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	$125 per person $125 per person
Out-of-pocket max	$1,500 per person $3,000 per family
Metal tier	Silver

Visit Copay

Primary care visit	$1 copay
Specialist visit	$10 copay after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$50 copay
Emergency room	$200 copay 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)	$15 copay after deductible
Physical rehabilitation	$10 copay after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	5% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$1 copay
Brand	$30 copay after deductible
Non-preferred Brand	40% coinsurance after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	$5 copay after deductible
Imaging (CT/PET/MRI)	$10 copay after deductible
Blood work	$1 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://www.uhc.com/ifp/sbc.69461AL0110021-06.en.2024
Drug and medication plan formulary	https://www.uhc.com/xaldruglist2024
Search doctor list	https://www.uhc.com/xaldocfindoa2024