UHC Gold Advantage+ (Dental + Vision) - 33764SC0040001 Health Insurance Plan
UnitedHealthcare of South Carolina, Inc. health insurance plan with the Plan ID 33764SC0040001. The plan is called UHC Gold Advantage+ (Dental + Vision).
Based on the data of Health Plan Issuer, this plan has an actuarial value of 78.01% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 21.99% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 33764SC0040001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | South Carolina | ||||||||||||||||||
| Health Insurance Issuer | UnitedHealthcare of South Carolina, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 33764SC0040001-01 | ||||||||||||||||||
| Provider Network(s) | NON-PREFERRED NETWORK | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 33764SC0040001-00 Standard On Exchange Plan - 33764SC0040001-01 |
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| Last Plan Update Date | Tue, 24 Oct 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of UHC Gold Advantage+ (Dental + Vision) Health Insurance Plan, 33764SC0040001-01
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 20% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $50.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
Limit: 1000.0 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults; Excluded from In-Network Out-of-Pocket Limit |
YES | 50.00% |
100.00% |
| Basic Dental Care - Child
|
YES | 20% Coinsurance after deductible |
100.00% |
| Chemotherapy
|
YES | 20% Coinsurance after deductible |
100.00% |
| Chiropractic Care
|
YES | 20% Coinsurance after deductible |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Childbirth/delivery professional services follow inpatient physician/surgeon fees |
YES | 20% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
Limit: 1.0 Visit(s) per 6 Months |
YES | No Charge |
100.00% |
| Diabetes Education
Diabetes self-management training and education will be provided on an outpatient basis when done by a registered or licensed health care professional that is certified in diabetes. |
YES | 20% Coinsurance after deductible |
100.00% |
| Dialysis
|
YES | 20% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 20% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | 20% Coinsurance after deductible |
20% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | 20% Coinsurance after deductible |
20% Coinsurance after deductible |
| Eye Glasses - Adult
Limit: 1.0 Item(s) per Year |
YES | $25.00 |
100.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | 20% Coinsurance after deductible |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Limit: 30.0 Days per Month 90-day supplies are available through retail pharmacies or home delivery.? Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information. |
YES | $1.00 |
100.00% |
| Habilitation Services
Supplementing with the federal definition of habilitative services. Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. |
YES | $50.00 |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 60.0 Visit(s) per Benefit Period |
YES | 20% Coinsurance after deductible |
100.00% |
| Hospice Services
Limit: 6.0 Months per Episode |
YES | 20% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $250.00 |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 20% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 20% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 20% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
Limit: 18.0 Visit(s) per Year Limited to 18 Presumptive Drug Tests per year. Limited to 18 Definitive Drug Tests per year. |
YES | $10.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
Limit: 1000.0 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults; Excluded from In-Network Out-of-Pocket Limit |
YES | 50.00% |
100.00% |
| Major Dental Care - Child
|
YES | 20% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Inpatient Services
Removed limits to meet Mental Health Parity |
YES | 20% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Removed limits to meet Mental Health Parity |
YES | $50.00 |
100.00% |
| Non-Preferred Brand Drugs
Limit: 30.0 Days per Month 90-day supplies are available through retail pharmacies or home delivery.? Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information. |
YES | 30% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
|
YES | 20% Coinsurance after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
YES | 50% Coinsurance after deductible |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | 20% Coinsurance after deductible |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $300.00 |
100.00% |
| Outpatient Rehabilitation Services
|
YES | $50.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $300.00 |
100.00% |
| Preferred Brand Drugs
Limit: 30.0 Days per Month 90-day supplies are available through retail pharmacies or home delivery.? Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information. |
YES | $50.00 |
100.00% |
| Prenatal and Postnatal Care
Exclusions: Maternity Benefits aren?t payable for Dependent children. |
YES | No Charge |
100.00% |
| Preventive Care/Screening/Immunization
Mammography services, OBGYN exams (limit 2 per year), pap smear services, prostate services, and routine colorectal cancer screening/testing |
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Cost sharing for Virtual Primary Care matches in-person office visit. See SBC for additional cost share details. |
YES | $5.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 20% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 20% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Reconstructive Surgery that is considered a Covered Expense is limited to Surgery: To correct a functional defect that results from a birth defect, disease and anomaly; or Performed to correct a seriously disfiguring condition resulting from injury; or For breast reconstruction after a mastectomy. |
YES | $300.00 |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year |
YES | $50.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year |
YES | $50.00 |
100.00% |
| Routine Dental Services (Adult)
Limit: 1.0 Visit(s) per 6 Months |
YES | No Charge |
100.00% |
| Routine Eye Exam (Adult)
Limit: 1.0 Visit(s) per Year |
YES | No Charge |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year |
YES | No Charge |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 60.0 Days per Benefit Period |
YES | 20% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $50.00 |
100.00% |
| Specialty Drugs
Limit: 30.0 Days per Month Specialty medications are limited to a 30-day supply. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information. |
YES | 40% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Removed limits to meet Mental Health Parity |
YES | 20% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Removed limits to meet Mental Health Parity |
YES | $50.00 |
100.00% |
| Transplant
|
YES | 20% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
|
YES | $50.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | $65.00 |
100.00% |
UHC Gold Advantage+ (Dental + Vision) Health Insurance Plan Variant 33764SC0040001-01 Attributes
| Plan Attribute | Value |
|---|---|
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold On Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| EHB Percent of Total Premium | 0.9627914536400201 |
| First Tier Utilization | 100% |
| Formulary ID | SCF010 |
| Formulary URL | URL |
| HIOS Product ID | 33764SC004 |
| Import Date | 2023-10-24 01:01:46 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | New |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 78.01% |
| Issuer ID | 33764 |
| Issuer Marketplace Marketing Name | UnitedHealthcare |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | SCN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Plan covers eligible expenses provided by a Network Physician or other provider or facility within the Network Area. The Network Area may include select Network providers located in a neighboring state. |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan ID (Standard Component ID with Variant) | 33764SC0040001-01 |
| Plan Marketing Name | UHC Gold Advantage+ (Dental + Vision) |
| Plan Type | HMO |
| Plan Variant Marketing Name | UHC Gold Advantage+ (Dental + Vision) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,700 |
| SBC Scenario, Having a Baby, Copayment | $100 |
| SBC Scenario, Having a Baby, Deductible | $1,200 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $200 |
| SBC Scenario, Having Diabetes, Deductible | $1,200 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $400 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,200 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | SCS001 |
| Source Name | HIOS |
| Plan ID | 33764SC0040001 |
| State Code | SC |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 20.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $2400 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1200 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,200 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $15000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7500 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,500 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | Yes |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of UHC Gold Advantage+ (Dental + Vision) Health Insurance Plan, 33764SC0040001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about UHC Gold Advantage+ (Dental + Vision), 33764SC0040001 Health Insurance Plan, 33764SC0040001
-
Does UHC Gold Advantage+ (Dental + Vision) Health Insurance Plan, 33764SC0040001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (33764SC0040001) Health Insurance Plan, Variant (33764SC0040001-01) have Out Of Country Coverage?
Does (33764SC0040001) Health Insurance Plan, Variant (33764SC0040001-01) have Out of Service Area Coverage?
Disclaimer: This is based on the import(Date: Thu, 21 Nov 2024 00:44 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API