| In Network |
Out of Network |
Copay |
30% |
50% or Not Covered |
Office Visits |
Visits 1-3: $50 (Deductible Waived) Visits 3+ Aetna discount applies; Specialist and non-Specialist do not share visits |
Visits 1-3: $50 (Deductible Waived) Visits 3+ Aetna discount applies; Specialist and non-Specialist do not share visits |
Annual Deductible |
Individual: $8,000 Family: $16,000 |
Individual: $10,000 Family: $20,000 |
Annual Out-Of-Pocket Limit |
Individual: $12,500 Family: $25,000 |
Individual: $12,500 Family: $25,000 |
Lifetime Maximum |
Not Applicable |
Not Applicable |
Prescription Drugs |
Generic: $20 (Deductible Waived)
|
50% plus Generic: $20 (Deductible Waived) |
Laboratory & X-Ray |
30% after Deductible (Non-Preventive)
|
50% after Deductible (Non-Preventive)
|
Annual Physical Exam |
No Charge |
50% after Deductible
|
Annual OB-GYN Exam |
No Charge |
50% after Deductible
|
Well Baby Care |
No Charge (Age and frequency limits apply) |
50% after Deductible
(Age and frequency limits apply) |
Outpatient Surgery |
40% after Deductible |
50% after Deductible |
Emergency Room |
$100 (waived if admitted) plus 30% after Deductible
|
$100 (waived if admitted) plus 30% after Deductible
|
Inpatient Hospital |
40% after Deductible
|
50% after Deductible |
Ambulance |
30% after Deductible
|
30% after Deductible
|
Home Health Care |
30% after Deductible (30 visits/calendar year; In and Out-of-Network combined)
|
50% after Deductible (30 visits/calendar year; In and Out-of-Network combined)
|
Mental Health - Outpatient |
Not Covered |
Not Covered |
Chiropractic Care |
30% (24 visit max; $25 per visit max)
|
50% (24 visit max; $25 per visit max)
|
Acupuncture |
See Brochure |
See Brochure |
Mental Health - Inpatient |
Not Covered |
Not Covered |
Chemical Dependency |
30% |
50% |
Maternity Care |
Not Covered (except for pregnancy complications)
|
Not Covered (except for pregnancy complications)
|
