UHC Silver-C Value $250 Indiv Ded ($1 Tier 2 Rx, No Referrals) – EPO

Description

This plan has 94% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	EPO
Deductible	$250 per person $250 per person
Out-of-pocket max	$1,100 per person $2,200 per family
Metal tier	Silver

Visit Copay

Primary care visit	10% coinsurance after deductible
Specialist visit	10% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$50 copay
Emergency room	$100 copay after deductible, 10% coinsurance after deductible
Ambulance	10% coinsurance after deductible
Hospital stay (facility)	10% coinsurance after deductible
Hospital stay (physician)	10% coinsurance after deductible
Outpatient procedure (facility)	10% after deductible
Outpatient procedure (physician)	10% coinsurance after deductible
Physical rehabilitation	10% coinsurance after deductible

Maternitowny and Pregnancy

Labor, delivery, hospital stay

10% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$1 copay
Brand	10% coinsurance after deductible
Non-preferred Brand	10% coinsurance after deductible
Specialty	10% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	10% coinsurance after deductible
Imaging (CT/PET/MRI)	10% coinsurance after deductible
Blood work	10% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	10% coinsurance after deductible
Psychiatric hospital stay	10% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://d2ed110nmrd591.cloudfront.net/blobs/WGJDGpXvPVTjBzKYJGP5tfW9.pdf
Drug and medication plan formulary	https://www.uhc.com/xnjdruglist2024
Search doctor list	https://www.uhc.com/xnjdocfindmoa2024