UHC Gold Advantage+ ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) – EPO

Network type: EPO
Coverage tier: Gold
Primary care visit: $5 copay
Specialist visit: $75 copay
Urgent care visit: $50 copay

SKU: 94968KS0100001 Categories: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

Description

Health Care Plan Details

Network type EPO
Deductible $500 per person $500 per person
Out-of-pocket max $7,000 per person $14,000 per family
Metal tier Gold

Visit Copay

Primary care visit $5 copay
Specialist visit $75 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $50 copay
Emergency room $600 copay after deductible
Ambulance 45% coinsurance after deductible
Hospital stay (facility) 35% coinsurance after deductible
Hospital stay (physician) 35% coinsurance after deductible
Outpatient procedure (facility) $300 copay after deductible
Outpatient procedure (physician) $300 copay after deductible
Physical rehabilitation $75 copay after deductible

Maternitowny and Pregnancy

Well baby care No charge
Labor, delivery, hospital stay 35% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic $3 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 after deductible
Imaging (CT/PET/MRI) $250 copay after deductible
Blood work $10 copay

Mental and Psychiatric Health Care

Mental Health outpatient services $75 copay
Psychiatric hospital stay 35% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits https://www.uhc.com/ifp/sbc.94968KS0100001-01.en.2024
Drug and medication plan formulary https://www.uhc.com/xksdruglist2024
Search doctor list https://www.uhc.com/xksdocfindoa2024