UHC Silver Advantage+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) – EPO

Network type: EPO
Coverage tier: Silver
Primary care visit: $5 copay
Specialist visit: $100 copay after deductible
Urgent care visit: $100 copay

SKU: 69461AL0120001 Categories: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

Description

Health Care Plan Details

Network type EPO
Deductible $2,750 per person $2,750 per person
Out-of-pocket max $9,450 per person $18,900 per family
Metal tier Silver

Visit Copay

Primary care visit $5 copay
Specialist visit $100 copay after deductible
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $100 copay
Emergency room $1000 copay after deductible
Ambulance 30% coinsurance after deductible
Hospital stay (facility) 30% coinsurance after deductible
Hospital stay (physician) 30% coinsurance after deductible
Outpatient procedure (facility) $375 copay after deductible
Outpatient procedure (physician) $375 copay after deductible
Physical rehabilitation $100 copay after deductible

Maternitowny and Pregnancy

Well baby care No charge
Labor, delivery, hospital stay 30% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic $5 copay
Brand $85 copay after deductible
Non-preferred Brand 40% coinsurance after deductible
Specialty 50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays $35 copay after deductible
Imaging (CT/PET/MRI) $200 copay after deductible
Blood work $15 copay after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services $100 copay after deductible
Psychiatric hospital stay 30% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits https://www.uhc.com/ifp/sbc.69461AL0120001-01.en.2024
Drug and medication plan formulary https://www.uhc.com/xaldruglist2024
Search doctor list https://www.uhc.com/xaldocfindoa2024