Aetna PPO Plan Highlights

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

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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

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Lifetime Maximum	Unlimited (A)	Unlimited (A)	Unlimited (B)	Unlimited (B)

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Professional Services	In-Network (A)	Out-of-Network (A)	In-Network (B)	Out-of-Network (B)
Primary Care Physician (PCP)	$15 Copay + 5%	40%	$25 Copy + 25%	50%
Specialist	$15 Copay + 5%	40%	$25 Copy + 25%	50%
Preventive Care Exam	No Charge (2)	N/A	No Charge (2)	N/A
Well-baby care (first 5 years)	No Charge (2)	N/A	No Charge (2)	N/A
Diagnostic X-ray and Lab	5%	40%	25%	50%
Complex Diagnostics (MRI/CT Scan)	5%	40%	25%	50%
Therapy (3)(Physical, Occupational, Speech)	5%	40%	25%	50%

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Professional Hospital Services	In-Network (A)	Out-of-Network (A)	In-Network (B)	Out-of-Network (B)
Inpatient (3)	5%	40%	25%	50%
Outpatient Surgery (3)	$100 Copay + 5%	N/A	$100 Copay + 25%	N/A
Emergency Room	$100 Copay + 5% (Copay waived if admitted)	$100 Copay + 5% (Copay waived if admitted)	$100 Copay + 25% (Copay waived if admitted)	$100 Copay + 25% (Copay waived if admitted)
Urgent Care	$35 + 5%	$35 + 40%	$35 + 25%	$35 + 50%

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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%	25%	50%

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• *Maternity Care – Dependent children are only covered for preventive care services
• (1) Member pays coinsurance applicable to Usual, Customary and Reasonable (UCR) rate
• (2) Plan deductible waived
• (3) Requires pre-authorization

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