UnitedHealthcare of New Mexico, Inc.

UHC Silver Advantage On Exchange

Plan Overview

Medical Deductible
  • Individual: $4,250
  • Family: $8,500
  • Per Person: $4,250
Prescription Drug Deductible
  • Individual: Included in Medical
  • Family: Included in Medical
  • Per Person: Included in Medical
Medical Out-of-Pocket Maximum
  • Individual: $9,200
  • Family: $18,400
  • Per Person: $9,200
Drug Out-of-Pocket Maximum
  • Individual: Included in Medical
  • Family: Included in Medical
  • Per Person: Included in Medical

Office Visit

Primary Doctor
  • Standard: Copay: 60.00 | Coinsurance: Not Applicable | Explanation: Cost sharing for Virtual Primary Care matches in-person office visit.
Specialist
  • Standard: Copay: 120.00 | Coinsurance: Not Applicable | Explanation:

Prescription Drug Information

Preferred Brand Drugs
  • Standard: Copay: $60.00 Copay after deductible | Coinsurance: Not Applicable | Explanation: Members can obtain a 1 month supply through network pharmacies or home delivery. Members also have the option to receive a 3 month supply through network pharmacy or home delivery. Other quantity limits may apply. Check the plans Summary of Benefits or Prescription Drug List for more information.
Non Preferred Brand Drugs
  • Standard: Copay: Not Applicable | Coinsurance: 40.00% Coinsurance after deductible | Explanation: Members can obtain a 1 month supply through network pharmacies or home delivery. Members also have the option to receive a 3 month supply through network pharmacy or home delivery. Other quantity limits may apply. Check the plans Summary of Benefits or Prescription Drug List for more information.
Generic Drugs
  • Standard: Copay: 1.00 | Coinsurance: Not Applicable | Explanation: Members can obtain a 1 month supply through network pharmacies or home delivery. Members also have the option to receive a 3 month supply through network pharmacy or home delivery. Other quantity limits may apply. Check the plans Summary of Benefits or Prescription Drug List for more information.
Specialty Drugs
  • Standard: Copay: Not Applicable | Coinsurance: 40.00% Coinsurance after deductible | Explanation: Specialty medications are limited to a 1-month supply. Other quantity limits may apply. Check the plans Summary of Benefits or Prescription Drug List for more information.

Inpatient Coverage

Hospital Services
  • Standard: Copay: Not Applicable | Coinsurance: 30.00% Coinsurance after deductible | Explanation:
Inpatient Services
  • Standard: Copay: Not Applicable | Coinsurance: 30.00% Coinsurance after deductible | Explanation:

Emergency and Urgent Care

Emergency Room
  • Standard: Copay: 1,350.00 | Coinsurance: Not Applicable | Explanation:

Medical plan coverage offered by: UnitedHealthcare of Arizona, Inc.; Rocky Mountain Health Maintenance Organization, Incorporated in CO; UnitedHealthcare of Florida, Inc.; UnitedHealthcare of Georgia, Inc.; UnitedHealthcare of Illinois, Inc.; UnitedHealthcare Insurance Company in LA, TN and AL; Optimum Choice, Inc. in VA and MD; UnitedHealthcare Community Plan, Inc. in MI; UnitedHealthcare of North Carolina, Inc.; UnitedHealthcare of Oklahoma, Inc.; UnitedHealthcare of Texas, Inc.; and UnitedHealthcare of Oregon, Inc. in WA. Administrative Services provided by United HealthCare Services, Inc. or their affiliates.

Plan specifics and benefits may vary by coverage area and by plan category. Please review the plan details to learn more. This policy has exclusions, limitations, reduction of benefits, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company (whichever is applicable). By responding to this offer, you agree that a representative may contact you.

You are required to select a Primary Care Physician (PCP) within our network. Your PCP refers you to specialists when necessary. If you use a specialist without a referral or see a provider who is not in your network, you may have to pay the full cost of the benefits and services. Emergency services received by an out-of-network provider are covered.

Health Maintenance Organization, Inc. in Colorado and UnitedHealthcare Insurance Co. in Tennessee. Administrative Services provided by United HealthCare Services, Inc. or their affiliates.

Plan specifics and benefits may vary by coverage area and by plan category. Please review the plan details to learn more. This policy has exclusions, limitations, reduction of benefits, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company (whichever is applicable). By responding to this offer, you agree that a representative may contact you.