Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 - 18628FL0160030 Health Insurance Plan
Aetna Health Inc. (a FL corp.) health insurance plan with the Plan ID 18628FL0160030. The plan is called Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.06% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 21.94% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
| Health Insurance Plan ID | 18628FL0160030 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Florida | ||||||||||||||||||
| Health Insurance Issuer | Aetna Health Inc. (a FL corp.) | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 18628FL0160030-00 | ||||||||||||||||||
| Provider Network(s) | PREFERRED NON-PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 16 Sep 2025 15:17 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 18628FL0160030-00 Standard On Exchange Plan - 18628FL0160030-01 |
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| Last Plan Update Date | Wed, 02 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 16 Sep 2025 15:17 GMT |
Benefits of Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, 18628FL0160030-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Exclusions: nan nan |
NO | ||
| Accidental Dental
Exclusions: nan Member cost share based on place and type of service. |
YES | $60.00 |
100.00% |
| Acupuncture
Exclusions: nan nan |
NO | ||
| Allergy Testing
Exclusions: nan Member cost share based on place and type of service. |
YES | $60.00 |
100.00% |
| Bariatric Surgery
Exclusions: nan nan |
NO | ||
| Basic Dental Care - Adult
Exclusions: nan nan |
NO | ||
| Basic Dental Care - Child
Exclusions: nan nan |
NO | ||
| Chemotherapy
Exclusions: nan Member cost share based on place and type of service. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 35.0 Visit(s) per Year Exclusions: nan Coverage is limited to 35 visits per year for Physical Therapy, Occupational Therapy, and Chiropractic Care combined. |
YES | $30.00 |
100.00% |
| Cosmetic Surgery
Exclusions: nan nan |
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Exclusions: Maternity services rendered to a covered person who is acting as a gestational surrogate are excluded. nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
Exclusions: nan nan |
NO | ||
| Diabetes Education
Exclusions: nan Member cost share based on place and type of service. |
YES | $60.00 |
100.00% |
| Dialysis
Exclusions: nan Member cost share based on place and type of service. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
Exclusions: No coverage for non-emergency use of the emergency room. nan |
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Exclusions: nan Coverage is limited to 1 set of frames and 1 set of contact lenses or eyeglass lenses per year, through the end of the month in which the member turns 19. |
YES | $10.00 |
100.00% |
| Gender Affirming Care
Exclusions: nan nan |
NO | ||
| Generic Drugs
Exclusions: nan Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details. |
YES | $15.00 |
100.00% |
| Habilitation Services
Exclusions: nan 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. |
YES | $30.00 |
100.00% |
| Hearing Aids
Exclusions: nan nan |
NO | ||
| Home Health Care Services
Limit: 60.0 Visit(s) per Year Exclusions: nan nan |
YES | $30.00 |
100.00% |
| Hospice Services
Exclusions: nan Member cost share based on place and type of service. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
Exclusions: nan Coverage limited to diagnosis and treatment of the underlying medical condition. Member cost share based on place and type of service. |
NO | ||
| Infusion Therapy
Exclusions: nan Member cost share based on place and type of service. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
Exclusions: nan nan |
NO | ||
| Major Dental Care - Adult
Exclusions: nan nan |
NO | ||
| Major Dental Care - Child
Exclusions: nan nan |
NO | ||
| Mental/Behavioral Health Inpatient Services
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Exclusions: nan 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. |
YES | $30.00 |
100.00% |
| Non-Preferred Brand Drugs
Exclusions: nan Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details. |
YES | $60.00 |
100.00% |
| Nutritional Counseling
Exclusions: nan Nutritional Counseling for Diabetes included |
YES | No Charge |
100.00% |
| Orthodontia - Adult
Exclusions: nan nan |
NO | ||
| Orthodontia - Child
Exclusions: nan nan |
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Exclusions: nan 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. |
YES | $30.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Exclusions: nan Member cost share based on place and type of service. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 35.0 Visit(s) per Year Exclusions: nan Coverage is limited to 35 visits per year, Physical Therapy, Occupational Therapy, Speech Therapy, and Chiropractic care combined. |
YES | $30.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
Exclusions: nan Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details. |
YES | $30.00 |
100.00% |
| Prenatal and Postnatal Care
Exclusions: nan Member cost sharing applies to postnatal care. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Preventive Care/Screening/Immunization
Exclusions: nan Age and frequency schedules may apply. |
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Exclusions: nan 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. |
YES | $30.00 |
100.00% |
| Private-Duty Nursing
Exclusions: nan nan |
NO | ||
| Prosthetic Devices
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Radiation
Exclusions: nan Member cost share based on place and type of service. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Exclusions: nan Member cost share based on place and type of service. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 35.0 Visit(s) per Year Exclusions: nan Coverage is limited to 35 visits per year, Physical Therapy, Occupational Therapy, Speech Therapy, and Chiropractic care combined. |
YES | $30.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 35.0 Visit(s) per Year Exclusions: nan Coverage is limited to 35 visits per year, Physical Therapy, Occupational Therapy, Speech Therapy, and Chiropractic care combined. |
YES | $30.00 |
100.00% |
| Routine Dental Services (Adult)
Exclusions: nan nan |
NO | ||
| Routine Eye Exam (Adult)
Exclusions: nan nan |
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year Exclusions: nan Coverage is limited to 1 exam every 12 months through the end of the month in which the member turns 19. |
YES | $10.00 |
100.00% |
| Routine Foot Care
Exclusions: nan Covered Services may include the trimming of toenails, corns, calluses, and therapeutic shoes (including inserts and/or modifications) for the treatment of severe diabetic foot disease. |
NO | ||
| Skilled Nursing Facility
Limit: 60.0 Days per Year Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
Exclusions: nan nan |
YES | $60.00 |
100.00% |
| Specialty Drugs
Exclusions: nan Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details. |
YES | $250.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Exclusions: nan nan |
YES | $30.00 |
100.00% |
| Transplant
Exclusions: nan Member cost share based on place and type of service. Network benefits must be received within the Institutes of Excellence (IOE) transplant network. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Exclusions: nan Member cost share based on place and type of service. Payment for splints for the treatment of temporomandibular joint ("TMJ") dysfunction is limited to one splint in a six-month period unless a more frequent replacement is determined by us to be Medically Necessary. |
YES | $60.00 |
100.00% |
| Urgent Care Centers or Facilities
Exclusions: No coverage for non-urgent care. nan |
YES | $45.00 |
100.00% |
| Weight Loss Programs
Exclusions: nan nan |
NO | ||
| Well Baby Visits and Care
Exclusions: nan Age and frequency schedules may apply. |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan Variant 18628FL0160030-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7806 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold Off Exchange Plan |
| Dental Only Plan | No |
| Design Type | Design 1 |
| Disease Management Programs Offered | Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | FLF015 |
| Formulary URL | URL |
| HIOS Product ID | 18628FL016 |
| Import Date | 2024-10-02 01:01:28 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | Yes |
| Issuer ID | 18628 |
| Issuer Marketplace Marketing Name | Aetna CVS Health |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | FLN006 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Out of Service Area Coverage Description | Except for Emergencies |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan ID (Standard Component ID with Variant) | 18628FL0160030-00 |
| Plan Marketing Name | Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 |
| Plan Type | HMO |
| Plan Variant Marketing Name | Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,500 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $1,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,200 |
| SBC Scenario, Having Diabetes, Deductible | $100 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | FLS006 |
| Source Name | HIOS |
| Specialist Requiring a Referral | Referral required for all physicians EXCEPT OB/GYN, ER, Internal Medicine, Family Practice, General Medicine and Pediatrician. |
| Plan ID | 18628FL0160030 |
| State Code | FL |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $15600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $7800 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $7,800 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $3000 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $1500 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $1,500 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 25.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $3000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,500 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $15600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7800 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,800 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, 18628FL0160030
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7, 18628FL0160030 Health Insurance Plan, 18628FL0160030
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Does Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, 18628FL0160030 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (18628FL0160030) Health Insurance Plan, Variant (18628FL0160030-00) offer Disease Management Programs?
Does (18628FL0160030) Health Insurance Plan, Variant (18628FL0160030-00) have Out Of Country Coverage?
Does (18628FL0160030) Health Insurance Plan, Variant (18628FL0160030-00) have Out of Service Area Coverage?
Does (18628FL0160030) Health Insurance Plan, Variant (18628FL0160030-00) offer Disease Management Programs?
Does Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (18628FL0160030-00) offer Disease Management Programs for Asthma?
Does Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (18628FL0160030-00) offer Disease Management Programs for Heart disease?
Does Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (18628FL0160030-00) offer Disease Management Programs for Depression?
Does Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (18628FL0160030-00) offer Disease Management Programs for Diabetes?
Does Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (18628FL0160030-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (18628FL0160030-00) offer Disease Management Programs for Low back pain?
Does Gold S: Aetna network + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 Health Insurance Plan, Variant (18628FL0160030-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 16 Sep 2025 15:17 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API