The Patriot X Plan

When using in-network providers, Aetna's Patriot V Plan offers no out of pocket maximums per calendar year, a $10 copay to visit your Primary Care Provider (PCP), and specialist visits within the Aetna network with referral from your PCP for only a $5/$10 copay.

IMPORTANT:

The benefits listed in this chart are for illustrative purposes only. Specific benefit coverage information for your plan may vary. Please consult your Plan Document for particulars.

Type of Service	In Network w/ referral	Out of Network
Deductible
Individual	None	$100/cal year
Family	None	$200/cal year
Annual Out Of Pocket Max
Individual	N/A	$400
Family	N/A	$1,200
Lifetime Maximum	None	None
Primary/Preventive Care
PCP Office Visits	$10 Copay/visit	80% after deductible
After Hours/Home Visits	$15 Copay/visit	80% after deductible
Routine Exams	$10 Copay/visit	Covered 100% up to $150 preventive care allowance
Routine Child/Well Baby Care	$10 Copay/visit	Covered 100% up to $150 preventive care allowance
Immunizations	$10 Copay/visit	Covered 100% up to $150 preventive care allowance
Routine GYN Exams	$15 Copay/visit	Covered 100% up to $150 preventive care allowance
Routine Mammogram	$15 Copay/visit	Covered 100% up to $150 preventive care allowance
Routine Eye Exams	$15 Copay/visit	Not Covered
Eyeglasses/Contact Lenses	$70 every 2 yrs plus discount	Not Covered
Hearing Exams	$10 Copay: Routine exam by PCP	Not Covered
Hearing Aids	Not Covered	Not Covered
Specialty Care
Office Visits	$15 Copay	80% after deductible
Prenatal Care	$15 Copay	80% after deductible
Infertility Services	$15 Copay per visit **	80% after deductible (Testing only. Treatment is not covered)
Alergy Testing and Traetment	$15 Copay per visit	80% after deductible
X-Rays and Lab Tests	$15 Copay	100% of UCR
Therapy (speech, occupational, physical)	$15 Copay per visit(60 visits per consecutive day period per illness or injury)	100% of UCR
Home Health Care	100% (60 visits max per calendar year)	100% (60 visits max per calendar year)
Hospice	No Copay	80% after deductible
Durable Medical Equipment	Not Covered	70% after deductible
Dental Services
TMJ Treatment	Not Covered	Not Covered
Oral Surgery	%15 Copay per visit physician's office	80% after deductible
Inpatient Services
Room and Board	No Copay	100% of UCR
X-Rays and Lab Tests	No Copay	100% of UCR
Private Duty Nursing	Covered if medically necessary and pre-approved by Aetna	100% of UCR
Special Care Units, Maternity Care, Birthing Center	No Copay	100% of UCR
Skilled Nursing Facility	No Copay	80% after deductible; 240 days per calendar year
Surgery and Anesthesia
Inpatient Surgery	No Copay	100% of UCR
Outpatient Surgery	No Copay outpatient facility. $15 Copay for physician's office	100% of UCR
Mental and Nervous Conditions
Inpatient Treatment - combined max of 35 days per calendar year for referred care and 90 days lifetime for self referred care	No Copay	100% for Day 1-30; 80% after deductible for day 31-90; 90 day lifetime max
Outpatient Treatment - combined max of 20 visits per calendar year for referred and self referred care	$5 Copay per visit	80% after deductible
Emergency Care
Emergency Room	$35 Copay (waived if admitted)	$35 Copay (waived if admitted)
Non Emergency use of the Emergency Room	Not Covered	Not Covered
Ambulance	No Copay when medically necessary	80% after deductible

* GYN - Direct access (no referral) to participating providers for one routine exam and pap smear per calendar year.

** Infertility - Diagnosis and treatment of the underlying cause only.

Note: This is only intended to be a general outline of some of the benefits when using the network of the Aetna Patriot V Plan and is not a binding schedule of benefits, fees or allowances.

Consult your Plan Document for complete details of referral process, maximum visits permitted and other allowances