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CALIFORNIA AETNA ADVANTAGE PLAN OPTIONS

The Aetna California Advantage PPO 500 Plan, an insurance plan underwritten by Aetna Life Insurance Company, features our lowest annual deductibles, annual out-of-pocket outlays and copays for office visits, plus quality prescription drug coverage. They also feature the highest premiums of our individual plans.

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies. The Aetna company that offers, underwrites, or administers insurance coverage is Aetna Life Insurance Company

MEMBER BENEFITS

In-Network

Out-of-Network

Deductible

Individual

$1,500

$3,000

Family

$3,000

$6,000

Coinsurance (Member’s responsibility)

30% after deductible

50% after deductible

Coinsurance Maximum

Individual

$6,000

$12,000

Family

$12,000

$24,000

Lifetime Maximum* per insured

$5,000,000

Non-specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist)

$30 copay
not subject to deductible

50% after
deductible

Specialist Visit

$40 copay
not subject to deductible

50% after
deductible

Hospital Admission

30% after
deductible

50% after
deductible

Outpatient Surgery

30% after
deductible

50% after
deductible

Emergency Room

(after deductible)

$100 copay (waived if admitted);

30% co-insurance

Annual Routine Gyn Exam
(Annual Pap / Mammogram)

No Copay
not subject to deductible

50% after
deductible

Maternity

Not covered

Preventive Health (Annual Physical)

($200 per calendar year*)

$30 Copay
not subject to deductible

50% after
deductible

Lab / X-Ray

30% after
deductible

50% after
deductible

Skilled Nursing (In lieu of Hospital)

(30 days per calendar year*)

30% after
deductible

50% after
deductible

Physical / Occupational Therapy

(24 visits per calendar year*)

30% after
deductible (Aetna will pay a max. of $25 per visit)

50% after
deductible (Aetna will pay a max. of $25 per visit)

Home Health Care

(30 visits per calendar year*)

30% after
deductible

50% after
deductible

PHARMACY

Pharmacy Deductible

$250

Generic Copay

(Contraceptives Included

$15 copay
not subject to deductible

$15 copay plus 50% not subject to deductible

Preferred Brand Copay

(Oral Contraceptives Included

$30 copay after
deductible

$30 copay plus 50% after deductible

Non-Preferred Brand Copay

(Oral Contraceptives Included

$50 copay after
deductible

$50 copay plus 50% after deductible

Calendar Year Maximum

per Individual

Unlimited

* Maximum applies to combined in and out of network benefits. * + Payment for out-of-network facility care is determined based upon Aetna’s Allowable Fee Schedule. Payment for other out-of network care is determined based upon the negotiated charge that would apply if such services or supplies were received from a Preferred Provider. A summary of exclusions is listed on page 19 of the Aetna Advantage Brochure.

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies. The Aetna company that offers, underwrites, or administers insurance coverage is Aetna Life Insurance Company

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CALIFORNIA AETNA ADVANTAGE PLAN OPTIONS