UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision)
UnitedHealthcare
Plan overview
Medical deductible
Individual: $500
Family: $1000
Per Person: $500
Prescription drug deductible
Individual: $0
Family: $0
Per Person: $0
Combined medical and drug out of pocket maximum
Individual: $9000
Family: $18000
Per Person: $9000
Office visit
Primary Doctor
CoPay: $20.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Cost sharing for Virtual Primary Care matches in-person office visit.
Specialist
CoPay: $50.00
CoInsurance: Not Applicable
Covered: Covered
Prescription drug information
Preferred brand drugs
CoPay: $50.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 30
Limit Unit: Days per Month
Benefit 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 plan's Summary of Benefits or Prescription Drug List for more information.
Non preferred brand drugs
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Limit Quantity: 30
Limit Unit: Days per Month
Benefit 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 plan's Summary of Benefits or Prescription Drug List for more information.
Generic drugs
CoPay: $1.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 30
Limit Unit: Days per Month
Benefit 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 plan's Summary of Benefits or Prescription Drug List for more information.
Specialty drugs
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Limit Quantity: 30
Limit Unit: Days per Month
Benefit Explanation: Specialty medications are limited to a 1-month supply. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information.
Inpatient coverage
Hospital services
CoPay: Not Applicable
CoInsurance: 35.00% Coinsurance after deductible
Covered: Covered
Inpatient services
CoPay: Not Applicable
CoInsurance: No Charge
Covered: Covered
Emergency and urgent care
Emergency room
CoPay: $500.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Urgent care facility
CoPay: $50.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: $0 Virtual Urgent Care visits are available through vendor. See SBC for additional cost share details for in-person urgent care visits.
Maternity
Labor and delivery hospital stay
CoPay: Not Applicable
CoInsurance: 35.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Childbirth/delivery professional services follow inpatient physician/surgeon fees.
Pre and Postnatal office visit
CoPay: Not Applicable
CoInsurance: No Charge
Covered: Covered
Vision
Routine Eye Exams for Children
CoPay: Not Applicable
CoInsurance: No Charge
Covered: Covered
Limit Quantity: 1
Limit Unit: Visit(s) per Year
Major dental care
Routine dental checkups for children
CoPay: Not Applicable
CoInsurance: No Charge
Covered: Covered
Limit Quantity: 2
Limit Unit: Exam(s) per Year
Routine dental checkups for adults
CoPay: Not Applicable
CoInsurance: No Charge
Covered: Covered
Limit Quantity: 2
Limit Unit: Exam(s) per Year
Benefit Explanation: 1,000 annual benefit maximum includes all Dental Services (Routine, Basic and Major) for Adults
These policies have exclusions, limitations, reduction of benefits, 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).
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.