Bronze S: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS

92120FL0080013
Expanded Bronze
HMO

Bronze S: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS is an Expanded Bronze HMO plan by Aetna CVS Health.

IMPORTANT: You are viewing the 2023 version of Bronze S: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS 92120FL0080013. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Bronze S: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Bronze S: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS 92120FL0080013.
Insurer: Aetna CVS Health
Network Type: HMO
Metal Type: Expanded Bronze
HSA Eligible?: No
Plan ID: 92120FL0080013

Cost-Sharing Overview

Bronze S: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS 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 S: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS?

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 S: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS 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: Yes
Specialist Requiring Referral: Referral required for all physicians EXCEPT OB/GYN, ER, Internal Medicine, Family Practice, General Medicine and Pediatrician.
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Bronze S: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS 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 S: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS 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
$50.00 100.00%
Specialist Visit
Covered
$100.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$50.00 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
50.00% Coinsurance after deductible 100.00% Member cost share based on place and type of service.
Outpatient Surgery Physician/Surgical Services
Covered
50.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
50.00% Coinsurance after deductible 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
Not Covered
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$75.00 100.00% No coverage for non-urgent care.
Home Health Care Services
Covered
50.00% Coinsurance after deductible 100.00%60 Visit(s) per Year Coverage is limited to 60 visits per calendar year. 3 visits per day times 20 days
Emergency Room Services
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
50.00% Coinsurance after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
50.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
50.00% Coinsurance after deductible 100.00%60 Days per Year Coverage is limited to 60 days per calendar year.
Prenatal and Postnatal Care
Covered
50.00% Coinsurance after deductible 100.00% Member cost sharing applies to postnatal care
Delivery and All Inpatient Services for Maternity Care
Covered
50.00% Coinsurance after deductible 100.00% Maternity services rendered to a covered person who is acting as a gestational surrogate are excluded.
Mental/Behavioral Health Outpatient Services
Covered
$50.00 100.00%
Mental/Behavioral Health Inpatient Services
Covered
50.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$50.00 100.00%
Substance Abuse Disorder Inpatient Services
Covered
50.00% Coinsurance after deductible 100.00%
Generic Drugs
Covered
$25.00 100.00% Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.
Preferred Brand Drugs
Covered
$50.00 Copay after deductible 100.00% Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.
Non-Preferred Brand Drugs
Covered
$100.00 Copay after deductible 100.00% Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.
Specialty Drugs
Covered
$500.00 Copay after deductible 100.00% Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.
Outpatient Rehabilitation Services
Covered
$50.00 100.00%35 Visit(s) per Year Coverage is limited to 35 visits per calendar year, PT/OT/ST/Chiro combined. Benefit limits for rehabilitation and habilitation services are separate.
Habilitation Services
Covered
50.00% Coinsurance after deductible 100.00%
Chiropractic Care
Covered
$50.00 100.00%35 Visit(s) per Year Coverage is limited to 35 visits per calendar year, PT/OT/ST/Chiro combined. Benefit limits for rehabilitation and habilitation services are separate.
Durable Medical Equipment
Covered
50.00% Coinsurance after deductible 100.00%
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
50.00% Coinsurance after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
0.00% 100.00% Age and frequency schedules may apply.
Routine Foot Care
Not Covered
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.
Acupuncture
Covered
$50.00 100.00%10 Visit(s) per Year Coverage is limited to 10 visits per calendar year.
Weight Loss Programs
Not Covered
Online weight loss programs are available.
Routine Eye Exam for Children
Covered
50.00% Coinsurance after deductible 100.00%1 Exam(s) per Year Coverage is limited to 1 exam every 12 months.
Eye Glasses for Children
Covered
50.00% Coinsurance after deductible 100.00%1 Item(s) per Year Coverage is limited to 1 set of frames and 1 set of contact lenses or eyeglass lenses every 12 months.
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$50.00 100.00%35 Visit(s) per Year Coverage is limited to 35 visits per calendar year, PT/OT/ST/Chiro combined. Benefit limits for rehabilitation and habilitation services are separate.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$50.00 100.00%35 Visit(s) per Year Coverage is limited to 35 visits per calendar year, PT/OT/ST/Chiro combined. Benefit limits for rehabilitation and habilitation services are separate.
Well Baby Visits and Care
Covered
No Charge No Charge 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. Deductible waived OON through age 16.
Laboratory Outpatient and Professional Services
Covered
50.00% Coinsurance after deductible 100.00%
X-rays and Diagnostic Imaging
Covered
50.00% Coinsurance after deductible 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
50.00% Coinsurance after deductible 100.00% Member cost share based on place and type of service. Network benefits must be received within the transplant network.
Accidental Dental
Covered
$100.00 100.00% Member cost share based on place and type of service.
Dialysis
Covered
50.00% Coinsurance after deductible 100.00% Member cost share based on place and type of service.?
Allergy Testing
Covered
$100.00 100.00% Member cost share based on place and type of service.
Chemotherapy
Covered
50.00% Coinsurance after deductible 100.00% Member cost share based on place and type of service.
Radiation
Covered
50.00% Coinsurance after deductible 100.00% Member cost share based on place and type of service.
Diabetes Education
Covered
$100.00 100.00% Member cost share based on place and type of service.
Prosthetic Devices
Covered
50.00% Coinsurance after deductible 100.00%
Infusion Therapy
Covered
50.00% Coinsurance after deductible 100.00% Member cost share based on place and type of service.
Treatment for Temporomandibular Joint Disorders
Covered
$100.00 100.00% 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.
Nutritional Counseling
Covered
No Charge No Charge 100.00% Nutritional Counseling for Diabetes included
Reconstructive Surgery
Covered
50.00% Coinsurance after deductible 100.00% Member cost share based on place and type of service.?
Gender Affirming Care
Bone Marrow Transplant
Covered
50.00% Coinsurance after deductible 100.00% Member cost share based on place and type of service. Network benefits must be received within the transplant network.
Congenital Anomaly, including Cleft Lip/Palate
Covered
50.00% Coinsurance after deductible 100.00% Member cost share based on place and type of service.
Dental Anesthesia
Covered
50.00% Coinsurance after deductible 100.00%
Diabetes Care Management
Covered
$100.00 100.00% Member cost share based on place and type of service.?
Nutrition/Formulas
Covered
50.00% Coinsurance after deductible 100.00% State Mandate
Off Label Prescription Drugs
Covered
$100.00 Copay after deductible 100.00% Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.
Osteoporosis
Covered
$100.00 100.00% Member cost share based on place and type of service.

Free Preventive Services

There is no copayment or coinsurance for any of the following Bronze S: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS 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 S: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS 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 S: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS?

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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