UHC Silver Advantage (No Referrals) – EPO
Network type: EPO
Coverage tier: Silver
Primary care visit: $5 copay
Specialist visit: $100 copay after deductible
Urgent care visit: $100 copay
Description
Health Care Plan Details
| Network type | EPO |
| 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 | $5 copay |
| Specialist visit | $100 copay after deductible |
| 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 | $100 copay after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| 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 | $85 copay after deductible |
| Psychiatric hospital stay | 30% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.uhc.com/ifp/sbc.69443TN0140029-01.en.2024 |
| Drug and medication plan formulary | https://www.uhc.com/xtndruglist2024 |
| Search doctor list | https://www.uhc.com/xtndocfindoa2024 |
