UHC Bronze Value HSA – HMO
Network type: HMO
Coverage tier: Expanded Bronze
Primary care visit: $50 copay after deductible
Specialist visit: $100 copay after deductible
Urgent care visit: $75 copay after deductible
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 | $100 copay 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% after deductible |
| Outpatient procedure (physician) | 30% coinsurance after deductible |
| Physical rehabilitation | 30% coinsurance after deductible |
Maternitowny and Pregnancy
| 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 | 50% 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 | $50 copay after deductible |
| Psychiatric hospital stay | 30% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/n6uDNPwAHwU71x5k4VdyQbJL.pdf |
| Drug and medication plan formulary | https://www.uhc.com/xvadruglist2024 |
| Search doctor list | https://www.uhc.com/xvadocfindoa2024 |
