Effective January 1, 2017 U.S. Network Out-of-Network Aetna Open Choice PPO General A plan year is a calendar year, January 1 through December 31 Medical Deductible (per person) $400 per plan year Medical Deductible (per family) $800 per plan year Medical Out-of-pocket limits (Office visit co-payments and dental services do not accrue toward the out of pocket limits) Medical out-of-pocket limits per person $3,250 per plan year Medical out-of-pocket limits per family $6,500 per plan year Office visits Office visits for Illness or Specialist 100% after $15 co-pay Routine annual physicals and defined preventive services* 100% 80% after deductible Ob/GYN (well woman) exam – one per plan year* 100% Laboratory and X-rays All services; (unless covered under defined preventive services above) 90% after deductible 80% after deductible Emergency room related 90% after deductible 80% after deductible if non-emergency use 90% after deductible Inpatient Hospital costs including anesthesia Surgery (physician) 90% after deductible 90% after deductible Hospice Outpatient Hospital costs including anesthesia 90% after deductible Surgery (physician) 90% after deductible Hospice Chemotherapy and Radiation Therapy Chemotherapy and Radiation Therapy: Does not include oral or injectable medications 100%, no deductible purchased through pharmacy benefit In-office/facility administration only Maternity 90% after deductible Obstetrics: Routine prenatal office visits covered Single fee/delivery charge incl. Office visits at 100%, no deductible Obstetrics: 80% after deductible Routine prenatal office visits billed separately 100% after $15 co-pay from single fee 90% after deductible Infertility Lifetime Limits: Contact Insurance Administrator for details Mental Health and Substance Abuse Inpatient hospitalization for mental health or 90% after deductible substance abuse 90% after deductible Outpatient facility, including day treatment 90% after deductible 90% after deductible programs Office visits 100% after $15 co-pay 80% after deductible
Effective January 1, 2017 U.S. Network Aetna Open Choice PPO Out-of-Network General A plan year is a calendar year, January 1 through December 31 Medical Deductible (per person) $400 per plan year Medical Deductible (per family) $800 per plan year Medical Out-of-pocket limits (Office visit co-payments and dental services do not accrue toward the out of pocket limits) Medical out-of-pocket limits per person $3,250 per plan year Medical out-of-pocket limits per family $6,500 per plan year Office visits Office visits for Illness or Specialist 100% after $15 co-pay 80% after deductible Routine annual physicals and defined preventive services* 100% Ob/GYN (well woman) exam – one per plan year* 100% Laboratory and X-rays All services; (unless covered under defined preventive services above) 90% after deductible 80% after deductible Emergency room related 90% after deductible 80% after deductible if non-emergency use 90% after deductible Inpatient Hospital costs including anesthesia 90% after deductible 90% after deductible Surgery (physician) Hospice Outpatient Hospital costs including anesthesia 90% after deductible 90% after deductible Surgery (physician) Hospice Chemotherapy and Radiation Therapy Chemotherapy and Radiation Therapy: Does not include oral or injectable medications purchased through pharmacy benefit 100%, no deductible In-office/facility administration only Maternity Obstetrics: Single fee/delivery charge incl. Office visits 90% after deductible Routine prenatal office visits covered at 100%, no deductible 80% after deductible Obstetrics: Routine prenatal office visits billed separately from single fee 100% after $15 co-pay 90% after deductible Infertility Lifetime Limits: Contact Insurance Administrator for details Mental Health and Substance Abuse Inpatient hospitalization for mental health or substance abuse 90% after deductible 90% after deductible Outpatient facility, including day treatment programs 90% after deductible 90% after deductible Office visits 100% after $15 co-pay 80% after deductible
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