AZ, CO, CT, DE, GA, IL, IN, KS, KY, MO, NC, NJ, NY, NV, OH, OK, PA, TN, TX, WA
CO, CT, DE, NJ, NY, OK, PA, TX
(These markets also have a high option. See column to left)
CA
Aetna HMO Options
Open Access HMO
Open Access HMO
Open Access HMO
HMO
HIGH OPTION
BASIC OPTION
HIGH OPTION
BASIC OPTION
HIGH OPTION
Benefit Features
No Referrals!
No Referrals!
No Referrals!
No Referrals!
Primary care office visit copay (When using your designated PCP)
$15
$20
$20
$15
$20
Preventive care Routine well-child exams w/PCP (through age 17) Routine physicals w/PCP Routine gynecological exam Immunizations with PCP office visit
$0
$15 $25 $15
$0
$20 $30 $20
$0
$20 $30 $20
$15
$15 $30 $15
$0
$20 $30 $20
Hospital copay
$150/day $450 max/stay
90% (Aetna pays)
$150/day $750 max/stay
80% (Aetna Pays)
$150/day $750 max/stay
Outpatient surgery copay
$175
90% (Aetna pays)
$175
80% (Aetna pays)
$175
Emergency room copay
$100
$100
$100
$200
$100
Urgent care center copay
$50
$50
$50
$100
$50
Dental
See below for dental benefits
Vision Routine refraction
Prescription eyewear reimbursement
Aetna VisionSM Discounts
$25
$100/24 months included
$30
$100/24 months included
$30
$100/24 months included
$30
$200/24 months included
$30
$100/24 months included
Prescription copays (up to 30 days) Generic formulary Brand-name formulary Non-formulary Mail order available for maintenance prescriptions
$5 $25 $50
$10 $25 $50
$10 $25 $50
$5 $30 $50
$10 $25 $50
Dental benefits include: You are automatically enrolled for dental benefits in our Basic Dental option. To get more choice in dentists, switch to the dental PPO option, at no extra cost by filling out our online form online form or by calling at 1-800-537-9384.
YOU ARE AUTOMATICALLY ENROLLED IN THE BASIC DENTAL OPTION
YOU MAY SWITCH TO THE DENTAL PPO OPTION
In-network
Out-of-network
Annual Deductible
None
$20
$20
Diagnostic x-rays
$5
$0
50%**
Preventive Care
$5
$0
50%**
Amalgam Fillings
$5
$0
50%**
Other Services
Reduced Fee
Reduced Fee
You pay 100%
*In California only the standard HMO plan is available, where referrals are required.
**You pay 50% of our negotiated rate and any other difference between our allowance and the billed amount.
Open Access Features
PPO dental network option at no extra cost
No referrals
No claim forms
Nationwide access to the Aetna Open Access and HMO network of doctors.
Online provider directory
Aetna Navigator™ website features personal benefits information
