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

61671NC0100018
Gold
HMO

Gold 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 is a Gold HMO plan by Aetna CVS Health.

IMPORTANT: You are viewing the 2024 version of Gold 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 61671NC0100018. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

Gold 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of Gold 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 61671NC0100018.
Insurer: Aetna CVS Health
Network Type: HMO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 61671NC0100018

Cost-Sharing Overview

Gold 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 offers the following cost-sharing.

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

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 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 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 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 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 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 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 ApplicableNot Applicable 100.00%
Specialist Visit
Covered
$10.00 Not ApplicableNot Applicable 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
No Charge Not ApplicableNot Applicable 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Hospice Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Excludes homemaker services, such as cooking, housekeeping, and food or meal preparation. Benefits for Hospice services for care of a terminally ill Member with a life expectancy of six months or less.
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Infertility Services- Benefits are provided for certain services related to the diagnosis, treatment and correction of any underlying causes of infertility for all members. Benefits are limited to three medical ovulation induction cycles per lifetime per member.
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$10.00 Not ApplicableNot Applicable 100.00% No coverage for non-urgent care.
Home Health Care Services
Covered
$10.00 Not ApplicableNot Applicable 100.00%
Emergency Room Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 25.00% Coinsurance after deductible No coverage for non-emergency use of the emergency room.
Emergency Transportation/Ambulance
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 25.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Inpatient Physician and Surgical Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Bariatric Surgery
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Pre-certification is required.
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%90.0 Days per Year Coverage is limited to 90 days per calendar year.
Prenatal and Postnatal Care
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Member cost sharing applies to postnatal care
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Mental/Behavioral Health Outpatient Services
Covered
No Charge Not ApplicableNot Applicable 100.00%
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Substance Abuse Disorder Outpatient Services
Covered
No Charge Not ApplicableNot Applicable 100.00%
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Generic Drugs
Covered
No Charge Not ApplicableNot Applicable 100.00% Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.
Preferred Brand Drugs
Covered
$20.00 Not ApplicableNot Applicable 100.00% Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.
Non-Preferred Brand Drugs
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00% Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.
Specialty Drugs
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00% Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.
Outpatient Rehabilitation Services
Covered
$10.00 Not ApplicableNot Applicable 100.00%30.0 Visit(s) per Year Coverage is limited to 30 visits per calendar year, PT/OT/Chiro combined, separate from habilitation.
Habilitation Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Chiropractic Care
Covered
No Charge Not ApplicableNot Applicable 100.00%30.0 Visit(s) per Year Coverage is limited to 30 visits per calendar year PT, OT and Chiro combined, separate from habilitation and includes all outpatient places of service for PT, OT, and Chiro
Durable Medical Equipment
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Appliances and accessories that serve no medical purpose or that are primarily for comfort or convenience; repair or replacement of equipment due to abuse or desire for new equipment. Orthotic devices for correction of POSITIONAL PLAGIOCEPHALY are limited to 1 device per lifetime.
Hearing Aids
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%1.0 Item(s) per 3 Years Coverage is limited to 1 item per hearing impaired ear every 36 months.
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Preventive Care/Screening/Immunization
Covered
Not Applicable No ChargeNot Applicable 100.00% Age and frequency schedules may apply.
Routine Foot Care
Covered
$10.00 Not ApplicableNot Applicable 100.00% Coverage is limited to the treatment of corns, calluses and care of the toenails for patients with diabetes or vascular disease and treatment of bunions (capsular or bone surgery). Member cost share based on place and type of service.
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
$10.00 Not ApplicableNot Applicable 100.00%1.0 Exam(s) per Year Coverage is limited to 1 exam every 12 months.
Eye Glasses for Children
Covered
$10.00 Not ApplicableNot 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 year. Age 0-19.
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$10.00 Not ApplicableNot Applicable 100.00%30.0 Visit(s) per Year Coverage is limited to 30 visits per calendar year,, separate from habilitation.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$10.00 Not ApplicableNot Applicable 100.00%30.0 Visit(s) per Year Coverage is limited to 30 visits per calendar year, PT/OT/Chiro combined, separate from habilitation.
Well Baby Visits and Care
Covered
Not Applicable No ChargeNot Applicable 100.00% Coverage is limited 7 exams in the first 12 months of life; 3 exams in the second 12 months of life; 3 exams in the third 12 months of life; 1 exam every 12 months thereafter to age 22.
Laboratory Outpatient and Professional Services
Covered
No Charge Not ApplicableNot Applicable 100.00%
X-rays and Diagnostic Imaging
Covered
$10.00 Not ApplicableNot Applicable 100.00% Lab tests that are not ordered by a Doctor or Other Provider.
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% The purchase price of organs or tissue if any organ or tissue is sold rather than donated to the recipient member; the procurement of organs, tissue, bone marrow, or peripheral blood stem cells or any other donor services if a recipient is not a member; transplants, including high dose chemotherapy, considered experimental or investigational; services for or related to the transplantation of animal or artificial organs or tissues.. Benefits are provided for reasonable and necessary
Accidental Dental
Covered
$10.00 Not ApplicableNot Applicable 100.00% Member cost share based on place and type of service.
Dialysis
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Member cost share based on place and type of service.
Allergy Testing
Covered
$10.00 Not ApplicableNot Applicable 100.00% Member cost share based on place and type of service.
Chemotherapy
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Member cost share based on place and type of service.
Radiation
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Member cost share based on place and type of service.
Diabetes Education
Covered
$10.00 Not ApplicableNot Applicable 100.00% Member cost share based on place and type of service.
Prosthetic Devices
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Dental appliances except when medically necessary for the treatment of temporomandibular joint disease or obstructive sleep apnea; cosmetic improvements, such as implants of hair follicles and skin tone enhancements; lenses for keratoconus or any other eye procedure except as specifically covered under the health plan. Prosthetic appliance must replace all or part of a body
Infusion Therapy
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Member cost share based on place and type of service.
Treatment for Temporomandibular Joint Disorders
Covered
$10.00 Not ApplicableNot Applicable 100.00% Excludes Treatment for periodontal disease; Dental implants or root canals; Crowns and bridges; Orthodontic brace; Occlusal (bite) adjustments; Extractions. Therapeutic benefits for TMJ disease include splinting
Nutritional Counseling
Covered
Not Applicable No ChargeNot Applicable 100.00% Nutritional counseling visits are separate from the obesity-related office visits.
Reconstructive Surgery
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Member cost share based on place and type of service.
Gender Affirming Care
Clinical Trials
Covered
$10.00 Not ApplicableNot Applicable 100.00% Member cost share based on place and type of service.
Congenital Anomaly, including Cleft Lip/Palate
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Member cost share based on place and type of service.
Dental Anesthesia
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Diabetes Care Management
Covered
$10.00 Not ApplicableNot Applicable 100.00% Member cost share based on place and type of service.
Mental Health Other
Covered
No Charge Not ApplicableNot Applicable 100.00% Member cost share based on place and type of service.
Off Label Prescription Drugs
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00% Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.

Free Preventive Services

There is no copayment or coinsurance for any of the following Gold 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 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.

Additional Resources

Below are additional resources for Gold 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 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 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7?

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

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