UHC Gold Advantage – EPO
Network type: EPO
Coverage tier: Gold
Primary care visit: $10 copay
Specialist visit: $35 copay
Urgent care visit: $50 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $500 per person $500 per person |
| Out-of-pocket max | $7,500 per person $15,000 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $10 copay |
| Specialist visit | $35 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | $500 copay after deductible |
| Ambulance | 45% coinsurance after deductible |
| Hospital stay (facility) | $1500 copay per Day after deductible |
| Hospital stay (physician) | 45% coinsurance after deductible |
| Outpatient procedure (facility) | $300 copay after deductible |
| Outpatient procedure (physician) | $300 copay after deductible |
| Physical rehabilitation | $35 copay after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $1500 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $3 copay |
| Brand | $60 copay |
| Non-preferred Brand | 30% coinsurance after deductible |
| Specialty | 40% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $65 copay after deductible |
| Imaging (CT/PET/MRI) | $250 copay after deductible |
| Blood work | $10 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $35 copay |
| Psychiatric hospital stay | $1500 copay per Day after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.uhc.com/ifp/sbc.62650WA0020020-01.en.2024 |
| Drug and medication plan formulary | https://www.uhc.com/xwadruglist2024 |
| Search doctor list | https://www.uhc.com/xwadocfindg2024 |
