| OHIO AETNA ADVANTAGE PLAN OPTIONS - First Dollar PPO 30 |
|
MEMBER BENEFITS |
In Network |
Out-of-Network+ |
|
Deductible Individual Family |
$0
$0 |
$5,000
$10,000 |
|
Coinsurance (Member's responsibility) |
30% up to out-of-pocket max. |
50% after deductible up to out-of-pocket max. |
|
$0 once out-of-pocket max. is satisfied |
|
Coinsurance Maximum Individual Family |
$7,500
$15,000 |
$7,500
$15,000 |
|
Out-of-Pocket Maximum Individual Family |
$7,500
$15,000 |
$12,500
$25,000 |
|
Includes deductible |
|
Lifetime Maximum* per insured |
$5,000,000 |
|
Non-Specialist Office Visit Unlimited visits General Physician, Family Practitioner Pediatrician or Internist |
$30 copay |
50% after deductible |
|
Specialist Visit Unlimited visits |
$40 copay |
50% after deductible |
|
Hospital Admission |
30% |
50% after deductible |
|
Outpatient Surgery |
30% |
50% after deductible |
|
Urgent Care Facility |
$50 copay |
50% after deductible |
|
Emergency Room |
$100 copay** (waived if admitted); 30% coinsurance |
|
Annual Routine Gyn Exam No waiting period, No calendar year max. Annual Pap/Mammogram |
$0 copay |
50% after deductible |
|
Maternity |
Not Covered Except for pregnancy complications |
|
Preventive Health - Routine Physical Aetna will pay up to $200 per exam* |
$30 copay |
50% after deductible |
|
Includes lab work and X-rays |
|
Lab/X-Ray |
30% |
50% after deductible |
|
Skilled Nursing - in lieu of hospital 30 days per calendar year* |
30% |
50% after deductible |
|
Physical/Occupational Therapy and Chiropractic Care 24 visits per calendar year* Aetna will pay up to $25 per visit max.* |
30% |
50% after deductible |
|
Home Health Care - in lieu of hospital 30 visits per calendar year* |
30% |
50% after deductible |
|
Durable Medical Equipment |
30% |
50% after deductible |
|
PHARMACY |
|
Pharmacy Deductible per individual |
$500 |
$500 |
|
Does not apply to generic |
|
Generic Oral Contraceptives Included |
$15 copaydeductible waived |
$15 copay plus 50% deductible waived |
|
Preferred Brand Oral Contraceptives Included |
$40 copay after deductible |
$40 copay plus 50% after deductible |
|
Non-Preferred Brand Oral Contraceptives Included |
$60 copay afterdeductible |
$60 copay plus 50% after deductible |
|
Calendar Year Maximum per individual* |
Unlimited |
