UHC Silver-E Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, $0 Insulin) – HMO

Description

This plan has 73% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	HMO
Deductible	$2,650 per person $2,650 per person
Out-of-pocket max	$7,150 per person $14,300 per family
Metal tier	Silver

Visit Copay

Primary care visit	$1 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	$80 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	$80 copay after deductible
Psychiatric hospital stay	30% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.uhc.com/content/dam/uhcdotcom/en/ifp/sbc/ga/sbc.43802GA0040044-04.en.2024.pdf
Drug and medication plan formulary	https://www.uhc.com/xgadruglist2024
Search doctor list	https://www.uhc.com/xgadocfindg2024