You have options when it comes to your medical and pharmacy benefits, each with different levels of coverage. When you visit providers within the Aetna (All States) OA PPO or (CA only) Aetna Value Network HMO network, your cost is less. When seeking care outside of the network, you will pay an increased portion of the costs.
Understanding Your Options:
Aetna Value Network (AVN) HMO A Health Maintenance Organization (HMO) is a group of medical providers that work together to keep the cost of medical services down. In Network Coverage Only— Aetna contracts with private physicians and hospitals. The AVN HMO plan maintains a network of preferred physicians, specialists, and hospitals that have agreed to contracted rates and will also complete and submit your benefit claims. You will need to specify who your PCP or IPA/Medical Group is.
Primary Care Physician (PCP) The Primary Care Physician (PCP) is a doctor you select from the provider directory to be the single source for all of your medical needs. Whenever you have a medical need (including emergencies, if you are able), your PCP should be contacted on a HMO. This doctor or office will determine the proper course of action and handle your medical needs within their facility or refer you to another doctor or specialist. If you need to be hospitalized, your PCP will assist you in facilitating your care during the entire hospitalization. In the event of an emergency, contact your PCP who will determine proper treatment, except in the case of dire emergency, where you are incapacitated, or a life- threatening situation has occurred.
Independent Physicians’ Association (IPA Or Medical Group) The IPA is a medical group or organization that acts like a PCP on a HMO. However, instead of a single physician, you have a group of physicians available to handle your medical needs. The same criteria apply under an IPA that applies when you choose a PCP. You will simply contact the medical group’s main offices to schedule appointments or referrals, and in emergencies.
Aetna OA Managed Choice POS PPO stands for Open Access Managed Choice. A Open Access Managed Choice acts like a PPO plan and allows you to seek care outside the Aetna OA provider network. You do not need a referral and are not required to select a Primary Care Provider (PCP). You or your covered dependents will pay less out of your pocket by obtaining care in the Aetna provider network.
Comparing the Options
A set percentage you pay of the cost of the care you receive, for example 20%.
A set dollar amount you pay when you receive health care, for example $35 when you see a specialist.
A set amount you must pay out of your pocket before the plan starts paying part of the cost unless a copay applies.
The most you will pay in a calendar year for provider visits, prescriptions, etc., for covered expenses and includes your deductible, copays, and coinsurance. This “safety net” provides peace of mind for those who have a serious condition or illness.
Aetna Value Network HMO (AVN) |
|---|
| In Network only |
| $1,000 |
| $2,000 |
| $4,000 |
| $8,000 |
| N/A |
| $30 copay no ded |
| $50 copay no ded |
| 100%, no copay |
| 100% |
| $50 copay no ded |
| $150 copay, after ded |
| 30% after ded |
| 30% after ded |
| $50 copay no ded |
| $150 copay no ded |
| 30% after ded |
| $50 copay |
| $30 copay after ded |
| $15 copay no ded |
| $15 copay no ded |
| 30 days |
| $10 copay |
| $40 copay |
| $60 copay |
| 30%, $250 max |
| 90 days |
| $20 copay |
| $80 copay |
| $120 copay |
| N/A |
Aetna OA Managed Choice POS | OA Managed Choice POS HDHP |
|||
|---|---|---|---|---|
| Plan Highlights | In-Network | Out-of-Network | In-Network | Out-of-Network |
| Deductible (ded) | $1,000 Indi. / $2,000 Fam. | $2,000 Indi. / $4,000 Fam. | $3,300 Indi. / $6,600 Fam. | $10,000 Indi. / $20,000 Fam. |
| Out-of-Pocket Maximum | $3,500 Indi. / $7,000 Fam. | $8,000 Indi. / $16,000 Fam. | $6,000 Indi. / $12,000 Fam. | $20,000 Indi. / $40,000 Fam. |
| Coinsurance | 20% | 40% | 0% | 50% |
| Preventive Care | Covered 100% | 40% after ded | Covered 100% | 50% after ded |
| Primary Care Physician Visit/Telehealth | $25 copay | 40% after ded | 0% after ded | 50% after ded |
| Specialist Visit/Telehealth | $50 copay | 40% after ded | 0% after ded | 50% after ded |
| Diagnostic X-ray | 20% after ded | 40% after ded | 0% after ded | 50% after ded |
| Diagnostic Lab | 20% after ded | 40% after ded | ||
| Diagnostic Complex Imaging | 20% after ded | 40% after ded | 0% after ded | 50% after ded |
| Urgent Care | $50 copay | 40% after ded | 0% after ded | 50% after ded |
| Emergency Room (Copay waived if admitted) | 20% after $250 copay | 0% after ded | ||
| Inpatient Hospital | 20% after ded | 40% after ded | 0% after ded | 50% after ded |
| Outpatient Surgery | 20% after ded | 40% after ded | 0% after ded | 50% after ded |
| Chiropractic Care (20 visits per year) | $50 copay | 40% after ded | 0% after ded | 50% after ded |
| Outpatient Rehabilitation (PT, OT, ST) | $50 copay | 40% after ded | ||
| Acupuncture (20 visits per year) | $25 copay | 40% after ded | 0% after ded | 50% after ded |
| Prescription Drug Benefits – Advanced Control Formulary | ||||
| Prescription Drug Deductible | None | Medical Deductible applies | ||
| Retail Supply | 30 days | Not Covered | 30 days | Not Covered |
| Generic | $10 copay | $10 copay after ded | ||
| Preferred Brand | $30 copay | $30 copay after ded | ||
| Non-Preferred Brand | $50 copay | $50 copay after ded | ||
| Specialty | 30% w/ $250 max | 30% w/ $250 max after ded | ||
| Mail Order Supply | 90 days | 90 days | ||
| Generic | $20 copay | $20 copay after ded | ||
| Preferred Brand | $60 copay | $60 copay after ded | ||
| Non-Preferred Brand | $100 copay | $100 copay after ded | ||
| Specialty | N/A | N/A | ||