Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

96992IN0060002
Expanded Bronze
HMO

Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 is an Expanded Bronze HMO plan by Aetna CVS Health.

IMPORTANT: You are viewing the 2024 version of Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 96992IN0060002. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

Bronze 4: 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 Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 96992IN0060002.
Insurer: Aetna CVS Health
Network Type: HMO
Metal Type: Expanded Bronze
HSA Eligible?: No
Plan ID: 96992IN0060002

Cost-Sharing Overview

Bronze 4: 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 Bronze 4: 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

Bronze 4: 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 Bronze 4: 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

Bronze 4: 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
$15.00 Not ApplicableNot Applicable 100.00%
Specialist Visit
Covered
$100.00 Not ApplicableNot Applicable 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$15.00 Not ApplicableNot Applicable 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
$1,000.00 Not ApplicableNot Applicable 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
$500.00 Not ApplicableNot Applicable 100.00%
Hospice Services
Covered
$2,500.00 Not ApplicableNot Applicable 100.00% Member cost share based on place and type of service. Copay per day for days 1-3
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%Not Applicable 100.00%82.0 Visit(s) per Year Coverage is limited to 82 shifts per calendar year.
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$50.00 Not ApplicableNot Applicable 100.00% No coverage for non-urgent care.
Home Health Care Services
Covered
$80.00 Not ApplicableNot Applicable 100.00%100.0 Visit(s) per Benefit Period Coverage limited to 100 visits per calendar year. Combined In and out of network. Maximum does not include Home Infusion Therapy or Private Duty Nursing rendered in the home.
Emergency Room Services
Covered
$2,200.00 Not Applicable$2,200.00 Not Applicable No coverage for non-emergency use of the emergency room.
Emergency Transportation/Ambulance
Covered
$2,200.00 Not Applicable$2,200.00 Not Applicable
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
$2500.00 Copay per Day Not ApplicableNot Applicable 100.00% Maximum 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis). Limit is combined both In and Out of Network.Copay per day for days 1-3
Inpatient Physician and Surgical Services
Covered
No Charge Not ApplicableNot Applicable 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Covered for reconstructive surgery. Copay per day for days 1-3
Skilled Nursing Facility
Covered
$2500.00 Copay per Day Not ApplicableNot Applicable 100.00%90.0 Days per Benefit Period Coverage limited to 90 days per calendar year. Limit is combined both In and Out of Network.Copay per day for days 1-3
Prenatal and Postnatal Care
Covered
No Charge Not ApplicableNot Applicable 100.00% Member cost sharing applies to postnatal care
Delivery and All Inpatient Services for Maternity Care
Covered
$2,500.00 Not ApplicableNot Applicable 100.00% Copay per day for days 1-3
Mental/Behavioral Health Outpatient Services
Covered
$15.00 Not ApplicableNot Applicable 100.00% Cost share driven by provider/setting.
Mental/Behavioral Health Inpatient Services
Covered
$2500.00 Copay per Day Not ApplicableNot Applicable 100.00% Copay per day for days 1-3
Substance Abuse Disorder Outpatient Services
Covered
$15.00 Not ApplicableNot Applicable 100.00% Cost share driven by provider/setting.
Substance Abuse Disorder Inpatient Services
Covered
$2500.00 Copay per Day Not ApplicableNot Applicable 100.00% Copay per day for days 1-3
Generic Drugs
Covered
$40.00 Not ApplicableNot Applicable 100.00% Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. No Copayment /Coinsurance will apply to orally administered cancer chemotherapy when obtained from a Network Pharmacy, Mail Service Program, or Specialty Pharmacy Network.
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. No Copayment /Coinsurance will apply to orally administered cancer chemotherapy when obtained from a Network Pharmacy, Mail Service Program, or Specialty Pharmacy Network.
Non-Preferred Brand Drugs
Covered
Not Applicable 45.00% Coinsurance after deductibleNot Applicable 100.00% Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. No Copayment /Coinsurance will apply to orally administered cancer chemotherapy when obtained from a Network Pharmacy, Mail Service Program, or Specialty Pharmacy Network.
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. No Copayment /Coinsurance will apply to orally administered cancer chemotherapy when obtained from a Network Pharmacy, Mail Service Program, or Specialty Pharmacy Network.
Outpatient Rehabilitation Services
Covered
$80.00 Not ApplicableNot Applicable 100.00%60.0 Visit(s) per Benefit Period Coverage is limited to 20 visits each for PT/OT/ST per calendar year, rehabilitation & habilitation separate. Cost share is driven by provider/setting. Coverage for Speech Therapy is limited to 20 visits per benefit period, Occupational Therapy is limited to 20 visits per benefit period, and Physical Therapy is limited to 20 visits per benefit period. These limits are combined in and out of network. Benefit includes an Inpatient maximum of 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis). Limit is combined both In and Out of Network. Cardiac Rehabilitation limited to 36 visits when rendered as Physician Home Visits and Office Services or Outpatient Services, combined Network and Non- Network when rendered in the home, Home Care Services limits apply. Pulmonary Rehabilitation limited to 20 visits when rendered as Physician Home Visits and Office Services or Outpatient Services, combined Network and Non- Network. When rendered in the home, Home Care Services limits apply. When rendered as part of physical therapy, the Physical Therapy limit will apply instead of the limit indicated.
Habilitation Services
Covered
$100.00 Not ApplicableNot Applicable 100.00% Cost share is driven by provider/setting.
Chiropractic Care
Covered
$15.00 Not ApplicableNot Applicable 100.00%12.0 Visit(s) per Benefit Period Coverage limited to 12 visits per calendar year. Limit combined In and out of network. Cost share driven by provider/setting.
Durable Medical Equipment
Covered
Not Applicable 50.00%Not Applicable 100.00% One wig per benefit period combined both In and Out of Network. Network and Non-Network for wigs following cancer treatment.
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
$750.00 Not ApplicableNot Applicable 100.00%
Preventive Care/Screening/Immunization
Covered
Not Applicable No ChargeNot Applicable 100.00% Age and frequency schedules may apply.
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 per calendar year, 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
$80.00 Not ApplicableNot Applicable 100.00%20.0 Visit(s) per Benefit Period Coverage is limited to 20 visits per calendar year, rehabilitation & habilitation separate. Combined In and out of network. Cost share driven by provider/setting.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$80.00 Not ApplicableNot Applicable 100.00%40.0 Visit(s) per Benefit Period Coverage is limited to 20 visits PT and 20 visits OT per calendar year, rehabilitation & habilitation separate. Cost share is driven by provider/setting. Occupational Therapy is limited to 20 visits per benefit period, and Physical Therapy is limited to a separate 20 visits per benefit period. Both apply to In-Network Providers and Non-Network Providers combined. Coverage also includes an additional 20 visits each for habilitative services.
Well Baby Visits and Care
Covered
Not Applicable No ChargeNot Applicable 100.00% Age and frequency schedules may apply. 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
$50.00 Not ApplicableNot Applicable 100.00%
X-rays and Diagnostic Imaging
Covered
$75.00 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
Per Indiana law, abortion only covered if performed because a woman becomes pregnant through an act of rape or incest; or an abortion is necessary to avert the pregnant woman?s death or a substantial and irreversible impairment of a major bodily function of the pregnant woman
Transplant
Covered
$2,500.00 Not ApplicableNot Applicable 100.00% Member cost share based on place and type of service. Network benefits must be received within the transplant network. Includes coverage for unrelated donor search services ($30,000 per transplant/network & Non network combined) and travel/lodging as approved by the plan ($10,000 per transplant/network & Non network combined).Copay per day for days 1-3
Accidental Dental
Covered
$100.00 Not ApplicableNot Applicable 100.00% Member cost share based on place and type of service.
Dialysis
Covered
$1,000.00 Not ApplicableNot Applicable 100.00% Member cost share based on place and type of service.
Allergy Testing
Covered
$100.00 Not ApplicableNot Applicable 100.00% Member cost share based on place and type of service. Cost share driven by provider/setting.
Chemotherapy
Covered
$750.00 Not ApplicableNot Applicable 100.00% Member cost share based on place and type of service. Cost share driven by provider/setting.
Radiation
Covered
Not Applicable 50.00%Not Applicable 100.00% Member cost share based on place and type of service. Cost share driven by provider/setting.
Diabetes Education
Covered
$100.00 Not ApplicableNot Applicable 100.00% Member cost share based on place and type of service.
Prosthetic Devices
Covered
Not Applicable 50.00%Not Applicable 100.00% Must be medically necessary.
Infusion Therapy
Covered
$750.00 Not ApplicableNot Applicable 100.00% Member cost share based on place and type of service. Cost share driven by provider/setting.
Treatment for Temporomandibular Joint Disorders
Covered
$100.00 Not ApplicableNot Applicable 100.00% Coverage includes diagnostic and surgical treatment of TMJ .
Nutritional Counseling
Covered
Not Applicable No ChargeNot Applicable 100.00% Cost share driven by provider/setting.
Reconstructive Surgery
Covered
$2,500.00 Not ApplicableNot Applicable 100.00% Member cost share based on place and type of service.Excludes all other reconstructive services that are not specifically outlined in Covered Services. Certain reconstructive services required to correct a deformity caused by disease, trauma, congenital anomalies, or previous therapeutic process are covered. Coverage includes breast reconstruction on which a mastectomy has been performed. Reconstructive services required due to prior therapeutic process are payable only if the original procedure would have been a covered service under this plan.Copay per day for days 1-3
Gender Affirming Care
Clinical Trials
Covered
$100.00 Not ApplicableNot Applicable 100.00% Member cost share based on place and type of service.
Dental Anesthesia
Covered
Not Applicable 50.00%Not Applicable 100.00%
Diabetes Care Management
Covered
$100.00 Not ApplicableNot Applicable 100.00% Member cost share based on place and type of service.
Inherited Metabolic Disorder – PKU
Covered
Not Applicable 50.00%Not Applicable 100.00% Covers nutritional supplements, metabolic disorders, and medical products. Applicable medical or prescription drug cost share may apply.
Mental Health Other
Covered
$15.00 Not ApplicableNot Applicable 100.00% Member cost share based on place and type of service.
Off Label Prescription Drugs
Covered
Not Applicable 45.00% Coinsurance after deductibleNot Applicable 100.00% Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.

Free Preventive Services

There is no copayment or coinsurance for any of the following Bronze 4: 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 Bronze 4: 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 Bronze 4: 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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