Aetna Advantage Managed Choice OA and PPO In-Network Benefit Summary*
(click here for Out-of-Network benefit summary)

Description of Benefits
 MC OA/PPO 1500 MC OA/PPO 2500 MC OA/PPO 3500

MC OA/PPO 5000
 MC OA/PPO
Value 2000		 MC OA/PPO
Value 5000
Lifetime Maximum Per Member

$5,000,000

$5,000,000

$5,000,000

$5,000,000

$5,000,000

$5,000,000
Annual Deductible Per Member (2 person maximum)

$1,500

$2,500

$3,500

$5,000

$2,000

$5,000
Annual Out-of-Pocket Maximum
(2 person family maximum)

$3,000 per member-Includes deductible

$5,000 per member-Includes deductible

$10,000 per member-Includes deductible

$10,000 per member-Includes deductible

$4,000 per member-Includes deductible

$10,000 per member-Includes deductible
Office Visits - (PPO Physicians/Specialists -includes X-ray and lab work when performed and billed by the physician's office) Not subject to calendar year deductible unless specified differently

$25/$35

$30/$40

$35/$45

$40/$50

First 6 Visits: $40/$50 (ded waived); after 6 visits 30% combined with office visits to specialists

First 6 Visits: $40/$50 (ded waived); after 6 visits 30% combined with office visits to specialists
Preventive Care for Babies and Children (through age 5) - Not subject to calendar year deductible

$25

$30

$35

$40

$40

$40
Preventive Care for Adults and Children Over 5 Years of Age ($200 benefit max. per year) -

$25 (ded.
waived for Lab
& x-ray)
$200 Max payout

$30

$35

$40

$40

$40
Professional Services
Including surgery, anesthesia, in-hospital physician care, diagnostic X-ray and lab processed outside of the doctors office.

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible
Inpatient Hospital Services
Surgery, x-ray, in-hospital physician visits

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible
Maternity

Not Covered

Not Covered

Not Covered

Not Covered

Not Covered

Not Covered
Outpatient Medical Care

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible
Physical/Occupational Therapy, Chiropractic (Limited to 24 visits per year combined)

Plan pays 80% after deductible Aetna pays up to Max of $25 per visit

Plan pays 80% after deductible Aetna pays up to Max of $25 per visit

Plan pays 80% after deductible Aetna pays up to Max of $25 per visit

Plan pays 80% after deductible Aetna pays up to Max of $25 per visit

Plan pays 70% after deductible Aetna pays up to Max of $25 per visit

Plan pays 70% after deductible Aetna pays up to Max of $25 per visit
Mental, Emotional or Functional Nervous Disorders - Hospital Inpatient - 30 day maximum per calendar year

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible
 Mental, Emotional or Functional Nervous Disorders - Outpatient care - 48 visit maximum per calendar year

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible
Infusion Therapy and Chemotherapy

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible
Emergency Room Care For Medical Emergency or Serious Accidental Injury
(copay waived if admitted)

$300 copay

$300 copay

$300 copay

$300 copay

$300 copay

$300 copay
Urgent Care  $50 Copay with Ded. Waived  $50 Copay with Ded. Waived  $50 Copay with Ded. Waived  $50 Copay with Ded. Waived  $50 Copay with Ded. Waived  $50 Copay with Ded. Waived
Ambulatory Surgical Center

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible
Ambulance Service - $1000 maximum per trip

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible
Home Health Care
Maximum of 30 visits per year for preferred and non-preferred providers combined

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible
Skilled Nursing (in lieu of hospital stay) Maximum of 30 days per year

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible
Hospice
Maximum lifetime covered expense of $10,000

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible
Home Health Care -
Maximum of 30 visits per calendar year

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible
Durable Medical Equipment and Prosthetics - $2,000 maximum per year

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 80% after deductible

Plan pays 70% after deductible

Plan pays 70% after deductible
Prescription Drugs

$250- does not apply to generic prescriptions

$500- does not apply to generic prescriptions

$500- does not apply to generic prescriptions

$500- does not apply to generic prescriptions

$200- does not apply to generic prescriptions

$500- does not apply to generic prescriptions
   Drug Deductible
(does not apply to generic drugs)
Generic - (no yearly deductible)

$15 copayment

$15 copayment

$15 copayment

$15 copayment

$15 copayment

$15 copayment
Brand Formulary

$25 copay
after Deduct.

$25 copayment

$25 copayment

$25 copayment

$25 copayment

$25 copayment
Non-Brand Formulary

$40 copay
after Deduct.

$40 copayment

$40 copayment

$40 copayment

$40 copayment

$40 copayment
  Calendar Year Pharmacy Maximum per Individual (in and out of network combined)

 Unlimited

 Unlimited

Unlimited

 Unlimited

 Unlimited

 Unlimited
* If you live in Areas 1, 3, or 5 you will use the Aetna Managed Choice Network- Areas 1 & 3 also use the Aexcel Specialist Network
If you live in Areas 2, 4 or 6, you will use the Aetna PPO Network-See list below to find your area and rates
For a full list of benefit coverage and exclusions, refer to the plan documents

Area 1 Counties - Banks, Barrow, Bartow, Butts, Catoosa, Chattooga, Cherokee, Clarke, Clayton, Cobb, Coweta, Dawson, Dekalb, Douglas, Fayette, Floyd, Forsyth, Fulton, Gordon, Gwinnett, Hall, Haralson, Henry, Jackson, Jasper, Lamar, Madison, Newton, Oconee, Oglethorpe, Paulding, Pickens, Pike, Polk, Rockdale, Spalding, Walton - Click here for Area 1 Rates

Area 2 Counties - Carroll, Chattahoochee, Dade, Harris, Heard, Muscogee, Troup, Walker - Click here for Area 2 Rates

Area 3 Counties - Elbert, Fannin, Franklin, Gilmer, Habersham, Lumpkin, Murray, Rabun, Stephens, Towns, Union, White, Whitfield - Click here for Area 3 Rates

Area 4 Counties - Atkinson, Bacon, Baker, Ben Hill, Berrien, Bleckley, Brantley, Brooks, Burke, Calhoun, Camden, Charlton, Clay, Clinch, Colquitt, Columbia, Cook, Crisp, Decatur, Dooly, Early, Echols, Emmanuel, Glascock, Glynn, Grady, Greene, Hancock, Hart, Irwin, Jeff Davis, Jefferson, Jenkins, Johnson, Lanier, Lincoln, Lowndes, Macon, Marion, McDuffie, McIntosh, Meriwether, Miller, Mitchell, Montgomery, Morgan, Pierce, Putnam, Quitman, Randolph, Richmond, Schey, Screven, Seminole, Stewart, Sumter, Talbot, Taliaferro, Taylor, Telfair, Terrell, Thomas, Tift, Toombs, Treutlen, Turner, Upson, Ware, Warren, Wayne, Webster, Wheeler, Wilcox, Wilkes, Wilkinson, Worth - Click here for Area 4 Rates

Area 5 Counties - Appling, Baldwin, Bibb, Bryan, Bulloch, Candler, Chatham, Coffee, Crawford, Dougherty, Effingham, Evans, Houston, Jones, Laurens, Lee, Liberty, Long, Monroe, Peach, Pulaski, Tattnall, Twiggs, Washington - Click here for Area 5 Rates

Area 6 County - Douglas - Click here for Area 6 Rates


Click here to have an enrollment kit mailed or e-mailed to you (be sure to specify which plan)

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Call Holly, Bob or Chris at
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Outside of the Atlanta area,
call toll-free:
1-877-711-8376.
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