UCare M Health Fairview Gold – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $20 copay
Specialist visit: $35 copay
Urgent care visit: $35 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $950 per person $950 per person |
| Out-of-pocket max | $7,400 per person $14,800 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $20 copay |
| Specialist visit | $35 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $35 copay |
| Emergency room | $500 plus 20% after deductible copay, $500 plus 20% after deductible |
| Ambulance | 20% after deductible |
| Hospital stay (facility) | 20% after deductible |
| Hospital stay (physician) | 20% after deductible |
| Outpatient procedure (facility) | 20% after deductible |
| Outpatient procedure (physician) | 20% after deductible |
| Physical rehabilitation | $35 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 20% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $5 copay |
| Brand | $125 copay |
| Non-preferred Brand | $250 copay |
| Specialty | $550 copay |
Lab Tests and Diagnostic Procedures
| X-rays | 20% after deductible |
| Imaging (CT/PET/MRI) | 20% after deductible |
| Blood work | 20% after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $20 copay |
| Psychiatric hospital stay | 20% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/YtgUfMD2ydigSnqV8AEWkrT7.pdf |
| Drug and medication plan formulary | https://www.ucare.org/health-plans/ifp/formulary/?utm_source=vanity&utm_medium=vanity&utm_campaign=grdocs |
