Bronze 4 PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care – PPO
Network type: PPO
Coverage tier: Expanded Bronze
Primary care visit: $15 copay
Specialist visit: $100 copay
Urgent care visit: $50 copay
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $9,400 per person $18,800 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | $15 copay |
| Specialist visit | $100 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | $2,200 copay |
| Ambulance | $2,200 copay |
| Hospital stay (facility) | $2500 copay per Day |
| Hospital stay (physician) | No charge |
| Outpatient procedure (facility) | $1,000 copay |
| Outpatient procedure (physician) | $500 copay |
| Physical rehabilitation | $80 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $2,500 copay |
Pharmacy, Drugs, and Medication
| Generic | $40 copay |
| Brand | 40% coinsurance after deductible |
| Non-preferred Brand | 45% coinsurance after deductible |
| Specialty | 50% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $75 copay |
| Imaging (CT/PET/MRI) | $750 copay |
| Blood work | $50 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $15 copay |
| Psychiatric hospital stay | $2500 copay per Day |
Health Plan Provider Information
| Health Plan Benefits | https://www.aetnacvshealth.com/documents/2024-IFP-769382_72547IL0170002-01_SBC.pdf |
| Drug and medication plan formulary | http://aet.na/ilivl24 |
| Search doctor list | https://www.aetna.com/dsepublic/#/contentPage?page=providerSearchLanding&site_id=aetnaivlexchange |
