Aetna 5000 PPO Health Insurance Plan

Plan Type: PPO
Health Savings Account (HSA) Eligible: Yes

Physicians
Office Visit for Primary Doctor: No Charge after deductible
Office Visit for Specialist: No Charge after deductible

Coinsurance:No Charge after deductible

Prescription Drugs
Generic: No Charge after deductible
Brand: No Charge after deductible
Non-Formulary: No Charge after deductible
Separate Prescription Drugs Deductible: Medical Plan Deductible Applies

Out-of-Network Coverage: Yes
Out of Country Coverage: Yes. Paid as out-of-network benefits

Preventive Care Coverage
Periodic Health Exam: $25 Copay
Periodic OB-GYN Exam: No Charge
Well Baby Care: $25 copay

Hospital Services Coverage
Emergency Room: No Charge after deductible
Outpatient Lab/X-Ray: No Charge after deductible
Outpatient Surgery: No Charge after deductible
Hospitalization: No Charge after deductible

Maternity Coverage
Pre & Postnatal Office Visit Not Covered. Except for pregnancy complications
Labor & Delivery Hospital Stay: Not Covered. Except for pregnancy complications

Additional Coverage
Chiropractic Coverage: No Charge after deductible. Aetna will pay $25 Max. Per Visit/ 24 Visits Per Year.
Mental Health Coverage: Not covered except for severe biologically based mental and nervous disorders with associated treatment of drug and alcohol dependencies