Silver S: Aetna network of doctors & hospitals + telemedicine + $0 MinuteClinic visits at CVS
38234VA0170014
Silver
EPO
Silver S: Aetna network of doctors & hospitals + telemedicine + $0 MinuteClinic visits at CVS is a Silver EPO plan by Aetna Life Insurance Company.
IMPORTANT: You are viewing the 2023 version of Silver S: Aetna network of doctors & hospitals + telemedicine + $0 MinuteClinic visits at CVS 38234VA0170014. You can enroll in this plan if you qualify for special enrollment until the end of 2023.
Locations
Silver S: Aetna network of doctors & hospitals + telemedicine + $0 MinuteClinic visits at CVS is offered in the following counties.
Plan Overview
This is a plan overview for 2023 version of Silver S: Aetna network of doctors & hospitals + telemedicine + $0 MinuteClinic visits at CVS 38234VA0170014.
| Insurer: | Aetna Life Insurance Company |
| Network Type: | EPO |
| Metal Type: | Silver |
| HSA Eligible?: | No |
| Plan ID: | 38234VA0170014 |
Cost-Sharing Overview
Silver S: Aetna network of doctors & hospitals + telemedicine + $0 MinuteClinic visits at CVS offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for Silver S: Aetna network of doctors & hospitals + telemedicine + $0 MinuteClinic visits at CVS includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $8,900.00 | $8900 per person | $17800 per group |
| Deductible: | $5,800.00 | $5800 per person | $11600 per group |
| Coinsurance: | 40.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for Silver S: Aetna network of doctors & hospitals + telemedicine + $0 MinuteClinic visits at CVS will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | Not Applicable | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | Not Applicable | per person not applicable | per group not applicable |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | $5,800.00 |
| Copayment: | $10.00 |
| Coinsurance: | $2,300.00 |
| Limit: | $60.00 |
| Deductible: | $100.00 |
| Copayment: | $1,600.00 |
| Coinsurance: | $0.00 |
| Limit: | $20.00 |
| Deductible: | $1,900.00 |
| Copayment: | $300.00 |
| Coinsurance: | $0.00 |
| Limit: | $0.00 |
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 S: Aetna network of doctors & hospitals + telemedicine + $0 MinuteClinic visits 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
Silver S: Aetna network of doctors & hospitals + telemedicine + $0 MinuteClinic visits 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: | 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 S: Aetna network of doctors & hospitals + telemedicine + $0 MinuteClinic visits 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
Silver S: Aetna network of doctors & hospitals + telemedicine + $0 MinuteClinic visits 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 |
|---|---|---|---|
| Routine Eye Exam (Adult) Not Covered | |||
| Urgent Care Centers or Facilities Covered | $60.00 | 100.00% | No coverage for non-urgent care. Includes X-ray services; Care for broken bones; Tests such as flu, urinalysis, allergy test, pregnancy test, rapid strep; Lab services; Stitches for simple cuts; and Draining an abscess. |
| Home Health Care Services Covered | 40.00% Coinsurance after deductible | 100.00% | 100 Visit(s) per Year Visit limit does not apply to home infusion therapy or home dialysis. The Home Care visit limit will apply instead of the Therapy Services limits for physical, occupational, speech therapy, or cardiac rehabilitation for therapy in the home. Benefit includes intermittent skilled nursing services by an R.N. or L.P.N.; Medical/social services; Diagnostic services; Nutritional guidance; Training of the patient and/or family/caregiver; Home health aide services; Therapy Services; Medical supplies; Durable medical equipment. Coverage is limited to 100 visits per calendar year. |
| Emergency Room Services Covered | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | Benefits are available in a Hospital Emergency Room or an independent, free-standing emergency facility for services and supplies to treat the onset of symptoms for a medical emergency. |
| Emergency Transportation/Ambulance Covered | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | Includes medically necessary transportation to the nearest appropriate hospital for a medical emergency, or between hospitals or other approved facilities. Includes ground, water, fixed wing and rotary air transportation. Benefits also include medically necessary treatment of a sickness or injury by medical professionals from an ambulance service, even if you are not taken to a facility. Benefits are only available for air ambulance when it is not appropriate to use a ground or water ambulance. |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | 40.00% Coinsurance after deductible | 100.00% | Benefits for room, board, and nursing services include: a room with two or more beds; a private room when medically necessary for isolation and no isolation facilities are available; a room in an approved special care unit; meals, special diets; general nursing services; operating, childbirth, and treatment rooms and equipment; prescribed drugs; anesthesia, anesthesia supplies and services given by the hospital or other provider; medical and surgical dressings and supplies, casts, and splints; blood and blood products; diagnostic services. Includes coverage for general anesthesia and hospitalization services when determined by dentist and treating physician that such services are required to effectively and safely provide dental care for (i) children under the age of 5, (ii) covered persons who are severely disabled, or (iii) covered persons who have a medical condition that requires admission to a hospital or Outpatient surgery facility. |
| Inpatient Physician and Surgical Services Covered | 40.00% Coinsurance after deductible | 100.00% | Includes medical care visits; intensive medical care when medically necessary; treatment for a health problem by a Doctor who is not your surgeon while you are in the Hospital for surgery; treatment by two or more Doctors during one Hospital stay when the nature or severity of your health problem calls for the skill of separate Doctors; a personal bedside exam by another Doctor when asked for by your Doctor; surgery and general anesthesia; professional charges to interpret diagnostic tests such as imaging, pathology reports, and cardiology. Surgeries and procedures to correct congenital abnormalities that cause functional impairment and congenital abnormalities in newborn children; other invasive procedures, such as angiogram, arteriogram, amniocentesis, tap or puncture of brain or spine; endoscopic exams, such as arthroscopy, bronchoscopy, colonoscopy, laparoscopy; treatment of fractures and dislocations; anesthesia and surgical support when medically necessary; medically necessary pre-operative and post-operative care. Medical benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is medically necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Includes surgical treatment of injuries and illnesses of the eye. |
| Bariatric Surgery Not Covered | Morbid Obesity surgery | ||
| Cosmetic Surgery Not Covered | |||
| Primary Care Visit to Treat an Injury or Illness Covered | $40.00 | 100.00% | Including doctor visits in the home and online visits. |
| Specialist Visit Covered | $80.00 | 100.00% | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $40.00 | 100.00% | Includes Retail Health Clinics (walk-ins). |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | 40.00% Coinsurance after deductible | 100.00% | Includes coverage for blood and blood products, anesthesia and anesthesia supplies and services given by the Hospital or other Facility, medical and surgical dressings and supplies, casts, and splints. Includes coverage for general anesthesia and hospitalization services when determined by dentist and treating physician that such services are required to effectively and safely provide dental care for (i) children under the age of 5, (ii) covered persons who are severely disabled, or (iii) covered persons who have a medical condition that requires admission to a hospital or Outpatient surgery facility. Surgeries and procedures to correct congenital abnormalities that cause functional impairment and congenital abnormalities in newborn children; other invasive procedures, such as angiogram, arteriogram, amniocentesis, tap or puncture of brain or spine; endoscopic exams, such as arthroscopy, bronchoscopy, colonoscopy, laparoscopy; treatment of fractures and dislocations; anesthesia and surgical support when Medically Necessary; Medically Necessary pre-operative and post-operative care. Benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is Medically Necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Includes surgical treatment of injuries and illnesses of the eye. |
| Outpatient Surgery Physician/Surgical Services Covered | 40.00% Coinsurance after deductible | 100.00% | Includes coverage for blood and blood products, anesthesia and anesthesia supplies and services given by the Hospital or other Facility, medical and surgical dressings and supplies, casts, and splints. Includes coverage for general anesthesia and hospitalization services when determined by dentist and treating physician that such services are required to effectively and safely provide dental care for (i) children under the age of 5, (ii) covered persons who are severely disabled, or (iii) covered persons who have a medical condition that requires admission to a hospital or outpatient surgery facility. Surgeries and procedures to correct congenital abnormalities that cause functional impairment and congenital abnormalities in newborn children; other invasive procedures, such as angiogram, arteriogram, amniocentesis, tap or puncture of brain or spine; endoscopic exams, such as arthroscopy, bronchoscopy, colonoscopy, laparoscopy; treatment of fractures and dislocations; anesthesia and surgical support when Medically Necessary; Medically Necessary pre-operative and post-operative care. Benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is Medically Necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Includes surgical treatment of injuries and illnesses of the eye. |
| Hospice Services Covered | 40.00% 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 | |||
| Long-Term/Custodial Nursing Home Care Not Covered | |||
| Private-Duty Nursing Covered | 50.00% Coinsurance after deductible | 100.00% | 16 Hours per Year |
| Skilled Nursing Facility Covered | 40.00% Coinsurance after deductible | 100.00% | 100 Days per Admission |
| Prenatal and Postnatal Care Covered | 40.00% Coinsurance after deductible | 100.00% | Includes prenatal and postnatal services for the mother; postnatal services for the baby, including hemoglobinopathies screening; gonorrhea prophylactic medication; hypothyroidism screening, PKY screening and Rh incompatibility testing. Member cost sharing applies to postnatal care |
| Delivery and All Inpatient Services for Maternity Care Covered | 40.00% Coinsurance after deductible | 100.00% | Includes services needed during a normal or complicated pregnancy and for services needed for a miscarriage. Covered maternity services include: pregnancy testing; professional and facility services for childbirth including use of the delivery room and care for normal deliveries, in a facility or the home including the services of an appropriately licensed nurse midwife; anesthesia services to provide partial or complete loss of sensation before delivery; routine nursery care for the newborn during the mother?s normal hospital stay, including circumcision of a covered male dependent; allowed fetal screenings, which are genetic or chromosomal tests of the fetus. Hospital stay for childbirth for mother and newborn may not be limited to less than 48 hours after vaginal birth or less than 96 hours after a cesarean section, unless the mother and attending provider request it. |
| Mental/Behavioral Health Outpatient Services Covered | $40.00 | 100.00% | Includes treatment in an outpatient department of a hospital and office visits, individual psychotherapy, group psychotherapy, psychological testing and medication management visits. Services may be received by a psychiatrist, psychologist, neuropsychologist, licensed clinical social worker (L.C.S.W.), clinical nurse specialist, licensed marriage and family therapist (L.M.F.T.), licensed professional counselor (L.P.C) or any agency licensed by the state to give these services that must be covered by law. |
| Mental/Behavioral Health Inpatient Services Covered | 40.00% Coinsurance after deductible | 100.00% | Includes services in a hospital or any facility required to be covered by state law. Inpatient benefits include individual psychotherapy, group psychotherapy, psychological testing, counseling with family members to assist with the patient?s diagnosis and treatment, convulsive therapy, detoxification, and rehabilitation. |
| Substance Abuse Disorder Outpatient Services Covered | $40.00 | 100.00% | Includes treatment in an outpatient department of a hospital and office visits, individual psychotherapy, group psychotherapy, psychological testing and medication management visits. Services may be received by a psychiatrist, psychologist, neuropsychologist, licensed clinical social worker (L.C.S.W.), clinical nurse specialist, licensed marriage and family therapist (L.M.F.T.), licensed professional counselor (L.P.C) or any agency licensed by the state to give these services that must be covered by law. |
| Substance Abuse Disorder Inpatient Services Covered | 40.00% Coinsurance after deductible | 100.00% | Includes services in a hospital or any facility required to be covered by state law. Inpatient benefits include individual psychotherapy, group psychotherapy, psychological testing, counseling with family members to assist with the patient?s diagnosis and treatment, convulsive therapy, detoxification, and rehabilitation. |
| Generic Drugs Covered | $20.00 | 100.00% | Covers prescription legend drugs from either a Retail Pharmacy or the PBM’s Home Delivery Pharmacy; self-administered injectable drugs; self-injectable insulin and supplies and equipment used to administer insulin; self-administered contraceptives, including oral contraceptive drugs, self-injectable contraceptive drugs, contraceptive patches, and contraceptive rings. Certain contraceptives are covered under the ‘Preventive Care’ benefit. Includes coverage for special food products or supplements when prescribed by a Doctor when medically necessary; Flu Shots (including administration). Inpatient or IV therapy drugs used in the treatment of cancer pain will not be denied on the basis that the dosage exceeds the recommended dosage of the pain relieving agent, if prescribed in compliance with established statutes pertaining to patients with intractable cancer pain. |
| Preferred Brand Drugs Covered | $40.00 | 100.00% | Covers prescription legend drugs from either a Retail Pharmacy or the PBM’s Home Delivery Pharmacy; self-administered injectable drugs; self-injectable insulin and supplies and equipment used to administer insulin; self-administered contraceptives, including oral contraceptive drugs, self-injectable contraceptive drugs, contraceptive patches, and contraceptive rings. Certain contraceptives are covered under the ‘Preventive Care’ benefit. Includes coverage for special food products or supplements when prescribed by a Doctor when medically necessary; Flu Shots (including administration). Inpatient or IV therapy drugs used in the treatment of cancer pain will not be denied on the basis that the dosage exceeds the recommended dosage of the pain relieving agent, if prescribed in compliance with established statutes pertaining to patients with intractable cancer pain. |
| Non-Preferred Brand Drugs Covered | $80.00 Copay after deductible | 100.00% | Covers prescription legend drugs from either a Retail Pharmacy or the PBM’s Home Delivery Pharmacy; self-administered injectable drugs; self-injectable insulin and supplies and equipment used to administer insulin; self-administered contraceptives, including oral contraceptive drugs, self-injectable contraceptive drugs, contraceptive patches, and contraceptive rings. Certain contraceptives are covered under the ‘Preventive Care’ benefit. Includes coverage for special food products or supplements when prescribed by a Doctor when medically necessary; Flu Shots (including administration). Inpatient or IV therapy drugs used in the treatment of cancer pain will not be denied on the basis that the dosage exceeds the recommended dosage of the pain relieving agent, if prescribed in compliance with established statutes pertaining to patients with intractable cancer pain. |
| Specialty Drugs Covered | $350.00 Copay after deductible | 100.00% | Covers prescription legend drugs from either a Retail Pharmacy or the PBM’s Home Delivery Pharmacy; self-administered injectable drugs; specialty drugs; self-injectable insulin and supplies and equipment used to administer insulin; self-administered contraceptives, including oral contraceptive drugs, self-injectable contraceptive drugs, contraceptive patches, and contraceptive rings. Certain contraceptives are covered under the ‘Preventive Care’ benefit. Includes coverage for special food products or supplements when prescribed by a Doctor when medically necessary; Flu Shots (including administration). Inpatient or IV therapy drugs used in the treatment of cancer pain will not be denied on the basis that the dosage exceeds the recommended dosage of the pain relieving agent, if prescribed in compliance with established statutes pertaining to patients with intractable cancer pain. |
| Outpatient Rehabilitation Services Covered | $40.00 | 100.00% | 30 Visit(s) per Year Benefits are based on the setting in which covered services are received. See individual limits. Limit does not apply when received as part of hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders. Coverage is limited to 30 visits PT/OT combined and 30 visits ST per calendar year. Benefit limits are separate between rehabilitation and habilitation services. Limit does not apply when received as part of hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders. |
| Habilitation Services Covered | 40.00% Coinsurance after deductible | 100.00% | Benefits that help you keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn?t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, medical devices, and other services for people with disabilities in a variety of inpatient and/or outpatient settings. |
| Chiropractic Care Covered | $40.00 | 100.00% | 30 Visit(s) per Year Includes therapy to treat problems of the bones, joints, joints of the spine, the nervous system, and the back, and osteopathic therapy which focuses on the joints and surrounding muscles, tendons and ligaments. Visit limit applies to habilitative and rehabilitative services separately. Coverage is limited to 30 visits per calendar year for rehabilitative services, and includes all outpatient places of service for Chiropractic Care. |
| Durable Medical Equipment Covered | 50.00% Coinsurance after deductible | 100.00% | Includes Medical Devices, Orthotics, Medical and Surgical Supplies. Benefits include equipment and devices (e.g., crutches and customized equipment, Hospital beds and wheelchairs, oxygen concentrator, ventilator, and negative pressure, wound therapy devices). Coverage for ongoing rental of equipment may be limited to the cost of purchasing the equipment. Benefits include repair and replacement costs as well as supplies and equipment needed for the use of the equipment or device, for example, a battery for a powered wheelchair. Oxygen and equipment for its administration are also covered services. Benefits are also available for cochlear implants. Benefits are available for certain types of orthotics (braces, boots, and splints). Covered Services include the initial purchase, fitting, and repair of a custom made rigid or semi-rigid supportive device used to support, align, prevent, or correct deformities or to improve the function of movable parts of the body, or which limits or stops motion of a weak or diseased body part. Also, includes coverage for devices and supplies, such as APAP, CPAP, BPAP and oral devices for sleep treatment, subject to medical necessity. |
| Hearing Aids Not Covered | |||
| Imaging (CT/PET Scans, MRIs) Covered | 40.00% Coinsurance after deductible | 100.00% | Includes x-rays/regular imaging services; radiology (including mammograms), ultrasound or nuclear medicine; and advanced imaging, including CT scan, CTA scan, Magnetic Resonance Imaging (MRI); Magnetic Resonance Angiography (MRA); Magnetic Resonance Spectroscopy (MRS); Nuclear Cardiology; PET scans; PET/CT Fusion scans; QTC Bone Densitometry; Diagnostic CT Colonography; Single photon emission computed tomography (SPCECT) scans. |
| Preventive Care/Screening/Immunization Covered | 0.00% | 100.00% | Covers: (1) Services with an ‘A’ or ‘B’ rating from the United States Preventive Services Task Force; (2) Immunizations for children, adolescents, and adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; (3) Preventive care and screenings for infants, children and adolescents as listed in the guidelines supported by the Health Resources and Services Administration (including infant hearing screening); (4) Preventive care and screening for women as listed in the guidelines supported by the Health Resources and Services Administration; and (5) Counseling services related to nutrition, and to smoking and tobacco use cessation. Prescription drugs that help you stop smoking or reduce your dependence on tobacco products are also covered preventive services. Smoking cessation products and over the counter nicotine replacement products (limited to nicotine patches and gum) are covered when obtained with a prescription. Additionally, state law requires coverage for routine screening mammograms and routine prostate specific antigen testing and digital rectal exams. |
| Routine Foot Care Not Covered | Coverage is limited to the medically necessary treatment of corns, calluses and care of the toenails, and treatment of bunions (capsular or bone surgery). Member cost share based on place and type of service. | ||
| Acupuncture Covered | $40.00 | 100.00% | 10 Visit(s) per Year Coverage is limited to 10 visits per calendar year. |
| Weight Loss Programs Not Covered | |||
| 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. Age 0 – 19. Includes complete eye exam with dilation, as needed to check all aspects of vision, including the structure of the eyes and how well they work together. |
| Eye Glasses for Children Covered | 50.00% Coinsurance after deductible | 100.00% | 1 Item(s) per Year Includes a choice of eyeglass lenses with factory scratch coating or contact lenses in one benefit period. Covered eyeglass lenses include standard plastic (CR39) lenses up to 55mm in: Single vision; Bifocal; Trifocal (FT 25-28); and Progressive. Members choose from a limited frame selection. Coverage for contact lenses includes elective or non-elective contact lenses. Non-elective contact lenses are covered only for the following medical conditions: Keratoconus when your vision is not correctable to 20/40 in either or both eyes using standard spectacle lenses; High Ametropia exceeding -12D or +9D in spherical equivalent; Anisometropia of 3D or more; when your vision can be corrected three lines of improvement on the visual acuity chart when compared to best corrected standard spectacle lenses. Coverage is limited to 1 set of frames and 1 set of contact lenses or eyeglass lenses every 12 months. Age 0 -19. |
| Dental Check-Up for Children Not Covered | Includes coverage for D1110, D1120, D1203, D1204, D1206, and D1208. | ||
| Rehabilitative Speech Therapy Covered | $40.00 | 100.00% | 30 Visit(s) per Year Includes services to identify, assess, and treat speech, language, and swallowing disorders in children and adults. Therapy will develop or treat communication or swallowing skills to correct a speech impairment. Limit does not apply when received as part of hospice benefit, early intervention benefit or for the treatment autism spectrum disorder. Limit applies separately to habilitative and rehabilitative services. |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | $40.00 | 100.00% | 30 Visit(s) per Year Includes treatment to restore a physically disabled person?s ability to do activities of daily living, such as walking, eating, drinking, dressing, using the toilet, moving from a wheelchair to a bed, bathing, and therapy for tasks needed for the person?s job. Also, includes the treatment by physical means to ease pain, restore health, and to avoid disability after an illness, injury, or loss of an arm or a leg by means of hydrotherapy, heat, physical agents, bio-mechanical and neuro-physiological principles and devices. Limit is combined for physical and occupational therapy. Limit applies separately to habilitative and rehabilitative services. Limit does not apply when received as part of hospice benefit, early intervention benefit or for the treatment of autism spectrum disorder. Coverage is limited to 30 visits PT/OT combined per calendar year. Benefit limits are separate between rehabilitation and habilitation services. Limit does not apply when received as part of hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders. |
| Well Baby Visits and Care Covered | No Charge No Charge | 100.00% | Includes immunizations for children recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; Preventive care and screenings for infants as listed in the guidelines supported by the Health Resources and Services Administration (including infant hearing screening). 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 | 40.00% Coinsurance after deductible | 100.00% | |
| X-rays and Diagnostic Imaging Covered | 40.00% Coinsurance after deductible | 100.00% | Includes benefits for tests or procedures to find or check a condition when specific symptoms exist, as well as benefits for interpretation of diagnostic tests such as imaging, and cardiology. Tests must be ordered by a Provider and include diagnostic services ordered before a surgery or Hospital admission. Benefits include the following services: x-rays/regular imaging services; radiology (including mammograms), ultrasound or nuclear medicine. |
| 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 | 40.00% Coinsurance after deductible | 100.00% | Includes coverage for medically necessary human organ, tissue, and stem cell/bone marrow transplants and infusions including necessary acquisition procedures, mobilization, harvest and storage. It also includes medically necessary myeloablative or reduced intensity preparative chemotherapy, radiation therapy, or a combination of these therapies. When a human organ transplant is provided from a living donor to a covered member, both the recipient and the donor may receive benefits. Member cost share based on place and type of service. Network benefits must be received within the transplant network. |
| Accidental Dental Covered | $80.00 | 100.00% | Includes dental work, to include oral/surgical correction needed to treat injuries to the jaw, sound natural teeth, mouth or face as a result of an accident. Dental appliances required to diagnose or treat an accidental injury to the teeth, and the repair of dental appliances damaged as a result of accidental injury to the jaw, mouth or face, are also covered. Treatment must begin within 12 months of the injury, or as soon after that as possible to be a covered service. Member cost share based on place and type of service. |
| Dialysis Covered | 40.00% Coinsurance after deductible | 100.00% | Includes services for acute renal failure and chronic (end-stage) renal disease, including hemodialysis, home intermittent peritoneal dialysis (IPD), home continuous cycling peritoneal dialysis (CCPD), and home continuous ambulatory peritoneal dialysis (CAPD). Dialysis treatments can be rendered in an outpatient dialysis Facility, doctor?s office, or home dialysis and training for the covered person and the person who will help with home self-dialysis. Member cost share based on place and type of service. |
| Allergy Testing Covered | $80.00 | 100.00% | Includes benefits for medically necessary allergy testing and treatment, including allergy serum and allergy shots. Member cost share based on place and type of service. |
| Chemotherapy Covered | 40.00% Coinsurance after deductible | 100.00% | Member cost share based on place and type of service. |
| Radiation Covered | 40.00% Coinsurance after deductible | 100.00% | Includes treatment (tele therapy, brachytherapy and intraoperative radiation, photon or high-energy particle sources), materials and supplies needed, administration, and treatment planning. Member cost share based on place and type of service. |
| Diabetes Education Covered | $80.00 | 100.00% | Includes education for diabetes care for all diabetics, including outpatient self-management training and education performed in-person; medical nutrition therapy, when provided by a certified, licensed, or registered health care professional. Diabetic education may be received from pharmacies that are authorized to perform this service. Member cost share based on place and type of service. |
| Prosthetic Devices Covered | 30.00% Coinsurance after deductible | 100.00% | Includes benefits for prosthetics and components when they are medically necessary for activities of daily living. A prosthetic device is an artificial substitute to replace, in whole or in part, a limb or body part, such as an arm, leg, foot or eye. Coverage is also included for the repair, fitting, adjustments and replacement of a prosthetic device. In additional, components for artificial limbs are covered. Components are the materials and equipment needed to ensure the comfort and functioning of the prosthetic device. Covered services may include: 1) Artificial limbs and components (the materials and equipment needed to ensure the comfort and functioning of the prosthetic device); 2) Breast prosthesis (whether internal or external) after a mastectomy, as required by the Women?s Health and Cancer Rights Act. 3) Colostomy and other ostomy (surgical construction of an artificial opening) supplies directly related to ostomy care. 4) Restoration prosthesis (composite facial prosthesis) 5) Wigs needed after cancer treatment (limited to one wig per benefit period). |
| Infusion Therapy Covered | 40.00% Coinsurance after deductible | 100.00% | Includes nursing, durable medical equipment and drug services that are delivered and administered to you through an I.V. in your home. Also includes Total Parenteral Nutrition (TPN), Enteral nutrition therapy, antibiotic therapy, pain care and chemotherapy. May include injections (intra-muscular, subcutaneous, continuous subcutaneous). Also covers prescription drugs when they are administered to you as part of a doctor?s visit, home care visit, or at an outpatient Facility. Member cost share based on place and type of service. |
| Treatment for Temporomandibular Joint Disorders Covered | $80.00 | 100.00% | Includes services to treat temporomandibular and craniomandibular disorders, such as removable appliances for TMJ repositioning and related surgery, medical care, and diagnostic services. Dental benchmark plan covers occlusal orthotic devices for temporomandibular pain, dysfunction or associated musculature. Member cost share based on place and type of service. |
| Nutritional Counseling Covered | No Charge No Charge | 100.00% | |
| Reconstructive Surgery Covered | 40.00% Coinsurance after deductible | 100.00% | Includes reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance. Also includes surgery performed to restore symmetry after a mastectomy. Reconstructive services needed as a result of an earlier treatment are covered only if the first treatment would have been a covered service. Hospital admissions for covered radical or modified radical mastectomy for the treatment of breast cancer shall be approved for a period of no less than 48 hours. Hospital admissions for a covered total or partial mastectomy with lymph node dissection for the treatment of breast cancer shall be approved for a period of no less than 24 hours. Member cost share based on place and type of service. |
| Gender Affirming Care |
Free Preventive Services
There is no copayment or coinsurance for any of the following Silver S: Aetna network of doctors & hospitals + telemedicine + $0 MinuteClinic visits 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.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for Silver S: Aetna network of doctors & hospitals + telemedicine + $0 MinuteClinic visits 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 Silver S: Aetna network of doctors & hospitals + telemedicine + $0 MinuteClinic visits 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