UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals) – EPO

Description

Health Care Plan Details

Network type	EPO
Deductible	$3,000 per person $3,000 per person
Out-of-pocket max	$9,450 per person $18,900 per family
Metal tier	Expanded Bronze

Visit Copay

Primary care visit	$50 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	$100 copay after deductible, 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% after deductible
Outpatient procedure (physician)	50% coinsurance after deductible
Physical rehabilitation	50% coinsurance after deductible

Maternitowny and Pregnancy

Labor, delivery, hospital stay

50% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$20 copay
Brand	50% coinsurance after deductible
Non-preferred Brand	50% 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://d2ed110nmrd591.cloudfront.net/blobs/WPDnwuG1Rb2h7ZELEGX7xd2q.pdf
Drug and medication plan formulary	https://www.uhc.com/xnjdruglist2024
Search doctor list	https://www.uhc.com/xnjdocfindmoa2024