Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 - 18628FL0160054 Health Insurance Plan
Aetna Health Inc. (a FL corp.) health insurance plan with the Plan ID 18628FL0160054. The plan is called Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 64.98% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.02% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 18628FL0160054 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Florida | ||||||||||||||||||
| Health Insurance Issuer | Aetna Health Inc. (a FL corp.) | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 18628FL0160054-00 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 30 Apr 2024 06:06 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 18628FL0160054-00 Standard On Exchange Plan - 18628FL0160054-01 |
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| Last Plan Update Date | Thu, 21 Sep 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 30 Apr 2024 06:06 GMT |
Benefits of Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, 18628FL0160054-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Exclusions: Member cost share based on place and type of service. |
YES | $100.00 |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
Exclusions: Member cost share based on place and type of service. |
YES | $100.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Bone Marrow Transplant
Exclusions: Member cost share based on place and type of service. Network benefits must be received within the transplant network. Copay per day for days 1-3 |
YES | $2,500.00 |
100.00% |
| Chemotherapy
Exclusions: Member cost share based on place and type of service. |
YES | $750.00 |
100.00% |
| Chiropractic Care
Limit: 35.0 Visit(s) per Year Exclusions: Coverage is limited to 35 visits per calendar year, PT/OT/ST/Chiro combined. Benefit limits for rehabilitation and habilitation services are separate. |
YES | $80.00 |
100.00% |
| Congenital Anomaly, including Cleft Lip/Palate
Exclusions: Member cost share based on place and type of service. Copay per day for days 1-3 |
YES | $2,500.00 |
100.00% |
| Cosmetic Surgery
Copay per day for days 1-3 |
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Maternity services rendered to a covered person who is acting as a gestational surrogate are excluded.Copay per day for days 1-3 |
YES | $2,500.00 |
100.00% |
| Dental Anesthesia
|
YES | 50.00% |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Care Management
Exclusions: Member cost share based on place and type of service.? |
YES | $100.00 |
100.00% |
| Diabetes Education
Exclusions: Member cost share based on place and type of service. |
YES | $100.00 |
100.00% |
| Dialysis
Exclusions: 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
|
YES | $2,200.00 |
$2,200.00 |
| Emergency Transportation/Ambulance
|
YES | $2,200.00 |
$2,200.00 |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Exclusions: Coverage is limited to 1 set of frames and 1 set of contact lenses or eyeglass lenses every 12 months. |
YES | $10.00 |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | $40.00 |
100.00% |
| Habilitation Services
|
YES | $100.00 |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 60.0 Visit(s) per Year Exclusions: Coverage is limited to 60 visits per calendar year. 3 visits per day times 20 days |
YES | $80.00 |
100.00% |
| Hospice Services
Exclusions: 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 | $750.00 |
100.00% |
| Infertility Treatment
Exclusions: Coverage limited to diagnosis and treatment of the underlying medical condition. Member cost share based on place and type of service. |
NO | ||
| Infusion Therapy
Exclusions: 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
|
NO | ||
| 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
|
YES | $15.00 |
100.00% |
| Non-Preferred Brand Drugs
Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | 45.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
Nutritional Counseling for Diabetes included |
YES | No Charge |
100.00% |
| Nutrition/Formulas
State Mandate |
YES | 50.00% |
100.00% |
| Off Label Prescription Drugs
Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | 45.00% Coinsurance after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Osteoporosis
Exclusions: Member cost share based on place and type of service. |
YES | $100.00 |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $15.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Exclusions: Member cost share based on place and type of service. |
YES | $1,000.00 |
100.00% |
| Outpatient Rehabilitation Services
Limit: 35.0 Visit(s) per Year Exclusions: Coverage is limited to 35 visits per calendar year, PT/OT/ST/Chiro combined. Benefit limits for rehabilitation and habilitation services are separate. |
YES | $80.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $500.00 |
100.00% |
| Preferred Brand Drugs
Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Prenatal and Postnatal Care
Exclusions: Member cost sharing applies to postnatal care |
YES | No Charge |
100.00% |
| Preventive Care/Screening/Immunization
Exclusions: Age and frequency schedules may apply. |
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $15.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 50.00% |
100.00% |
| Radiation
Exclusions: Member cost share based on place and type of service. |
YES | 50.00% |
100.00% |
| Reconstructive Surgery
Exclusions: 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: 35.0 Visit(s) per Year Exclusions: Coverage is limited to 35 visits per calendar year, PT/OT/ST/Chiro combined. Benefit limits for rehabilitation and habilitation services are separate. |
YES | $80.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 35.0 Visit(s) per Year Exclusions: Coverage is limited to 35 visits per calendar year, PT/OT/ST/Chiro combined. Benefit limits for rehabilitation and habilitation services are separate. |
YES | $80.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year Exclusions: Coverage is limited to 1 exam every 12 months. |
YES | $10.00 |
100.00% |
| Routine Foot Care
Exclusions: Covered Services may include the trimming of toenails, corns, calluses, and therapeutic shoes (including inserts and/or modifications) for the treatment of severe diabetic foot disease. |
NO | ||
| Skilled Nursing Facility
Limit: 60.0 Days per Year Exclusions: Coverage is limited to 60 days per calendar year. Copay per day for days 1-3 |
YES | $2500.00 Copay per Day |
100.00% |
| Specialist Visit
|
YES | $100.00 |
100.00% |
| Specialty Drugs
Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full 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 | $15.00 |
100.00% |
| Transplant
Exclusions: Member cost share based on place and type of service. Network benefits must be received within the transplant network. Copay per day for days 1-3 |
YES | $2,500.00 |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Exclusions: Member cost share based on place and type of service. Payment for splints for the treatment of temporomandibular joint ("TMJ") dysfunction is limited to one splint in a six-month period unless a more frequent replacement is determined by us to be Medically Necessary. |
YES | $100.00 |
100.00% |
| Urgent Care Centers or Facilities
Exclusions: No coverage for non-urgent care. |
YES | $50.00 |
100.00% |
| Weight Loss Programs
Exclusions: Online weight loss programs are available. |
NO | ||
| Well Baby Visits and Care
Exclusions: Coverage is limited 7 exams in the first 12 months of life; 3 exams in the second 12 months of life; 3 exams in the third 12 months of life; 1 exam every 12 months thereafter to age 22. Deductible waived OON through age 16. |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | $75.00 |
100.00% |
Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan Variant 18628FL0160054-00 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 | 2024 |
| 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 | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $8990 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $4495 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $4,495 |
| 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 | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | FLF009 |
| Formulary URL | URL |
| HIOS Product ID | 18628FL016 |
| Import Date | 2023-09-21 01:01:38 |
| 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? | Yes |
| Issuer Actuarial Value | 64.98% |
| Issuer ID | 18628 |
| Issuer Marketplace Marketing Name | Aetna CVS Health |
| 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 | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| 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 | FLN006 |
| 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 | 2024-01-01 |
| Plan ID (Standard Component ID with Variant) | 18628FL0160054-00 |
| Plan Marketing Name | Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 |
| Plan Type | HMO |
| Plan Variant Marketing Name | Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $5,300 |
| 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 | $600 |
| SBC Scenario, Having Diabetes, Deductible | $3,100 |
| 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 | FLS006 |
| Source Name | HIOS |
| Specialist Requiring a Referral | Referral required for all physicians EXCEPT OB/GYN, ER, Internal Medicine, Family Practice, General Medicine and Pediatrician. |
| Plan ID | 18628FL0160054 |
| State Code | FL |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $18800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9400 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,400 |
| 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 Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, 18628FL0160054
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7, 18628FL0160054 Health Insurance Plan, 18628FL0160054
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Does Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, 18628FL0160054 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (18628FL0160054) Health Insurance Plan, Variant (18628FL0160054-00) offer Disease Management Programs?
Does (18628FL0160054) Health Insurance Plan, Variant (18628FL0160054-00) have Out Of Country Coverage?
Does (18628FL0160054) Health Insurance Plan, Variant (18628FL0160054-00) have Out of Service Area Coverage?
Does (18628FL0160054) Health Insurance Plan, Variant (18628FL0160054-00) offer Disease Management Programs?
Does Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (18628FL0160054-00) offer Disease Management Programs for Asthma?
Does Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (18628FL0160054-00) offer Disease Management Programs for Heart disease?
Does Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (18628FL0160054-00) offer Disease Management Programs for Depression?
Does Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (18628FL0160054-00) offer Disease Management Programs for Diabetes?
Does Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (18628FL0160054-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (18628FL0160054-00) offer Disease Management Programs for Low back pain?
Does Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (18628FL0160054-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 30 Apr 2024 06:06 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