Gold 10 Advanced: $0 PCP + Aetna network + $0 MinuteClinic + Adult Dental + Vision
84867OH0100012
Gold
HMO
Gold 10 Advanced: $0 PCP + Aetna network + $0 MinuteClinic + Adult Dental + Vision is a Gold HMO plan by Aetna CVS Health.
Locations
Gold 10 Advanced: $0 PCP + Aetna network + $0 MinuteClinic + Adult Dental + Vision is offered in the following counties.
Plan Overview
This is a plan overview for 2025 version of Gold 10 Advanced: $0 PCP + Aetna network + $0 MinuteClinic + Adult Dental + Vision 84867OH0100012.
| Insurer: | Aetna CVS Health |
| Network Type: | HMO |
| Metal Type: | Gold |
| HSA Eligible?: | No |
| Plan ID: | 84867OH0100012 |
Cost-Sharing Overview
Gold 10 Advanced: $0 PCP + Aetna network + $0 MinuteClinic + Adult Dental + Vision offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for Gold 10 Advanced: $0 PCP + Aetna network + $0 MinuteClinic + Adult Dental + Vision includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $6595 per person | $13190 per group |
| Deductible: | $0 per person | $0 per group |
| Coinsurance: | $0 per group | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for Gold 10 Advanced: $0 PCP + Aetna network + $0 MinuteClinic + Adult Dental + Vision will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | per person not applicable | per group not applicable |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | $0 |
| Copayment: | $2,200 |
| Coinsurance: | $0 |
| Limit: | $60 |
| Deductible: | $0 |
| Copayment: | $700 |
| Coinsurance: | $0 |
| Limit: | $20 |
| Deductible: | $0 |
| Copayment: | $1,500 |
| Coinsurance: | $0 |
| Limit: | $0 |
Notes:
- Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
- You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Gold 10 Advanced: $0 PCP + Aetna network + $0 MinuteClinic + Adult Dental + Vision?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904
Plan Features
Gold 10 Advanced: $0 PCP + Aetna network + $0 MinuteClinic + Adult Dental + Vision offers the following features and referral requirements.
| Wellness Program: | Yes |
| Disease Program: | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy |
| Notice Pregnancy: | No |
| Referral Specialist: | No |
| Specialist Requiring Referral: | |
| Plan Exclusions: | |
| Child Only Option?: | Allows Adult and Child-Only |
Network Details
The following network details will help you understand what Gold 10 Advanced: $0 PCP + Aetna network + $0 MinuteClinic + Adult Dental + Vision covers when you are out of the service area or out of the country.
| Out of Country Coverage: | No |
| Out of Country Coverage Description: | |
| Out of Service Area Coverage: | No |
| Out of Service Area Coverage Description: | Except for Emergencies |
| National Network: | No |
Additional Benefits and Cost-Sharing
Gold 10 Advanced: $0 PCP + Aetna network + $0 MinuteClinic + Adult Dental + Vision includes the following benefits at the cost sharing rates listed below.
| Service | In-Network Copay / Coinsurance | Out-of-Network Copay / Coinsurance | Limits and Explanation |
|---|---|---|---|
| Primary Care Visit to Treat an Injury or Illness Covered | No Charge Not Applicable | Not Applicable 100.00% | 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. |
| Specialist Visit Covered | $25.00 Not Applicable | Not Applicable 100.00% | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | No Charge Not Applicable | Not Applicable 100.00% | 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. |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | $600.00 Not Applicable | Not Applicable 100.00% | |
| Outpatient Surgery Physician/Surgical Services Covered | $250.00 Not Applicable | Not Applicable 100.00% | |
| Hospice Services Covered | $1,000.00 Not Applicable | Not Applicable 100.00% | Member cost share based on place and type of service.Copay per day for days 1-5 |
| Routine Dental Services (Adult) Covered | Not Applicable No Charge | Not Applicable 100.00% | 2.0 Visit(s) per Year Coverage is limited to ages 19 and up. $1,000 calendar year maximum for all dental services (Routine check-up, Basic & Major). |
| Infertility Treatment Not Covered | Coverage limited to diagnosis and treatment of the underlying medical condition. Member cost share based on place and type of service. | ||
| Long-Term/Custodial Nursing Home Care Not Covered | |||
| Private-Duty Nursing Covered | Not Applicable 50.00% | Not Applicable 100.00% | 90.0 Visit(s) per Year Coverage is limited to 90 visits per calendar year in home setting only. |
| Routine Eye Exam (Adult) Covered | $10.00 Not Applicable | Not Applicable 100.00% | 1.0 Exam(s) per Year Coverage is limited to ages 19 and up. Benefit limitations may apply. |
| Urgent Care Centers or Facilities Covered | $25.00 Not Applicable | Not Applicable 100.00% | No coverage for non-urgent care. |
| Home Health Care Services Covered | $25.00 Not Applicable | Not Applicable 100.00% | 100.0 Visit(s) per Year |
| Emergency Room Services Covered | $750.00 Not Applicable | $750.00 Not Applicable | No coverage for non-emergency use of the emergency room. |
| Emergency Transportation/Ambulance Covered | $750.00 Not Applicable | $750.00 Not Applicable | |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | $1000.00 Copay per Day Not Applicable | Not Applicable 100.00% | Copay per day for days 1-5 |
| Inpatient Physician and Surgical Services Covered | No Charge Not Applicable | Not Applicable 100.00% | |
| Bariatric Surgery Not Covered | |||
| Cosmetic Surgery Not Covered | Copay per day for days 1-5 | ||
| Skilled Nursing Facility Covered | $1000.00 Copay per Day Not Applicable | Not Applicable 100.00% | 90.0 Days per Year Copay per day for days 1-5 |
| Prenatal and Postnatal Care Covered | No Charge Not Applicable | Not Applicable 100.00% | Member cost sharing applies to postnatal care. |
| Delivery and All Inpatient Services for Maternity Care Covered | $1,000.00 Not Applicable | Not Applicable 100.00% | 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.Copay per day for days 1-5 |
| Mental/Behavioral Health Outpatient Services Covered | No Charge Not Applicable | Not Applicable 100.00% | 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. |
| Mental/Behavioral Health Inpatient Services Covered | $1000.00 Copay per Day Not Applicable | Not Applicable 100.00% | Copay per day for days 1-5 |
| Substance Abuse Disorder Outpatient Services Covered | No Charge Not Applicable | Not Applicable 100.00% | |
| Substance Abuse Disorder Inpatient Services Covered | $1000.00 Copay per Day Not Applicable | Not Applicable 100.00% | Copay per day for days 1-5 |
| Generic Drugs Covered | $3.00 Not Applicable | Not Applicable 100.00% | Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details. |
| Preferred Brand Drugs Covered | $35.00 Not Applicable | Not Applicable 100.00% | Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details. |
| Non-Preferred Brand Drugs Covered | Not Applicable 35.00% Coinsurance after deductible | Not Applicable 100.00% | Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details. |
| Specialty Drugs Covered | Not Applicable 45.00% Coinsurance after deductible | Not Applicable 100.00% | Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details. |
| Outpatient Rehabilitation Services Covered | $25.00 Not Applicable | Not Applicable 100.00% | 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. |
| Habilitation Services Covered | $25.00 Not Applicable | Not Applicable 100.00% | 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. |
| Chiropractic Care Covered | $25.00 Not Applicable | Not Applicable 100.00% | 12.0 Visit(s) per Year Manipulation therapy services rendered in the home as part of Home Care Services. |
| Durable Medical Equipment Covered | Not Applicable 50.00% | Not Applicable 100.00% | |
| Hearing Aids Not Covered | |||
| Imaging (CT/PET Scans, MRIs) Covered | $500.00 Not Applicable | Not Applicable 100.00% | |
| Preventive Care/Screening/Immunization Covered | Not Applicable No Charge | Not Applicable 100.00% | Age and frequency schedules may apply. |
| Routine Foot Care Not Covered | 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. | ||
| Acupuncture Not Covered | |||
| Weight Loss Programs Not Covered | |||
| Routine Eye Exam for Children Covered | $10.00 Not Applicable | Not Applicable 100.00% | 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. |
| Eye Glasses for Children Covered | $10.00 Not Applicable | Not Applicable 100.00% | 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. |
| Dental Check-Up for Children Not Covered | |||
| Rehabilitative Speech Therapy Covered | $25.00 Not Applicable | Not Applicable 100.00% | 20.0 Visit(s) per Year Coverage is limited to 20 visits per year separate from habilitation. |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | $25.00 Not Applicable | Not Applicable 100.00% | 20.0 Visit(s) per Year Coverage is limited to 20 visits each per year separate from habilitation. |
| Well Baby Visits and Care Covered | Not Applicable No Charge | Not Applicable 100.00% | Age and frequency schedules may apply. |
| Laboratory Outpatient and Professional Services Covered | $20.00 Not Applicable | Not Applicable 100.00% | |
| X-rays and Diagnostic Imaging Covered | $35.00 Not Applicable | Not Applicable 100.00% | |
| Basic Dental Care – Child Not Covered | |||
| Orthodontia – Child Not Covered | |||
| Major Dental Care – Child Not Covered | |||
| Basic Dental Care – Adult Covered | Not Applicable 50.00% | Not Applicable 100.00% | Coverage is limited to ages 19 and up.?$50 deductible / $1,000 calendar year maximum for all dental services (Routine check-up, Basic & Major). |
| Orthodontia – Adult Not Covered | |||
| Major Dental Care – Adult Covered | Not Applicable 50.00% | Not Applicable 100.00% | Coverage is limited to ages 19 and up. 6 month waiting period regardless of prior coverage. $50 deductible / $1,000 calendar year maximum for all dental services (Routine check-up, Basic & Major). |
| Abortion for Which Public Funding is Prohibited Not Covered | |||
| Transplant Covered | $1,000.00 Not Applicable | Not Applicable 100.00% | Member cost share based on place and type of service. Network benefits must be received within the Institutes of Excellence (IOE) transplant network.Copay per day for days 1-5 |
| Accidental Dental Covered | $25.00 Not Applicable | Not Applicable 100.00% | 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. |
| Dialysis Covered | $600.00 Not Applicable | Not Applicable 100.00% | Member cost share based on place and type of service. |
| Allergy Testing Covered | $25.00 Not Applicable | Not Applicable 100.00% | Member cost share based on place and type of service. |
| Chemotherapy Covered | $250.00 Not Applicable | Not Applicable 100.00% | Member cost share based on place and type of service. |
| Radiation Covered | Not Applicable 50.00% | Not Applicable 100.00% | Member cost share based on place and type of service. |
| Diabetes Education Covered | $25.00 Not Applicable | Not Applicable 100.00% | Member cost share based on place and type of service. |
| Prosthetic Devices Covered | Not Applicable 50.00% | Not Applicable 100.00% | Includes coverage for cochlear implants. |
| Infusion Therapy Covered | $250.00 Not Applicable | Not Applicable 100.00% | Member cost share based on place and type of service. |
| Treatment for Temporomandibular Joint Disorders Covered | $25.00 Not Applicable | Not Applicable 100.00% | Member cost share based on place and type of service. |
| Nutritional Counseling Covered | Not Applicable No Charge | Not Applicable 100.00% | |
| Reconstructive Surgery Covered | $1,000.00 Not Applicable | Not Applicable 100.00% | Member cost share based on place and type of service.Copay per day for days 1-5 |
| Gender Affirming Care |
Free Preventive Services
There is no copayment or coinsurance for any of the following Gold 10 Advanced: $0 PCP + Aetna network + $0 MinuteClinic + Adult Dental + Vision preventive services. This is true even if you haven’t met your yearly deductible.
Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for Gold 10 Advanced: $0 PCP + Aetna network + $0 MinuteClinic + Adult Dental + Vision including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.
| Summary of Benefits: | Summary of Benefits Link |
| Plan Brochure: | Plan Brochure Link |
| Formulary: | Formulary Link |
| Premium Payment Website: | Premium Payment Link |
Ready to sign up for Gold 10 Advanced: $0 PCP + Aetna network + $0 MinuteClinic + Adult Dental + Vision?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904