Aetna of Texas Managed Choice Open Access and PPO Value 5000 Plan Information

MEMBER BENEFITS

Deductible (Individual Family):

In Network:$5,000/$10,000

Out-of-Network: $10,000/$20,000

Coinsurance (Member’s responsibility):

In Network:30% after deductible up to out-of-pocket max.

Out-of-Network:50% after deductible up to out-of-pocket max.

$0 once out-of-pocket max. is satisfied

Coinsurance Maximum (Individual Family):

In Network:$5,000/$10,000

Out-of-Network:$2,500/$10,000

Out-of-Pocket Maximum (Individual Family):

In Network:$10,000/$20,000

Out-of-Network:$12,500/$25,000

Lifetime Maximum per insured:

In Network: $1,000,000

Out-of-Network:$1,000,000

Non-Specialist Office Visit (Unlimited visits to General Physician, Family Practitioner, Pediatrician or Internist):

In Network:$30 copay/ 30% deductible

Out-of-Network:30% after deductible

Specialist Visit (Unlimited visits):

In Network:$30 copay/ 30% deductible

Out-of-Network:30% after deductible

Hospital Admission:

In Network:30% after deductible

Out-of-Network:50% after deductible

Outpatient Surgery:

In Network:30% after deductible

Out-of-Network:50% after deductible

Urgent Care Facility:

In Network:$50 copay ded. waived

Out-of-Network:50% after deductible

Emergency Room:

$100 copay (waived if admitted) 30% coinsurance after deductible

Annual Routine Gyn Exam:

In Network: $0 copay deductible waived

Out-of-Network:30% after deductible

Maternity: Not Covered- except for pregnancy complications

Preventive Health - Routine Physical (Aetna will pay up to $200 per exam):

In Network: $50 copay deductible waived

Out-of-Network:30% after deductible

Lab/X-Ray:

In Network:30% after deductible

Out-of-Network:50% after deductible

Skilled Nursing - in lieu of hospial (30 days per calendar year):

In Network:30% after deductible

Out-of-Network:50% after deductible

Physical/Occupational Therapy and Chiropractic Care (24 visits per calendar year):

In Network:30% after deductible

Out-of-Network:50% after deductible

Home Health Care - in lieu of hospital ( 80 visits per calendar year):

In Network:30%

Out-of-Network:50% after deductible

Durable Medical Equipment (Aetna will pay up to $2000 per calendar year):

In Network:30% after deductible

Out-of-Network:50% after deductible

Pharmacy:

Generic - oral contraceptives included:

In Network: $20 copay deductible waived

Out-of-Network:$20 copay plus 30% deductible waived

Preferred Brand - oral contraceptives included:

In Network: $40 copay after deductible

Out-of-Network:$40 plus 30% after deductible

Non-Preferred Brand - oral contraceptives included:

In Network: Not Covered/Aetna Discount Applies

Out-of-Network:Not Covered

Calendar Year Maximum - per individual:

In Network: $5,000

Out-of-Network:$5,000

Other Aetna of Texas health insurance plans:

• Managed Choice Open Access and PPO High Deductible 3000 Plan
• Managed Choice Open Access and PPO High Deductible 5000
• Managed Choice Open Access & PPO First Dollar 30
• Managed Choice Open Access & PPO First Dollar 40
• Managed Choice Open Access and PPO Value 1500
• Managed Choice Open Access and PPO 2500
• Managed Choice Open Access and PPO 5000
• Managed Choice Open Access and PPO Value 2500
• Preventative & Hospital Care 1250
• Preventative & Hospital Care 3000