UHC Gold Advantage+ (Dental + Vision, No Referrals) – EPO
Network type: EPO
Coverage tier: Gold
Primary care visit: $5 copay
Specialist visit: $50 copay after deductible
Urgent care visit: $50 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $500 per person $500 per person |
| Out-of-pocket max | $7,500 per person $15,000 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $5 copay |
| Specialist visit | $50 copay after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | $650 copay after deductible |
| Ambulance | 45% coinsurance after deductible |
| Hospital stay (facility) | 45% coinsurance after deductible |
| Hospital stay (physician) | 45% coinsurance after deductible |
| Outpatient procedure (facility) | $300 copay after deductible |
| Outpatient procedure (physician) | $300 copay after deductible |
| Physical rehabilitation | $50 copay after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 45% 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 | $50 copay |
| Psychiatric hospital stay | 45% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.uhc.com/ifp/sbc.69443TN0180002-01.en.2024 |
| Drug and medication plan formulary | https://www.uhc.com/xtndruglist2024 |
| Search doctor list | https://www.uhc.com/xtndocfindoa2024 |
