Gold 4: Aetna network of doctors & hospitals + $0 walk-in clinic + $0 Virtual Care options 24/7 – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: No charge
Specialist visit: $10 copay
Urgent care visit: $10 copay
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 after deductible |
| Specialty | 40% coinsurance after deductible |
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-768229_58840TX0110088-01_SBC.pdf |
| Drug and medication plan formulary | http://aet.na/txivl24 |
| Search doctor list | https://www.aetna.com/dsepublic/#/contentPage?page=providerSearchLanding&site_id=aetnaivlexchange |
