UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) – HMO

Network type: HMO
Coverage tier: Gold
Primary care visit: $1 copay
Specialist visit: $50 copay after deductible
Urgent care visit: $50 copay

SKU: 54332NC0030015 Categories: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

Description

Health Care Plan Details

Network type HMO
Deductible $750 per person $750 per person
Out-of-pocket max $7,500 per person $15,000 per family
Metal tier Gold

Visit Copay

Primary care visit $1 copay
Specialist visit $50 copay after deductible
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $50 copay
Emergency room 20% coinsurance after deductible
Ambulance 20% coinsurance after deductible
Hospital stay (facility) 20% coinsurance after deductible
Hospital stay (physician) 20% coinsurance after deductible
Outpatient procedure (facility) $300 copay
Outpatient procedure (physician) $300 copay
Physical rehabilitation $50 copay

Maternitowny and Pregnancy

Well baby care No charge
Labor, delivery, hospital stay 20% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic $1 copay
Brand $50 copay
Non-preferred Brand 30% coinsurance after deductible
Specialty 40% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays $65 copay
Imaging (CT/PET/MRI) $250 copay
Blood work $10 copay

Mental and Psychiatric Health Care

Mental Health outpatient services $50 copay
Psychiatric hospital stay 20% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits https://www.uhc.com/ifp/sbc.54332NC0030015-01.en.2024
Drug and medication plan formulary https://www.uhc.com/xncdruglist2024
Search doctor list https://www.uhc.com/xncdocfindoa2024