BannerAetna Gold S (Unlimited Free 98point6 Telehealth & MinuteClinic Visits) - 23435AZ0040012 Health Insurance Plan

Banner Health and Aetna Health Plan Inc. health insurance plan with the Plan ID 23435AZ0040012. The plan is called BannerAetna Gold S (Unlimited Free 98point6 Telehealth & MinuteClinic Visits).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 100.00% (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 0.00% 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 23435AZ0040012
Health Insurance Plan Year 2023
State Arizona
Health Insurance Issuer Banner Health and Aetna Health Plan Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 23435AZ0040012-02
Provider Network(s) ['AZN003']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Wed, 27 Mar 2024 12:10 GMT).

Providers Arizona All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 23435AZ0040012-00

Standard On Exchange Plan - 23435AZ0040012-01

Open to Indians below 300% FPL - 23435AZ0040012-02

Open to Indians above 300% FPL - 23435AZ0040012-03

Last Plan Update Date Fri, 16 Sep 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of BannerAetna Gold S (Unlimited Free 98point6 Telehealth & MinuteClinic Visits) Health Insurance Plan, 23435AZ0040012-02

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental

Exclusions: Member cost share based on place and type of service.

Benefits are payable for the services of a Physician, dentist, or dental surgeon, provided the services are rendered for treatment of an accidental injury to sound natural teeth where the continuous course of treatment is started within six (6) months of the accident.

YES

No Charge

100.00%
Acupuncture

Limit: 10.0 Visit(s) per Year

Exclusions: Coverage is limited to 10 visits per calendar year.

YES

No Charge

100.00%
Allergy Testing

Exclusions: Member cost share based on place and type of service.

YES

No Charge

100.00%
Bariatric Surgery

Exclusions: 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.

YES

No Charge

100.00%
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy

Exclusions: Member cost share based on place and type of service.

YES

No Charge

100.00%
Chiropractic Care

Limit: 20.0 Visit(s) per Year

Exclusions: HMO coverage is limited to 20 visits per calendar year. No visit limits on PPO IN or OON.

HMOs may limit chiropractic visits to 20; PPOs must cover medically necessary chiropractic visits.

YES

No Charge

100.00%
Clinical Trials

Exclusions: Member cost share based on place and type of service.

YES

No Charge

100.00%
Cosmetic Surgery

Cosmetic surgery or procedures excluded, other than to treat congenital defects and birth abnormalities

NO
Delivery and All Inpatient Services for Maternity Care
YES

No Charge

100.00%
Dental Check-Up for Children
NO
Diabetes Care Management

Exclusions: Member cost share based on place and type of service.

YES

No Charge

100.00%
Diabetes Education

Exclusions: Member cost share based on place and type of service.

YES

No Charge

100.00%
Dialysis

Exclusions: Member cost share based on place and type of service.

YES

No Charge

100.00%
Durable Medical Equipment
YES

No Charge

100.00%
Emergency Room Services

Exclusions: No coverage for non-emergency use of the emergency room.

YES

No Charge

No Charge
Emergency Transportation/Ambulance
YES

No Charge

No Charge
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

Exclusions: Coverage is limited to 1 set of frames and 1 set of contact lenses or eyeglass lenses per calendar year age 0-19.

YES

No Charge

100.00%
Gender Affirming Care
NO
Generic Drugs

Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.

YES

No Charge

100.00%
Habilitation Services

Speech therapy is not covered to improve speech skills that have not fully developed or when "not restorative in nature."

YES

No Charge

100.00%
Hearing Aids

Limit: 1.0 Item(s) per Year

Exclusions: Coverage is limited to one hearing aid per ear per year.

YES

No Charge

100.00%
Home Health Care Services

Limit: 42.0 Visit(s) per Year

YES

No Charge

100.00%
Hospice Services

Exclusions: Member cost share based on place and type of service.

YES

No Charge

100.00%
Imaging (CT/PET Scans, MRIs)
YES

No Charge

100.00%
Infertility Treatment

Exclusions: 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: Member cost share based on place and type of service.

YES

No Charge

100.00%
Inherited Metabolic Disorder - PKU

Exclusions: Coverage is limited to formulas, both tube-fed and oral, when medically necessary for the treatment of Eosinophilic Gastrointestinal Disorder and inherited metabolic disease.

YES

No Charge

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)
YES

No Charge

100.00%
Inpatient Physician and Surgical Services
YES

No Charge

100.00%
Laboratory Outpatient and Professional Services
YES

No Charge

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services
YES

No Charge

100.00%
Mental/Behavioral Health Outpatient Services
YES

No Charge

100.00%
Non-Preferred Brand Drugs

Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.

YES

No Charge

100.00%
Nutritional Counseling
YES

No Charge

100.00%
Off Label Prescription Drugs

Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.

YES

No Charge

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

No Charge

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

No Charge

100.00%
Outpatient Rehabilitation Services

Limit: 60.0 Visit(s) per Year

Exclusions: Coverage is limited to 60 visits per calendar year PT/OT/ST combined.

YES

No Charge

100.00%
Outpatient Surgery Physician/Surgical Services
YES

No Charge

100.00%
Preferred Brand Drugs

Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.

YES

No Charge

100.00%
Prenatal and Postnatal Care

Exclusions: Member cost sharing applies to postnatal care

YES

No Charge

100.00%
Prescription Drugs Other

Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.

YES

No Charge

100.00%
Preventive Care/Screening/Immunization

Exclusions: Age and frequency schedules may apply.

YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness
YES

No Charge

100.00%
Private-Duty Nursing

Private hospital rooms and/or private duty nursing are only available during inpatient stays and determined to be medically appropriate. Private duty nursing is available only in an inpatient setting when skilled nursing is not available from the facility. Custodial Nursing is not covered.

NO
Prosthetic Devices
YES

No Charge

100.00%
Radiation

Exclusions: Member cost share based on place and type of service.

YES

No Charge

100.00%
Reconstructive Surgery

Exclusions: Member cost share based on place and type of service.

YES

No Charge

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 60.0 Visit(s) per Year

Exclusions: Coverage is limited to 60 visits per calendar year PT/OT/ST combined. Benefit limits are separate for rehabilitation and habilitation services.

YES

No Charge

100.00%
Rehabilitative Speech Therapy

Limit: 60.0 Visit(s) per Year

Exclusions: Coverage is limited to 60 visits per calendar year PT/OT/ST combined. Benefit limits are separate for rehabilitation and habilitation services.

Speech therapy is not covered when: a. Used to improve speech skills that have not fully developed; b. Considered custodial or educational; c. Intended to maintain speech communication; or d. Not restorative in nature.

YES

No Charge

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Visit(s) per Year

Exclusions: Coverage is limited to 1 exam per calendar year age 0-19.

YES

No Charge

100.00%
Routine Foot Care
NO
Routine Hearing Exam

Limit: 1.0 Visit(s) per Year

YES

No Charge

100.00%
Skilled Nursing Facility

Limit: 90.0 Days per Year

YES

No Charge

100.00%
Specialist Visit
YES

No Charge

100.00%
Specialty Drugs

Exclusions: Coinsurance up to applicable maximum per prescription. Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.

YES

No Charge

100.00%
Substance Abuse Disorder Inpatient Services
YES

No Charge

100.00%
Substance Abuse Disorder Outpatient Services
YES

No Charge

100.00%
Transplant

Exclusions: Member cost share based on place and type of service. Network benefits must be received within the transplant network.

YES

No Charge

100.00%
Treatment for Temporomandibular Joint Disorders

Exclusions: Member cost share based on place and type of service.

Coverage is limited to accident, trauma, congenital/developmental defects or pathology.

YES

No Charge

100.00%
Urgent Care Centers or Facilities
YES

No Charge

100.00%
Weight Loss Programs

Exclusions: Online weight loss programs are available.

NO
Well Baby Visits and Care

Exclusions: Coverage is limited to 7 exams in the first year of life; 3 exams in the second year of life; 3 exams in the third year of life; 1 exam per year thereafter to age 22.

Well Child visits and immunizations are covered through 47 months as recommended by the American Academy of Pediatrics.

YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

No Charge

100.00%

BannerAetna Gold S (Unlimited Free 98point6 Telehealth & MinuteClinic Visits) Health Insurance Plan Variant 23435AZ0040012-02 Attributes

Plan Attribute Value
AV Calculator Output Number 1
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2023
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Zero Cost Sharing Plan Variation
Dental Only Plan No
Design Type Design 1
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID AZF006
Formulary URL URL
HIOS Product ID 23435AZ004
Import Date 9/16/2022 1:01
Limited Cost Sharing Plan Variation - Estimated Advanced Payment 0
Inpatient Copayment Maximum Days 0
HSA Eligible No
New/Existing Plan New
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer ID 23435
Issuer Marketplace Marketing Name BannerAetna
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 AZN003
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 1/1/2023
Plan ID (Standard Component ID with Variant) 23435AZ0040012-02
Plan Marketing Name BannerAetna Gold S (Unlimited Free 98point6 Telehealth & MinuteClinic Visits)
Plan Type HMO
Plan Variant Marketing Name BannerAetna Gold S (Unlimited Free 98point6 Telehealth & MinuteClinic Visits)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $0
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $0
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $0
SBC Scenario, Treatment of a Simple Fracture, Deductible $0
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID AZS003
Source Name HIOS
Plan ID 23435AZ0040012
State Code AZ
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 0.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $0 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $0
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 $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $0 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $0
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 BannerAetna Gold S (Unlimited Free 98point6 Telehealth & MinuteClinic Visits) Health Insurance Plan, 23435AZ0040012

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about BannerAetna Gold S (Unlimited Free 98point6 Telehealth & MinuteClinic Visits), 23435AZ0040012 Health Insurance Plan, 23435AZ0040012

  • Does BannerAetna Gold S (Unlimited Free 98point6 Telehealth & MinuteClinic Visits) Health Insurance Plan, 23435AZ0040012 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (23435AZ0040012) Health Insurance Plan, Variant (23435AZ0040012-02) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy

    Does (23435AZ0040012) Health Insurance Plan, Variant (23435AZ0040012-02) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan).

    Does (23435AZ0040012) Health Insurance Plan, Variant (23435AZ0040012-02) have Out of Service Area Coverage?

    No, unfortunately there is no Out of Service Area Coverage for this Health Insurance Plan (variant of plan). Details: Except for Emergencies

    Does (23435AZ0040012) Health Insurance Plan, Variant (23435AZ0040012-02) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy

    Does BannerAetna Gold S (Unlimited Free 98point6 Telehealth & MinuteClinic Visits) Health Insurance Plan, Variant (23435AZ0040012-02) offer Disease Management Programs for Asthma?

    Yes, the BannerAetna Gold S (Unlimited Free 98point6 Telehealth & MinuteClinic Visits) Health Insurance Plan Variant 23435AZ0040012-02 offers Disease Management Program for Asthma.

    Does BannerAetna Gold S (Unlimited Free 98point6 Telehealth & MinuteClinic Visits) Health Insurance Plan, Variant (23435AZ0040012-02) offer Disease Management Programs for Heart disease?

    Yes, the BannerAetna Gold S (Unlimited Free 98point6 Telehealth & MinuteClinic Visits) Health Insurance Plan Variant 23435AZ0040012-02 offers Disease Management Program for Heart disease.

    Does BannerAetna Gold S (Unlimited Free 98point6 Telehealth & MinuteClinic Visits) Health Insurance Plan, Variant (23435AZ0040012-02) offer Disease Management Programs for Depression?

    Yes, the BannerAetna Gold S (Unlimited Free 98point6 Telehealth & MinuteClinic Visits) Health Insurance Plan Variant 23435AZ0040012-02 offers Disease Management Program for Depression.

    Does BannerAetna Gold S (Unlimited Free 98point6 Telehealth & MinuteClinic Visits) Health Insurance Plan, Variant (23435AZ0040012-02) offer Disease Management Programs for Diabetes?

    Yes, the BannerAetna Gold S (Unlimited Free 98point6 Telehealth & MinuteClinic Visits) Health Insurance Plan Variant 23435AZ0040012-02 offers Disease Management Program for Diabetes.

    Does BannerAetna Gold S (Unlimited Free 98point6 Telehealth & MinuteClinic Visits) Health Insurance Plan, Variant (23435AZ0040012-02) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the BannerAetna Gold S (Unlimited Free 98point6 Telehealth & MinuteClinic Visits) Health Insurance Plan Variant 23435AZ0040012-02 offers Disease Management Program for High blood pressure & high cholesterol.

    Does BannerAetna Gold S (Unlimited Free 98point6 Telehealth & MinuteClinic Visits) Health Insurance Plan, Variant (23435AZ0040012-02) offer Disease Management Programs for Low back pain?

    Yes, the BannerAetna Gold S (Unlimited Free 98point6 Telehealth & MinuteClinic Visits) Health Insurance Plan Variant 23435AZ0040012-02 offers Disease Management Program for Low back pain.

    Does BannerAetna Gold S (Unlimited Free 98point6 Telehealth & MinuteClinic Visits) Health Insurance Plan, Variant (23435AZ0040012-02) offer Disease Management Programs for Pregnancy?

    Yes, the BannerAetna Gold S (Unlimited Free 98point6 Telehealth & MinuteClinic Visits) Health Insurance Plan Variant 23435AZ0040012-02 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Wed, 27 Mar 2024 12:10 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