Aetna 1500 PPO Health Insurance Plan

Plan Type: PPO
Office Visit for Primary Doctor : $25 Copay
Office Visit for Specialist: $35 Copay

Coinsurance: 20% after deductible

Prescription Drugs:: Generic $15 Copay, Brand: $35 Copay, Non-Formulary: $50 Copay
Separate Prescription Drugs Deductible: $250 Individual applies to Brand, Non-Formulary

Health Savings Account (HSA) Eligible: No
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, Age and frequency schedule apply

Hospital Services Coverage
Emergency Room:$100 Copay (waived if admitted) plus 20% Coinsurance after deductible
Outpatient Lab/X-Ray: 20% after deductible
Outpatient Surgery: 20% after deductible
Hospitalization: 20% 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: 20% Coinsurance 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.