UHC Silver Copay Focus (No Referrals) – EPO
Network type: EPO
Coverage tier: Silver
Primary care visit: $5 copay
Specialist visit: $100 copay
Urgent care visit: $75 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $0 per person $0 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 |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $75 copay |
| Emergency room | $1,500 copay |
| Ambulance | 30% coinsurance |
| Hospital stay (facility) | $2500 copay per Day |
| Hospital stay (physician) | 30% coinsurance |
| Outpatient procedure (facility) | $750 copay |
| Outpatient procedure (physician) | $750 copay |
| Physical rehabilitation | $100 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $2,500 copay |
Pharmacy, Drugs, and Medication
| Generic | $5 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 | $65 copay |
| Imaging (CT/PET/MRI) | $300 copay |
| Blood work | $20 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $100 copay |
| Psychiatric hospital stay | $2500 copay per Day |
Health Plan Provider Information
| Health Plan Benefits | https://www.uhc.com/ifp/sbc.69443TN0140020-01.en.2024 |
| Drug and medication plan formulary | https://www.uhc.com/xtndruglist2024 |
| Search doctor list | https://www.uhc.com/xtndocfindoa2024 |
