Silver 5: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

48161MO0200014
Silver
EPO

Silver 5: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 is a Silver EPO plan by Aetna CVS Health.

IMPORTANT: You are viewing the 2024 version of Silver 5: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 48161MO0200014. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

Silver 5: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of Silver 5: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 48161MO0200014.
Insurer: Aetna CVS Health
Network Type: EPO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 48161MO0200014

Cost-Sharing Overview

Silver 5: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Silver 5: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Silver 5: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 offers the following features and referral requirements.

Wellness Program: Yes
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Silver 5: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 covers when you are out of the service area or out of the country.

Out of Country Coverage: No
Out of Country Coverage Description:
Out of Service Area Coverage: No
Out of Service Area Coverage Description: Except for Emergencies
National Network: No

Additional Benefits and Cost-Sharing

Silver 5: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$30.00 Not ApplicableNot Applicable 100.00%
Specialist Visit
Covered
$60.00 Not ApplicableNot Applicable 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$30.00 Not ApplicableNot Applicable 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Hospice Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Member cost share based on place and type of service.
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Coverage limited to diagnosis and treatment of the underlying medical condition. Member cost share based on place and type of service.
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%82.0 Visit(s) per Year Coverage is limited to the home setting; 82 shifts of 8 hours each per calendar year.
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$50.00 Not ApplicableNot Applicable 100.00%
Home Health Care Services
Covered
$30.00 Not ApplicableNot Applicable 100.00%100.0 Visit(s) per Year Coverage is limited to 100 visits per calendar year.
Emergency Room Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Inpatient Physician and Surgical Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%150.0 Days per Year Coverage is limited to 150 days per calendar year.
Prenatal and Postnatal Care
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Member cost sharing applies to postnatal care
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$30.00 Not ApplicableNot Applicable 100.00%
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$30.00 Not ApplicableNot Applicable 100.00%
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Generic Drugs
Covered
$25.00 Not ApplicableNot Applicable 100.00% Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.
Preferred Brand Drugs
Covered
$55.00 Not ApplicableNot Applicable 100.00% Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.
Non-Preferred Brand Drugs
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00% Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.
Specialty Drugs
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.
Outpatient Rehabilitation Services
Covered
$30.00 Not ApplicableNot Applicable 100.00%20.0 Visit(s) per Year Coverage is limited to 20 visits each for PT/OT per calendar year, rehabilitation & habilitation separate limits.
Habilitation Services
Covered
$30.00 Not ApplicableNot Applicable 100.00%
Chiropractic Care
Covered
$20.00 Not ApplicableNot Applicable 100.00%
Durable Medical Equipment
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Hearing Aids
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Coverage is limited to 1 per ear every 4 years.
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Preventive Care/Screening/Immunization
Covered
Not Applicable No ChargeNot Applicable 100.00% Age and frequency schedules may apply. Out-of-Network: Childhood immunizations covered 100% for children up to 5 years of age.
Routine Foot Care
Not Covered
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Online weight loss programs are available.
Routine Eye Exam for Children
Covered
$10.00 Not ApplicableNot Applicable 100.00%1.0 Exam(s) per Year Coverage is limited to 1 exam every 12 months age 0-19.
Eye Glasses for Children
Covered
$10.00 Not ApplicableNot Applicable 100.00%1.0 Item(s) per Year Coverage is limited to 1 set of frames and 1 set of contact lenses or eyeglass lenses per calendar year age 0-19.
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$30.00 Not ApplicableNot Applicable 100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$30.00 Not ApplicableNot Applicable 100.00%20.0 Visit(s) per Year Coverage is limited to 20 visits each for PT/OT per calendar year, rehabilitation & habilitation separate limits.
Well Baby Visits and Care
Covered
Not Applicable No ChargeNot Applicable 100.00% 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.
Laboratory Outpatient and Professional Services
Covered
$25.00 Not ApplicableNot Applicable 100.00%
X-rays and Diagnostic Imaging
Covered
$30.00 Copay after deductible Not ApplicableNot Applicable 100.00%
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Member cost share based on place and type of service. Network benefits must be received within the transplant network.
Accidental Dental
Covered
$60.00 Not ApplicableNot Applicable 100.00% Member cost share based on place and type of service.
Dialysis
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Member cost share based on place and type of service.
Allergy Testing
Covered
$60.00 Not ApplicableNot Applicable 100.00% Member cost share based on place and type of service.
Chemotherapy
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00% Member cost share based on place and type of service.
Radiation
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Member cost share based on place and type of service.
Diabetes Education
Covered
$60.00 Not ApplicableNot Applicable 100.00% Member cost share based on place and type of service.
Prosthetic Devices
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Infusion Therapy
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00% Member cost share based on place and type of service.
Treatment for Temporomandibular Joint Disorders
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Includes coverage for surgical treatment.
Nutritional Counseling
Covered
Not Applicable No ChargeNot Applicable 100.00%
Reconstructive Surgery
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Member cost share based on place and type of service.
Gender Affirming Care
Applied Behavior Analysis Based Therapies
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Bone Marrow Testing
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Member cost share based on place and type of service. Network benefits must be received within the transplant network.
Clinical Trials
Covered
$60.00 Not ApplicableNot Applicable 100.00% Member cost share based on place and type of service.
Dental Anesthesia
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Early Intervention Services
Covered
$30.00 Not ApplicableNot Applicable 100.00%
Inherited Metabolic Disorder – PKU
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Covered Service for formula and low protein modified food products for patients with phenylketonuria (PKU) or inherited disease of amino and organic acids for a child less than six (6) years old.
Newborn Services Other
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Member cost share based on place and type of service.

Free Preventive Services

There is no copayment or coinsurance for any of the following Silver 5: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for Silver 5: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Silver 5: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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