IL AetnaWholeHealth Chicago Bronze Deductible Only HSA Eligible
IL Aetna Whole Health Chicago Bronze Deductible Only HSA Eligible
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Important Questions Answers Why this Matters: |
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What is the overall deductible? |
In-network: Individual $6,450 / Family $12,900. Does not apply to preventive care in-network. |
You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. |
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Are there other deductibles for specific services? |
No. |
You don’t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. |
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Is there an out-of-pocket limit on my expenses? |
Yes. In-network: Individual $6,450 / Family $12,900. |
The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. |
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What is not included in the out-of-pocket limit? |
Premiums and health care this plan does not cover. |
Even though you pay these expenses, they don’t count toward the out-of pocket limit. |
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Is there an overall annual limit on what the plan pays? |
No. |
The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. |
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If you use an in-network doctor or other health care provider, this plan will pay |
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Does this plan use a network of providers? |
Yes. See www.aetna.comor call 1-855-586-6960 for a list of in-network providers. |
some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. |
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Do I need a referral to see a specialist? |
Yes. A written referral is required for most specialist visits. |
This plan will pay some or all of the costs to see a specialist for covered services but only if you have the plan’s permission before you see the specialist. |
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Are there services this plan doesn’t cover? |
Yes. |
Some of the services this plan doesn’t cover are listed on page 4. See your policy or plan document for additional information about excluded services. |
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Common |
Services You May Need |
Your Cost If |
Your Cost If |
Limitations & Exceptions |
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If you visit a health care provider’s office or clinic |
Primary care visit to treat an injury or illness |
0% coinsurance |
Not covered |
–––––––––––none––––––––––– |
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Specialist visit |
0% coinsurance |
Not covered |
–––––––––––none––––––––––– |
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Other practitioner office visit |
0% coinsurance for |
Not covered |
Coverage is limited to 12 visits for Chiropractic care. |
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Preventive care /screening /immunization |
No charge |
Not covered |
Age and frequency schedules may apply. |
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If you have a test |
Diagnostic test (x-ray, blood work) |
0% coinsurance |
Not covered |
–––––––––––none––––––––––– |
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Imaging (CT/PET scans, MRIs) |
0% coinsurance |
Not covered |
–––––––––––none––––––––––– |
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If you need drugs to treat your illness or condition. |
Preferred/Non-preferred generic drugs |
0% coinsurance for up to a 90 day supply |
Not covered |
Covers up to a 90 day supply (retail & mail order prescription). Applicable cost share plus difference (brand minus generic cost) applies for brand when generic available. |
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Preferred brand drugs |
0% coinsurance for up to a 90 day supply |
Not covered |
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Non-preferred brand drugs |
0% coinsurance for up to a 90 day supply |
Not covered |
FDA-approved women’s contraceptives in-network. Precertification and step therapy required. |
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Preferred/non-preferred specialty drugs |
0% coinsurance for up to a 30 day supply |
Not covered |
Aetna Specialty CareRxSM – First |
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If you have outpatient surgery |
Facility fee (e.g., ambulatory surgery center) |
0% coinsurance |
Not covered |
–––––––––––none––––––––––– |
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Physician/surgeon fees |
0% coinsurance |
Not covered |
–––––––––––none––––––––––– |
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If you need immediate medical attention |
Emergency room services |
0% coinsurance |
0% coinsurance |
Out-of-network emergency room services cost-share same as in-network. |
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Emergency medical transportation |
0% coinsurance |
0% coinsurance |
Out-of-network cost-share same as in-network. |
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Urgent care |
0% coinsurance |
Not covered |
–––––––––––none––––––––––– |
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If you have a hospital stay |
Facility fee (e.g., hospital room) |
0% coinsurance |
Not covered |
–––––––––––none––––––––––– |
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Physician/surgeon fee |
0% coinsurance |
Not covered |
–––––––––––none––––––––––– |
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If you have mental health, behavioral health, or substance abuse needs |
Mental/Behavioral health outpatient services |
0% coinsurance |
Not covered |
–––––––––––none––––––––––– |
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Mental/Behavioral health inpatient services |
0% coinsurance |
Not covered |
–––––––––––none––––––––––– |
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Substance use disorder outpatient services |
0% coinsurance |
Not covered |
–––––––––––none––––––––––– |
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Substance use disorder inpatient services |
0% coinsurance |
Not covered |
–––––––––––none––––––––––– |
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If you are pregnant |
Prenatal and postnatal care |
Prenatal: No charge; Postnatal: 0% coinsurance |
Not covered |
–––––––––––none––––––––––– |
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Delivery and all inpatient services |
0% coinsurance |
Not covered |
–––––––––––none––––––––––– |
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If you need help recovering or have |
Home health care |
0% coinsurance |
Not covered |
–––––––––––none––––––––––– |
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Rehabilitation services |
0% coinsurance |
Not covered |
–––––––––––none––––––––––– |
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Habilitation services |
0% coinsurance |
Not covered |
–––––––––––none––––––––––– |
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Skilled nursing care |
0% coinsurance |
Not covered |
–––––––––––none––––––––––– |
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Durable medical equipment |
0% coinsurance |
Not covered |
–––––––––––none––––––––––– |
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Hospice service |
0% coinsurance |
Not covered |
–––––––––––none––––––––––– |
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If your child needs dental or eye care |
Eye exam |
No charge |
Not covered |
Coverage is limited to 1 exam per calendar year. |
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Glasses |
0% coinsurance |
Not covered |
Coverage is limited to 1 set of frames and 1 set of contact lenses or eyeglass lenses per calendar year. |
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Dental check-up |
Not covered |
Not covered |
Not covered. |
Excluded Services & Other Covered Services:
| Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.) |
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| Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) |
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