UHC Silver-C Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) – EPO

Description

This plan has 94% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	EPO
Deductible	$175 per person $175 per person
Out-of-pocket max	$1,500 per person $3,000 per family
Metal tier	Silver

Visit Copay

Primary care visit	$5 copay
Specialist visit	$10 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$50 copay
Emergency room	$100 copay after deductible, 5% coinsurance after deductible
Ambulance	5% coinsurance after deductible
Hospital stay (facility)	5% coinsurance after deductible
Hospital stay (physician)	5% coinsurance after deductible
Outpatient procedure (facility)	$15 copay after deductible
Outpatient procedure (physician)	5% coinsurance after deductible
Physical rehabilitation	5% coinsurance after deductible

Maternitowny and Pregnancy

Labor, delivery, hospital stay

5% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$1 copay
Brand	40% coinsurance after deductible
Non-preferred Brand	40% coinsurance after deductible
Specialty	40% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	$5 copay after deductible
Imaging (CT/PET/MRI)	5% coinsurance after deductible
Blood work	$5 copay after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$10 copay after deductible
Psychiatric hospital stay	5% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://d2ed110nmrd591.cloudfront.net/blobs/JtwNAtz5Y7HA5RJqoof4VGq3.pdf
Drug and medication plan formulary	https://www.uhc.com/xnjdruglist2024
Search doctor list	https://www.uhc.com/xnjdocfindmoa2024