BannerAetna Bronze 4: No PCP required + $0 PCP + free 98.6 virtual care 24/7 + Adult Dental + Vision - 23435AZ0040022 Health Insurance Plan

Banner Health and Aetna Health Plan Inc. health insurance plan with the Plan ID 23435AZ0040022. The plan is called BannerAetna Bronze 4: No PCP required + $0 PCP + free 98.6 virtual care 24/7 + Adult Dental + Vision.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 64.99% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.01% of the costs of all covered benefits (according to the Issuer).

Health Insurance Plan ID 23435AZ0040022
Health Insurance Plan Year 2025
State Arizona
Health Insurance Issuer Banner Health and Aetna Health Plan Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 23435AZ0040022-00
Provider Network(s) PREFERRED NON-PREFERRED
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 10 Dec 2024 06:32 GMT).

Providers Arizona All US States
All 17697 29543
PCP 1954 2172
Allergy 5 6
OB/GYN 98 114
Dentists 2286 2559
Available Variants of the Health Plan

Standard Off Exchange Plan - 23435AZ0040022-00

Standard On Exchange Plan - 23435AZ0040022-01

Open to Indians below 300% FPL - 23435AZ0040022-02

Open to Indians above 300% FPL - 23435AZ0040022-03

Last Plan Update Date Thu, 03 Oct 2024 00:00 GMT
Last Import Date Tue, 10 Dec 2024 06:32 GMT

Benefits of BannerAetna Bronze 4: No PCP required + $0 PCP + free 98.6 virtual care 24/7 + Adult Dental + Vision Health Insurance Plan, 23435AZ0040022-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental

Benefits are payable for the services of a Physician, dentist, or dental surgeon, provided the services are rendered for treatment of an accidental injury to sound natural teeth where the continuous course of treatment is started within six (6) months of the accident. Member cost share based on place and type of service.

YES

$80.00

100.00%
Acupuncture
NO
Allergy Testing

Member cost share based on place and type of service.

YES

$80.00

100.00%
Bariatric Surgery

Pre-certification is required. Surgery for obesity will be a Covered Service only when required due to morbid obesity. The participant meets the current NIH (National Institutes of Health) surgical criteria.Copay per day for days 1-3

YES

$2,500.00

100.00%
Basic Dental Care - Adult

Coverage is limited to ages 19 and up.?$50 deductible / $1,000 calendar year maximum for all dental services (Routine check-up, Basic & Major).

YES

50.00%

100.00%
Basic Dental Care - Child
NO
Chemotherapy

Member cost share based on place and type of service.

YES

$750.00

100.00%
Chiropractic Care

Limit: 20.0 Visit(s) per Year

YES

$80.00

100.00%
Cosmetic Surgery

Cosmetic surgery or procedures excluded, other than to treat congenital defects and birth abnormalitiesCopay per day for days 1-3

NO
Delivery and All Inpatient Services for Maternity Care

Copay per day for days 1-3

YES

$2,500.00

100.00%
Dental Check-Up for Children
NO
Diabetes Education

Member cost share based on place and type of service.

YES

$80.00

100.00%
Dialysis

Member cost share based on place and type of service.

YES

$1,000.00

100.00%
Durable Medical Equipment
YES

50.00%

100.00%
Emergency Room Services

Exclusions: No coverage for non-emergency use of the emergency room.

YES

$2,500.00

$2,500.00
Emergency Transportation/Ambulance
YES

$2,500.00

$2,500.00
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

Coverage is limited to 1 set of frames and 1 set of contact lenses or eyeglass lenses per year through the end of the month in which the member turns 19.

YES

$10.00

100.00%
Gender Affirming Care
NO
Generic Drugs

Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details.

YES

$3.00

100.00%
Habilitation Services

Health care services that are needed to keep, learn, or improve your skills and functioning for daily living which may include physical therapy, occupational therapy, and speech therapy. Please refer to the plan policy documents for detailed information.

YES

$80.00

100.00%
Hearing Aids

Limit: 1.0 Item(s) per Year

Coverage is limited to one hearing aid per ear per year.

YES

50.00%

100.00%
Home Health Care Services

Limit: 42.0 Visit(s) per Year

YES

$80.00

100.00%
Hospice Services

Member cost share based on place and type of service.Copay per day for days 1-3

YES

$2,500.00

100.00%
Imaging (CT/PET Scans, MRIs)
YES

$850.00

100.00%
Infertility Treatment

Coverage limited to diagnosis and treatment of the underlying medical condition. Member cost share based on place and type of service.

NO
Infusion Therapy

Member cost share based on place and type of service.

YES

$750.00

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)

Copay per day for days 1-3

YES

$2500.00 Copay per Day

100.00%
Inpatient Physician and Surgical Services
YES

No Charge

100.00%
Laboratory Outpatient and Professional Services
YES

$50.00

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult

Coverage is limited to ages 19 and up. 6 month waiting period regardless of prior coverage. $50 deductible / $1,000 calendar year maximum for all dental services (Routine check-up, Basic & Major).

YES

50.00%

100.00%
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services

Copay per day for days 1-3

YES

$2500.00 Copay per Day

100.00%
Mental/Behavioral Health Outpatient Services

The cost sharing that displays applies to outpatient office visits only. All other outpatient services may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.

YES

No Charge

100.00%
Non-Preferred Brand Drugs

Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details.

YES

$275.00 Copay after deductible

100.00%
Nutritional Counseling
YES

No Charge

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)

Cost share applies to both in-person and virtual services from in-network providers. Cost share does not apply to virtual services from designated telemedicine providers. If this is an HSA plan, deductible applies.

YES

No Charge

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

$1,000.00

100.00%
Outpatient Rehabilitation Services

Limit: 60.0 Visit(s) per Year

Coverage is limited to 60 visits per year for Physical Therapy, Occupational Therapy, and Speech Therapy combined.

YES

$80.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

$500.00

100.00%
Preferred Brand Drugs

Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details.

YES

$195.00

100.00%
Prenatal and Postnatal Care

Member cost sharing applies to postnatal care.

YES

No Charge

100.00%
Preventive Care/Screening/Immunization

Age and frequency schedules may apply.

YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness

Cost share applies to both in-person and virtual services from in-network providers. Cost share does not apply to virtual services from designated telemedicine providers. If this is an HSA plan, deductible applies.

YES

No Charge

100.00%
Private-Duty Nursing

Private hospital rooms and/or private duty nursing are only available during inpatient stays and determined to be medically appropriate. Private duty nursing is available only in an inpatient setting when skilled nursing is not available from the facility. Custodial Nursing is not covered.

NO
Prosthetic Devices
YES

50.00%

100.00%
Radiation

Member cost share based on place and type of service.

YES

50.00%

100.00%
Reconstructive Surgery

Member cost share based on place and type of service.Copay per day for days 1-3

YES

$2,500.00

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 60.0 Visit(s) per Year

Coverage is limited to 60 visits per year for Physical Therapy, Occupational Therapy, and Speech Therapy combined.

YES

$80.00

100.00%
Rehabilitative Speech Therapy

Limit: 60.0 Visit(s) per Year

Coverage is limited to 60 visits per year for Physical Therapy, Occupational Therapy, and Speech Therapy combined.

YES

$80.00

100.00%
Routine Dental Services (Adult)

Limit: 2.0 Visit(s) per Year

Coverage is limited to ages 19 and up. $1,000 calendar year maximum for all dental services (Routine check-up, Basic & Major).

YES

No Charge

100.00%
Routine Eye Exam (Adult)

Limit: 1.0 Exam(s) per Year

Coverage is limited to ages 19 and up. Benefit limitations may apply.

YES

$10.00

100.00%
Routine Eye Exam for Children

Limit: 1.0 Visit(s) per Year

Coverage through the end of the month in which the member turns 19.

YES

$10.00

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 90.0 Days per Year

Copay per day for days 1-3

YES

$2500.00 Copay per Day

100.00%
Specialist Visit
YES

$80.00

100.00%
Specialty Drugs

Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details.

YES

50.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services

Copay per day for days 1-3

YES

$2500.00 Copay per Day

100.00%
Substance Abuse Disorder Outpatient Services
YES

No Charge

100.00%
Transplant

Member cost share based on place and type of service. Network benefits must be received within the Institutes of Excellence (IOE) transplant network.Copay per day for days 1-3

YES

$2,500.00

100.00%
Treatment for Temporomandibular Joint Disorders

Coverage is limited to accident, trauma, congenital/developmental defects or pathology. Member cost share based on place and type of service.

YES

$80.00

100.00%
Urgent Care Centers or Facilities

Exclusions: No coverage for non-urgent care.

YES

$50.00

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care

Age and frequency schedules may apply.

YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

$85.00

100.00%

BannerAetna Bronze 4: No PCP required + $0 PCP + free 98.6 virtual care 24/7 + Adult Dental + Vision Health Insurance Plan Variant 23435AZ0040022-00 Attributes

Plan Attribute Value
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2025
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Bronze Off Exchange Plan
Drug EHB Deductible, Combined In/Out of Network, Family Per Group $9990 per group
Drug EHB Deductible, Combined In/Out of Network, Family Per Person $4995 per person
Drug EHB Deductible, Combined In/Out of Network, Individual $4,995
Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 0.00%
Drug EHB Deductible, In Network (Tier 1), Family Per Group $9990 per group
Drug EHB Deductible, In Network (Tier 1), Family Per Person $4995 per person
Drug EHB Deductible, In Network (Tier 1), Individual $4,995
Drug EHB Deductible, Out of Network, Family Per Group per group not applicable
Drug EHB Deductible, Out of Network, Family Per Person per person not applicable
Drug EHB Deductible, Out of Network, Individual Not Applicable
Dental Only Plan No
Design Type Not Applicable
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy
EHB Percent of Total Premium 0.9478
First Tier Utilization 100%
Formulary ID AZF003
Formulary URL URL
HIOS Product ID 23435AZ004
Import Date 2024-10-03 01:01:22
Limited Cost Sharing Plan Variation - Estimated Advanced Payment 0
Inpatient Copayment Maximum Days 0
HSA Eligible No
New/Existing Plan New
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer Actuarial Value 64.99%
Issuer ID 23435
Issuer Marketplace Marketing Name BannerAetna
Market Coverage Individual
Medical Drug Deductibles Integrated No
Medical Drug Maximum Out of Pocket Integrated Yes
Medical EHB Deductible, Combined In/Out of Network, Family Per Group $0 per group
Medical EHB Deductible, Combined In/Out of Network, Family Per Person $0 per person
Medical EHB Deductible, Combined In/Out of Network, Individual $0
Medical EHB Deductible, In Network (Tier 1), Default Coinsurance 50.00%
Medical EHB Deductible, In Network (Tier 1), Family Per Group $0 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person $0 per person
Medical EHB Deductible, In Network (Tier 1), Individual $0
Medical EHB Deductible, Out of Network, Family Per Group per group not applicable
Medical EHB Deductible, Out of Network, Family Per Person per person not applicable
Medical EHB Deductible, Out of Network, Individual Not Applicable
Metal Level Expanded Bronze
Multiple In Network Tiers No
National Network No
Network ID AZN003
Out of Country Coverage No
Out of Service Area Coverage No
Out of Service Area Coverage Description Except for Emergencies
Plan Brochure URL
Plan Effective Date 2025-01-01
Plan ID (Standard Component ID with Variant) 23435AZ0040022-00
Plan Marketing Name BannerAetna Bronze 4: No PCP required + $0 PCP + free 98.6 virtual care 24/7 + Adult Dental + Vision
Plan Type HMO
Plan Variant Marketing Name BannerAetna Bronze 4: No PCP required + $0 PCP + free 98.6 virtual care 24/7 + Adult Dental + Vision
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $5,400
SBC Scenario, Having a Baby, Deductible $0
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $2,900
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $2,000
SBC Scenario, Treatment of a Simple Fracture, Deductible $0
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID AZS003
Source Name HIOS
Plan ID 23435AZ0040022
State Code AZ
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $18390 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $9195 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $9,195
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $18390 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $9195 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $9,195
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual Not Applicable
Unique Plan Design Yes
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered Yes

Copay & Coinsurance of BannerAetna Bronze 4: No PCP required + $0 PCP + free 98.6 virtual care 24/7 + Adult Dental + Vision Health Insurance Plan, 23435AZ0040022

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about BannerAetna Bronze 4: No PCP required + $0 PCP + free 98.6 virtual care 24/7 + Adult Dental + Vision, 23435AZ0040022 Health Insurance Plan, 23435AZ0040022

  • Does BannerAetna Bronze 4: No PCP required + $0 PCP + free 98.6 virtual care 24/7 + Adult Dental + Vision Health Insurance Plan, 23435AZ0040022 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (23435AZ0040022) Health Insurance Plan, Variant (23435AZ0040022-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy

    Does (23435AZ0040022) Health Insurance Plan, Variant (23435AZ0040022-00) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan).

    Does (23435AZ0040022) Health Insurance Plan, Variant (23435AZ0040022-00) have Out of Service Area Coverage?

    No, unfortunately there is no Out of Service Area Coverage for this Health Insurance Plan (variant of plan). Details: Except for Emergencies

    Does (23435AZ0040022) Health Insurance Plan, Variant (23435AZ0040022-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy

    Does BannerAetna Bronze 4: No PCP required + $0 PCP + free 98.6 virtual care 24/7 + Adult Dental + Vision Health Insurance Plan, Variant (23435AZ0040022-00) offer Disease Management Programs for Asthma?

    Yes, the BannerAetna Bronze 4: No PCP required + $0 PCP + free 98.6 virtual care 24/7 + Adult Dental + Vision Health Insurance Plan Variant 23435AZ0040022-00 offers Disease Management Program for Asthma.

    Does BannerAetna Bronze 4: No PCP required + $0 PCP + free 98.6 virtual care 24/7 + Adult Dental + Vision Health Insurance Plan, Variant (23435AZ0040022-00) offer Disease Management Programs for Heart disease?

    Yes, the BannerAetna Bronze 4: No PCP required + $0 PCP + free 98.6 virtual care 24/7 + Adult Dental + Vision Health Insurance Plan Variant 23435AZ0040022-00 offers Disease Management Program for Heart disease.

    Does BannerAetna Bronze 4: No PCP required + $0 PCP + free 98.6 virtual care 24/7 + Adult Dental + Vision Health Insurance Plan, Variant (23435AZ0040022-00) offer Disease Management Programs for Depression?

    Yes, the BannerAetna Bronze 4: No PCP required + $0 PCP + free 98.6 virtual care 24/7 + Adult Dental + Vision Health Insurance Plan Variant 23435AZ0040022-00 offers Disease Management Program for Depression.

    Does BannerAetna Bronze 4: No PCP required + $0 PCP + free 98.6 virtual care 24/7 + Adult Dental + Vision Health Insurance Plan, Variant (23435AZ0040022-00) offer Disease Management Programs for Diabetes?

    Yes, the BannerAetna Bronze 4: No PCP required + $0 PCP + free 98.6 virtual care 24/7 + Adult Dental + Vision Health Insurance Plan Variant 23435AZ0040022-00 offers Disease Management Program for Diabetes.

    Does BannerAetna Bronze 4: No PCP required + $0 PCP + free 98.6 virtual care 24/7 + Adult Dental + Vision Health Insurance Plan, Variant (23435AZ0040022-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the BannerAetna Bronze 4: No PCP required + $0 PCP + free 98.6 virtual care 24/7 + Adult Dental + Vision Health Insurance Plan Variant 23435AZ0040022-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does BannerAetna Bronze 4: No PCP required + $0 PCP + free 98.6 virtual care 24/7 + Adult Dental + Vision Health Insurance Plan, Variant (23435AZ0040022-00) offer Disease Management Programs for Low back pain?

    Yes, the BannerAetna Bronze 4: No PCP required + $0 PCP + free 98.6 virtual care 24/7 + Adult Dental + Vision Health Insurance Plan Variant 23435AZ0040022-00 offers Disease Management Program for Low back pain.

    Does BannerAetna Bronze 4: No PCP required + $0 PCP + free 98.6 virtual care 24/7 + Adult Dental + Vision Health Insurance Plan, Variant (23435AZ0040022-00) offer Disease Management Programs for Pregnancy?

    Yes, the BannerAetna Bronze 4: No PCP required + $0 PCP + free 98.6 virtual care 24/7 + Adult Dental + Vision Health Insurance Plan Variant 23435AZ0040022-00 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Tue, 10 Dec 2024 06:32 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API