{ "resourceType": "Bundle", "id": "bps-aetna-ppo-1500-80-50", "type": "collection", "entry": [ { "fullUrl": "urn:uuid:5645973f-1a29-5e77-9465-e0d115bcde8a", "resource": { "resourceType": "InsurancePlan", "id": "aetna-ppo-1500-80-50", "meta": { "profile": [ "http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-insurance-plan" ] }, "text": { "status": "generated", "div": "

Aetna FL PPO 1500 80/50 CY V25

Carrier: Aetna. Plan type: PPO. Period: 2026-01-01 to 2026-12-31.

26 benefits are placed in CARIN SBC benefit categories. 1 benefits have no code in the SBC benefit category code system and are listed, by identity only, in the bps-unmapped-benefit extension.

Converted from Benefit Plan Standard document AETNA_PPO_1500_80_50 (schema version 1.1.0).

" }, "extension": [ { "extension": [ { "url": "schemaVersion", "valueString": "1.1.0" }, { "url": "planYear", "valueInteger": 2026 }, { "url": "market", "valueString": "large_group" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-plan-metadata" }, { "extension": [ { "url": "pageNumber", "valueInteger": 1 }, { "url": "excerpt", "valueString": "Coverage Period: 01/01/2026 - 12/31/2026 | FL PPO 1500 80/50 CY V25 | Coverage for: Employee + Family | Plan Type: PPO" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 1 }, { "url": "excerpt", "valueString": "What is the overall deductible? In-network: Individual $1,500 / Family $3,000" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 1 }, { "url": "excerpt", "valueString": "What is the out-of-pocket limit for this plan? In-network: Individual $5,500 / Family $11,000." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 2 }, { "url": "excerpt", "valueString": "Primary care visit to treat an injury or illness: $25 copay/visit, deductible does not apply; 50% coinsurance out-of-network" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 2 }, { "url": "excerpt", "valueString": "Specialist visit: $75 copay/visit, deductible does not apply; 50% coinsurance out-of-network" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 2 }, { "url": "excerpt", "valueString": "Preventive care /screening /immunization: No charge in-network" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 2 }, { "url": "excerpt", "valueString": "Diagnostic test (x-ray, blood work): 20% coinsurance in-network; 50% coinsurance out-of-network" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 2 }, { "url": "excerpt", "valueString": "Imaging (CT/PET scans, MRIs): 20% coinsurance in-network; 50% coinsurance out-of-network" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 2 }, { "url": "excerpt", "valueString": "Preferred generic drugs: Copay/ prescription, deductible does not apply: Tier 1A: $3 for up to a 30 day supply" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 2 }, { "url": "excerpt", "valueString": "Preferred brand drugs: $45 for up to a 30 day supply, $90 for up to a 90 day supply" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 2 }, { "url": "pageRange", "valueString": "2-3" }, { "url": "excerpt", "valueString": "Specialty drugs: Preferred: 20% coinsurance for up to a 30 day supply; Not covered out-of-network" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 3 }, { "url": "excerpt", "valueString": "Emergency room care: 20% coinsurance after $300 copay/visit (in-network and out-of-network). Copay waived if admitted." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 3 }, { "url": "excerpt", "valueString": "Emergency medical transportation: 20% coinsurance. Out-of-network cost-share same as in-network." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 3 }, { "url": "excerpt", "valueString": "Urgent care: $75 copay/visit, deductible does not apply; 50% coinsurance out-of-network" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 3 }, { "url": "excerpt", "valueString": "If you have a hospital stay - Facility fee (e.g., hospital room): 20% coinsurance; 50% coinsurance out-of-network" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 4 }, { "url": "excerpt", "valueString": "Rehabilitation services: $75 copay/visit; 50% coinsurance out-of-network. Coverage is limited to 60 visits for Physical Therapy, Occupational Therapy, Speech Therapy & Chiropractic care combined." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 4 }, { "url": "excerpt", "valueString": "Durable medical equipment: 50% coinsurance; 50% coinsurance out-of-network" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 4 }, { "url": "excerpt", "valueString": "Children's eye exam: No charge in-network. Coverage is limited to 1 exam every 12 months." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 4 }, { "url": "excerpt", "valueString": "Children's glasses: Not covered. Children's dental check-up: Not covered." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "benefitId", "valueString": "HOME_HEALTH_CARE" }, { "url": "canonicalKey", "valueString": "home_health_care" }, { "url": "serviceName", "valueString": "Home health care" }, { "url": "category", "valueString": "HOME_HEALTH" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" } ], "identifier": [ { "system": "https://benefitplanstandard.org/plan-id", "value": "AETNA_PPO_1500_80_50" } ], "status": "active", "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/insurance-plan-type", "code": "medical", "display": "Medical" } ] } ], "name": "Aetna FL PPO 1500 80/50 CY V25", "period": { "start": "2026-01-01", "end": "2026-12-31" }, "ownedBy": { "reference": "urn:uuid:f075485f-1797-58a5-a8ad-8729e4214db0", "display": "Aetna" }, "contact": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason", "valueCode": "unknown" } ], "purpose": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/contactentity-type", "code": "PAYOR", "display": "Payor" } ] } } ], "coverage": [ { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "preventive-care", "display": "Preventive Care/Screening/Immunization" } ] }, "benefit": [ { "extension": [ { "extension": [ { "url": "benefitId", "valueString": "PREVENTIVE_CARE" }, { "url": "benefitType", "valueString": "medical" }, { "url": "category", "valueString": "PREVENTIVE_CARE" }, { "url": "rawLabel", "valueString": "Yes. Certain office visits, preventive care, urgent care and prescription drugs in-network." }, { "url": "moopApplicability", "valueString": "plan_default" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" } ], "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "preventive-care", "display": "Preventive Care/Screening/Immunization" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "preventive_care", "display": "Preventive care" } ], "text": "Preventive care" } } ] }, { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "primary-care-visit", "display": "Primary Care Visit" } ] }, "benefit": [ { "extension": [ { "extension": [ { "url": "benefitId", "valueString": "PRIMARY_CARE" }, { "url": "benefitType", "valueString": "medical" }, { "url": "category", "valueString": "PHYSICIAN_SERVICES" }, { "url": "rawLabel", "valueString": "Primary care visit to treat an injury or illness" }, { "url": "moopApplicability", "valueString": "plan_default" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" } ], "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "primary-care-visit", "display": "Primary Care Visit" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "primary_care", "display": "Primary care visit" } ], "text": "Primary care visit" } } ] }, { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "specialist-visit", "display": "Specialist Visit" } ] }, "benefit": [ { "extension": [ { "extension": [ { "url": "benefitId", "valueString": "SPECIALIST" }, { "url": "benefitType", "valueString": "medical" }, { "url": "category", "valueString": "PHYSICIAN_SERVICES" }, { "url": "rawLabel", "valueString": "Specialist visit" }, { "url": "moopApplicability", "valueString": "plan_default" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" } ], "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "specialist-visit", "display": "Specialist Visit" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "specialist", "display": "Specialist visit" } ], "text": "Specialist visit" } } ] }, { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "diagnostic-test", "display": "Diagnostic Test" } ] }, "benefit": [ { "extension": [ { "extension": [ { "url": "benefitId", "valueString": "DIAGNOSTIC_TEST" }, { "url": "benefitType", "valueString": "medical" }, { "url": "category", "valueString": "DIAGNOSTIC_SERVICES" }, { "url": "rawLabel", "valueString": "Diagnostic test (x-ray, blood work)" }, { 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"https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" } ], "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "facility-fee", "display": "Facility Fee" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "outpatient_surgery", "display": "Outpatient surgery" } ], "text": "Outpatient surgery" } }, { "extension": [ { "extension": [ { "url": "benefitId", "valueString": "SURGERY_PROFESSIONAL" }, { "url": "benefitType", "valueString": "medical" }, { "url": "category", "valueString": "SURGICAL_SERVICES" }, { "url": "rawLabel", "valueString": "Physician/surgeon fees" }, { "url": "moopApplicability", "valueString": "plan_default" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" } ], "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "physician-surgeon-fee", "display": "Physician/Surgeon Fees" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "surgery_professional", "display": "Surgery professional" } ], "text": "Surgery professional" } } ] }, { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "emergency-room-care", "display": "Emergency Room Care" } ] }, "benefit": [ { "extension": [ { "extension": [ { "url": "benefitId", "valueString": "EMERGENCY_ROOM" }, { "url": "benefitType", "valueString": "medical" }, { "url": "category", "valueString": "EMERGENCY_CARE" }, { "url": "rawLabel", "valueString": "Emergency room care" }, { "url": "moopApplicability", "valueString": "plan_default" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" } ], "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "emergency-room-care", "display": "Emergency Room Care" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "emergency_room", "display": "Emergency room" } ], "text": "Emergency room" } } ] }, { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "emergency-medical-transport", "display": "Emergency Medical Transportation" } ] }, "benefit": [ { "extension": [ { "extension": [ { "url": "benefitId", "valueString": "AMBULANCE" }, { "url": "benefitType", "valueString": "medical" }, { "url": "category", "valueString": "EMERGENCY_CARE" }, { "url": "rawLabel", "valueString": "Emergency medical transportation" }, { "url": "moopApplicability", "valueString": "plan_default" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" } ], "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "emergency-medical-transport", "display": "Emergency Medical Transportation" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "ambulance", "display": "Ambulance services" } ], "text": "Ambulance services" } } ] }, { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "urgent-care", "display": "Urgent Care" } ] }, "benefit": [ { "extension": [ { "extension": [ { "url": "benefitId", "valueString": "URGENT_CARE" }, { "url": "benefitType", "valueString": "medical" }, { "url": "category", "valueString": "URGENT_CARE" }, { "url": "rawLabel", "valueString": "Urgent care" }, { "url": "moopApplicability", "valueString": "plan_default" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" } ], "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "urgent-care", "display": "Urgent Care" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "urgent_care", "display": "Urgent care" } ], "text": "Urgent care" } } ] }, { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "hospital-inpatient", "display": "Hospital Inpatient Care" } ] }, "benefit": [ { "extension": [ { "extension": [ { "url": "benefitId", "valueString": "INPATIENT_HOSPITAL" }, { "url": "benefitType", "valueString": "medical" }, { "url": "category", "valueString": "HOSPITAL_SERVICES" }, { "url": "rawLabel", "valueString": "If you have a hospital stay" }, { "url": "moopApplicability", "valueString": "plan_default" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" } ], "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "facility-fee", "display": "Facility Fee" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "inpatient_hospital", "display": "Inpatient hospital" } ], "text": "Inpatient hospital" } } ] }, { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "mental-health-outpatient", "display": "Mental/Behavioral Health Outpatient Services" } ] }, "benefit": [ { "extension": [ { "extension": [ { "url": "benefitId", "valueString": "MENTAL_HEALTH_OUTPATIENT" }, { "url": "benefitType", "valueString": "medical" }, { "url": "category", "valueString": "BEHAVIORAL_HEALTH" }, { "url": "rawLabel", "valueString": "Outpatient services" }, { "url": "moopApplicability", "valueString": "plan_default" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" } ], "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "mental-health-outpatient", "display": "Mental/Behavioral Health Outpatient Services" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": 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