UCare Silver StandardRx – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: $40 copay
Specialist visit: $95 copay
Urgent care visit: $95 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $2,500 per person $2,500 per person |
| Out-of-pocket max | $8,400 per person $16,800 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $40 copay |
| Specialist visit | $95 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $95 copay |
| Emergency room | 30% after deductible |
| Ambulance | 30% after deductible |
| Hospital stay (facility) | 30% after deductible |
| Hospital stay (physician) | 30% after deductible |
| Outpatient procedure (facility) | 30% after deductible |
| Outpatient procedure (physician) | 30% after deductible |
| Physical rehabilitation | $95 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 30% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $10 copay |
| Brand | $175 copay |
| Non-preferred Brand | $400 copay |
| Specialty | $700 copay |
Lab Tests and Diagnostic Procedures
| X-rays | 30% after deductible |
| Imaging (CT/PET/MRI) | 30% after deductible |
| Blood work | 30% after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $40 copay |
| Psychiatric hospital stay | 30% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/nnR8z8QQKM5TrXEhrzVFXQY2.pdf |
| Drug and medication plan formulary | https://www.ucare.org/health-plans/ifp/formulary/?utm_source=vanity&utm_medium=vanity&utm_campaign=grdocs |
