Aetna First Dollar Managed Choice Open Access 40 California Health Insurance Plan Details

Insurance Plan Summary
Company
Aetna
Plan Name
First Dollar Managed Choice Open Access 40
Plan Type
PPO
Primary Care Physician Required
No 
Specialist Referrals Required
No 
HSA Eligible
No 
Out-of-Network Coverage
Yes
In-Network Coverage
Coinsurance
40% Coinsurance 
Office Visit
 
Primary Doctor
$40 Copay 
Specialist
$50 Copay 
Periodic Health Exam
$40 Copay 
Periodic OB-GYN Exam
No Charge 
Well Baby Care
$40 copay; Age and frequency schedule apply 
Chiropractic
40% Coinsurance. Aetna will pay $25 Max. Per Visit/ 24 Visits Per Year. 
Mental Health
Not covered except for severe biologically based mental and nervous disorders with associated treatment of drug and alcohol dependencies 
Prescription Drugs
 
Generic
$15 Copay 
Brand
$30 Copay 
Non-Formulary
$50 Copay 
Separate Rx Deductible
$500 Individual
applies to
Brand, Non-Formulary 
Mail Order
Available
Outpatient Lab/X-Ray
40% Coinsurance 
Emergency Room
$100 Copay (waived if admitted) plus 40% Coinsurance 
Outpatient Surgery
40% Coinsurance 
Hospitalization
40% Coinsurance 
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
First Dollar Managed Choice Open Access 40
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