Silver S: Aetna network of doctors & hospitals - 38927UT0380009 Health Insurance Plan
Aetna Health of Utah Inc. health insurance plan with the Plan ID 38927UT0380009. The plan is called Silver S: Aetna network of doctors & hospitals.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.01% (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 29.99% 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 | 38927UT0380009 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Utah | ||||||||||||||||||
| Health Insurance Issuer | Aetna Health of Utah Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 38927UT0380009-00 | ||||||||||||||||||
| Provider Network(s) | NON-PREFERRED PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 04 Nov 2025 05:30 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 38927UT0380009-00 Standard On Exchange Plan - 38927UT0380009-01 Open to Indians below 300% FPL - 38927UT0380009-02 Open to Indians above 300% FPL - 38927UT0380009-03 73% AV Silver Plan - 38927UT0380009-04 |
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| Last Plan Update Date | Wed, 16 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 04 Nov 2025 05:30 GMT |
Benefits of Silver S: Aetna network of doctors & hospitals Health Insurance Plan, 38927UT0380009-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Exclusions: nan Abortion services & supplies not covered except in the cases where (i) a Member suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would, as certified by a Physician, place the Member in danger of death unless an abortion is performed or (ii) the pregnancy is the result of an act of rape or incest. |
NO | ||
| Accidental Dental
Exclusions: nan nan |
NO | ||
| Acupuncture
Exclusions: nan nan |
NO | ||
| Allergy Testing
Exclusions: nan Member cost share based on place and type of service. |
YES | $80.00 |
100.00% |
| Autism Spectrum Disorders
Exclusions: nan Member cost share based on place and type of service |
YES | $40.00 |
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 | 40.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Exclusions: nan nan |
NO | ||
| Cosmetic Surgery
Exclusions: nan nan |
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Exclusions: nan nan |
YES | 40.00% 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 | $80.00 |
100.00% |
| Dialysis
Exclusions: nan Member cost share based on place and type of service. |
YES | 40.00% 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 | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
Exclusions: nan nan |
YES | 40.00% Coinsurance after deductible |
40.00% 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 prescription lenses or 1 set of contact lenses every 12 months, through the end of the month after the person attains age 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 | $20.00 |
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 | $40.00 |
100.00% |
| Hearing Aids
Exclusions: nan nan |
NO | ||
| Home Health Care Services
Limit: 30.0 Visit(s) per Year Exclusions: nan nan |
YES | $40.00 |
100.00% |
| Hospice Services
Exclusions: nan Member cost share based on place and type of service. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Exclusions: nan nan |
YES | 40.00% 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 | 40.00% Coinsurance after deductible |
100.00% |
| Inherited Metabolic Disorder - PKU
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: nan nan |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
Exclusions: nan nan |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
Exclusions: nan nan |
YES | 40.00% 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 | 40.00% 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 | $40.00 |
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 | $80.00 Copay after deductible |
100.00% |
| Nutritional Counseling
Exclusions: nan Not considered a separate benefit. Should be considered under the benefits outlined for diabetes education, anorexia, bulimia, or as allowed under the Affordable Care Act Preventive Services. |
NO | ||
| 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. If this is an HSA plan, deductible applies. |
YES | $40.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Exclusions: nan nan |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 20.0 Visit(s) per Year Exclusions: nan Coverage is limited to 20 visits per year, Physical Therapy, Occupational Therapy, and Speech Therapy combined. |
YES | $40.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
Exclusions: nan nan |
YES | 40.00% 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 | $40.00 |
100.00% |
| Prenatal and Postnatal Care
Exclusions: nan Member cost share applies to postnatal care. |
YES | 40.00% 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. If this is an HSA plan, deductible applies. |
YES | $40.00 |
100.00% |
| Private-Duty Nursing
Exclusions: nan nan |
NO | ||
| Prosthetic Devices
Exclusions: nan nan |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Radiation
Exclusions: nan Member cost share based on place and type of service. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Exclusions: nan Member cost share based on place and type of service. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Visit(s) per Year Exclusions: nan Coverage is limited to 20 visits per year, Physical Therapy, Occupational Therapy, and Speech Therapy combined. |
YES | $40.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year Exclusions: nan Coverage is limited to 20 visits per year, Physical Therapy, Occupational Therapy, and Speech Therapy combined. |
YES | $40.00 |
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 through the end of the month in which the member turns 19. |
YES | $10.00 |
100.00% |
| Routine Foot Care
Exclusions: nan nan |
NO | ||
| Skilled Nursing Facility
Limit: 30.0 Days per Year Exclusions: nan nan |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
Exclusions: nan nan |
YES | $80.00 |
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 | $350.00 Copay after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Exclusions: nan nan |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Exclusions: nan nan |
YES | $40.00 |
100.00% |
| Transplant
Exclusions: nan Member cost share based on place and type of service. Network benefits must be received within the Institute of Excellence (IOE) transplant network. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Exclusions: nan nan |
NO | ||
| Urgent Care Centers or Facilities
Exclusions: No coverage for non-urgent care. nan |
YES | $60.00 |
100.00% |
| Weight Loss Programs
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. |
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 | 40.00% Coinsurance after deductible |
100.00% |
Silver S: Aetna network of doctors & hospitals Health Insurance Plan Variant 38927UT0380009-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7001 |
| 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 Silver 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 | UTF005 |
| Formulary URL | URL |
| HIOS Product ID | 38927UT038 |
| Import Date | 2024-10-16 20:01:50 |
| 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? | No |
| Issuer ID | 38927 |
| 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 | Silver |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | UTN002 |
| 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) | 38927UT0380009-00 |
| Plan Marketing Name | Silver S: Aetna network of doctors & hospitals |
| Plan Type | HMO |
| Plan Variant Marketing Name | Silver S: Aetna network of doctors & hospitals |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,600 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $5,000 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,600 |
| SBC Scenario, Having Diabetes, Deductible | $100 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $300 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,900 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | UTS002 |
| Source Name | SERFF |
| Plan ID | 38927UT0380009 |
| State Code | UT |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $16000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $8000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $8,000 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $10000 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $5000 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $5,000 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 40.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $10000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $5000 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $5,000 |
| 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 | $16000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,000 |
| 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 Silver S: Aetna network of doctors & hospitals Health Insurance Plan, 38927UT0380009
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Silver S: Aetna network of doctors & hospitals, 38927UT0380009 Health Insurance Plan, 38927UT0380009
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Does Silver S: Aetna network of doctors & hospitals Health Insurance Plan, 38927UT0380009 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (38927UT0380009) Health Insurance Plan, Variant (38927UT0380009-00) offer Disease Management Programs?
Does (38927UT0380009) Health Insurance Plan, Variant (38927UT0380009-00) have Out Of Country Coverage?
Does (38927UT0380009) Health Insurance Plan, Variant (38927UT0380009-00) have Out of Service Area Coverage?
Does (38927UT0380009) Health Insurance Plan, Variant (38927UT0380009-00) offer Disease Management Programs?
Does Silver S: Aetna network of doctors & hospitals Health Insurance Plan, Variant (38927UT0380009-00) offer Disease Management Programs for Asthma?
Does Silver S: Aetna network of doctors & hospitals Health Insurance Plan, Variant (38927UT0380009-00) offer Disease Management Programs for Heart disease?
Does Silver S: Aetna network of doctors & hospitals Health Insurance Plan, Variant (38927UT0380009-00) offer Disease Management Programs for Depression?
Does Silver S: Aetna network of doctors & hospitals Health Insurance Plan, Variant (38927UT0380009-00) offer Disease Management Programs for Diabetes?
Does Silver S: Aetna network of doctors & hospitals Health Insurance Plan, Variant (38927UT0380009-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Silver S: Aetna network of doctors & hospitals Health Insurance Plan, Variant (38927UT0380009-00) offer Disease Management Programs for Low back pain?
Does Silver S: Aetna network of doctors & hospitals Health Insurance Plan, Variant (38927UT0380009-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 04 Nov 2025 05:30 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