UHC Silver Value Plan – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: $35 copay
Specialist visit: $90 copay
Urgent care visit: $75 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $4,500 per person $4,500 per person |
| Out-of-pocket max | $7,600 per person $15,200 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $35 copay |
| Specialist visit | $90 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $75 copay |
| Emergency room | $500 copay after deductible |
| Ambulance | $350 copay |
| Hospital stay (facility) | $550 copay per Stay after deductible |
| Hospital stay (physician) | 30% coinsurance after deductible |
| Outpatient procedure (facility) | $150 copay after deductible |
| Outpatient procedure (physician) | $150 copay after deductible |
| Physical rehabilitation | $35 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $550 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $25 copay |
| Brand | $75 copay after deductible |
| Non-preferred Brand | $80 copay after deductible |
| Specialty | $100 copay after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $150 copay |
| Imaging (CT/PET/MRI) | $600 copay after deductible |
| Blood work | $80 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $35 copay |
| Psychiatric hospital stay | $550 copay per Stay after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.uhc.com/ifp/sbc.72375MD0070032-01.en.2024 |
| Drug and medication plan formulary | https://www.uhc.com/xmddruglist2024 |
| Search doctor list | https://www.uhc.com/xmddocfindg2024 |
