Gold 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 – HMO

Network type: HMO
Coverage tier: Gold
Primary care visit: No charge
Specialist visit: $10 copay
Urgent care visit: $10 copay

SKU: 18628FL0160057 Categories: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

Description

Health Care Plan Details

Network type HMO
Deductible $3,500 per person $3,500 per person
Out-of-pocket max $9,000 per person $18,000 per family
Metal tier Gold

Visit Copay

Primary care visit No charge
Specialist visit $10 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $10 copay
Emergency room 25% coinsurance after deductible
Ambulance 25% coinsurance after deductible
Hospital stay (facility) 25% coinsurance after deductible
Hospital stay (physician) 25% coinsurance after deductible
Outpatient procedure (facility) 25% coinsurance after deductible
Outpatient procedure (physician) 25% coinsurance after deductible
Physical rehabilitation $10 copay

Maternitowny and Pregnancy

Well baby care No charge
Labor, delivery, hospital stay 25% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic No charge
Brand $20 copay
Non-preferred Brand 30% coinsurance
Specialty 40% coinsurance

Lab Tests and Diagnostic Procedures

X-rays $10 copay
Imaging (CT/PET/MRI) 25% coinsurance after deductible
Blood work No charge

Mental and Psychiatric Health Care

Mental Health outpatient services No charge
Psychiatric hospital stay 25% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits https://www.aetnacvshealth.com/documents/2024-IFP-771761_18628FL0160057-01_SBC.pdf
Drug and medication plan formulary http://aet.na/flivl24
Search doctor list https://www.aetna.com/dsepublic/#/contentPage?page=providerSearchLanding&site_id=aetnaivlexchange