BannerAetna Gold S: No PCP required + Unlimited $0 MinuteClinic + free 98point6 virtual care 24/7 - 23435AZ0040012 Health Insurance Plan
Banner Health and Aetna Health Plan Inc. health insurance plan with the Plan ID 23435AZ0040012. The plan is called BannerAetna Gold S: No PCP required + Unlimited $0 MinuteClinic + free 98point6 virtual care 24/7.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 78.02% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 21.98% of the costs of all covered benefits (according to the Issuer).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.02% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 21.98% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
| Health Insurance Plan ID | 23435AZ0040012 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Arizona | ||||||||||||||||||
| Health Insurance Issuer | Banner Health and Aetna Health Plan Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 23435AZ0040012-01 | ||||||||||||||||||
| Provider Network(s) | PREFERRED NON-PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 23435AZ0040012-00 Standard On Exchange Plan - 23435AZ0040012-01 |
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| Last Plan Update Date | Tue, 24 Oct 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of BannerAetna Gold S: No PCP required + Unlimited $0 MinuteClinic + free 98point6 virtual care 24/7 Health Insurance Plan, 23435AZ0040012-01
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Exclusions: Member cost share based on place and type of service. Benefits are payable for the services of a Physician, dentist, or dental surgeon, provided the services are rendered for treatment of an accidental injury to sound natural teeth where the continuous course of treatment is started within six (6) months of the accident. |
YES | $60.00 |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
Exclusions: Member cost share based on place and type of service. |
YES | $60.00 |
100.00% |
| Bariatric Surgery
Exclusions: Pre-certification is required. Surgery for obesity will be a Covered Service only when required due to morbid obesity. The participant meets the current NIH (National Institutes of Health) surgical criteria. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
Exclusions: Member cost share based on place and type of service. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 20.0 Visit(s) per Year Exclusions: HMO coverage is limited to 20 visits per calendar year. No visit limits on PPO IN or OON. HMOs may limit chiropractic visits to 20; PPOs must cover medically necessary chiropractic visits. |
YES | $30.00 |
100.00% |
| Clinical Trials
Exclusions: Member cost share based on place and type of service. |
YES | $60.00 |
100.00% |
| Cosmetic Surgery
Cosmetic surgery or procedures excluded, other than to treat congenital defects and birth abnormalities |
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Care Management
Exclusions: Member cost share based on place and type of service. |
YES | $60.00 |
100.00% |
| Diabetes Education
Exclusions: Member cost share based on place and type of service. |
YES | $60.00 |
100.00% |
| Dialysis
Exclusions: Member cost share based on place and type of service. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 45.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
Exclusions: No coverage for non-emergency use of the emergency room. |
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Exclusions: Coverage is limited to 1 set of frames and 1 set of contact lenses or eyeglass lenses per calendar year age 0-19. |
YES | $10.00 |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | $15.00 |
100.00% |
| Habilitation Services
Speech therapy is not covered to improve speech skills that have not fully developed or when "not restorative in nature." |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Hearing Aids
Limit: 1.0 Item(s) per Year Exclusions: Coverage is limited to one hearing aid per ear per year. |
YES | 45.00% Coinsurance after deductible |
100.00% |
| Home Health Care Services
Limit: 42.0 Visit(s) per Year |
YES | $30.00 |
100.00% |
| Hospice Services
Exclusions: Member cost share based on place and type of service. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
Exclusions: Coverage limited to diagnosis and treatment of the underlying medical condition. Member cost share based on place and type of service. |
NO | ||
| Infusion Therapy
Exclusions: Member cost share based on place and type of service. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inherited Metabolic Disorder - PKU
Exclusions: Coverage is limited to formulas, both tube-fed and oral, when medically necessary for the treatment of Eosinophilic Gastrointestinal Disorder and inherited metabolic disease. |
YES | 25.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $30.00 |
100.00% |
| Non-Preferred Brand Drugs
Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | $60.00 |
100.00% |
| Nutritional Counseling
|
YES | No Charge |
100.00% |
| Off Label Prescription Drugs
Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | $60.00 |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $30.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 60.0 Visit(s) per Year Exclusions: Coverage is limited to 60 visits per calendar year PT/OT/ST combined. |
YES | $30.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | $30.00 |
100.00% |
| Prenatal and Postnatal Care
Exclusions: Member cost sharing applies to postnatal care |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Prescription Drugs Other
Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | $60.00 |
100.00% |
| Preventive Care/Screening/Immunization
Exclusions: Age and frequency schedules may apply. |
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $30.00 |
100.00% |
| Private-Duty Nursing
Private hospital rooms and/or private duty nursing are only available during inpatient stays and determined to be medically appropriate. Private duty nursing is available only in an inpatient setting when skilled nursing is not available from the facility. Custodial Nursing is not covered. |
NO | ||
| Prosthetic Devices
|
YES | 45.00% Coinsurance after deductible |
100.00% |
| Radiation
Exclusions: Member cost share based on place and type of service. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Exclusions: Member cost share based on place and type of service. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 60.0 Visit(s) per Year Exclusions: Coverage is limited to 60 visits per calendar year PT/OT/ST combined. Benefit limits are separate for rehabilitation and habilitation services. |
YES | $30.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 60.0 Visit(s) per Year Exclusions: Coverage is limited to 60 visits per calendar year PT/OT/ST combined. Benefit limits are separate for rehabilitation and habilitation services. Speech therapy is not covered when: a. Used to improve speech skills that have not fully developed; b. Considered custodial or educational; c. Intended to maintain speech communication; or d. Not restorative in nature. |
YES | $30.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year Exclusions: Coverage is limited to 1 exam per calendar year age 0-19. |
YES | $10.00 |
100.00% |
| Routine Foot Care
|
NO | ||
| Routine Hearing Exam
Limit: 1.0 Visit(s) per Year |
YES | $60.00 |
100.00% |
| Skilled Nursing Facility
Limit: 90.0 Days per Year |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $60.00 |
100.00% |
| Specialty Drugs
Exclusions: Coinsurance up to applicable maximum per prescription. Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | $250.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $30.00 |
100.00% |
| Transplant
Exclusions: Member cost share based on place and type of service. Network benefits must be received within the transplant network. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Exclusions: Member cost share based on place and type of service. Coverage is limited to accident, trauma, congenital/developmental defects or pathology. |
YES | $60.00 |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $45.00 |
100.00% |
| Weight Loss Programs
Exclusions: Online weight loss programs are available. |
NO | ||
| Well Baby Visits and Care
Exclusions: Coverage is limited to 7 exams in the first year of life; 3 exams in the second year of life; 3 exams in the third year of life; 1 exam per year thereafter to age 22. Well Child visits and immunizations are covered through 47 months as recommended by the American Academy of Pediatrics. |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 25.00% Coinsurance after deductible |
100.00% |
BannerAetna Gold S: No PCP required + Unlimited $0 MinuteClinic + free 98point6 virtual care 24/7 Health Insurance Plan Variant 23435AZ0040012-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7802 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold On Exchange Plan |
| Dental Only Plan | No |
| Design Type | Design 1 |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | AZF023 |
| Formulary URL | URL |
| HIOS Product ID | 23435AZ004 |
| Import Date | 2023-10-24 01:01:46 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | 0 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 78.02% |
| Issuer ID | 23435 |
| Issuer Marketplace Marketing Name | BannerAetna |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | AZN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Out of Service Area Coverage Description | Except for Emergencies |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan ID (Standard Component ID with Variant) | 23435AZ0040012-01 |
| Plan Marketing Name | BannerAetna Gold S: No PCP required + Unlimited $0 MinuteClinic + free 98point6 virtual care 24/7 |
| Plan Type | HMO |
| Plan Variant Marketing Name | BannerAetna Gold S: No PCP required + Unlimited $0 MinuteClinic + free 98point6 virtual care 24/7 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,500 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $1,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,200 |
| SBC Scenario, Having Diabetes, Deductible | $100 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | AZS003 |
| Source Name | HIOS |
| Plan ID | 23435AZ0040012 |
| State Code | AZ |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 25.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $3000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,500 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $17400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8700 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,700 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | Yes |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of BannerAetna Gold S: No PCP required + Unlimited $0 MinuteClinic + free 98point6 virtual care 24/7 Health Insurance Plan, 23435AZ0040012
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about BannerAetna Gold S: No PCP required + Unlimited $0 MinuteClinic + free 98point6 virtual care 24/7, 23435AZ0040012 Health Insurance Plan, 23435AZ0040012
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Does BannerAetna Gold S: No PCP required + Unlimited $0 MinuteClinic + free 98point6 virtual care 24/7 Health Insurance Plan, 23435AZ0040012 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (23435AZ0040012) Health Insurance Plan, Variant (23435AZ0040012-01) offer Disease Management Programs?
Does (23435AZ0040012) Health Insurance Plan, Variant (23435AZ0040012-01) have Out Of Country Coverage?
Does (23435AZ0040012) Health Insurance Plan, Variant (23435AZ0040012-01) have Out of Service Area Coverage?
Does (23435AZ0040012) Health Insurance Plan, Variant (23435AZ0040012-01) offer Disease Management Programs?
Does BannerAetna Gold S: No PCP required + Unlimited $0 MinuteClinic + free 98point6 virtual care 24/7 Health Insurance Plan, Variant (23435AZ0040012-01) offer Disease Management Programs for Asthma?
Does BannerAetna Gold S: No PCP required + Unlimited $0 MinuteClinic + free 98point6 virtual care 24/7 Health Insurance Plan, Variant (23435AZ0040012-01) offer Disease Management Programs for Heart disease?
Does BannerAetna Gold S: No PCP required + Unlimited $0 MinuteClinic + free 98point6 virtual care 24/7 Health Insurance Plan, Variant (23435AZ0040012-01) offer Disease Management Programs for Depression?
Does BannerAetna Gold S: No PCP required + Unlimited $0 MinuteClinic + free 98point6 virtual care 24/7 Health Insurance Plan, Variant (23435AZ0040012-01) offer Disease Management Programs for Diabetes?
Does BannerAetna Gold S: No PCP required + Unlimited $0 MinuteClinic + free 98point6 virtual care 24/7 Health Insurance Plan, Variant (23435AZ0040012-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Does BannerAetna Gold S: No PCP required + Unlimited $0 MinuteClinic + free 98point6 virtual care 24/7 Health Insurance Plan, Variant (23435AZ0040012-01) offer Disease Management Programs for Low back pain?
Does BannerAetna Gold S: No PCP required + Unlimited $0 MinuteClinic + free 98point6 virtual care 24/7 Health Insurance Plan, Variant (23435AZ0040012-01) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Thu, 21 Nov 2024 00:44 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API