Gold 10 Advanced: $0 PCP + Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 - 96992IN0060011 Health Insurance Plan
Aetna Health Inc. (a PA corp.) health insurance plan with the Plan ID 96992IN0060011. The plan is called Gold 10 Advanced: $0 PCP + Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.97% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.03% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 96992IN0060011 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Indiana | ||||||||||||||||||
| Health Insurance Issuer | Aetna Health Inc. (a PA corp.) | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 96992IN0060011-03 | ||||||||||||||||||
| Provider Network(s) | NON-PREFERRED 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 - 96992IN0060011-00 Standard On Exchange Plan - 96992IN0060011-01 |
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| Last Plan Update Date | Thu, 26 Sep 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Gold 10 Advanced: $0 PCP + Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, 96992IN0060011-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Per Indiana law, abortion only covered if performed because a woman becomes pregnant through an act of rape or incest; or an abortion is necessary to avert the pregnant woman?s death or a substantial and irreversible impairment of a major bodily function of the pregnant woman. |
NO | ||
| Accidental Dental
Cost share driven by provider/setting. |
YES | $25.00 |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
Cost share driven by provider/setting. |
YES | $25.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
Cost share driven by provider/setting. |
YES | $250.00 |
100.00% |
| Chiropractic Care
Limit: 12.0 Visit(s) per Year Cost share driven by provider/setting. |
YES | No Charge |
100.00% |
| Cosmetic Surgery
Covered for reconstructive surgery.Copay per day for days 1-5 |
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Copay per day for days 1-5 |
YES | $1,000.00 |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
Cost share driven by provider/setting. |
YES | $25.00 |
100.00% |
| Dialysis
Cost share driven by provider/setting. |
YES | $600.00 |
100.00% |
| Durable Medical Equipment
One wig per year following cancer treatment. |
YES | 50.00% |
100.00% |
| Emergency Room Services
Exclusions: No coverage for non-emergency use of the emergency room. |
YES | $750.00 |
$750.00 |
| Emergency Transportation/Ambulance
|
YES | $750.00 |
$750.00 |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Coverage is limited to 1 set of frames and 1 set of contact lenses or eyeglass lenses per year, through the end of the month in which the member turns 19. |
YES | $10.00 |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details. |
YES | $3.00 |
100.00% |
| Habilitation Services
Health care services that are needed to keep, learn, or improve your skills and functioning for daily living which may include physical therapy, occupational therapy, and speech therapy. Please refer to the plan policy documents for detailed information. Cost share is driven by provider/setting. |
YES | $25.00 |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 100.0 Visit(s) per Year Maximum does not include Home Infusion Therapy or Private Duty Nursing rendered in the home. |
YES | $25.00 |
100.00% |
| Hospice Services
Cost share driven by provider/setting.Copay per day for days 1-5 |
YES | $1,000.00 |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $500.00 |
100.00% |
| Infertility Treatment
Coverage limited to diagnosis and treatment of the underlying medical condition. Cost share driven by provider/setting. |
NO | ||
| Infusion Therapy
Cost share driven by provider/setting. |
YES | $250.00 |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Copay per day for days 1-5 |
YES | $1000.00 Copay per Day |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | No Charge |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | $20.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
Copay per day for days 1-5 |
YES | $1000.00 Copay per Day |
100.00% |
| Mental/Behavioral Health Outpatient Services
The cost sharing that displays applies to outpatient office visits only. All other outpatient services may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information. |
YES | No Charge |
100.00% |
| Non-Preferred Brand Drugs
Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
Cost share driven by provider/setting. |
YES | No Charge |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Cost share applies to both in-person and virtual services from in-network providers. Cost share does not apply to virtual services from designated telemedicine providers. If this is an HSA plan, deductible applies. |
YES | No Charge |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $600.00 |
100.00% |
| Outpatient Rehabilitation Services
Limit: 60.0 Visit(s) per Year Coverage for Speech Therapy is limited to 20 visits per year, Occupational Therapy is limited to 20 visits per year, and Physical Therapy is limited to 20 visits per year. Benefit limits for rehabilitation and habilitation services are separate. |
YES | $25.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $250.00 |
100.00% |
| Preferred Brand Drugs
Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details. |
YES | $35.00 |
100.00% |
| Prenatal and Postnatal Care
Member cost share applies to postnatal care. |
YES | No Charge |
100.00% |
| Preventive Care/Screening/Immunization
Age and frequency schedules may apply. |
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Cost share applies to both in-person and virtual services from in-network providers. Cost share does not apply to virtual services from designated telemedicine providers. If this is an HSA plan, deductible applies. |
YES | No Charge |
100.00% |
| Private-Duty Nursing
Limit: 82.0 Visit(s) per Year Coverage is limited to 82 shifts per year. |
YES | 50.00% |
100.00% |
| Prosthetic Devices
|
YES | 50.00% |
100.00% |
| Radiation
Cost share driven by provider/setting. |
YES | 50.00% |
100.00% |
| Reconstructive Surgery
Exclusions: Excludes all other reconstructive services that are not specifically outlined in Covered Services. Cost share driven by provider/setting. Certain reconstructive services required to correct a deformity caused by disease, trauma, congenital anomalies, or previous therapeutic process are covered. Coverage includes breast reconstruction on which a mastectomy has been performed.Copay per day for days 1-5 |
YES | $1,000.00 |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 40.0 Visit(s) per Year Occupational Therapy is limited to 20 visits per Year, and Physical Therapy is limited to a separate 20 visits per year. Benefit limits for rehabilitation and habilitation services are separate. |
YES | $25.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year Coverage is limited to 20 visits per year. Benefit limits for rehabilitation and habilitation services are separate. |
YES | $25.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year Coverage is limited to 1 exam every 12 months, through the end of the month in which the member turns 19. |
YES | $10.00 |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 90.0 Days per Year Copay per day for days 1-5 |
YES | $1000.00 Copay per Day |
100.00% |
| Specialist Visit
|
YES | $25.00 |
100.00% |
| Specialty Drugs
Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details. |
YES | 45.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Copay per day for days 1-5 |
YES | $1000.00 Copay per Day |
100.00% |
| Substance Abuse Disorder Outpatient Services
Cost share driven by provider/setting. |
YES | No Charge |
100.00% |
| Transplant
Cost share driven by provider/setting. Network benefits must be received within the Institutes of Excellence (IOE) transplant network. Copay per day for days 1-5 |
YES | $1,000.00 |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Coverage includes diagnostic and surgical treatment of TMJ. |
YES | $25.00 |
100.00% |
| Urgent Care Centers or Facilities
Exclusions: No coverage for non-urgent care. |
YES | $25.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
Age and frequency schedules may apply. |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | $35.00 |
100.00% |
Gold 10 Advanced: $0 PCP + Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan Variant 96992IN0060011-03 Attributes
| Plan Attribute | Value |
|---|---|
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Limited Cost Sharing Plan Variation |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $500 per group |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $250 per person |
| Drug EHB Deductible, Combined In/Out of Network, Individual | $250 |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $500 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $250 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $250 |
| Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| 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 | INF011 |
| Formulary URL | URL |
| HIOS Product ID | 96992IN006 |
| Import Date | 2024-09-26 03:01:39 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | 0 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | New |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 81.97% |
| Issuer ID | 96992 |
| Issuer Marketplace Marketing Name | Aetna CVS Health |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | No |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Group | $0 per group |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | $0 per person |
| Medical EHB Deductible, Combined In/Out of Network, Individual | $0 |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $0 |
| Medical EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | INN001 |
| 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 | 2025-01-01 |
| Plan ID (Standard Component ID with Variant) | 96992IN0060011-03 |
| Plan Marketing Name | Gold 10 Advanced: $0 PCP + Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 |
| Plan Type | HMO |
| Plan Variant Marketing Name | Gold 10 Advanced: $0 PCP + Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $2,200 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $700 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,500 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | INS001 |
| Source Name | HIOS |
| Plan ID | 96992IN0060011 |
| State Code | IN |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $13190 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $6595 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $6,595 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $13190 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $6595 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,595 |
| 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 Gold 10 Advanced: $0 PCP + Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, 96992IN0060011
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Gold 10 Advanced: $0 PCP + Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7, 96992IN0060011 Health Insurance Plan, 96992IN0060011
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Does Gold 10 Advanced: $0 PCP + Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, 96992IN0060011 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (96992IN0060011) Health Insurance Plan, Variant (96992IN0060011-03) offer Disease Management Programs?
Does (96992IN0060011) Health Insurance Plan, Variant (96992IN0060011-03) have Out Of Country Coverage?
Does (96992IN0060011) Health Insurance Plan, Variant (96992IN0060011-03) have Out of Service Area Coverage?
Does (96992IN0060011) Health Insurance Plan, Variant (96992IN0060011-03) offer Disease Management Programs?
Does Gold 10 Advanced: $0 PCP + Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (96992IN0060011-03) offer Disease Management Programs for Asthma?
Does Gold 10 Advanced: $0 PCP + Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (96992IN0060011-03) offer Disease Management Programs for Heart disease?
Does Gold 10 Advanced: $0 PCP + Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (96992IN0060011-03) offer Disease Management Programs for Depression?
Does Gold 10 Advanced: $0 PCP + Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (96992IN0060011-03) offer Disease Management Programs for Diabetes?
Does Gold 10 Advanced: $0 PCP + Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (96992IN0060011-03) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Gold 10 Advanced: $0 PCP + Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (96992IN0060011-03) offer Disease Management Programs for Low back pain?
Does Gold 10 Advanced: $0 PCP + Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (96992IN0060011-03) 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