Bronze 4 PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care - 72547IL0170002 Health Insurance Plan
Aetna Life Insurance Company health insurance plan with the Plan ID 72547IL0170002. The plan is called Bronze 4 PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care.
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 | 72547IL0170002 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Illinois | ||||||||||||||||||
| Health Insurance Issuer | Aetna Life Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 72547IL0170002-00 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 07 May 2024 06:08 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 72547IL0170002-00 Standard On Exchange Plan - 72547IL0170002-01 |
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| Last Plan Update Date | Tue, 12 Sep 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 07 May 2024 06:08 GMT |
Benefits of Bronze 4 PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care Health Insurance Plan, 72547IL0170002-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Abortions are only covered when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest |
YES | $100.00 |
50.00% Coinsurance after deductible |
| Accidental Dental
|
YES | $100.00 |
50.00% Coinsurance after deductible |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $100.00 |
50.00% Coinsurance after deductible |
| Autism Spectrum Disorders
Member cost share based on place and type of service. |
YES | $15.00 |
50.00% Coinsurance after deductible |
| 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. |
YES | 50.00% |
50.00% Coinsurance after deductible |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Bones/Joints
Member cost share based on place and type of service.Copay per day for days 1-3 |
YES | $2,500.00 |
50.00% Coinsurance after deductible |
| Breast Implant Removal
Member cost share based on place and type of service.Copay per day for days 1-3 |
YES | $2,500.00 |
50.00% Coinsurance after deductible |
| Chemotherapy
Member cost share based on place and type of service. |
YES | $750.00 |
50.00% Coinsurance after deductible |
| Chiropractic Care
Limit: 25.0 Visit(s) per Year Exclusions: New Style Accumulation and Cost Share- Coverage is limited to 25 visits per manipulation per calendar year, separate from habilitation and includes all outpatient places of service for Chiro. Benefits will be provided for manipulation or adjustment of osseous or articular structures, commonly referred to as chiropractic and osteopathic manipulation, when performed by a person licensed to perform such procedures. |
YES | $80.00 |
50.00% Coinsurance after deductible |
| Clinical Trials
Member cost share based on place and type of service. |
YES | $100.00 |
50.00% Coinsurance after deductible |
| Cosmetic Surgery
Cosmetic surgery for the correction of the congenital deformities or for conditions resulting from accidental injuries, scars, tumors or disease is covered.Copay per day for days 1-3 |
YES | $2,500.00 |
50.00% Coinsurance after deductible |
| Delivery and All Inpatient Services for Maternity Care
Copay per day for days 1-3 |
YES | $2,500.00 |
50.00% Coinsurance after deductible |
| Dental Anesthesia
|
YES | 50.00% |
50.00% Coinsurance after deductible |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Care Management
Member cost share based on place and type of service. |
YES | $100.00 |
50.00% Coinsurance after deductible |
| Diabetes Education
Services must be rendered by a physician, or duly certified, registered or licensed health care professional with expertise in diabetes management. |
YES | $100.00 |
50.00% Coinsurance after deductible |
| Dialysis
|
YES | $1,000.00 |
50.00% Coinsurance after deductible |
| Durable Medical Equipment
|
YES | 50.00% |
50.00% Coinsurance after deductible |
| 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 per year. Age 0-19. |
YES | $10.00 |
50.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | $40.00 |
50.00% |
| Habilitation Services
Treatment must be medically necessary and therapeutic and not investigational. |
YES | $100.00 |
50.00% Coinsurance after deductible |
| Hearing Aids
Limit: 1.0 Item(s) per 2 Years Exclusions: Hearing aids limited to 1 hearing aid per ear every 24 months. Bone anchored hearing aids and cochlear implants are covered. |
YES | 50.00% |
50.00% Coinsurance after deductible |
| Home Health Care Services
|
YES | $80.00 |
50.00% Coinsurance after deductible |
| Hospice Services
Copay per day for days 1-3 |
YES | $2,500.00 |
50.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs)
|
YES | $750.00 |
50.00% Coinsurance after deductible |
| Infertility Treatment
Exclusions: Limited to 4 attempts; if live birth, 2 additional attempts covered. |
YES | $100.00 |
50.00% Coinsurance after deductible |
| Infusion Therapy
Member cost share based on place and type of service. |
YES | $750.00 |
50.00% Coinsurance after deductible |
| Inherited Metabolic Disorder - PKU
|
YES | 50.00% |
50.00% Coinsurance after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay)
Copay per day for days 1-3 |
YES | $2500.00 Copay per Day |
50.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services
|
YES | No Charge |
50.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services
|
YES | $50.00 |
50.00% Coinsurance after deductible |
| 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 |
50.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Services
|
YES | $15.00 |
50.00% Coinsurance after deductible |
| Multiple Sclerosis
Member cost share based on place and type of service. |
YES | $80.00 |
50.00% Coinsurance after deductible |
| Non-Preferred Brand Drugs
Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | 45.00% Coinsurance after deductible |
50.00% |
| Nutritional Counseling
|
YES | No Charge |
50.00% Coinsurance after deductible |
| Organ Transplants
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 |
50.00% Coinsurance after deductible |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $15.00 |
50.00% Coinsurance after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $1,000.00 |
50.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services
|
YES | $80.00 |
50.00% Coinsurance after deductible |
| Outpatient Surgery Physician/Surgical Services
|
YES | $500.00 |
50.00% Coinsurance after deductible |
| Preferred Brand Drugs
Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | 40.00% Coinsurance after deductible |
50.00% |
| Prenatal and Postnatal Care
Member cost sharing applies to postnatal care |
YES | No Charge |
50.00% Coinsurance after deductible |
| Prescription Drugs Other
Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | 45.00% Coinsurance after deductible |
50.00% |
| Preventive Care/Screening/Immunization
Exclusions: Age and frequency schedules may apply. |
YES | No Charge |
50.00% Coinsurance after deductible |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $15.00 |
50.00% Coinsurance after deductible |
| Private-Duty Nursing
Exclusions: Inpatient Private Duty Nursing Services are not covered. |
YES | 50.00% |
50.00% Coinsurance after deductible |
| Prosthetic Devices
|
YES | 50.00% |
50.00% Coinsurance after deductible |
| Radiation
|
YES | 50.00% |
50.00% Coinsurance after deductible |
| Reconstructive Surgery
Member cost share based on place and type of service.Copay per day for days 1-3 |
YES | $2,500.00 |
50.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Provided when rendered by a registered Occupational Therapist or registered professional Physical Therapist under the supervision of a Physician. |
YES | $80.00 |
50.00% Coinsurance after deductible |
| Rehabilitative Speech Therapy
Provided when rendered by a licensed Speech Therapist or Speech Therapist certified by the American Speech and Hearing Association. |
YES | $80.00 |
50.00% Coinsurance after deductible |
| 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 age 0-19. |
YES | $10.00 |
50.00% |
| Routine Foot Care
Only covered for persons diagnosed with diabetes. |
YES | $100.00 |
50.00% Coinsurance after deductible |
| Skilled Nursing Facility
Copay per day for days 1-3 |
YES | $2500.00 Copay per Day |
50.00% Coinsurance after deductible |
| Specialist Visit
|
YES | $100.00 |
50.00% Coinsurance after deductible |
| Specialty Drugs
Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | 50.00% Coinsurance after deductible |
50.00% |
| Substance Abuse Disorder Inpatient Services
Copay per day for days 1-3 |
YES | $2500.00 Copay per Day |
50.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services
|
YES | $15.00 |
50.00% Coinsurance after deductible |
| Transplant
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 |
50.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders
Member cost share based on place and type of service. |
YES | 50.00% |
50.00% Coinsurance after deductible |
| Urgent Care Centers or Facilities
|
YES | $50.00 |
50.00% Coinsurance after deductible |
| Weight Loss Programs
Online weight loss programs are available. |
NO | ||
| Well Baby Visits and Care
Exclusions: Children immunizations covered at 100% deductible waived for children up to 72 months of age. Coverage is limited to 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. |
YES | No Charge |
50.00% Coinsurance after deductible |
| X-rays and Diagnostic Imaging
|
YES | $75.00 |
50.00% Coinsurance after deductible |
Bronze 4 PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care Health Insurance Plan Variant 72547IL0170002-00 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 | $0 per group |
| Drug EHB Deductible, Out of Network, Family Per Person | $0 per person |
| Drug EHB Deductible, Out of Network, Individual | $0 |
| 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 | 0.9991 |
| First Tier Utilization | 100% |
| Formulary ID | ILF007 |
| Formulary URL | URL |
| HIOS Product ID | 72547IL017 |
| Import Date | 2023-09-12 20:01:55 |
| 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 | 64.98% |
| Issuer ID | 72547 |
| 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 | $28000 per group |
| Medical EHB Deductible, Out of Network, Family Per Person | $14000 per person |
| Medical EHB Deductible, Out of Network, Individual | $14,000 |
| Metal Level | Expanded Bronze |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | ILN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Covered with Limitations |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan ID (Standard Component ID with Variant) | 72547IL0170002-00 |
| Plan Marketing Name | Bronze 4 PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care |
| Plan Type | PPO |
| Plan Variant Marketing Name | Bronze 4 PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care |
| 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 | ILS001 |
| Source Name | SERFF |
| Plan ID | 72547IL0170002 |
| State Code | IL |
| 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 PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care Health Insurance Plan, 72547IL0170002
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Bronze 4 PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care, 72547IL0170002 Health Insurance Plan, 72547IL0170002
-
Does Bronze 4 PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care Health Insurance Plan, 72547IL0170002 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (72547IL0170002) Health Insurance Plan, Variant (72547IL0170002-00) offer Disease Management Programs?
Does (72547IL0170002) Health Insurance Plan, Variant (72547IL0170002-00) have Out Of Country Coverage?
Does (72547IL0170002) Health Insurance Plan, Variant (72547IL0170002-00) have Out of Service Area Coverage?
Does (72547IL0170002) Health Insurance Plan, Variant (72547IL0170002-00) offer Disease Management Programs?
Does Bronze 4 PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care Health Insurance Plan, Variant (72547IL0170002-00) offer Disease Management Programs for Asthma?
Does Bronze 4 PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care Health Insurance Plan, Variant (72547IL0170002-00) offer Disease Management Programs for Heart disease?
Does Bronze 4 PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care Health Insurance Plan, Variant (72547IL0170002-00) offer Disease Management Programs for Depression?
Does Bronze 4 PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care Health Insurance Plan, Variant (72547IL0170002-00) offer Disease Management Programs for Diabetes?
Does Bronze 4 PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care Health Insurance Plan, Variant (72547IL0170002-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Bronze 4 PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care Health Insurance Plan, Variant (72547IL0170002-00) offer Disease Management Programs for Low back pain?
Does Bronze 4 PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care Health Insurance Plan, Variant (72547IL0170002-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 07 May 2024 06:08 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