UHC Silver-D Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)ls) – EPO

Description

This plan has 87% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	EPO
Deductible	$750 per person $750 per person
Out-of-pocket max	$3,150 per person $6,300 per family
Metal tier	Silver

Visit Copay

Primary care visit	$1 copay
Specialist visit	$40 copay after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$50 copay
Emergency room	$300 copay after deductible
Ambulance	25% coinsurance after deductible
Hospital stay (facility)	25% coinsurance after deductible
Hospital stay (physician)	25% coinsurance after deductible
Outpatient procedure (facility)	$50 copay after deductible
Outpatient procedure (physician)	$50 copay after deductible
Physical rehabilitation	$40 copay after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	25% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$1 copay
Brand	$50 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)	$50 copay after deductible
Blood work	$5 copay after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$40 copay after deductible
Psychiatric hospital stay	25% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.uhc.com/ifp/sbc.69461AL0120001-05.en.2024
Drug and medication plan formulary	https://www.uhc.com/xaldruglist2024
Search doctor list	https://www.uhc.com/xaldocfindoa2024