UHC Gold Virtual First (Unlimited $0 App-based Care, $3 Tier 2 Rx, $0 Insulin) (Disponible en espanol) – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: No charge
Specialist visit: $100 copay
Urgent care visit: $75 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $1,000 per person $1,000 per person |
| Out-of-pocket max | $8,400 per person $16,800 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | No charge |
| Specialist visit | $100 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $75 copay |
| Emergency room | 25% coinsurance after deductible |
| Ambulance | 25% coinsurance after deductible |
| Hospital stay (facility) | 25% coinsurance after deductible |
| Hospital stay (physician) | 25% coinsurance after deductible |
| Outpatient procedure (facility) | 25% coinsurance after deductible |
| Outpatient procedure (physician) | 25% coinsurance after deductible |
| Physical rehabilitation | 25% coinsurance after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 25% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $3 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 | 25% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 25% coinsurance after deductible |
| Blood work | $8 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $90 copay |
| Psychiatric hospital stay | 25% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.uhc.com/ifp/sbc.40220TX0080029-01.en.2024 |
| Drug and medication plan formulary | https://www.uhc.com/xtxdruglist2024 |
| Search doctor list | https://www.uhc.com/xtxdocfindvf2024 |
