You have options when it comes to your medical and pharmacy benefits, each with different levels of coverage. When you visit providers within the Aetna OA PPO or Aetna Value Network HMO network, your cost is less. When seeking care outside of the Aetna OA PPO network, you will pay an increased portion of the costs.
Understanding Your Options
AETNA (AETNA WHOLE HEALTH AND AETNA FULL NETWORK) HMO
A Health Maintenance Organization (HMO) is a group of medical providers that work together to keep the cost of medical services down. In Network Coverage Only— Aetna contracts with private physicians and hospitals. The AWH HMO plan maintains a network of preferred physicians, specialists, and hospitals that have agreed to contracted rates and will also complete and submit your benefit claims. You will need to specify who your PCP or IPA/Medical Group is.
PRIMARY CARE PHYSICIAN (PCP)
The Primary Care Physician (PCP) is a doctor you select from the provider directory to be the single source for all of your medical needs. Whenever you have a medical need (including emergencies, if you are able), your PCP should be contacted on a HMO. This doctor or office will determine the proper course of action and handle your medical needs within their facility or refer you to another doctor or specialist. If you need to be hospitalized, your PCP will assist you in facilitating your care during the entire hospitalization. In the event of an emergency, contact your PCP who will determine proper treatment, except in the case of dire emergency, where you are incapacitated, or a life- threatening situation has occurred.
INDEPENDENT PHYSICIANS’ ASSOCIATION (IPA OR MEDICAL GROUP)
The IPA is a medical group or organization that acts like a PCP on a HMO. However, instead of a single physician, you have a group of physicians available to handle your medical needs. The same criteria apply under an IPA that applies when you choose a PCP. You will simply contact the medical group’s main offices to schedule appointments or referrals, and in emergencies.
AETNA OA MANAGED CHOICE POS PPO
This stands for Open Access Managed Choice. An Open Access Managed Choice acts like a PPO plan and allows you to seek care outside the Aetna OA provider network. You do not need a referral and are not required to select a Primary Care Provider (PCP). You or your covered dependents will pay less out of your pocket by obtaining care in the Aetna provider network.
Comparing the Options
Before you review your medical plan options, you should understand how they work. Start with these terms:
A set percentage you pay of the cost of the care you receive, for example 20%.
A set dollar amount you pay when you receive health care, for example $35 when you see a specialist.
A set amount you must pay out of your pocket before the plan starts paying part of the cost unless a copay applies.
The most you will pay in a calendar year for provider visits, prescriptions, etc., for covered expenses and includes your deductible, copays, and coinsurance. This “safety net” provides peace of mind for those who have a serious condition or illness.
Aetna AWH HMO | Aetna HMO |
|
|---|---|---|
| Narrow Network | Full Network | |
| General Plan Information Deductible | In Network | In Network |
| Deductible | ||
| Individual Deductible (ded) | None | None |
| Family Deductible (ded) | None | None |
| Out of Pocket Maximum | ||
| Individual | $4,000 | $4,000 |
| Family | $8,000 | $8,000 |
| Copays | ||
| Physician Visits | $30 copay | $30 copay |
| Specialist | $45 copay | $45 copay |
| Teladoc Visit | $30 copay | 100% |
| Preventative Care Services | 100% | 100% |
| Emergency & Ambulatory | ||
| Urgent Care | $60 copay | $60 copay |
| Emergency Room (waived if admitted) | $300 copay | $300 copay |
| Hospital Services | ||
| Inpatient | $500 per day, up to 5 days then 100% covered | $500 per day, up to 5 days then 100% covered |
| Outpatient | $200 copay | $200 copay |
| Diagnostic Services | ||
| Lab and X-ray | Lab: $30 X-ray: $45 | Lab: $30 X-ray: $45 |
| Complex imaging | $200 copay | $200 copay |
| Therapy Visits | ||
| Mental Health/Substance Abuse | ||
| Inpatient | $500 per day, up to 5 days then 100% covered | $500 per day, up to 5 days then 100% covered |
| Mental health office visits | $45 copay | $45 copay |
| Durable Medical Equipment | $30 copay | $30 copay |
| Chiropractic Care (20 visits per year) | $15 copay | $15 copay |
| Acupuncture (20 visits per year) | $30 copay | $30 copay |
| Prescription Drugs | ||
| Retail | 30 days | 30 days |
| Generic | $10 copay | $10 copay |
| Preferred (Preferred Brand) | $30 copay | $30 copay |
| Non-Preferred Brand | $50 copay | $50 copay |
| Preferred Specialty | 30%, $250 max | 30%, $250 max |
| Mail Order | 90 days | 90 days |
| Preferred (Generic) | $20 copay | $20 copay |
| Preferred (Preferred Brand) | $60 copay | $60 copay |
| Non-Preferred Brand | $100 copay | $100 copay |
| Preferred Specialty | N/A | N/A |
Aetna PPO 3000 | Aetna PPO 500 |
|||
|---|---|---|---|---|
| General Plan Information | In Network | Out of Network | In Network | Out of Network |
| Deductible | ||||
| Individual Deductible (ded) | $3,000 | $6,000 | $500 | $5,000 |
| Family Deductible (ded) | $6,000 | $12,000 | $1,000 | $10,000 |
| Out of Pocket Maximum | ||||
| Individual | $6,000 | $12,000 | $4,000 | $10,000 |
| Family | $12,000 | $24,000 | $8,000 | $20,000 |
| Coinsurance & Copays | ||||
| Coinsurance | 20% | 50% | 20% | 50% |
| Physician Visits | $40 copay no ded | 50% after ded | $30 copay no ded | 50% after ded |
| Specialist | $60 copay no ded | 50% after ded | $40 copay no ded | 50% after ded |
| Teladoc Visit | $30 copay no ded | N/A | 100% no copay | N/A |
| Preventative Care Services | 100% no ded | 50% after ded | 100% | 50% after ded |
| Emergency & Ambulatory | ||||
| Urgent Care | $75copay no ded | 50% after ded | $50 copay no ded | 50% after ded |
| Emergency Room (waived if admitted) | $300 copay no ded | $300 copay, after ded | ||
| Hospital Services | ||||
| Inpatient | $0 after ded | 50% after ded | $750 per day for first 3 days, then 100%, after ded | 50% after ded |
| Outpatient | $0 after ded | 50% after ded | $750 after ded | 50% after ded |
| Diagnostic Services | ||||
| X-ray and Lab | $0 after ded | 50% after ded | Lab: $25 no ded X-ray $50 copay no ded | 50% after ded |
| Complex imaging | $0 after ded | 50% after ded | $500 copay no ded | 50% after ded |
| Therapy Visits | ||||
| Mental Health/Substance Abuse | ||||
| Inpatient | $0 after ded | 50% after ded | $750 per day for first 3 days, then 100%, after ded | 50% after ded |
| Mental health office visits | $60 copay no ded | 50% after ded | $40 copay no ded | 50% after ded |
| Durable Medical Equipment | $0 after ded | 50% after ded | 20% after ded | 50% after ded |
| Chiropractic Care (20 visits per year) | $60 copay no ded | 50% after ded | $40 copay no ded | 50% after ded |
| Acupuncture (20 visits per year) | $25 copay no ded | 50% after ded | $30 copay no ded | 50% after ded |
| Prescription Drugs | ||||
| Retail | 30 days | 30 days | ||
| Generic | $10 copay | Not Covered | $10 copay | Not Covered |
| Preferred (Preferred Brand) | $30 copay | Not Covered | $30 copay | Not Covered |
| Non-Preferred Brand | $50 copay | Not Covered | $50 copay | Not Covered |
| Preferred Specialty | 30%, $250 max | Not Covered | 30%, $250 max | Not Covered |
| Mail Order | 90 days | 90 days | ||
| Preferred (Generic) | $20 copay | Not Covered | $20 copay | Not Covered |
| Preferred (Preferred Brand) | $60 copay | Not Covered | $60 copay | Not Covered |
| Non-Preferred Brand | $100 copay | Not Covered | $100 copay | Not Covered |