UHC Silver-E Virtual First (Unlimited $0 App-based Care, $3 Tier 2 Rx) (Disponible en espanol) – HMO

Description

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

Health Care Plan Details

Network type	HMO
Deductible	$3,200 per person $3,200 per person
Out-of-pocket max	$7,250 per person $14,500 per family
Metal tier	Silver

Visit Copay

Primary care visit	No charge
Specialist visit	$100 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$100 copay
Emergency room	40% coinsurance after deductible
Ambulance	35% coinsurance after deductible
Hospital stay (facility)	35% coinsurance after deductible
Hospital stay (physician)	35% coinsurance after deductible
Outpatient procedure (facility)	35% coinsurance after deductible
Outpatient procedure (physician)	35% coinsurance after deductible
Physical rehabilitation	35% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	35% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$3 copay
Brand	$55 copay after deductible
Non-preferred Brand	40% coinsurance after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	35% coinsurance after deductible
Imaging (CT/PET/MRI)	35% coinsurance after deductible
Blood work	$10 copay

Mental and Psychiatric Health Care

Mental Health outpatient services	$100 copay
Psychiatric hospital stay	35% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.uhc.com/ifp/sbc.33931OH0030017-04.en.2024
Drug and medication plan formulary	https://www.uhc.com/xohdruglist2024
Search doctor list	https://www.uhc.com/xohdocfindvf2024