UHC Bronze Standard (No Referrals) – HMO

Network type: HMO
Coverage tier: Expanded Bronze
Primary care visit: $50 copay
Specialist visit: $100 copay
Urgent care visit: $75 copay

SKU: 97560MS0030025 Categories: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

Description

Health Care Plan Details

Network type HMO
Deductible $7,500 per person $7,500 per person
Out-of-pocket max $9,400 per person $18,800 per family
Metal tier Expanded Bronze

Visit Copay

Primary care visit $50 copay
Specialist visit $100 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $75 copay
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 copay

Maternitowny and Pregnancy

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

Pharmacy, Drugs, and Medication

Generic $25 copay
Brand $50 copay after deductible
Non-preferred Brand $100 copay after deductible
Specialty $500 copay 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 $50 copay
Psychiatric hospital stay 50% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits https://www.uhc.com/ifp/sbc.97560MS0030025-01.en.2024
Drug and medication plan formulary https://www.uhc.com/xmsQdruglist2024
Search doctor list https://www.uhc.com/xmsdocfindoa2024