Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Primary Care - 84867OH0100005 Health Insurance Plan
Aetna Health Inc. (a PA corp.) health insurance plan with the Plan ID 84867OH0100005. The plan is called Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Primary Care.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.06% (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 21.94% 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 | 84867OH0100005 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Ohio | ||||||||||||||||||
| 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 | 84867OH0100005-03 | ||||||||||||||||||
| 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 - 84867OH0100005-00 Standard On Exchange Plan - 84867OH0100005-01 |
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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 S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Primary Care Health Insurance Plan, 84867OH0100005-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Exclusions: Damage to teeth due to chewing or biting is not deemed an accidental injury and is not covered. Member cost share based on place and type of service. |
YES | $60.00 |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
Member cost share based on place and type of service. |
YES | $60.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
Member cost share based on place and type of service. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 12.0 Visit(s) per Year Exclusions: Manipulation therapy services rendered in the home as part of Home Care Services. |
YES | $30.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Exclusions: Any services or supplies provided to a person not covered under the plan in connection with a surrogate pregnancy (including, but not limited to, the bearing of a child by another woman for an infertile couple); If Maternity Services are not covered for any reason, Hospital charges for ordinary routine nursery care for a well newborn are also not covered. Coverage for the Inpatient postpartum stay for mother and newborn child in a hospital will be, at a minimum, 48 hours for a vaginal delivery and 96 hours for a cesarean section. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
Member cost share based on place and type of service. |
YES | $60.00 |
100.00% |
| Dialysis
Member cost share based on place and type of service. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 50.00% 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 Coverage is limited to 1 set of frames and 1 set of contact lenses or eyeglass lenses per calendar year. Includes contact lens fitting. Coverage 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 | $15.00 |
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. |
YES | $30.00 |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 100.0 Visit(s) per Year |
YES | $30.00 |
100.00% |
| Hospice Services
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
Coverage limited to diagnosis and treatment of the underlying medical condition. Member cost share based on place and type of service. |
NO | ||
| Infusion Therapy
Member cost share based on place and type of service. |
YES | 25.00% Coinsurance after deductible |
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
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 | $30.00 |
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 | $60.00 |
100.00% |
| Nutritional Counseling
|
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 | $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 Coverage is limited to 20 visits each Physical Therapy, Occupational Therapy, and Speech Therapy per year separate from habilitation. 36 visits for Cardiac Rehabilitation. |
YES | $30.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 25.00% Coinsurance after deductible |
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 | $30.00 |
100.00% |
| Prenatal and Postnatal Care
Member cost sharing applies to postnatal care. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Preventive Care/Screening/Immunization
Age and frequency schedules may apply. |
YES | 0.00% |
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 | $30.00 |
100.00% |
| Private-Duty Nursing
Limit: 90.0 Visit(s) per Year Coverage is limited to 90 visits per calendar year in home setting only. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Prosthetic Devices
Includes coverage for cochlear implants. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Radiation
Member cost share based on place and type of service. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
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: 20.0 Visit(s) per Year Coverage is limited to 20 visits each per year separate from habilitation. |
YES | $30.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year Coverage is limited to 20 visits per year separate from habilitation. |
YES | $30.00 |
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
Exclusions: Coverage is limited to members with diabetes or for medical necessity due to illness; excludes any services, supplies, or devices to improve comfort or appearance of toes, feet or ankles. |
NO | ||
| 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
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 | $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
Member cost share based on place and type of service. Network benefits must be received within the Institutes of Excellence (IOE) transplant network. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Member cost share based on place and type of service. |
YES | $60.00 |
100.00% |
| Urgent Care Centers or Facilities
Exclusions: No coverage for non-urgent care. |
YES | $45.00 |
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 | 25.00% Coinsurance after deductible |
100.00% |
Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Primary Care Health Insurance Plan Variant 84867OH0100005-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7806 |
| 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 |
| 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 | OHF003 |
| Formulary URL | URL |
| HIOS Product ID | 84867OH010 |
| Import Date | 2024-09-26 20:01:44 |
| 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 ID | 84867 |
| Issuer Marketplace Marketing Name | Aetna CVS Health |
| 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 | OHN001 |
| 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) | 84867OH0100005-03 |
| Plan Marketing Name | Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Primary Care |
| Plan Type | HMO |
| Plan Variant Marketing Name | Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Primary Care |
| 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 | OHS001 |
| Source Name | SERFF |
| Plan ID | 84867OH0100005 |
| State Code | OH |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $15600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $7800 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $7,800 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $3000 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $1500 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $1,500 |
| 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 | $15600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7800 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,800 |
| 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 | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Primary Care Health Insurance Plan, 84867OH0100005
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Primary Care, 84867OH0100005 Health Insurance Plan, 84867OH0100005
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Does Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Primary Care Health Insurance Plan, 84867OH0100005 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (84867OH0100005) Health Insurance Plan, Variant (84867OH0100005-03) offer Disease Management Programs?
Does (84867OH0100005) Health Insurance Plan, Variant (84867OH0100005-03) have Out Of Country Coverage?
Does (84867OH0100005) Health Insurance Plan, Variant (84867OH0100005-03) have Out of Service Area Coverage?
Does (84867OH0100005) Health Insurance Plan, Variant (84867OH0100005-03) offer Disease Management Programs?
Does Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Primary Care Health Insurance Plan, Variant (84867OH0100005-03) offer Disease Management Programs for Asthma?
Does Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Primary Care Health Insurance Plan, Variant (84867OH0100005-03) offer Disease Management Programs for Heart disease?
Does Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Primary Care Health Insurance Plan, Variant (84867OH0100005-03) offer Disease Management Programs for Depression?
Does Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Primary Care Health Insurance Plan, Variant (84867OH0100005-03) offer Disease Management Programs for Diabetes?
Does Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Primary Care Health Insurance Plan, Variant (84867OH0100005-03) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Primary Care Health Insurance Plan, Variant (84867OH0100005-03) offer Disease Management Programs for Low back pain?
Does Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Primary Care Health Insurance Plan, Variant (84867OH0100005-03) 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