Gold 3: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 – EPO
Network type: EPO
Coverage tier: Gold
Primary care visit: $15 copay
Specialist visit: $35 copay
Urgent care visit: $25 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $795 per person $795 per person |
| Out-of-pocket max | $9,195 per person $18,390 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $15 copay |
| Specialist visit | $35 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $25 copay |
| Emergency room | 50% coinsurance after deductible |
| Ambulance | 50% coinsurance after deductible |
| Hospital stay (facility) | 50% coinsurance after deductible |
| Hospital stay (physician) | 50% coinsurance after deductible |
| Outpatient procedure (facility) | 40% coinsurance after deductible |
| Outpatient procedure (physician) | 40% coinsurance after deductible |
| Physical rehabilitation | $15 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 50% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $15 copay |
| Brand | $40 copay |
| Non-preferred Brand | 40% coinsurance after deductible |
| Specialty | 50% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $35 copay |
| Imaging (CT/PET/MRI) | 40% coinsurance after deductible |
| Blood work | $20 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $15 copay |
| Psychiatric hospital stay | 50% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.aetnacvshealth.com/documents/2024-IFP-767784_48161MO0200031-01_SBC.pdf |
| Drug and medication plan formulary | http://aet.na/moivl24 |
| Search doctor list | https://www.aetna.com/dsepublic/#/contentPage?page=providerSearchLanding&site_id=aetnaivlexchange |
