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Aetna OAMC PPO HD

Aetna
877-204-9186
Group Number: 237642

The Aetna Open Access Managed Care (PPO) plan offers employees the flexibility to see different doctors, whether or not they are in your plan’s network. High Deductible (HD) combines traditional medical coverage with a Health Savings Account (HSA). As evident by the name, this plan has a higher deductible members must reach before the plan kicks in.

Aetna OAMC PPO HD

In-Network

Out-Network

Annual Deductible    
Individual $2,000  $4,000 
Individual within Family $3,300  $4,000 
Family $4,000  $8,000 
Annual Out of Pocket Maximum    
Individual  $4,000 $8,000
Individual within Family $4,000 $8,000
Family $8,000 $16,000
Lifetime Maximum    
Individual Unlimited Unlimited

Medical Services

Primary Care Visit Covered at 90% Covered at 70%
Specialist Office Visit Covered at 90% Covered at 70%
Physician Home Visit Covered at 90% Covered at 70%
Routine Physical Exam / Preventative Care Covered at 100% Covered at 70%
Diagnostic X-ray and Laboratory Covered at 90% Covered at 70%
Inpatient Hospital Covered at 90% Covered at 70%
Outpatient Hospital  Covered at 90% Covered at 70%
Emergency Room (waived if admitted) Covered at 90% Covered at 90%
Urgent Care Covered at 90% Covered at 70%
Maternity Services Covered at 90% Covered at 70%
Chiropractic / Acupuncture (20 visits/year) Covered at 90% Covered at 70%
Hearing Aid: Limited to 1 pair of hearing aids every 24 months Covered at 90% Covered at 70%
Prescription Drugs After Deductible After Deductible 
Generic / Tier 1 (30-day supply) $5 copay N/A
Formulary / Tier 2 (30-day supply) $20 copay  N/A
Non-Formulary / Tier 3 (30-day supply) $40 copay N/A
Specialty/ Tier 4 (30-day supply) 30% up to $250 copay N/A
Mail Order (90-day supply) Tiers 1,2 & 3: 2x Retail Copay Not Covered