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Benefit Schedules: High Ded 3000 | High Ded 5000 | First Dollar 35 | Prevent/Hosp Care 1250 | Prevent/Hosp Care 3000
Arizona Health Insurance > Aetna > Preventative and Hospital Care 3000 Benefits
Quote & Apply - Electronic Application
| Preventative and Hospital Care 3000 (HSA Compatible) | ||
| Member Benefits | In-Network | Out-of-Network+ |
| Deductible Individual / Family | $3,000/$6,000 | $6,000/$12,000 |
| Coinsurance (Member’s Responsibility) | 20% after deductible |
50% after deductible |
| Coinsurance Maximum Individual / Family | $2,000/$4,000 | $4,000/$8,000 |
| Out-of-Pocket Maximum Individual / Family (Includes Deductible) | $5,000/$10,000 | $10,000/$20,000 |
| 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) |
$40 copay ded. waived |
50% after deductible |
| Maternity | Not covered (except for pregnancy complications) |
|
| Preventive Health (Routine Physical) ($200 maximum*) |
$35 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) |
Not covered*** | Not covered |
| 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* | Not Applicable | Not Applicable |
* 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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