UHC Bronze Value HSA (No Referrals) – HMO

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.45480OK0050027-01.en.2024
Drug and medication plan formulary	https://www.uhc.com/xokdruglist2024
Search doctor list	https://www.uhc.com/xokdocfindoa2024