Aetna CA MC 1500 Value California Health Insurance Plan Details

Insurance Plan Summary
Company
Aetna
Plan Name
CA MC 1500 Value
Plan Type
PPO
Primary Care Physician Required
No 
Specialist Referrals Required
No 
HSA Eligible
No 
Out-of-Network Coverage
Yes
In-Network Coverage
Coinsurance
25% after deductible 
Office Visit
 
Primary Doctor
25% Coinsurance after deductible 
Specialist
25% Coinsurance after deductible 
Periodic Health Exam
$50 Copay 
Periodic OB-GYN Exam
No Charge 
Well Baby Care
$50 Copay; Age and frequency schedule apply. 
Chiropractic
25% Coinsurance after deductible. Aetna will pay $25 Max. Per Visit/ 24 Visits Per Year. 
Mental Health
Severe Disorders with demonstrable Organic disease: 25% Coinsurance after deductible 
Prescription Drugs
 
Generic
$20 Copay 
Brand
$40 Copay 
Non-Formulary
Not Covered 
Separate Rx Deductible
$1,000 Individual
applies to
Brand 
Mail Order
Available
Outpatient Lab/X-Ray
25% Coinsurance after deductible 
Emergency Room
$100 Copay (waived if admitted) plus 25% Coinsurance after deductible 
Outpatient Surgery
25% Coinsurance after deductible 
Hospitalization
25% Coinsurance after deductible 
Maternity
 
Pre & Postnatal Office Visit
Not Covered 
Labor & Delivery Hospital Stay
Not Covered 
Additional Information
Will insurance company obtain and pay for medical records?
Yes
eSign
(electronic signature)
Yes
A.M. Best Rating
A
as of 06/11/2007
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Exclusions and Limitations
Exclusions and Limitations
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Company
Aetna
Plan Name
CA MC 1500 Value
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