Aetna First Dollar Health Insurance Plan

Plan Type: PPO

Physicians
Office Visit for Primary Doctor: $40 Copay
Office Visit for Specialist: $50 Copay
Primary Care Physician (PCP) Required: No
Specialist Referrals Required: No

Coinsurance: 40%

Prescription Drugs
Generic: $20 Copay
Brand: Not covered-Aetna Discount Applies
Non-Formulary: Not covered-Aetna Discount Applies
Separate Prescription Drugs Deductible: None

Health Savings Account (HSA) Eligible: No

Out-of-Network Coverage:Yes
Out of Country Coverage : Yes.

Preventive Care Coverage
Periodic Health Exam: $40 Copay
Periodic OB-GYN Exam: No charge
Well Baby Care: $40 copay.

Prescription Drug Coverage
Generic Prescription Drugs: $20 Copay
Brand Prescription Drugs: Not covered-Aetna Discount Applies
Non-Formulary Prescription Drugs Coverage: Not covered-Aetna Discount Applies
Mail Order for Prescription Drugs: Generic: $40 Copay, Days Supply: 60

Hospital Services Coverage
Emergency Room: $100 Copay plus 40% Coinsurance
Outpatient Lab/X-Ray: 40% Coinsurance
Outpatient Surgery: 40% Coinsurance
Hospitalization: 40% Coinsurance

Maternity Coverage
Pre & Postnatal Office Visit; Not Covered
Labor & Delivery Hospital Stay; Not Covered

Additional Coverage
Chiropractic Coverage: 40% Coinsurance. Aetna will pay $25 Max. per visit/ 24 visits per year
Mental Health Coverage: Not Covered, except for severe, biologically based mental or nervous disorders and associated treatment of drug and alcohol dependencies.