Bronze 4 Advanced: Aetna network of doctors & hospitals - 38927UT0380002 Health Insurance Plan
Aetna Health of Utah Inc. health insurance plan with the Plan ID 38927UT0380002. The plan is called Bronze 4 Advanced: Aetna network of doctors & hospitals.
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 | 38927UT0380002 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Utah | ||||||||||||||||||
| Health Insurance Issuer | Aetna Health of Utah Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 38927UT0380002-00 | ||||||||||||||||||
| Provider Network(s) | NON-PREFERRED PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 38927UT0380002-00 Standard On Exchange Plan - 38927UT0380002-01 |
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| Last Plan Update Date | Wed, 16 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Bronze 4 Advanced: Aetna network of doctors & hospitals Health Insurance Plan, 38927UT0380002-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Abortion services & supplies not covered except in the cases where (i) a Member suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would, as certified by a Physician, place the Member in danger of death unless an abortion is performed or (ii) the pregnancy is the result of an act of rape or incest. |
NO | ||
| Accidental Dental
|
NO | ||
| Acupuncture
|
NO | ||
| Allergy Testing
Member cost share based on place and type of service. |
YES | Tier 1: $80.00 Tier 2: $110.00 |
100.00% |
| Autism Spectrum Disorders
Member cost share based on place and type of service |
YES | Tier 1: No Charge Tier 2: $15.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
Member cost share based on place and type of service. |
YES | Tier 1: 35.00% Tier 2: 50.00% |
100.00% |
| Chiropractic Care
|
NO | ||
| Cosmetic Surgery
Copay per day for days 1-3 |
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Copay per day for days 1-3 |
YES | Tier 1: $2,500.00 Tier 2: $2,875.00 |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
Member cost share based on place and type of service. |
YES | Tier 1: $80.00 Tier 2: $110.00 |
100.00% |
| Dialysis
Member cost share based on place and type of service. |
YES | Tier 1: $1,000.00 Tier 2: $1,150.00 |
100.00% |
| Durable Medical Equipment
|
YES | Tier 1: 35.00% Tier 2: 50.00% |
100.00% |
| Emergency Room Services
Exclusions: No coverage for non-emergency use of the emergency room. |
YES | Tier 1: $2,200.00 Tier 2: $2,200.00 |
$2,200.00 |
| Emergency Transportation/Ambulance
|
YES | Tier 1: $2,200.00 Tier 2: $2,200.00 |
$2,200.00 |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Coverage is limited to 1 set of frames and prescription lenses or 1 set of contact lenses every 12 months, through the end of the month after the person attains age 19. |
YES | Tier 1: $10.00 Tier 2: $15.00 |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details. |
YES | Tier 1: $3.00 Tier 2: $3.00 |
100.00% |
| Habilitation Services
Health care services that are needed to keep, learn, or improve your skills and functioning for daily living which may include physical therapy, occupational therapy, and speech therapy. Please refer to the plan policy documents for detailed information. |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 30.0 Visit(s) per Year |
YES | Tier 1: $65.00 Tier 2: $80.00 |
100.00% |
| Hospice Services
Member cost share based on place and type of service.Copay per day for days 1-3 |
YES | Tier 1: $2,500.00 Tier 2: $2,875.00 |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | Tier 1: $750.00 Tier 2: $875.00 |
100.00% |
| Infertility Treatment
Coverage limited to diagnosis and treatment of the underlying medical condition. Member cost share based on place and type of service. |
NO | ||
| Infusion Therapy
Member cost share based on place and type of service. |
YES | Tier 1: 35.00% Tier 2: 50.00% |
100.00% |
| Inherited Metabolic Disorder - PKU
|
YES | Tier 1: 35.00% Tier 2: 50.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Copay per day for days 1-3 |
YES | Tier 1: $2,500.00 Copay per Day Tier 2: $2,875.00 Copay per Day |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | Tier 1: $55.00 Tier 2: $65.00 |
100.00% |
| 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 | Tier 1: $2,500.00 Copay per Day Tier 2: $2,875.00 Copay per Day |
100.00% |
| Mental/Behavioral Health Outpatient Services
The cost sharing that displays applies to outpatient office visits only. All other outpatient services may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information. |
YES | Tier 1: No Charge Tier 2: $15.00 |
100.00% |
| Non-Preferred Brand Drugs
Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details. |
YES | Tier 1: $275.00 Copay after deductible Tier 2: $275.00 Copay after deductible |
100.00% |
| Nutritional Counseling
Not considered a separate benefit. Should be considered under the benefits outlined for diabetes education, anorexia, bulimia, or as allowed under the Affordable Care Act Preventive Services. |
NO | ||
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Cost share applies to both in-person and virtual services from in-network providers. Cost share does not apply to virtual services from designated telemedicine providers. If this is an HSA plan, deductible applies. |
YES | Tier 1: No Charge Tier 2: $15.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | Tier 1: $1,000.00 Tier 2: $1,150.00 |
100.00% |
| Outpatient Rehabilitation Services
Limit: 20.0 Visit(s) per Year Coverage is limited to 20 visits per year, Physical Therapy, Occupational Therapy, and Speech Therapy combined. |
YES | Tier 1: $65.00 Tier 2: $80.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | Tier 1: $500.00 Tier 2: $575.00 |
100.00% |
| Preferred Brand Drugs
Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details. |
YES | Tier 1: $195.00 Tier 2: $195.00 |
100.00% |
| Prenatal and Postnatal Care
Member cost share applies to postnatal care. |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Preventive Care/Screening/Immunization
Age and frequency schedules may apply. |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Cost share applies to both in-person and virtual services from in-network providers. Cost share does not apply to virtual services from designated telemedicine providers. If this is an HSA plan, deductible applies. |
YES | Tier 1: No Charge Tier 2: $15.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | Tier 1: 20.00% Tier 2: 20.00% |
100.00% |
| Radiation
Member cost share based on place and type of service. |
YES | Tier 1: 35.00% Tier 2: 50.00% |
100.00% |
| Reconstructive Surgery
Member cost share based on place and type of service.Copay per day for days 1-3 |
YES | Tier 1: $2,500.00 Tier 2: $2,875.00 |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Visit(s) per Year Coverage is limited to 20 visits per year, Physical Therapy, Occupational Therapy, and Speech Therapy combined. |
YES | Tier 1: $65.00 Tier 2: $80.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year Coverage is limited to 20 visits per year, Physical Therapy, Occupational Therapy, and Speech Therapy combined. |
YES | Tier 1: $65.00 Tier 2: $80.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year Coverage through the end of the month in which the member turns 19. |
YES | Tier 1: $10.00 Tier 2: $15.00 |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 30.0 Days per Year Copay per day for days 1-3 |
YES | Tier 1: $2,500.00 Copay per Day Tier 2: $2,875.00 Copay per Day |
100.00% |
| Specialist Visit
|
YES | Tier 1: $80.00 Tier 2: $110.00 |
100.00% |
| Specialty Drugs
Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details. |
YES | Tier 1: 50.00% Coinsurance after deductible Tier 2: 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Copay per day for days 1-3 |
YES | Tier 1: $2,500.00 Copay per Day Tier 2: $2,875.00 Copay per Day |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | Tier 1: No Charge Tier 2: $15.00 |
100.00% |
| Transplant
Member cost share based on place and type of service. Network benefits must be received within the Institute of Excellence (IOE) transplant network.Copay per day for days 1-3 |
YES | Tier 1: $2,500.00 Tier 2: $2,875.00 |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
Exclusions: No coverage for non-urgent care. |
YES | Tier 1: $50.00 Tier 2: $60.00 |
100.00% |
| Weight Loss Programs
Member cost share based on place and type of service. Network benefits must be received within the Institutes of Excellence (IOE) transplant network. |
NO | ||
| Well Baby Visits and Care
Age and frequency schedules may apply. |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | Tier 1: $75.00 Tier 2: $90.00 |
100.00% |
Bronze 4 Advanced: Aetna network of doctors & hospitals Health Insurance Plan Variant 38927UT0380002-00 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 | 2025 |
| 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 | $10000 per group |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $5000 per person |
| Drug EHB Deductible, Combined In/Out of Network, Individual | $5,000 |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $10000 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $5000 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $5,000 |
| Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 0.00% |
| Drug EHB Deductible, In Network (Tier 2), Family Per Group | $10000 per group |
| Drug EHB Deductible, In Network (Tier 2), Family Per Person | $5000 per person |
| Drug EHB Deductible, In Network (Tier 2), Individual | $5,000 |
| Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| 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 | 1.0 |
| First Tier Utilization | 65% |
| Formulary ID | UTF001 |
| Formulary URL | URL |
| HIOS Product ID | 38927UT038 |
| Import Date | 2024-10-16 20:01:50 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | 0 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 64.98% |
| Issuer ID | 38927 |
| 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 | $0 per group |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | $0 per person |
| Medical EHB Deductible, Combined In/Out of Network, Individual | $0 |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 35.00% |
| 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, In Network (Tier 2), Default Coinsurance | 50.00% |
| Medical EHB Deductible, In Network (Tier 2), Family Per Group | $0 per group |
| Medical EHB Deductible, In Network (Tier 2), Family Per Person | $0 per person |
| Medical EHB Deductible, In Network (Tier 2), Individual | $0 |
| Medical EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Metal Level | Expanded Bronze |
| Multiple In Network Tiers | Yes |
| National Network | No |
| Network ID | UTN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Out of Service Area Coverage Description | Except for Emergencies |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan ID (Standard Component ID with Variant) | 38927UT0380002-00 |
| Plan Marketing Name | Bronze 4 Advanced: Aetna network of doctors & hospitals |
| Plan Type | HMO |
| Plan Variant Marketing Name | Bronze 4 Advanced: Aetna network of doctors & hospitals |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $5,400 |
| 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 | $2,900 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,900 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 35% |
| Service Area ID | UTS001 |
| Source Name | SERFF |
| Plan ID | 38927UT0380002 |
| State Code | UT |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $36800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $18400 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $18,400 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $18400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,200 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $18400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $9200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $9,200 |
| 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 Advanced: Aetna network of doctors & hospitals Health Insurance Plan, 38927UT0380002
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Bronze 4 Advanced: Aetna network of doctors & hospitals, 38927UT0380002 Health Insurance Plan, 38927UT0380002
-
Does Bronze 4 Advanced: Aetna network of doctors & hospitals Health Insurance Plan, 38927UT0380002 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (38927UT0380002) Health Insurance Plan, Variant (38927UT0380002-00) offer Disease Management Programs?
Does (38927UT0380002) Health Insurance Plan, Variant (38927UT0380002-00) have Out Of Country Coverage?
Does (38927UT0380002) Health Insurance Plan, Variant (38927UT0380002-00) have Out of Service Area Coverage?
Does (38927UT0380002) Health Insurance Plan, Variant (38927UT0380002-00) offer Disease Management Programs?
Does Bronze 4 Advanced: Aetna network of doctors & hospitals Health Insurance Plan, Variant (38927UT0380002-00) offer Disease Management Programs for Asthma?
Does Bronze 4 Advanced: Aetna network of doctors & hospitals Health Insurance Plan, Variant (38927UT0380002-00) offer Disease Management Programs for Heart disease?
Does Bronze 4 Advanced: Aetna network of doctors & hospitals Health Insurance Plan, Variant (38927UT0380002-00) offer Disease Management Programs for Depression?
Does Bronze 4 Advanced: Aetna network of doctors & hospitals Health Insurance Plan, Variant (38927UT0380002-00) offer Disease Management Programs for Diabetes?
Does Bronze 4 Advanced: Aetna network of doctors & hospitals Health Insurance Plan, Variant (38927UT0380002-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Bronze 4 Advanced: Aetna network of doctors & hospitals Health Insurance Plan, Variant (38927UT0380002-00) offer Disease Management Programs for Low back pain?
Does Bronze 4 Advanced: Aetna network of doctors & hospitals Health Insurance Plan, Variant (38927UT0380002-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Thu, 21 Nov 2024 00:44 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