductible |
Outpatient hospital services | 80% after deductible | 60% after deductible |
Outpatient surgical center | 80% after deductible | 60% after deductible |
30-day supply | ||
---|---|---|
Generic | $10 copay | |
Brand formulary | $30 copay | |
Nonformulary | $60 copay |
90-day supply | ||
---|---|---|
Generic | $20 copay | |
Brand formulary | $60 copay | |
Nonformulary | $120 copay |