The Premier PlanWhen using in-network providers, Aetna's Premier Plan offers no out of pocket maximums per calendar year, a $2 copay to visit your Primary Care Provider (PCP), and specialist visits within the Aetna network with referral from your PCP for only a $0/$2 copay. |
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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 | $1,000 |
| Family | None | $3,000 |
| Annual Out Of Pocket Max | ||
| Individual | N/A | $10,000 |
| Family | N/A | $30,000 |
| Lifetime Maximum | None | $500,000 |
| Primary/Preventive Care | ||
| PCP Office Visits | $2 Copay/visit | 50% after deductible |
| After Hours/Home Visits | $2 Copay/visit | 50% after deductible |
| Routine Exams | $2 Copay/visit | Not Covered |
| Routine Child/Well Baby Care | $2 Copay/visit | Not Covered |
| Immunizations | $2 Copay/visit | Not Covered |
| Routine GYN Exams | $2 Copay/visit | Not Covered |
| Routine Mammogram | $2 Copay/visit | 50% after deductible |
| Routine Eye Exams | $2 Copay/visit | Not Covered |
| Eyeglasses/Contact Lenses | $100 reimbursement every 24 months. Discounts available through Discount One program | Not Covered |
| Hearing Exams | $2 Copay: Routine exam by PCP | Not Covered |
| Hearing Aids | Not Covered | Not Covered |
| Specialty Care | ||
| Office Visits | No Copay | 50% after deductible |
| Prenatal Care | No Copay | 50% after deductible |
| Infertility Services | $2 Copay per visit ** | 50% after deductible (Testing only. Treatment is not covered) |
| Alergy Testing and Traetment | $2 Copay per visit | 50% after deductible |
| X-Rays and Lab Tests | No Copay | 50% after deductible |
| Therapy (speech, occupational, physical) | No Copay(60 visits per consecutive day period per illness or injury) | 50% after deductible |
| Chiropractor (20 visits max per calendar year) | $2 Copay per visit | 50% after deductible |
| Home Health Care | No Copay | 50% after deductible - one visit per day, up to 4 hours per visit, 60 visits per calendar year |
| Hospice | No Copay | 50% after deductible |
| Durable Medical Equipment | Not Covered | 50% after deductible |
| Dental Services | ||
| TMJ Treatment | Not Covered | Not Covered |
| Oral Surgery | No Copay - Physicians office or outpatient facility | 50% after deductible |
| Inpatient Services | ||
| Room and Board | No Copay | 50% after deductible |
| X-Rays and Lab Tests | No Copay | 50% after deductible |
| Private Duty Nursing | Covered if medically necessary and pre-approved by Aetna | 50% after deductible |
| Special Care Units, Maternity Care, Birthing Center | No Copay | 50% after deductible |
| Skilled Nursing Facility | No Copay | 50% 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 | 50% after deductible |
| Outpatient Treatment - combined max of 20 visits per calendar year for referred and self referred care | $10 Copay per visit | 50% after deductible |
| Emergency Care | ||
| Emergency Room | $15 Copay (waived if admitted) | $15 Copay (waived if admitted) |
| Non Emergency use of the Emergency Room | Not Covered | Not Covered |
| Ambulance | No Copay when medically necessary | 50% after deductible |
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* 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 |