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Aetna OAMC PPO HD

Aetna
877-204-9186
Group Number: 237642

The Aetna Open Access Managed Care (PPO) plan offers employees the flexibility to see different doctors, whether or not they are in your plan’s network. High Deductible (HD) combines traditional medical coverage with a Health Savings Account (HSA). As evident by the name, this plan has a higher deductible members must reach before the plan kicks in.

Aetna OAMC PPO HD

In-Network

Out-Network

Annual Deductible    
Individual $2,000  $4,000 
Individual within Family $3,200  $4,000 
Family $4,000  $8,000 
Annual Out of Pocket Maximum    
Individual  $4,000 $8,000
Family $8,000 $16,000

Medical Services

Primary Care Visit 10% 30% 
Specialist Office Visit 10% 30%  
Basic X-ray and Laboratory 10% 30%  
Inpatient Hospital 10% 30%  
Emergency Room 10% 10% 
Urgent Care 10% 30%  
Chiropractic 10% 30%  
Hearing Aid 10% 10% 
Prescription Drugs After Deductible After Deductible 
Generic / Tier 1 $10 copay Not Covered
Formulary / Tier 2 $40 copay  Not Covered
Non-Formulary / Tier 3 $50 copay Not Covered
Specialty/ Tier 4 30% up to $300 copay Not covered 
Semimonthly Employee Contribution
Employee Only $86.82
Employee + 1 $295.45
Employee + Family $468.81