Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services

Coverage Period: 01/01/2024 - 12/31/2024

: 2024 FL Silver 5: HMO CSR 94
Coverage for: Individual + Family | Plan Type: HMO
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would
share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage,
https://www.aetna.com/sbcsearch/getcbpolicydocs?P=0772373&Y=24, or by calling 1-844-365-7373. For general definitions of common terms, such as
allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at
https://www.healthcare.gov/sbc-glossary/ or call 1-844-365-7373 to request a copy.
Important Questions Answers Why This Matters:
What is the overall See the Common Medical Events chart below for your costs for services this plan
$0.
deductible? covers.
Are there services
covered before you meet No. You will have to meet the deductible before the plan pays for any services.
your deductible?
Are there other
deductibles for specific No. You don’t have to meet deductibles for specific services.
services?
The out-of-pocket limit is the most you could pay in a year for covered services. If you
What is the out-of-pocket In-Network: Individual $1,275 / Family $2,550. have other family members in this plan, they have to meet their own out-of-pocket
limit for this plan?
limits until the overall family out-of-pocket limit has been met.
What is not included in Premiums and health care this plan doesn't cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
the out-of-pocket limit?
This plan uses a provider network. You will pay less if you use a provider in the plan’s
network. You will pay the most if you use an out-of-network provider, and you might
Will you pay less if you Yes. See https://aet.na/providersearch_aetna or call receive a bill from a provider for the difference between the provider's charge and what
use a network provider? 1-844-365-7373 for a list of in-network providers. your plan pays (balance billing). Be aware, your network provider might use an
out-of-network provider for some services (such as lab work). Check with your provider
before you get services.
Do you need a referral to Yes. This plan will pay some or all of the costs to see a specialist for covered services but
see a specialist? only if you have a referral before you see the specialist.

082600-100020-042348 Page 1 of 6
 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

What You Will Pay

Common Out–of–Network Limitations, Exceptions, & Other Important
Services You May Need In-Network Provider (You Provider
Medical Event (You will pay Information
will pay the least) the most)
Primary care visit to treat an injury or
No charge Not covered None
illness
Specialist visit $15 copay/visit Not covered None
If you visit a health care
provider’s office or clinic You may have to pay for services that aren't
Preventive care /screening preventive. Ask your provider if the services
No charge Not covered
/immunization needed are preventive. Then check what your
plan will pay for.
Lab: No charge; X-ray: $15
Diagnostic test (x-ray, blood work) Not covered None
If you have a test copay/visit
Imaging (CT/PET scans, MRIs) 30% coinsurance Not covered None
No charge for up to a 90 Covers up to a 30 day supply (retail
Preferred generic drugs Not covered
day supply prescription), 31-90 day supply(retail & mail
If you need drugs to treat 10% coinsurance for up to order prescription). Applicable cost share plus
Preferred brand drugs Not covered
your illness or condition a 90 day supply difference (brand minus generic cost) applies
for brand when generic available. No charge for
More information about 40% coinsurance for up to
prescription drug Non-preferred generic/brand drugs Not covered preferred generic FDA-approved women's
a 90 day supply contraceptives in-network.
coverage is available at
http://aet.na/flivl24 All specialty prescription drug fills on initial fill
must be filled at a network specialty pharmacy
Preferred/non-preferred specialty 50% coinsurance for up to
Not covered except for urgent situations. Your plan may
drugs a 30 day supply
include access to CVS retail pharmacies for
certain specialty drugs.
30% coinsurance for
Facility fee (e.g., ambulatory surgery hospital facility; 20%
Not covered None
center) coinsurance for free
If you have outpatient standing facility
surgery 30% coinsurance for
hospital facility; 20%
Physician/surgeon fees Not covered None
coinsurance for free
standing facility

082600-100020-042348 Page 2 of 6
 What You Will Pay
Common Out–of–Network Limitations, Exceptions, & Other Important
Services You May Need In-Network Provider (You Provider
Medical Event (You will pay Information
will pay the least) the most)
Out-of-network emergency room care
Emergency room care 50% coinsurance 50% coinsurance cost-share same as in-network. No coverage
If you need immediate for non-emergency care.
medical attention
Emergency medical transportation 50% coinsurance 50% coinsurance Out-of-network cost-share same as in-network.
Urgent care $5 copay/visit Not covered No coverage for non-urgent use.
If you have a Facility fee (e.g., hospital room) 50% coinsurance Not covered None
hospital stay Physician/surgeon fees 50% coinsurance Not covered None
Outpatient office visits: No
Outpatient services charge; All other outpatient Not covered None
If you need mental health, services: 30% coinsurance
behavioral health, or
substance abuse services
Inpatient services 50% coinsurance Not covered None

Office visits No charge Not covered Cost sharing does not apply for preventive
Childbirth/delivery professional services. Maternity care may include tests
If you are pregnant 50% coinsurance Not covered
services and services described elsewhere in the SBC
Childbirth/delivery facility services 50% coinsurance Not covered (i.e., ultrasound).
Home health care 20% coinsurance Not covered Coverage is limited to 60 visits.
Coverage is limited to 35 visits for Physical
Rehabilitation services $15 copay/visit Not covered Therapy, Occupational Therapy, Speech
Therapy & Chiropractic care combined.
If you need help Habilitation services 30% coinsurance Not covered None
recovering or have other
special health needs Skilled nursing care 50% coinsurance Not covered Coverage is limited to 60 days.
Coverage is limited to 1 durable medical
Durable medical equipment 50% coinsurance Not covered equipment for same/similar purpose. Excludes
repairs for misuse/abuse.
Hospice services 50% coinsurance Not covered None

082600-100020-042348 Page 3 of 6
 What You Will Pay
Common Out–of–Network Limitations, Exceptions, & Other Important
Services You May Need In-Network Provider (You Provider
Medical Event (You will pay Information
will pay the least) the most)
Not covered Coverage is limited to 1 exam every 12 months
Children's eye exam $10 copay/visit
up to age 19.
If your child needs dental Not covered Coverage is limited to 1 set of frames and 1 set
or eye care Children's glasses $10 copay/visit of contact lenses or eyeglass lenses per
calendar year up to age 19.
Children's dental check-up Not covered Not covered Not covered.
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
• Abortion • Hearing aids • Private-duty nursing
• Acupuncture • Infertility treatment • Routine eye care (Adult)
• Bariatric surgery • Long-term care • Routine foot care
• Cosmetic surgery • Non-emergency care when traveling outside the • Weight loss programs
• Dental care (Adult & Child) U.S.

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
• Chiropractic care - Coverage is limited to 35 visits
for Physical Therapy, Occupational Therapy,
Speech Therapy & Chiropractic care combined.
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is:
Florida Department of Financial Services, Division of Consumer Services, 877-693-5236, 850-413-3089 (Out of State), Dial *711 (TDD),
http://www.myfloridacfo.com/Division/Consumers/.
● For more information on your rights to continue coverage, contact the plan at 1-844-365-7373.
Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about
the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596 or state health insurance marketplace or SHOP.
Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance
or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete
information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact:
● Florida Department of Financial Services, Division of Consumer Services, 877-693-5236, 850-413-3089 (Out of State), Dial *711 (TDD),

082600-100020-042348 Page 4 of 6
 http://www.myfloridacfo.com/Division/Consumers/.
Does this plan provide Minimum Essential Coverage? Yes.
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP,
TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.
Does this plan meet Minimum Value Standards? Not Applicable.
If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
To see examples of how this plan might cover costs for a sample medical situation, see the next section.

082600-100020-042348 Page 5 of 6
About these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be
different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing
amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of
costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby Managing Joe’s Type 2 Diabetes Mia’s Simple Fracture
(9 months of in-network pre-natal care and (a year of routine in-network care of a (in-network emergency room visit and
a hospital delivery) well-controlled condition) follow up care)

■ The plan’s overall deductible $0 ■ The plan’s overall deductible $0 ■ The plan’s overall deductible $0
■ Specialist copayment $15 ■ Specialist copayment $15 ■ Specialist copayment $15
■ Hospital (facility) coinsurance 50% ■ Hospital (facility) coinsurance 50% ■ Hospital (facility) coinsurance 50%
■ Other coinsurance 50% ■ Other coinsurance 50% ■ Other coinsurance 50%

This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:
Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical supplies)
Childbirth/Delivery Professional Services disease education) Diagnostic test (x-ray)
Childbirth/Delivery Facility Services Diagnostic tests (blood work) Durable medical equipment (crutches)
Diagnostic tests (ultrasounds and blood work) Prescription drugs Rehabilitation services (physical therapy)
Specialist visit (anesthesia) Diabetic supplies (glucose meter)

Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800
In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:
Cost Sharing Cost Sharing Cost Sharing
Deductibles $0 Deductibles $0 Deductibles $0
Copayments $30 Copayments $30 Copayments $80
Coinsurance $1,200 Coinsurance $300 Coinsurance $1,000
What isn't covered What isn't covered What isn't covered
Limits or exclusions $60 Limits or exclusions $20 Limits or exclusions $0
The total Peg would pay is $1,290 The total Joe would pay is $350 The total Mia would pay is $1,080

Note: These numbers assume the patient does not participate in the plan's wellness program. If you participate in the plan's wellness program, you may be able to
reduce your costs. For more information about the wellness program, please contact: 1-844-365-7373.

The plan would be responsible for the other costs of these EXAMPLE covered services.
082600-100020-042348 Page 6 of 6
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Non-Discrimination
Aetna complies with applicable Federal civil rights laws and does not unlawfully discriminate, exclude or treat people differently based on their race, color, national
origin, sex, age, disability, gender identity or sexual orientation.
We provide free aids/services to people with disabilities and to people who need language assistance.
If you need a qualified interpreter, written information in other formats, translation or other services, call the number on your ID card.
If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with the Civil
Rights Coordinator by contacting:

Civil Rights Coordinator,

P.O. Box 14462, Lexington, KY 40512 (CA HMO customers: P.O. Box 24030, Fresno, CA 93779),
1-800-648-7817, TTY: 711,
Fax: 859-425-3379 (CA HMO customers: 860-262-7705), [email protected].
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building,
Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD).

Health plans are offered or underwritten or administered by Aetna Health Inc. (Florida) (Aetna). Aetna is part of the CVS Health family of companies.
TTY: 711
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Tongan - Kapau ‘oku ke fiema’u ta’etōtōngi ‘a e ngaahi sēvesi kotoa pē he ngaahi lea kotoa, telefoni ki he 1-844-365-7373.
Trukese - Ren omw kopwe angei aninisin eman chon awewei (ese kamo), kopwe kori 1-844-365-7373.
Turkish - Sizin için ücretsiz dil hizmetlerine erişebilmek için, 1-844-365-7373 numarayı arayın.

Ukrainian - Щоб отримати безкоштовний доступ до мовних послуг, задзвоніть за номером 1-844-365-7373.
Urdu - .-‫ ےیل ےک ےنرک لصاح تامدخ ہقلعتم ےس نابز تمیقلاب‬1-844-365-7373 ‫ںیرک تاب رپ‬
Vietnamese - Nếu quý vị muốn sử dụng miễn phí các dịch vụ ngôn ngữ, hãy gọi tới số 1-844-365-7373.
Yiddish - 1-844-365-7373 ‫ רופן‬,‫צו צוטריט ךארפשַּ באדַינונגען אין קיין פרייַז צו איר‬
Yoruba - Lati wọnú awọn isẹ èdè l’ọfẹ fun ọ, pe 1-844-365-7373.