Aetna
877-204-9186
Group Number: 237642
An Exclusive Provider Organization (EPO) Plan contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. Using providers that belong in the plan’s network will provide predictable low out of pocket costs for services. If you go to a provider or facility outside the network, the health plan will not pay for those services unless it’s an emergency.
|
AETNA EPO MEDICAL PLAN |
Aetna |
|---|---|
| Annual Deductible | |
| Individual | $0 |
| Individual within Family | $0 |
| Family | $0 |
| Annual Out of Pocket Maximum | |
| Individual | $2,000 |
| Family | $4,000 |
| Lifetime Maximum | |
| Individual | Unlimited |
|
Medical Services |
|
| Primary Care Visit | $20 Copay |
| Specialist Office Visit | $20 Copay |
| Routine Physical Exam / Preventative Care | No Charge |
| Diagnostic X-ray / Lab | No Charge |
| Chiropractic Services - 20 visits/year | $15 Copay |
| Acupuncture Services - 20 visits/year | $20 Copay |
| Hearing Aid Benefit | $20 coinsurance, $4000 benefit maximum every 24 months |
| Hospital Services | |
| Room & Board | $250 Copay |
| Maternity Services | $250 Copay per Admission |
| Urgent Care | $25 Copay |
| Emergency Room Visit (waived if admitted) | $100 Copay |
| Prescription Drugs | |
| Contraceptive Drugs | No Charge |
| Tier 1 (30-day supply) | $5 Copay |
| Tier 2 (30-day supply) | $20 Copay |
| Tier 3 (30-day supply) | $40 Copay |
| Tier 4 (30-day supply) | 20% to $200 Copay |
| Mail Order (90-day supply) | Tiers 1, 2 & 3: 2x Retail Copy |
| Mental Health & Substance Abuse | |
| Inpatient | $250 Copay per admission |
| Outpatient | $20 Copay |
Plan Documents and Resources
Plan Documents