UHC Gold Value ($0 Virtual Urgent Care + $0 PCP Visits, $1 Tier 2 Rx, $0 Insulin, No Referrals) – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$2,000 per person $2,000 per person
Out-of-pocket max	$8,500 per person $17,000 per family
Metal tier	Gold

Visit Copay

Primary care visit	No charge
Specialist visit	20% coinsurance 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)	20% coinsurance after deductible
Outpatient procedure (physician)	20% coinsurance after deductible
Physical rehabilitation	20% coinsurance after deductible

Maternitowny and Pregnancy

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

Pharmacy, Drugs, and Medication

Generic	$1 copay
Brand	$60 copay after deductible
Non-preferred Brand	40% coinsurance after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	20% coinsurance after deductible
Imaging (CT/PET/MRI)	20% coinsurance after deductible
Blood work	$15 copay

Mental and Psychiatric Health Care

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

Health Plan Provider Information

Health Plan Benefits	https://www.uhc.com/ifp/sbc.45480OK0050033-01.en.2024
Drug and medication plan formulary	https://www.uhc.com/xokdruglist2024
Search doctor list	https://www.uhc.com/xokdocfindoa2024