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Arizona Health Insurance > Aetna > Preventative and Hospital Care 1250 Benefits

Aetna

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Preventative and Hospital Care 1250
Member Benefits In-Network Out-of-Network+
Deductible Individual / Family $1,250/$2,500 $2,500/$5,000
Coinsurance (Member’s Responsibility) 20%
after deductible		 50%
after deductible
Coinsurance Maximum Individual / Family $2,500/$5,000 $5,000/$10,000
Out-of-Pocket Maximum Individual / Family (Includes Deductible) $3,750/$7,500 $7,500/$15,000
Lifetime Maximum* $5,000,000 $5,000,000
Non-specialist Office Visit
(General Physician, Family Practitioner, Pediatrician or Internist)		 Not covered Not covered
Specialist Visit
(Aexcel Network available in specified counties.)		 Not covered Not covered
Hospital Admission 20%
after deductible		 50%
after deductible
Outpatient Surgery 20%
after deductible		 50%
after deductible
Urgent Care Facility Not covered Not covered
Emergency Room
$100 copay** (waived if admitted)
20% coinsurance after deductible
Annual Routine GYN Exam
(Annual Pap / Mammogram)		 $35 copay
ded. waived		 50%
after deductible
Maternity
Not covered (except for pregnancy complications)
Preventive Health
(Routine Physical) ($200 maximum*)		 $25 copay
ded. waived		 50%
after deductible
Lab / X-Ray Not covered Not covered
Skilled Nursing (In Lieu of Hospital)
(30 days per calendar year*)		 20%
after deductible		 50%
after deductible
Physical / Occupational Therapy & Chiropractic Care Not covered Not covered
Home Health Care
(In Lieu of Hospital)
(30 visits per calendar year*)		 20%
after deductible		 50%
after deductible
Durable Medical Equipment Not covered Not covered
Pharmacy
Pharmacy Deductible per Individual Not Applicable Not Applicable
Generic
(Oral Contraceptives included)		 $15 copay $15 copay plus 50%
Preferred Brand copay
(Oral Contraceptives included)		 Not covered*** Not covered
Non-Preferred Brand copay
(Oral Contraceptives included)		 Not covered*** Not covered
Calendar Year Maximum per Individual* $5,000 $5,000

* Maximum applies to combined in and out-of-network benefits.
** Copay is billed separately and not due at time of service. Copay does not count towards coinsurance or out-of-pocket maximum.
*** Aetna Discount Available
+ Payment for out-of-network facility care is determined based upon Aetna’s Allowable Fee Schedule. Payment for other out-of-network facility care is determined based upon the negotiated charge that would apply if such services or supplies were received from a Preferred Provider.

 
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