Alignment Health Plan AVA may be more appealing due to potentially lower costs (premium and deductible) and a lower copay for specialist visits. However, Aetna Open Access offers the flexibility of seeing in-network providers without a referral and includes prescription drug coverage.
| Attribute | Aetna Open Access | Alignment Health Plan AVA |
|---|---|---|
| Monthly Premium Cost | Not available | As low as $0. Some plans may offer a Medicare Part B premium reduction. |
| Deductible Amount | Some Aetna Open Access plans have no deductible. Other plans may have a $20 annual deductible for dental PPO network options. Some plans may have a $500 individual / $1,000 family deductible for in-network and out-of-network. Some plans may have a $2,000 Self / $6,000 Self plus one or Self and family deductible. | $0 |
| Out-of-Pocket Maximum | In-network: Some plans have an individual out-of-pocket maximum of $2,000 and a family maximum of $6,000. In-network: Some plans have an individual out-of-pocket maximum of $2,000 and a family maximum of $4,000. Global: Some plans have an individual out-of-pocket maximum of $8,550 and a family maximum of $17,100. | In-network: $2,899 or $3,900. Out-of-network: $5,750 combined or $8,950 combined. |
| Copay for Primary Care Visit | Some plans have a $20 copay. Some plans have a $25 copay. Some plans have a $30 copay. | As low as $0. Some plans have a $5 or $35 copay. Out-of-network can be $40. |
| Copay for Specialist Visit | Some plans have a $30 copay. Some plans have a $35 copay. Some plans have a $40 copay. Some plans have a $55 copay. You do not need a referral to see a specialist in the Aetna Open Access HMO network, unless you live in California. | $20 copay. Out-of-network can be $50. |
| Prescription Drug Coverage (Formulary) | Aetna Open Access plans typically include prescription drug coverage. Some plans may have a separate deductible for prescription drugs. Mail-order pharmacy service is available for maintenance medications. Your share of the cost for up to a 90-day prescription will be equal to two retail copays. Pharmacy clinical programs such as precertification, step therapy, and quantity limits may apply to your prescription drug coverage. | Has a formulary (drug list). May have 6 drug tiers. Some plans offer additional gap coverage. $0 copays on over 10,000 generic drugs on some plans. Insulin: Copays of $35 or less for a one-month supply. |
| In-network Coverage | Members can visit any in-network provider, like a primary care physician (PCP) or specialist, for covered services without a referral. | Generally requires you to receive care from in-network providers. |
| Out-of-network Coverage | Out-of-network services and supplies are generally not covered, but eligible expenses for emergency care services are covered. Some plans offer limited out-of-network benefits. Out-of-network rates are typically higher. | PPO plans allow you to see out-of-network providers, but costs may be higher. Non-contracted providers must agree to treat you, except in emergencies. |
| Coverage for Emergency Room Visits | Some plans have a copay of $125 per visit. Some plans have a copay of $200 per visit. Some plans have a copay of $250 per visit. The copay is waived if you are admitted to the hospital from the emergency room. | $85 copay. The copay might not be waived if admitted to the hospital. |
| Coverage for Mental Health Services | Mental/behavioral health outpatient services may have a copay. Pre-authorization may be required for care. | Inpatient: May have a daily copay for a certain number of days. Outpatient: Copays or coinsurance may apply. |
| Availability of Telehealth Services | Some plans offer telehealth services with a copay. 24/7 access to doctors via video with CVS Virtual Care. | Telehealth visits may have a low or $0 copay. Access to clinicians by phone or video. |
| Preventive Care Coverage | Some Aetna Open Access HMO plans offer 100% coverage in-network for preventive medical care. | $0 copay for Medicare-covered preventive services in-network. |