Plan Highlights
Aetna Plan A
Aetna Plan B
| Annual Calendar Year Deductible | In-Network (A) | Out-of-Network (A) | In-Network (B) | Out-of-Network (B) |
|---|---|---|---|---|
| Individual | $250 | $750 | $1,000 | $3,000 |
| Family | $500 | $1,500 | $2,000 | $6,000 |
| Maximum Calendar Year Out-of-Pocket | Medical/Mental Health (A) | Medical Only (A) | Medical/Mental Health (B) | Medical Only (B) |
|---|---|---|---|---|
| Individual | $2,100 | $10,000 | $5,700 | $12,000 |
| Family | $4,200 | $20,000 | $11,400 | $24,000 |
| Lifetime Maximum | Unlimited (A) | Unlimited (A) | Unlimited (B) | Unlimited (B) |
|---|---|---|---|---|
| Professional Services | In-Network (A) | Out-of-Network (A) | In-Network (B) | Out-of-Network (B) |
|---|---|---|---|---|
| Primary Care Physician (PCP) | $15 Copay | 40% | $25 Copy + 20% | 50% |
| Specialist | $15 Copay | 40% | $25 Copy + 20% | 50% |
| Preventive Care Exam | No Charge (3) | N/A | No Charge (3) | N/A |
| Well-baby care (first 5 years) | No Charge (3) | N/A | No Charge (3) | N/A |
| Diagnostic X-ray and Lab | No Charge | 40% | 20% | 50% |
| Complex Diagnostics (MRI/CT Scan) | No Charge | 40% | 20% | 50% |
| Therapy (3)(Physical, Occupational, Speech) | No Charge | 40% | 20% | 50% |
| Professional Hospital Services | In-Network (A) | Out-of-Network (A) | In-Network (B) | Out-of-Network (B) |
|---|---|---|---|---|
| Inpatient (3) | No Charge | 40% | 20% | 50% |
| Outpatient Surgery (3) | $100 Copay | N/A | $100 Copay + 20% | N/A |
| Emergency Room | $100 Copay (Copay waived if admitted) | $100 Copay (Copay waived if admitted) | $100 Copay + 20% (Copay waived if admitted) | $100 Copay + 20% (Copay waived if admitted) |
| Urgent Care | $35 | $35 + 40% | $35 + 20% | $35 + 50% |
| Maternity Care* | In-Network (A) | Out-of-Network (A) | In-Network (B) | Out-of-Network (B) |
|---|---|---|---|---|
| Physician Services (prenatal or postnatal) | $15 Copay | 40% | $25 Copay | 50% |
| Hospital Services | 5% | 40% | 20% | 50% |
- *Effective January 1, 2024, the annual deductible will be waived for all covered family members of a dual-covered member enrolled in the PPO Plan A or PPO Plan B
- (1) Member pays coinsurance applicable to Usual, Customary and Reasonable (UCR) rate
- (2) Refer to the Your Rights and Protections Against Surprise Medical Bills notice
- (3) Plan deductible waived
- (4) Requires pre-authorization
The above information is a summary only. Please refer to your Evidence of Coverage or Plan Booklet for complete details of Plan benefits, limitations and exclusions.