Gold 3: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 - 38927UT0380004 Health Insurance Plan
Aetna Health of Utah Inc. health insurance plan with the Plan ID 38927UT0380004. The plan is called Gold 3: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.03% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.97% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 38927UT0380004 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Utah | ||||||||||||||||||
| Health Insurance Issuer | Aetna Health of Utah Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 38927UT0380004-03 | ||||||||||||||||||
| 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 - 38927UT0380004-00 Standard On Exchange Plan - 38927UT0380004-01 |
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| Last Plan Update Date | Thu, 14 Sep 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Gold 3: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, 38927UT0380004-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Abortion services & supplies not covered except in the cases where (i) a Member suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would, as certified by a Physician, place the Member in danger of death unless an abortion is performed or (ii) the pregnancy is the result of an act of rape or incest. |
NO | ||
| Accidental Dental
|
NO | ||
| Acupuncture
|
NO | ||
| Allergy Testing
Exclusions: Member cost share based on place and type of service. |
YES | Tier 1: $25.00 Tier 2: $35.00 |
100.00% |
| Autism Spectrum Disorders
Exclusions: Member cost share based on place and type of service |
YES | Tier 1: $15.00 Tier 2: $25.00 |
100.00% |
| Bariatric Surgery
Obesity surgery such as gastric bypass, lap-band surgery, etc. including any present and future complications are not covered. |
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
Exclusions: Member cost share based on place and type of service. |
YES | Tier 1: 35.00% Tier 2: 50.00% |
100.00% |
| Chiropractic Care
|
NO | ||
| Cosmetic Surgery
Any care, treatment or procedure performed primarily for cosmetic purposes is not covered. |
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | Tier 1: 35.00% Tier 2: 50.00% |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
Exclusions: Member cost share based on place and type of service. |
YES | Tier 1: $25.00 Tier 2: $35.00 |
100.00% |
| Dialysis
Exclusions: Member cost share based on place and type of service. |
YES | Tier 1: 35.00% Tier 2: 50.00% |
100.00% |
| Durable Medical Equipment
|
YES | Tier 1: 35.00% Tier 2: 50.00% |
100.00% |
| Emergency Room Services
Exclusions: No coverage for non-emergency use of the emergency room. |
YES | Tier 1: 50.00% Tier 2: 50.00% |
50.00% |
| Emergency Transportation/Ambulance
|
YES | Tier 1: 50.00% Tier 2: 50.00% |
50.00% |
| 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 year. Age 0-19. |
YES | Tier 1: $10.00 Tier 2: $15.00 |
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 | Tier 1: $15.00 Tier 2: $15.00 |
100.00% |
| Habilitation Services
Health care services that help a person keep, learn or improve skills and functioning for daily living which may include physical therapy, occupational therapy, and speech language pathology. |
YES | Tier 1: 35.00% Tier 2: 50.00% |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 30.0 Visit(s) per Year |
YES | Tier 1: $25.00 Tier 2: $35.00 |
100.00% |
| Hospice Services
Exclusions: Member cost share based on place and type of service. |
YES | Tier 1: 35.00% Tier 2: 50.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | Tier 1: 35.00% Tier 2: 50.00% |
100.00% |
| Infertility Treatment
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 | Tier 1: 35.00% Tier 2: 50.00% |
100.00% |
| Inherited Metabolic Disorder - PKU
|
YES | Tier 1: 35.00% Tier 2: 50.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | Tier 1: 35.00% Tier 2: 50.00% |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | Tier 1: 35.00% Tier 2: 50.00% |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | Tier 1: $15.00 Tier 2: $25.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
|
YES | Tier 1: 35.00% Tier 2: 50.00% |
100.00% |
| Mental/Behavioral Health Outpatient Services
Exclusions: The cost applies to outpatient office visits. All other outpatient service are covered under a different cost-share. Please refer to the SBC for more information. |
YES | Tier 1: $15.00 Tier 2: $25.00 |
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 | Tier 1: 40.00% Tier 2: 40.00% |
100.00% |
| Nutritional Counseling
Not considered a separate benefit. Should be considered under the benefits outlined for diabetes education, anorexia, bulimia, or as allowed under the Affordable Care Act Preventive Services. |
NO | ||
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | Tier 1: $15.00 Tier 2: $25.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | Tier 1: 35.00% Tier 2: 50.00% |
100.00% |
| Outpatient Rehabilitation Services
Limit: 20.0 Visit(s) per Year Exclusions: Coverage is limited to 20 visits per calendar year, PT/OT/ST combined, rehabilitation and habilitation separate. The treatment of disease, injury, developmental delay or other cause, by physical agents and methods to assist in the rehabilitation of normal physical bodily function, that is goal oriented and where the Member has the potential for functional improvement and ability to progress. |
YES | Tier 1: $25.00 Tier 2: $35.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | Tier 1: 35.00% Tier 2: 50.00% |
100.00% |
| Preferred Brand Drugs
Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | Tier 1: $40.00 Tier 2: $40.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | Tier 1: 35.00% Tier 2: 50.00% |
100.00% |
| Preventive Care/Screening/Immunization
Exclusions: Age and frequency schedules may apply. |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | Tier 1: $15.00 Tier 2: $25.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | Tier 1: 50.00% Tier 2: 50.00% |
100.00% |
| Radiation
Exclusions: Member cost share based on place and type of service. |
YES | Tier 1: 35.00% Tier 2: 50.00% |
100.00% |
| Reconstructive Surgery
Exclusions: Member cost share based on place and type of service. |
YES | Tier 1: 35.00% Tier 2: 50.00% |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Visit(s) per Year Exclusions: Coverage is limited to 20 visits per calendar year, PT/OT/ST combined, rehabilitation and habilitation separate; Member cost share based on place and type of service. |
YES | Tier 1: $25.00 Tier 2: $35.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year Exclusions: Coverage is limited to 20 visits per calendar year, PT/OT/ST combined, rehabilitation and habilitation separate; Member cost share based on place and type of service. |
YES | Tier 1: $25.00 Tier 2: $35.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year |
YES | Tier 1: $10.00 Tier 2: $15.00 |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 30.0 Days per Year |
YES | Tier 1: 35.00% Tier 2: 50.00% |
100.00% |
| Specialist Visit
|
YES | Tier 1: $25.00 Tier 2: $35.00 |
100.00% |
| Specialty Drugs
Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
YES | Tier 1: 50.00% Tier 2: 50.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | Tier 1: 35.00% Tier 2: 50.00% |
100.00% |
| Substance Abuse Disorder Outpatient Services
Exclusions: The cost applies to outpatient office visits. All other outpatient service are covered under a different cost-share. Please refer to the SBC for more information. |
YES | Tier 1: $15.00 Tier 2: $25.00 |
100.00% |
| Transplant
Exclusions: Member cost share based on place and type of service. Network benefits must be received within the transplant network. |
YES | Tier 1: 35.00% Tier 2: 50.00% |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
|
YES | Tier 1: $25.00 Tier 2: $30.00 |
100.00% |
| Weight Loss Programs
Services for weight loss or in conjunction with weight loss programs regardless of the medical indications except as allowed under the Affordable Care Act Preventive Services. Online weight loss programs are available. |
NO | ||
| Well Baby Visits and Care
Exclusions: Coverage is limited to 7 exams in the first 12 months of life; 3 exams in the second 12 months of life; 3 exams in the third 12 months of life; 1 exam per 12 months thereafter to age 22. Benefit should mirror preventive care/screening/immunization. |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | Tier 1: $25.00 Tier 2: $35.00 |
100.00% |
Gold 3: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan Variant 38927UT0380004-03 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 | 2024 |
| 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 | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | per group not applicable |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | per person not applicable |
| Drug EHB Deductible, In Network (Tier 1), Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 50.00% |
| Drug EHB Deductible, In Network (Tier 2), Family Per Group | per group not applicable |
| Drug EHB Deductible, In Network (Tier 2), Family Per Person | per person not applicable |
| Drug EHB Deductible, In Network (Tier 2), Individual | Not Applicable |
| 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 | 60% |
| Formulary ID | UTF002 |
| Formulary URL | URL |
| HIOS Product ID | 38927UT038 |
| Import Date | 2023-09-14 20:01:43 |
| 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 | 81.03% |
| Issuer ID | 38927 |
| 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 | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 35.00% |
| 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, In Network (Tier 2), Default Coinsurance | 50.00% |
| Medical EHB Deductible, In Network (Tier 2), Family Per Group | $0 per group |
| Medical EHB Deductible, In Network (Tier 2), Family Per Person | $0 per person |
| Medical EHB Deductible, In Network (Tier 2), 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 | Yes |
| National Network | No |
| Network ID | UTN001 |
| 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) | 38927UT0380004-03 |
| Plan Marketing Name | Gold 3: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 |
| Plan Type | HMO |
| Plan Variant Marketing Name | Gold 3: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $3,500 |
| SBC Scenario, Having a Baby, Copayment | $100 |
| 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 | $1,000 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $1,000 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 40% |
| Service Area ID | UTS001 |
| Source Name | SERFF |
| Plan ID | 38927UT0380004 |
| State Code | UT |
| 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 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $18890 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9445 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,445 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $18890 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $9445 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $9,445 |
| 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 3: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, 38927UT0380004
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Gold 3: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7, 38927UT0380004 Health Insurance Plan, 38927UT0380004
-
Does Gold 3: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, 38927UT0380004 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (38927UT0380004) Health Insurance Plan, Variant (38927UT0380004-03) offer Disease Management Programs?
Does (38927UT0380004) Health Insurance Plan, Variant (38927UT0380004-03) have Out Of Country Coverage?
Does (38927UT0380004) Health Insurance Plan, Variant (38927UT0380004-03) have Out of Service Area Coverage?
Does (38927UT0380004) Health Insurance Plan, Variant (38927UT0380004-03) offer Disease Management Programs?
Does Gold 3: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (38927UT0380004-03) offer Disease Management Programs for Asthma?
Does Gold 3: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (38927UT0380004-03) offer Disease Management Programs for Heart disease?
Does Gold 3: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (38927UT0380004-03) offer Disease Management Programs for Depression?
Does Gold 3: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (38927UT0380004-03) offer Disease Management Programs for Diabetes?
Does Gold 3: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (38927UT0380004-03) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Gold 3: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (38927UT0380004-03) offer Disease Management Programs for Low back pain?
Does Gold 3: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (38927UT0380004-03) 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