UHC Choice Plus Silver 4000-2 – PPO
Network type: PPO
Coverage tier: Silver
Primary care visit: $40 copay
Specialist visit: $80 copay
Urgent care visit: $80 copay
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | N/A N/A |
| Out-of-pocket max | N/A per person N/A per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $40 copay |
| Specialist visit | $80 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $80 copay |
| Emergency room | $500 plus 20% after deductible copay, $500 plus 20% after deductible |
| Ambulance | 20% after deductible |
| Hospital stay (facility) | $750 plus 20% after deductible copay, $750 plus 20% after deductible |
| Hospital stay (physician) | 20% after deductible |
| Outpatient procedure (facility) | $250 plus 20% after deductible copay, $250 plus 20% after deductible |
| Outpatient procedure (physician) | 20% after deductible |
| Physical rehabilitation | $40 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | $750 plus 20% after deductible copay, $750 plus 20% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $10 copay |
| Brand | $60 copay |
| Non-preferred Brand | $150 copay after deductible |
| Specialty | $150 copay after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $80 copay |
| Imaging (CT/PET/MRI) | $500 copay |
| Blood work | $40 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $40 copay |
| Psychiatric hospital stay | 20% after deductible |