Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Primary Care + Rx Copay - 72547IL0170005 Health Insurance Plan
Aetna Life Insurance Company health insurance plan with the Plan ID 72547IL0170005. The plan is called Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Primary Care + Rx Copay.
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 | 72547IL0170005 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Illinois | ||||||||||||||||||
| Health Insurance Issuer | Aetna Life Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 72547IL0170005-00 | ||||||||||||||||||
| Provider Network(s) | NON-PREFERRED PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 03 Dec 2024 06:24 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 72547IL0170005-00 Standard On Exchange Plan - 72547IL0170005-01 |
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| Last Plan Update Date | Tue, 24 Sep 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Primary Care + Rx Copay Health Insurance Plan, 72547IL0170005-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Abortions are only covered when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest |
YES | $60.00 |
50.00% Coinsurance after deductible |
| Accidental Dental
|
YES | $60.00 |
50.00% Coinsurance after deductible |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $60.00 |
50.00% Coinsurance after deductible |
| Bariatric Surgery
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| 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 |
50.00% Coinsurance after deductible |
| Chiropractic Care
Limit: 25.0 Visit(s) per Year |
YES | $30.00 |
50.00% Coinsurance after deductible |
| Cosmetic Surgery
Cosmetic surgery for the correction of the congenital deformities or for conditions resulting from accidental injuries, scars, tumors or disease is covered. |
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
Services must be rendered by a physician, or duly certified, registered or licensed health care professional with expertise in diabetes management. |
YES | $60.00 |
50.00% Coinsurance after deductible |
| Dialysis
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Durable Medical Equipment
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Emergency Room Services
|
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 year, through the end of the month in which the member turns 19. |
YES | $10.00 |
50.00% |
| 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 |
50.00% |
| 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. Treatment must be medically necessary and therapeutic and not investigational. |
YES | $30.00 |
50.00% Coinsurance after deductible |
| Hearing Aids
Limit: 1.0 Item(s) per 2 Years Hearing aids limited to 1 hearing aid per ear every 24 months. Bone anchored hearing aids and cochlear implants are covered. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Home Health Care Services
|
YES | $30.00 |
50.00% Coinsurance after deductible |
| Hospice Services
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs)
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Infertility Treatment
Limitations vary based on procedures. |
YES | $60.00 |
50.00% Coinsurance after deductible |
| Infusion Therapy
Member cost share based on place and type of service. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| 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 |
50.00% Coinsurance after deductible |
| 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 |
50.00% Coinsurance after deductible |
| 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 |
50.00% |
| Nutritional Counseling
|
YES | No Charge |
50.00% Coinsurance after deductible |
| 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 |
50.00% Coinsurance after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services
|
YES | $30.00 |
50.00% Coinsurance after deductible |
| Outpatient Surgery Physician/Surgical Services
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| 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 |
50.00% |
| Prenatal and Postnatal Care
Member cost sharing applies to postnatal care |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Preventive Care/Screening/Immunization
Age and frequency schedules may apply. |
YES | 0.00% |
50.00% Coinsurance after deductible |
| 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. |
YES | $30.00 |
50.00% Coinsurance after deductible |
| Private-Duty Nursing
Exclusions: Inpatient Private Duty Nursing Services are not covered. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Prosthetic Devices
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Radiation
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Reconstructive Surgery
Member cost share based on place and type of service. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Provided when rendered by a registered Occupational Therapist or registered professional Physical Therapist under the supervision of a Physician. |
YES | $30.00 |
50.00% Coinsurance after deductible |
| Rehabilitative Speech Therapy
Provided when rendered by a licensed Speech Therapist or Speech Therapist certified by the American Speech and Hearing Association. |
YES | $30.00 |
50.00% Coinsurance after deductible |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year Coverage through the end of the month in which the member turns 19. |
YES | $10.00 |
50.00% |
| Routine Foot Care
Only covered for persons diagnosed with diabetes. |
YES | $60.00 |
50.00% Coinsurance after deductible |
| Skilled Nursing Facility
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Specialist Visit
|
YES | $60.00 |
50.00% Coinsurance after deductible |
| 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 |
50.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services
|
YES | $30.00 |
50.00% Coinsurance after deductible |
| 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 |
50.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders
Member cost share based on place and type of service. |
YES | $60.00 |
50.00% Coinsurance after deductible |
| Urgent Care Centers or Facilities
Exclusions: No coverage for non-urgent care. |
YES | $45.00 |
50.00% Coinsurance after deductible |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
Age and frequency schedules may apply. |
YES | No Charge |
50.00% Coinsurance after deductible |
| X-rays and Diagnostic Imaging
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Primary Care + Rx Copay Health Insurance Plan Variant 72547IL0170005-00 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 | Standard Gold Off 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 | 0.9998 |
| First Tier Utilization | 100% |
| Formulary ID | ILF010 |
| Formulary URL | URL |
| HIOS Product ID | 72547IL017 |
| Import Date | 2024-09-24 20:01:47 |
| 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 | 72547 |
| 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 | ILN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Covered with Limitations |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan ID (Standard Component ID with Variant) | 72547IL0170005-00 |
| Plan Marketing Name | Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Primary Care + Rx Copay |
| Plan Type | PPO |
| Plan Variant Marketing Name | Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Primary Care + Rx Copay |
| 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 | ILS001 |
| Source Name | SERFF |
| Plan ID | 72547IL0170005 |
| State Code | IL |
| 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 | $31000 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $15500 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $15,500 |
| 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 | $28000 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $14000 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $14,000 |
| 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 + Rx Copay Health Insurance Plan, 72547IL0170005
| 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 + Rx Copay, 72547IL0170005 Health Insurance Plan, 72547IL0170005
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Does Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Primary Care + Rx Copay Health Insurance Plan, 72547IL0170005 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (72547IL0170005) Health Insurance Plan, Variant (72547IL0170005-00) offer Disease Management Programs?
Does (72547IL0170005) Health Insurance Plan, Variant (72547IL0170005-00) have Out Of Country Coverage?
Does (72547IL0170005) Health Insurance Plan, Variant (72547IL0170005-00) have Out of Service Area Coverage?
Does (72547IL0170005) Health Insurance Plan, Variant (72547IL0170005-00) offer Disease Management Programs?
Does Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Primary Care + Rx Copay Health Insurance Plan, Variant (72547IL0170005-00) offer Disease Management Programs for Asthma?
Does Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Primary Care + Rx Copay Health Insurance Plan, Variant (72547IL0170005-00) offer Disease Management Programs for Heart disease?
Does Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Primary Care + Rx Copay Health Insurance Plan, Variant (72547IL0170005-00) offer Disease Management Programs for Depression?
Does Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Primary Care + Rx Copay Health Insurance Plan, Variant (72547IL0170005-00) offer Disease Management Programs for Diabetes?
Does Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Primary Care + Rx Copay Health Insurance Plan, Variant (72547IL0170005-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Primary Care + Rx Copay Health Insurance Plan, Variant (72547IL0170005-00) offer Disease Management Programs for Low back pain?
Does Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Primary Care + Rx Copay Health Insurance Plan, Variant (72547IL0170005-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 03 Dec 2024 06:24 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