Aetna

Aetna CVS Gold: $0 MinuteClinic Visits, Telehealth, Store Discounts

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $1,450.00 Family: $2,900 Per Person: $1,450
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,700.00 Family: $17,400 Per Person: $8,700

Office Visit

Primary Doctor	CoPay: $15.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $35.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $40.00 Copay after deductible CoInsurance: No Charge after deductible Covered: Covered Benefit Explanation: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.
Non Preferred Brand Drugs	CoPay: No Charge after deductible CoInsurance: 40.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.
Generic Drugs	CoPay: $10.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.
Specialty Drugs	CoPay: No Charge after deductible CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.

Inpatient Coverage

Hospital Services	CoPay: No Charge after deductible CoInsurance: 20.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: No Charge after deductible CoInsurance: 20.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: No Charge after deductible CoInsurance: 20.00% Coinsurance after deductible Covered: Covered Exclusions: No coverage for non-emergency use of the emergency room.
Urgent Care Facility	CoPay: $35.00 CoInsurance: Not Applicable Covered: Covered Exclusions: No coverage for non-urgent care.

Maternity

Labor and Delivery Hospital Stay	CoPay: No Charge after deductible CoInsurance: 20.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: No Charge after deductible CoInsurance: 20.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Member cost sharing applies to postnatal care

Vision

Routine Eye Exams For Children

CoPay: No Charge after deductible
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year
Benefit Explanation: Coverage is limited to 1 exam every 12 months.

Major Dental Care

Routine Dental Checkups for Children	Covered: Not Covered
Routine Dental Checkups for Adults	Covered: Not Covered

This site is not the Health Insurance Marketplace website, and the link to the FFM website is www.healthcare.gov"

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