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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 | |