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Summary of benefits and coverage

The basics about your health coverage

 

Under the Affordable Care Act (ACA), you must receive a Summary of Benefits and Coverage (SBC) document. It explains your benefits. It also has examples of how much you might pay out of pocket for certain health services. All SBCs must follow a standard format. This makes it easier to compare health plans and costs.

 

1. You'll find a link to the SBC on each plan page when you preview plans and prices. You'll also see the link when you've finished your application and are comparing plans.

 

2. You can ask for a copy from your insurance company or employer at any time. You will be provided the SBC at important points in the enrollment process, such as when you apply for or when you renew coverage. You also can get a copy of the uniform glossary to explain terms used in the SBC.

 

View a sample SBC (PDF)

 

View the uniform glossary (PDF)

The SBC includes the name of your health plan. This information is helpful when checking:

 

  • Which doctors, hospitals and other providers are in our network
  • Which prescription drugs the plan covers

If you're already a member, you can find health care provider and drug information on your secure member website.

 

Log in to your secure website

 

If you're not a member yet, look up doctors in our provider directory. Choose the plan name that matches the one in your SBC.

 

Find a doctor

 

You also can look up drug coverage without logging in. You'll need to know your pharmacy plan name. You can find the pharmacy plan name on your SBC.

 

Search your plan’s drug list (formulary)

Remember, the SBC is only a summary. You can link from the SBC to your plan documents which contain the complete details about the health plan.

 

You can review your plan documents to see:

 

  • What services will and will not be covered
  • Conditions you must meet to receive benefits
  • When and in what form benefits are paid
  • When you need approval before getting a service
  • How to file a claim for benefits

Here's how to get a sample plan policy document.

 

Note: This is a sample document for your information only. Legal entity, plan terms and benefits, including cost sharing, may vary from your actual coverage based on the plan selected and state mandates which are not reflected in this sample document.

 

If you're an individual covering yourself or your family member(s):

 

Individual Sample Policy Documents

 

Individual Elect Choice Open Access (EPO) sample policy (PDF)

 

Individual Health Maintenance Organization (HMO) sample policy (PDF)

 

 

If you're covered under an employer that has 50 or fewer employees:

 

Small group sample policy documents

 

Health network only (PDF)

 

Open access managed choice (PDF)

 

Health network option (PDF)

 

Indemnity (PDF)

 

Open access elect choice (PDF)

 

 PPO medical (PDF)

 

 

If you're covered under an employer that has 51 or more employees:

 

Large group sample policy documents

 

Health network only (PDF)

 

Open access managed choice (PDF)

 

Health network option (PDF)

 

Indemnity (PDF)

 

Open access elect choice (PDF)

 

PPO medical (PDF)

 

Managed choice (PDF)

If you already have an Aetna health plan, just call the Member Services number on your ID card. Or call us at one of these numbers.

 

Individual plans effective in 2022

 

FL, GA, MO, NC, NV, TX: 1-844-374-5217 (TTY: 711)

AZ (Non Banner|Aetna): 1-844-374-5217 (TTY: 711)

AZ (Banner|Aetna): 1-844-374-5218 (TTY: 711)

VA (Non Innovation Health): 1-844-374-5217 (TTY: 711)

VA (InnovationHealth): 1-844-374-5219 (TTY: 711)

 

Small Group plans

 

Aetna plan members

On exchange: 1-855-885-3289 (TTY: 711)

Off exchange (non-HMO): 1-888-802-3862 (TTY: 711)

Off exchange (HMO): 1-866-529-2517 (TTY: 711)

 

Innovation Health:

1-855-330-4545 (TTY: 711)

 

Aetna Fund Advantage (AFA) Small Group

1-888-982-3862 (TTY: 711)

Allina Health: 1-855-337-7170 (TTY: 711)

Banner Health: 1-877-312-3862 (TTY: 711)

Texas Health: 1-800-261-2441 (TTY: 711)

 

Small Group

Texas Health: 1-800-596-4015 (TTY: 711)

Banner Health: 1-877-312-3862 (TTY: 711)

 

Important information for employers

We'll give employers the information they need. But the law says employers have to give the SBCs to their employees. There are specific rules about what employers have to provide and when.

Legal notices

Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna).

Health benefits and health insurance plans contain exclusions and limitations.