Gold S PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care
72547IL0170005
Gold
PPO
Gold S PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care is a Gold PPO plan by Aetna CVS Health.
IMPORTANT: You are viewing the 2024 version of Gold S PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 72547IL0170005. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.
Locations
Gold S PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care is offered in the following counties.
Plan Overview
This is a plan overview for 2024 version of Gold S PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 72547IL0170005.
| Insurer: | Aetna CVS Health |
| Network Type: | PPO |
| Metal Type: | Gold |
| HSA Eligible?: | No |
| Plan ID: | 72547IL0170005 |
Cost-Sharing Overview
Gold S PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for Gold S PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $8700 per person | $17400 per group |
| Deductible: | $1500 per person | $3000 per group |
| Coinsurance: | 25.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for Gold S PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 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: | $14000 per person | $28000 per group |
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: | $1,500.00 |
| Copayment: | $10.00 |
| Coinsurance: | $2,500.00 |
| Limit: | $60.00 |
| Deductible: | $100.00 |
| Copayment: | $1,200.00 |
| Coinsurance: | $0.00 |
| Limit: | $20.00 |
| Deductible: | $1,500.00 |
| Copayment: | $200.00 |
| Coinsurance: | $100.00 |
| Limit: | $0.00 |
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 S PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care?
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 S PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 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 S PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 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: | Yes |
| Out of Service Area Coverage Description: | Covered with Limitations |
| National Network: | No |
Additional Benefits and Cost-Sharing
Gold S PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 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 | $30.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | |
| Specialist Visit Covered | $60.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $30.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Outpatient Surgery Physician/Surgical Services Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Hospice Services Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Routine Dental Services (Adult) Not Covered | |||
| Infertility Treatment Covered | $60.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | Limited to 4 attempts; if live birth, 2 additional attempts covered. |
| Long-Term/Custodial Nursing Home Care Not Covered | |||
| Private-Duty Nursing Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Inpatient Private Duty Nursing Services are not covered. |
| Routine Eye Exam (Adult) Not Covered | |||
| Urgent Care Centers or Facilities Covered | $45.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | |
| Home Health Care Services Covered | $30.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | |
| Emergency Room Services Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 25.00% Coinsurance after deductible | |
| Emergency Transportation/Ambulance Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 25.00% Coinsurance after deductible | |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Inpatient Physician and Surgical Services Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Bariatric Surgery Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Pre-certification is required. Surgery for obesity will be a Covered Service only when required due to morbid obesity. The participant meets the current NIH (National Institutes of Health) surgical criteria. |
| Cosmetic Surgery Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Cosmetic surgery for the correction of the congenital deformities or for conditions resulting from accidental injuries, scars, tumors or disease is covered. |
| Skilled Nursing Facility Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Prenatal and Postnatal Care Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Member cost sharing applies to postnatal care |
| Delivery and All Inpatient Services for Maternity Care Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Mental/Behavioral Health Outpatient Services Covered | $30.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | |
| Mental/Behavioral Health Inpatient Services Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Substance Abuse Disorder Outpatient Services Covered | $30.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | |
| Substance Abuse Disorder Inpatient Services Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Generic Drugs Covered | $15.00 Not Applicable | Not Applicable 50.00% | Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
| Preferred Brand Drugs Covered | $30.00 Not Applicable | Not Applicable 50.00% | Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
| Non-Preferred Brand Drugs Covered | $60.00 Not Applicable | Not Applicable 50.00% | Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
| Specialty Drugs Covered | $250.00 Not Applicable | Not Applicable 50.00% | Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details. |
| Outpatient Rehabilitation Services Covered | $30.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | |
| Habilitation Services Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Treatment must be medically necessary and therapeutic and not investigational. |
| Chiropractic Care Covered | $30.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | 25.0 Visit(s) per Year New Style Accumulation and Cost Share- Coverage is limited to 25 visits per manipulation per calendar year, separate from habilitation and includes all outpatient places of service for Chiro. Benefits will be provided for manipulation or adjustment of osseous or articular structures, commonly referred to as chiropractic and osteopathic manipulation, when performed by a person licensed to perform such procedures. |
| Durable Medical Equipment Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Hearing Aids Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | 1.0 Item(s) per 2 Years Hearing aids limited to 1 hearing aid per ear every 24 months. Bone anchored hearing aids and cochlear implants are covered. |
| Imaging (CT/PET Scans, MRIs) Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Preventive Care/Screening/Immunization Covered | Not Applicable 0.00% | Not Applicable 50.00% Coinsurance after deductible | Age and frequency schedules may apply. |
| Routine Foot Care Covered | $60.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | Only covered for persons diagnosed with diabetes. |
| Acupuncture Not Covered | |||
| Weight Loss Programs Not Covered | Online weight loss programs are available. | ||
| Routine Eye Exam for Children Covered | $10.00 Not Applicable | Not Applicable 50.00% | 1.0 Exam(s) per Year Coverage is limited to 1 exam every 12 months age 0-19. |
| Eye Glasses for Children Covered | $10.00 Not Applicable | Not Applicable 50.00% | 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 | $30.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | Provided when rendered by a licensed Speech Therapist or Speech Therapist certified by the American Speech and Hearing Association. |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | $30.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | Provided when rendered by a registered Occupational Therapist or registered professional Physical Therapist under the supervision of a Physician. |
| Well Baby Visits and Care Covered | Not Applicable No Charge | Not Applicable 50.00% Coinsurance after deductible | Children immunizations covered at 100% deductible waived for children up to 72 months of age. Coverage is limited to 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 | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| X-rays and Diagnostic Imaging Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| 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 Covered | $60.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | Abortions are only covered when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest |
| Transplant Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Member cost share based on place and type of service. Network benefits must be received within the transplant network. |
| Accidental Dental Covered | $60.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | |
| Dialysis Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Allergy Testing Covered | $60.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | |
| Chemotherapy Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Member cost share based on place and type of service. |
| Radiation Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Diabetes Education Covered | $60.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | Services must be rendered by a physician, or duly certified, registered or licensed health care professional with expertise in diabetes management. |
| Prosthetic Devices Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Infusion Therapy Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Member cost share based on place and type of service. |
| Treatment for Temporomandibular Joint Disorders Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Member cost share based on place and type of service. |
| Nutritional Counseling Covered | Not Applicable No Charge | Not Applicable 50.00% Coinsurance after deductible | |
| Reconstructive Surgery Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Member cost share based on place and type of service. |
| Gender Affirming Care | |||
| Autism Spectrum Disorders Covered | $30.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | Member cost share based on place and type of service. |
| Bones/Joints Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Member cost share based on place and type of service. |
| Breast Implant Removal Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Member cost share based on place and type of service. |
| Clinical Trials Covered | $60.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | Member cost share based on place and type of service. |
| Dental Anesthesia Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Diabetes Care Management Covered | $60.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | Member cost share based on place and type of service. |
| Inherited Metabolic Disorder – PKU Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Multiple Sclerosis Covered | $30.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | Member cost share based on place and type of service. |
| Organ Transplants Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Member cost share based on place and type of service. Network benefits must be received within the transplant network. |
| Prescription Drugs Other Covered | $60.00 Not Applicable | Not Applicable 50.00% | 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 S PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 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 S PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 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 S PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care?
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