Aetna Health Inc. (a FL corp.) health insurance plan with the Plan ID 18628FL0160022. The plan is called Bronze S: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.18% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.82% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
Health Insurance Plan ID | 18628FL0160022 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | Florida | ||||||||||||||||||
Health Insurance Issuer | Aetna Health Inc. (a FL corp.) | ||||||||||||||||||
Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
Health Insurance Plan Variant | 18628FL0160022-01 | ||||||||||||||||||
Provider Network(s) | ['FLN001'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 27 Aug 2024 05:58 GMT). |
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Available Variants of the Health Plan | Standard Off Exchange Plan - 18628FL0160022-00 Standard On Exchange Plan - 18628FL0160022-01 |
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Last Plan Update Date | Fri, 24 Feb 2023 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 27 Aug 2024 05:58 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
|
NO | ||
Accidental Dental
Exclusions: Member cost share based on place and type of service. |
YES | $100.00 |
100.00% |
Acupuncture
Limit: 10.0 Visit(s) per Year Exclusions: Coverage is limited to 10 visits per calendar year. |
YES | $50.00 |
100.00% |
Allergy Testing
Exclusions: Member cost share based on place and type of service. |
YES | $100.00 |
100.00% |
Bariatric Surgery
|
NO | ||
Basic Dental Care - Adult
|
NO | ||
Basic Dental Care - Child
|
NO | ||
Bone Marrow Transplant
Exclusions: Member cost share based on place and type of service. Network benefits must be received within the transplant network. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Chemotherapy
Exclusions: Member cost share based on place and type of service. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Chiropractic Care
Limit: 35.0 Visit(s) per Year Exclusions: Coverage is limited to 35 visits per calendar year, PT/OT/ST/Chiro combined. Benefit limits for rehabilitation and habilitation services are separate. |
YES | $50.00 |
100.00% |
Congenital Anomaly, including Cleft Lip/Palate
Exclusions: Member cost share based on place and type of service. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Cosmetic Surgery
|
NO | ||
Delivery and All Inpatient Services for Maternity Care
Maternity services rendered to a covered person who is acting as a gestational surrogate are excluded. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Dental Anesthesia
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Dental Check-Up for Children
|
NO | ||
Diabetes Care Management
Exclusions: Member cost share based on place and type of service.? |
YES | $100.00 |
100.00% |
Diabetes Education
Exclusions: Member cost share based on place and type of service. |
YES | $100.00 |
100.00% |
Dialysis
Exclusions: Member cost share based on place and type of service.? |
YES | 50.00% Coinsurance after deductible |
100.00% |
Durable Medical Equipment
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Emergency Room Services
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Emergency Transportation/Ambulance
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Eye Glasses for Children
Limit: 1.0 Item(s) per Year Exclusions: Coverage is limited to 1 set of frames and 1 set of contact lenses or eyeglass lenses every 12 months. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Gender Affirming Care
|
NO | ||
Generic Drugs
Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | $25.00 |
100.00% |
Habilitation Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Hearing Aids
|
NO | ||
Home Health Care Services
Limit: 60.0 Visit(s) per Year Exclusions: Coverage is limited to 60 visits per calendar year. 3 visits per day times 20 days |
YES | 50.00% Coinsurance after deductible |
100.00% |
Hospice Services
Exclusions: Member cost share based on place and type of service. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Imaging (CT/PET Scans, MRIs)
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Infertility Treatment
Exclusions: Coverage limited to diagnosis and treatment of the underlying medical condition. Member cost share based on place and type of service. |
NO | ||
Infusion Therapy
Exclusions: Member cost share based on place and type of service. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Inpatient Physician and Surgical Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Laboratory Outpatient and Professional Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Long-Term/Custodial Nursing Home Care
|
NO | ||
Major Dental Care - Adult
|
NO | ||
Major Dental Care - Child
|
NO | ||
Mental/Behavioral Health Inpatient Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Mental/Behavioral Health Outpatient Services
|
YES | $50.00 |
100.00% |
Non-Preferred Brand Drugs
Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | $100.00 Copay after deductible |
100.00% |
Nutritional Counseling
Nutritional Counseling for Diabetes included |
YES | No Charge |
100.00% |
Nutrition/Formulas
State Mandate |
YES | 50.00% Coinsurance after deductible |
100.00% |
Off Label Prescription Drugs
Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | $100.00 Copay after deductible |
100.00% |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
|
NO | ||
Osteoporosis
Exclusions: Member cost share based on place and type of service. |
YES | $100.00 |
100.00% |
Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $50.00 |
100.00% |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Exclusions: Member cost share based on place and type of service. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Outpatient Rehabilitation Services
Limit: 35.0 Visit(s) per Year Exclusions: Coverage is limited to 35 visits per calendar year, PT/OT/ST/Chiro combined. Benefit limits for rehabilitation and habilitation services are separate. |
YES | $50.00 |
100.00% |
Outpatient Surgery Physician/Surgical Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Preferred Brand Drugs
Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | $50.00 Copay after deductible |
100.00% |
Prenatal and Postnatal Care
Exclusions: Member cost sharing applies to postnatal care |
YES | 50.00% Coinsurance after deductible |
100.00% |
Preventive Care/Screening/Immunization
Exclusions: Age and frequency schedules may apply. |
YES | 0.00% |
100.00% |
Primary Care Visit to Treat an Injury or Illness
|
YES | $50.00 |
100.00% |
Private-Duty Nursing
|
NO | ||
Prosthetic Devices
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Radiation
Exclusions: Member cost share based on place and type of service. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Reconstructive Surgery
Exclusions: Member cost share based on place and type of service.? |
YES | 50.00% Coinsurance after deductible |
100.00% |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 35.0 Visit(s) per Year Exclusions: Coverage is limited to 35 visits per calendar year, PT/OT/ST/Chiro combined. Benefit limits for rehabilitation and habilitation services are separate. |
YES | $50.00 |
100.00% |
Rehabilitative Speech Therapy
Limit: 35.0 Visit(s) per Year Exclusions: Coverage is limited to 35 visits per calendar year, PT/OT/ST/Chiro combined. Benefit limits for rehabilitation and habilitation services are separate. |
YES | $50.00 |
100.00% |
Routine Dental Services (Adult)
|
NO | ||
Routine Eye Exam (Adult)
|
NO | ||
Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year Exclusions: Coverage is limited to 1 exam every 12 months. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Routine Foot Care
Exclusions: 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. |
NO | ||
Skilled Nursing Facility
Limit: 60.0 Days per Year Exclusions: Coverage is limited to 60 days per calendar year. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Specialist Visit
|
YES | $100.00 |
100.00% |
Specialty Drugs
Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | $500.00 Copay after deductible |
100.00% |
Substance Abuse Disorder Inpatient Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Outpatient Services
|
YES | $50.00 |
100.00% |
Transplant
Exclusions: Member cost share based on place and type of service. Network benefits must be received within the transplant network. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Treatment for Temporomandibular Joint Disorders
Exclusions: 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. |
YES | $100.00 |
100.00% |
Urgent Care Centers or Facilities
Exclusions: No coverage for non-urgent care. |
YES | $75.00 |
100.00% |
Weight Loss Programs
Exclusions: Online weight loss programs are available. |
NO | ||
Well Baby Visits and Care
Exclusions: 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. |
YES | No Charge |
100.00% |
X-rays and Diagnostic Imaging
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 0.6418 |
Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
Business Year | 2023 |
Child-Only Offering | Allows Adult and Child-Only |
Composite Rating Offered | No |
CSR Variation Type | Standard Bronze On Exchange Plan |
Dental Only Plan | No |
Design Type | Design 1 |
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 |
First Tier Utilization | 100% |
Formulary ID | FLF022 |
Formulary URL | URL |
HIOS Product ID | 18628FL016 |
Import Date | 2/24/2023 1:01 |
Limited Cost Sharing Plan Variation - Estimated Advanced Payment | 0 |
Inpatient Copayment Maximum Days | 0 |
HSA Eligible | No |
New/Existing Plan | New |
Notice Required for Pregnancy | No |
Is a Referral Required for Specialist? | Yes |
Issuer ID | 18628 |
Issuer Marketplace Marketing Name | Aetna CVS Health |
Market Coverage | Individual |
Medical Drug Deductibles Integrated | Yes |
Medical Drug Maximum Out of Pocket Integrated | Yes |
Metal Level | Expanded Bronze |
Multiple In Network Tiers | No |
National Network | No |
Network ID | FLN001 |
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 | 1/1/2023 |
Plan ID (Standard Component ID with Variant) | 18628FL0160022-01 |
Plan Marketing Name | Bronze S: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS |
Plan Type | HMO |
Plan Variant Marketing Name | Bronze S: Aetna network of doctors & hospitals + $0 walk-in & telemedicine via MinuteClinic at CVS |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $1,500 |
SBC Scenario, Having a Baby, Copayment | $0 |
SBC Scenario, Having a Baby, Deductible | $7,500 |
SBC Scenario, Having a Baby, Limit | $60 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $1,200 |
SBC Scenario, Having Diabetes, Deductible | $3,200 |
SBC Scenario, Having Diabetes, Limit | $20 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $400 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,900 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | FLS001 |
Source Name | HIOS |
Specialist Requiring a Referral | Referral required for all physicians EXCEPT OB/GYN, ER, Internal Medicine, Family Practice, General Medicine and Pediatrician. |
Plan ID | 18628FL0160022 |
State Code | FL |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $15000 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $7500 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $7,500 |
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $18000 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9000 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,000 |
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 | No |
URL for Enrollment Payment | URL |
URL for Summary of Benefits & Coverage | URL |
Wellness Program Offered | Yes |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 27 Aug 2024 05:58 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