UHC Silver Advantage+ (Dental + Vision) – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: No charge
Specialist visit: $100 copay
Urgent care visit: $100 copay
Description
Health Care Plan Details
Network type | HMO |
Deductible | $2,500 per person $2,500 per person |
Out-of-pocket max | $9,450 per person $18,900 per family |
Metal tier | Silver |
Visit Copay
Primary care visit | No charge |
Specialist visit | $100 copay |
Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
Urgent care | $100 copay |
Emergency room | $1000 copay after deductible |
Ambulance | 30% coinsurance after deductible |
Hospital stay (facility) | 30% coinsurance after deductible |
Hospital stay (physician) | 30% coinsurance after deductible |
Outpatient procedure (facility) | $375 copay after deductible |
Outpatient procedure (physician) | $375 copay after deductible |
Physical rehabilitation | $90 copay after deductible |
Maternitowny and Pregnancy
Labor, delivery, hospital stay | 30% coinsurance after deductible |
Pharmacy, Drugs, and Medication
Generic | $3 copay |
Brand | $85 copay after deductible |
Non-preferred Brand | 40% coinsurance after deductible |
Specialty | 50% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
X-rays | $35 copay after deductible |
Imaging (CT/PET/MRI) | $200 copay after deductible |
Blood work | $15 copay after deductible |
Mental and Psychiatric Health Care
Mental Health outpatient services | $45 copay after deductible |
Psychiatric hospital stay | 30% coinsurance after deductible |
Health Plan Provider Information
Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/TfEUZHRabYbwNEwCGq3Tjt1g.pdf |
Drug and medication plan formulary | https://www.uhc.com/xvadruglist2024 |
Search doctor list | https://www.uhc.com/xvadocfindoa2024 |