EPO/PPO Overview

How the EPO Plan Works

  • Provides both in-network and out-of-network coverage. However, you’ll pay less out of pocket when you use Aetna network providers.
  • For in-network care, no deductible applies, and you’ll pay a $20 copay for most office visits and other services ($40 copay for specialists).
  • For most out-of-network care, you must first satisfy a deductible before benefits begin. After you meet the deductible, you pay 50% coinsurance for care.

How the PPO Plan Works

  • Provides both in-network and out-of-network coverage. However, you’ll pay less out of pocket when you use Aetna network providers.
  • You pay copays for office visits and urgent care when you stay in network. For other types of in-network care, you must first meet a deductible and then you pay 10% coinsurance.
  • For most out-of-network services, you must first satisfy a deductible before benefits begin. After you meet the deductible, you pay 30% coinsurance for care.

Use Your EPO or PPO Plan Wisely

Here are ways to make the most of your EPO or PPO all year long.
  • Track your stats. Log in to Aetna’s website to see how much of your deductible you’ve met, review claims, use helpful tools, and more.
  • Pair it with a Healthcare Flexible Spending Account. During a separate enrollment in November, you may choose to enroll in the Healthcare Flexible Spending Account, which allows you to set aside before-tax dollars to help pay for your eligible medical, prescription, dental, and vision expenses. Keep in mind, you can only carry over up to $550 of unused money in your FSA to the next calendar year; amounts over $550 will be forfeited.
  • Be cost-conscious. Visit Aetna’s website, where you can search for in-network providers and use cost estimating tools to figure out what you may have to pay for care before you go to your doctor.

Plan Comparison

Plan Details Aetna EPO Plan Aetna PPO Plan
In-Network Out-of-Network* In-Network Out-of-Network*
Annual Deductible
(Individual/Family)
$750/$1,500 $5,000/$10,000 $750/$1,500 $1,000/$2,000
Out-of-Pocket Maximum
(Individual/Family)
$3,000/$9,000 $8,000/$24,000 $3,500/$7,000 $7,000/$14,000
PCP Required No No No No
Preventive Care Covered in full 50% after deductible Covered in full 40% after deductible
Office Visits/
Primary Care/Specialist
$20 copay/$40 copay 50% after deductible $20 copay/$20 copay 40% after deductible
Urgent Care $25 copay 50% after deductible $25 copay 40% after deductible
Emergency Room $200 copay (waived if admitted) $150 copay (waived if admitted)
Maternity Care (Inpatient) $200 per day for the first 3 days, then covered 100% after deductible 50% after deductible 20% after $250 copay, after deductible 40% after deductible
Inpatient Hospital $200 per day for the first 3 days, then covered 100% after deductible 50% after deductible 20% after $250 copay, after deductible 40% after deductible
Outpatient Surgery $200 copay after deductible 50% after deductible 20% after $150 copay, after deductible 40% after deductible

*Out-of-network coverage is based on the negotiated rate. If your provider’s rate is higher, you will be responsible for paying the difference.