UHC Gold Value ($0 Virtual Urgent Care + $0 PCP Visits, $1 Tier 2 Rx, No Referrals) – EPO
Network type: EPO
Coverage tier: Gold
Primary care visit: No charge
Specialist visit: 20% coinsurance after deductible
Urgent care visit: $50 copay
Description
Health Care Plan Details
| Network type | EPO |
| 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.95426MO0410017-01.en.2024 |
| Drug and medication plan formulary | https://www.uhc.com/xmodruglist2024 |
| Search doctor list | https://www.uhc.com/xmodocfindoa2024 |
