UHC Bronze Value HSA – HMO

Network type: HMO
Coverage tier: Expanded Bronze
Primary care visit: $50 copay after deductible
Specialist visit: 30% coinsurance after deductible
Urgent care visit: $75 copay after deductible

SKU: 42529IL0070020 Categories: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

Description

Health Care Plan Details

Network type HMO
Deductible $6,700 per person $6,700 per person
Out-of-pocket max $8,050 per person $16,100 per family
Metal tier Expanded Bronze

Visit Copay

Primary care visit $50 copay after deductible
Specialist visit 30% coinsurance after deductible
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $75 copay after deductible
Emergency room 30% coinsurance after deductible
Ambulance 30% coinsurance after deductible
Hospital stay (facility) 30% coinsurance after deductible
Hospital stay (physician) 30% coinsurance after deductible
Outpatient procedure (facility) 30% coinsurance after deductible
Outpatient procedure (physician) 30% coinsurance after deductible
Physical rehabilitation 30% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care No charge
Labor, delivery, hospital stay 30% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic $5 copay after deductible
Brand 30% coinsurance after deductible
Non-preferred Brand 45% coinsurance after deductible
Specialty 50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays 30% coinsurance after deductible
Imaging (CT/PET/MRI) 30% coinsurance after deductible
Blood work 30% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services 30% coinsurance after deductible
Psychiatric hospital stay 30% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits https://www.uhc.com/ifp/sbc.42529IL0070020-01.en.2024
Drug and medication plan formulary https://www.uhc.com/xildruglist2024
Search doctor list https://www.uhc.com/xildocfindg2024