UHC Bronze Essential ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) – EPO

Description

Health Care Plan Details

Network type	EPO
Deductible	$7,100 per person $7,100 per person
Out-of-pocket max	$9,450 per person $18,900 per family
Metal tier	Bronze

Visit Copay

Primary care visit	$40 copay after deductible
Specialist visit	$75 copay after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$75 copay after deductible
Emergency room	50% coinsurance after deductible
Ambulance	50% coinsurance after deductible
Hospital stay (facility)	50% coinsurance after deductible
Hospital stay (physician)	50% coinsurance after deductible
Outpatient procedure (facility)	50% coinsurance after deductible
Outpatient procedure (physician)	50% coinsurance after deductible
Physical rehabilitation	50% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	50% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$5 copay
Brand	40% coinsurance after deductible
Non-preferred Brand	45% coinsurance after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	50% coinsurance after deductible
Imaging (CT/PET/MRI)	50% coinsurance after deductible
Blood work	50% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$75 copay after deductible
Psychiatric hospital stay	50% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.uhc.com/ifp/sbc.69842LA0240020-01.en.2024
Drug and medication plan formulary	https://www.uhc.com/xladruglist2024
Search doctor list	https://www.uhc.com/xladocfindoa2024