The mantra, “location, location, location,” isn’t just about real estate. It also applies to whether the State Farm Aetna Accountable Care Organization (ACO) medical plan is available to you. (Spoiler alert: It is if you live within an eligible Phoenix, Arizona or Dallas, Texas area zip code).
How the plan works
Plan availability is tied to your zip code
Access to the Aetna ACO depends on your residential zip code. To determine which plans are available to you based on your home zip code and how much you’ll pay for coverage, use the Pricing Modeler.
You must use in-network providers
If you’re in Arizona, you’ll receive care from providers in the Banner Aetna Phoenix ACO network; if you’re in Texas, your providers will be affiliated with the Aetna Whole Health Texas Health ACO network. Except for emergencies, any care you receive outside of these networks won’t be covered by the plan.
You pay nothing for preventive care
In-network preventive care is covered at 100%. You do not have to meet the deductible first.
Having annual physicals and getting the suggested screenings and vaccinations helps you maintain good health and identify potential health issues as soon as possible.
You’ll pay a copay for primary care and specialist doctor’s office visits
The deductible does not apply.
For other services, you must meet your annual deductible before the plan helps cover the cost of your care
This includes inpatient labs and X-rays, hospital stays, and emergency care. Once you meet your deductible, you and the plan share the cost of these services through coinsurance.
After you reach the out-of-pocket maximum, the plan pays 100% of the cost of services for in-network services for the rest of the year
The annual deductible and the amount you pay out of pocket for coinsurance all count toward your out-of-pocket maximum.
Prior authorization may be required
Some medical services and prescription drugs require prior authorization before they are covered. This means your health care provider must get approval from your insurance provider in advance. If prior authorization isn’t obtained, you may be responsible for the full cost. This process helps ensure that care is safe, appropriate, and covered under the plan. Review the plan documents on the My State Farm Benefits Resource website (auto sign-on with SSOYou must be on the State Farm network to access this link. | log in). On the home page, select Plan Documents from the left navigation, then select the Health and Insurance dropdown.
How to find a provider
You can find an in-network doctor through Aetna’s online provider directory or by calling Member Services.
Plan at a glance
| Feature | In-network only |
|---|---|
| Availability | Select zip codes in Phoenix, Arizona and Dallas, Texas |
| Provider network | Banner Aetna (Arizona) Aetna Whole Health Texas Health (Texas) |
| Annual deductible (medical only) | Individual: $500 Family: $1,000 |
| Out-of-pocket maximum (medical and prescription drug) | Individual: $2,000 Family: $4,000 |
| Preventive care (screenings and immunizations) | $0, deductible does not apply |
| Primary care visit | $30 copay, deductible does not apply |
| Specialty care visit | $50 copay, deductible does not apply |
| Mental health visit | $50 copay, deductible does not apply |
| Virtual care visit through 98point6 | $0 |
| Coinsurance (costs that you and the plan share after you meet the deductible) | You pay 20% after deductible |
| Lab and X-ray | You pay 20%; deductible does not apply for outpatient services |
| Emergency care | You pay 20% after deductible |
| Hospitalization | You pay 20% after deductible |
For additional plan details, review the Aetna ACO Summary of Benefits and Coverage (SBC) on the My State Farm Benefits Resource website (auto sign-on with SSOYou must be on the State Farm network to access this link. | log in). On the home page, select Plan Documents from the left navigation, then select the Health and Insurance dropdown.
Prescription drugs
Your prescription drug coverage is administered by CVS Caremark. What you pay will depend on the type of medication and how you get it filled. You can get a 30-day supply of medication from retail pharmacies and a 90-day supply through mail order.
Maintenance medications: After your third fill at a retail pharmacy, you’ll need to order 90-day supplies by mail.
Specialty drugs: When you’re enrolled in PrudentRx, you may pay nothing for eligible specialty drugs. Specialty drugs are high-cost medications used to treat complex chronic conditions. You are automatically enrolled in PrudentRx when a specialty drug is prescribed to you, unless you opt out. If you opt out of PrudentRx, you’ll pay 30% coinsurance for fills. For answers to your questions, call 800-578-4403.
What you pay for in-network prescriptions
| Drug tier | Retail (30-day supply) | Mail order (90-day supply) |
|---|---|---|
| Tier 1: Generic | $10 copay | $20 copay |
| Tier 2: Preferred brand | You pay 30% coinsurance | You pay 30% coinsurance |
| Tier 3: Non-preferred brand | You pay 50% coinsurance | You pay 50% coinsurance |
| Tier 4: Specialty | You pay 30% coinsurance or $0 through PrudentRx | N/A |
How to save on prescriptions
A few simple choices can help you get the most out of your prescription benefits and keep more money in your pocket.
Start with these smart saving tips:
- Check the formulary first. The formulary is the list of medications covered by your plan. If your medication isn’t on the list, it typically costs more. To find covered medications, visit the CVS Caremark website (auto sign-on with SSOYou must be on the State Farm network to access this link. | log in).
- Know your drug tier. Medications are grouped into tiers, and your cost depends on which tier your prescription falls into. In general, lower tiers mean lower costs. You can check tiers and pricing on the CVS Caremark website (auto sign-on with SSOYou must be on the State Farm network to access this link. | log in).
- Choose generics when possible. Generic medications usually cost less and work the same as brand-name drugs. Choosing a brand-name drug when a generic is available may mean paying a higher copay or coinsurance plus the cost difference between the two drugs.
- Preventive medications may be free. Under the Affordable Care Act, certain preventive medications are covered at 100% when filled in-network. See the list on the CVS Caremark website (auto sign-on with SSOYou must be on the State Farm network to access this link. | log in).
Preauthorization
During preauthorization, pharmacists and/or a medical director decides whether a prescribed medication will be covered by the plan. When preauthorization is required, your doctor must get approval from your insurance provider before you fill your prescription. This process helps to ensure safety, save money, and prevent medication misuse.
Virtual care
Skip the waiting room, and connect with licensed providers from anywhere. Virtual care through 98point6 gives you quick access to medical advice, prescriptions, and follow-ups — all from the comfort of your couch and through a secure connection anytime, anywhere.
How it works
You can use virtual care for urgent care visits.
You pay $0 for all visits.
24/7 access to virtual urgent care
If you enroll in the Aetna ACO medical plan, you can schedule visits with licensed doctors and nurses through 98point6. They can treat you and prescribe medications for a wide range of nonemergency conditions, such as:
- Allergies
- Sore throats, colds, and flu
- Digestive issues
- Fevers
- Infections
- Bronchitis and laryngitis
- Skin rashes, including poison ivy and poison oak
- Sprains and strains
- Dermatology issues, such as acne, eczema, and rashes
To get started, visit 98point6, or download the app on the App Store or Google Play.