UHC Gold Virtual First (Unlimited App-based Care) (Disponible en espanol) – HMO

Network type: HMO
Coverage tier: Gold
Primary care visit: No charge
Specialist visit: $100 copay
Urgent care visit: $75 copay

SKU: 42529IL0070028 Categories: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

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 $100 copay
Psychiatric hospital stay 25% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits https://www.uhc.com/ifp/sbc.42529IL0070028-01.en.2024
Drug and medication plan formulary https://www.uhc.com/xildruglist2024
Search doctor list https://www.uhc.com/xildocfindvf2024