Aetna

Aetna CVS Silver 1: $0 MinuteClinic Visits, Telehealth, Roanoke

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $4,000.00 Family: $8,000 Per Person: $4,000
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,700.00 Family: $17,400 Per Person: $8,700

Office Visit

Primary Doctor	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $75.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $60.00 Copay after deductible CoInsurance: No Charge after deductible Covered: Covered Benefit Explanation: The cost sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply. Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered Benefit Explanation: The cost sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply. 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: The cost sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply. Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: The cost sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply. Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Benefits are available in a Hospital Emergency Room or an independent, free-standing emergency facility for services and supplies to treat the onset of symptoms for a medical emergency.
Urgent Care Facility	CoPay: $75.00 CoInsurance: Not Applicable Covered: Covered Exclusions: No coverage for non-urgent care.

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Member cost sharing applies to postnatal care

Vision

Routine Eye Exams For Children

CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year
Exclusions: Coverage is limited to 1 exam every 12 months. Age 0 - 19.

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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