UHC Gold Standard $0 Indiv Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 Rx, $0 Insulin) – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: No charge
Specialist visit: $60 copay
Urgent care visit: $75 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $9,100 per person $18,200 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | No charge |
| Specialist visit | $60 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $75 copay |
| Emergency room | 50% coinsurance |
| Ambulance | 50% coinsurance |
| Hospital stay (facility) | 50% coinsurance |
| Hospital stay (physician) | 50% coinsurance |
| Outpatient procedure (facility) | 50% coinsurance |
| Outpatient procedure (physician) | 50% coinsurance |
| Physical rehabilitation | 50% coinsurance |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 50% coinsurance |
Pharmacy, Drugs, and Medication
| Generic | $3 copay |
| Brand | 30% coinsurance |
| Non-preferred Brand | 30% coinsurance |
| Specialty | 40% coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | 50% coinsurance |
| Imaging (CT/PET/MRI) | 50% coinsurance |
| Blood work | $20 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 50% coinsurance |
| Psychiatric hospital stay | 50% coinsurance |
Health Plan Provider Information
| Health Plan Benefits | https://www.uhc.com/ifp/sbc.40220TX0080013-01.en.2024 |
| Drug and medication plan formulary | https://www.uhc.com/xtxdruglist2024 |
| Search doctor list | https://www.uhc.com/xtxdocfindg2024 |
