Non-Standard Low Gold: UHC Navigate Gold 2000 – EPO
Network type: EPO
Coverage tier: Gold
Primary care visit: $20 copay
Specialist visit: $50 copay
Urgent care visit: $55 copay
Description
Health Care Plan Details
Network type | EPO |
Deductible | $2,000 per person $2,000 per person |
Out-of-pocket max | $6,000 per person $12,000 per family |
Metal tier | Gold |
Visit Copay
Primary care visit | $20 copay |
Specialist visit | $50 copay |
Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
Urgent care | $55 copay |
Emergency room | $350 copay after deductible |
Ambulance | No charge after deductible |
Hospital stay (facility) | $500 copay after deductible |
Hospital stay (physician) | No charge after deductible |
Outpatient procedure (facility) | $300 copay after deductible |
Outpatient procedure (physician) | No charge after deductible |
Physical rehabilitation | $50 copay |
Maternitowny and Pregnancy
Labor, delivery, hospital stay | $500 copay after deductible |
Pharmacy, Drugs, and Medication
Generic | $25 copay |
Brand | $50 copay after deductible |
Non-preferred Brand | $125 copay after deductible |
Specialty | $50 copay after deductible |
Lab Tests and Diagnostic Procedures
X-rays | $50 copay |
Imaging (CT/PET/MRI) | $300 copay |
Blood work | $30 copay |
Mental and Psychiatric Health Care
Mental Health outpatient services | $20 copay |
Psychiatric hospital stay | $500 copay after deductible |