Aetna Life Insurance Company

Aetna CVS Gold: $0 Walk-In Clinic Visits, Telehealth, Store Discounts, Houston

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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

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

Preferred Brand Drugs	CoPay: $40.00 Copay after deductible CoInsurance: No Charge after deductible Covered: Covered Exclusions: 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 Exclusions: 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 Exclusions: 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 Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.

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 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

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 Exclusions: Member cost sharing applies to postnatal care.

Routine Eye Exams For Children

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

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