UHC Gold Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $2 T1 Preferred Rx, Dental + Vision) - 24251VA0060018 Health Insurance Plan
Optimum Choice, Inc health insurance plan with the Plan ID 24251VA0060018. The plan is called UHC Gold Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $2 T1 Preferred Rx, Dental + Vision).
Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.23% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.77% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 24251VA0060018 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Virginia | ||||||||||||||||||
| Health Insurance Issuer | Optimum Choice, Inc | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 24251VA0060018-03 | ||||||||||||||||||
| Provider Network(s) | ['VAN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 22 Oct 2024 06:47 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 24251VA0060018-00 Standard On Exchange Plan - 24251VA0060018-01 |
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| Last Plan Update Date | Wed, 17 Aug 2022 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 22 Oct 2024 06:47 GMT |
Benefits of UHC Gold Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $2 T1 Preferred Rx, Dental + Vision) Health Insurance Plan, 24251VA0060018-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Pursuant to Virginia law no QHP sold or offered on an exchange shall provide coverage for abortions, provided that this limitation shall not apply to an abortion performed (i) when the life of the mother is endangered by a physical disorder, physical illness, or physical injury, including a life endangering physical condition relating to the pregnancy, or (ii) when the pregnancy is the result of rape or incest. |
NO | ||
| Accidental Dental
Exclusions: An injury that results from chewing or biting is not considered an accidental injury and is not covered. Includes dental work, to include oral/surgical correction needed to treat injuries to the jaw, sound natural teeth, mouth or face as a result of an accident. Dental appliances required to diagnose or treat an accidental injury to the teeth, and the repair of dental appliances damaged as a result of accidental injury to the jaw, mouth or face, are also covered. Treatment must begin within 12 months of the injury, or as soon after that as possible to be a covered service. |
YES | 20% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 20% Coinsurance after deductible |
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
Benefit limitations may apply to individual services. |
YES | 20% Coinsurance after deductible |
100.00% |
| Chemotherapy
|
YES | 20% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 30.0 Visit(s) per Benefit Period Includes therapy to treat problems of the bones, joints, joints of the spine, the nervous system, and the back, and osteopathic therapy which focuses on the joints and surrounding muscles, tendons and ligaments. Visit limits apply to habilitative and rehabilitative services separately. |
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: 2.0 Visit(s) per Year |
YES | No Charge |
100.00% |
| Diabetes Education
|
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 | 40.00% Coinsurance after deductible |
40.00% 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 Excluded from In-Network Out-of-Pocket Limit |
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 | 20% Coinsurance after deductible |
100.00% |
| Generic Drugs
Limit: 30.0 Days per Month Lowest cost shares are available at preferred retail pharmacies and home delivery. See SBC for cost shares at other retail pharmacies and for non-preferred generics. 90-day supplies are available through preferred retail pharmacies or home delivery. Limited to 30 day supplies at all other pharmacies. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply. |
YES | $2.00 |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Benefit Period Limited to 30 visits per year combined for Physical and Occupational Therapy, 30 visits per year for Speech Therapy. These limits do not apply for the treatment of autism and autism spectrum disorders, for early intervention services, and if care is part of the hospice care benefit. When you get physical, occupational or speech therapy, in the home, the home health care visit limit will apply instead of the therapy services limits listed above. |
YES | 20% Coinsurance after deductible |
100.00% |
| Hearing Aids
This Exclusion does not apply to cochlear implants. |
NO | ||
| Home Health Care Services
Limit: 100.0 Visit(s) per Benefit Period The Home Care visit limit will apply instead of the Therapy Services limits for physical, occupational, speech therapy, or cardiac rehabilitation for therapy in the home |
YES | 20% Coinsurance after deductible |
100.00% |
| Hospice Services
|
YES | 20% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Includes x-rays/regular imaging services; radiology (including mammograms), ultrasound or nuclear medicine; and advanced imaging, including CT scan, CTA scan, Magnetic Resonance Imaging (MRI); Magnetic Resonance Angiography (MRA); Magnetic Resonance Spectroscopy (MRS); Nuclear Cardiology; PET scans; PET/CT Fusion scans; QCT Bone Densitometry; Diagnostic CT Colonography; Single photon emission computed tomography (SPCECT) scans. |
YES | 20% Coinsurance after deductible |
100.00% |
| Infertility Treatment
Exclusions: Assisted reproductive technologies (ART) such as artificial insemination, in-vitro fertilization, zygote intrafallopian transfer (ZIFT), or gamete intrafallopian transfer (GIFT) are NOT covered. Covered Services include diagnostic tests to find the cause of infertility, such as diagnostic laparoscopy, endometrial biopsy, and semen analysis. Benefits also include services to treat the underlying medical conditions that cause infertility (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency). |
NO | ||
| Infusion Therapy
|
YES | 20% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is Medically Necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Benefits for room, board, and nursing services include: a room with two or more beds; a private room when medically necessary for isolation and no isolation facilities are available; a room in an approved special care unit; meals, special diets; general nursing services; operating, childbirth, and treatment rooms and equipment; prescribed drugs; anesthesia, anesthesia supplies and services given by the hospital or other provider; medical and surgical dressings and supplies, casts, and splints; blood and blood products; diagnostic services. Includes coverage for general anesthesia and hospitalization services when determined by dentist and treating physician that such services are required to effectively and safely provide dental care for (i) children under the age of 5, (ii) covered persons who are severely disabled, or (iii) covered persons who have a medical condition that requires admission to a hospital or Outpatient surgery facility. |
YES | 20% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
Benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is Medically Necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Includes medical care visits; intensive medical care when medically necessary; treatment for a health problem by a Doctor who is not your surgeon while you are in the Hospital for surgery; treatment by two or more Doctors during one Hospital stay when the nature or severity of your health problem calls for the skill of separate Doctors; a personal bedside exam by another Doctor when asked for by your Doctor; surgery and general anesthesia; professional charges to interpret diagnostic tests such as imaging, pathology reports, and cardiology. Surgeries and procedures to correct congenital abnormalities that cause functional impairment and congenital abnormalities in newborn children; other invasive procedures, such as angiogram, arteriogram, amniocentesis, tap or puncture of brain or spine; endoscopic exams, such as arthroscopy, bronchoscopy, colonoscopy, laparoscopy; treatment of fractures and dislocations; anesthesia and surgical support when medically necessary; medically necessary pre-operative and post-operative care. Medical benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is medically necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Includes surgical treatment of injuries and illnesses of the eye. |
YES | 20% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 20% Coinsurance after deductible |
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
Benefit limitations may apply to individual services. |
YES | 20% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | 20% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | 20% Coinsurance after deductible |
100.00% |
| Non-Preferred Brand Drugs
Limit: 30.0 Days per Month Non-preferred brand medications are available in 90-day supplies through preferred retail pharmacies or home delivery. Limited to 30 day supplies at all other pharmacies. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply. |
YES | 30% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
|
YES | 20% Coinsurance after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Coverage is for medically necessary orthodontia only. |
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)
Benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is Medically Necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Includes coverage for blood and blood products, anesthesia and anesthesia supplies and services given by the Hospital or other Facility, medical and surgical dressings and supplies, casts, and splints. Includes coverage for general anesthesia and hospitalization services when determined by dentist and treating physician that such services are required to effectively and safely provide dental care for (i) children under the age of 5, (ii) covered persons who are severely disabled, or (iii) covered persons who have a medical condition that requires admission to a hospital or Outpatient surgery facility. Surgeries and procedures to correct congenital abnormalities that cause functional impairment and congenital abnormalities in newborn children; other invasive procedures, such as angiogram, arteriogram, amniocentesis, tap or puncture of brain or spine; endoscopic exams, such as arthroscopy, bronchoscopy, colonoscopy, laparoscopy; treatment of fractures and dislocations; anesthesia and surgical support when Medically Necessary; Medically Necessary pre-operative and post-operative care. Benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is Medically Necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Includes surgical treatment of injuries and illnesses of the eye. |
YES | 20% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Benefit Period Limited to 30 visits per year combined for Physical and Occupational Therapy, 30 visits per year for Speech Therapy. Limits will not apply if care is part of the hospice care benefit. When you get physical, occupational or speech therapy, in the home, the home health care visit limit will apply instead of the therapy services limits listed above. Limit does not apply when received as part of the hospice, early intervention benefit, and for the treatment of autism spectrum disorders. |
YES | 20% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
Benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is Medically Necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Includes coverage for blood and blood products, anesthesia and anesthesia supplies and services given by the Hospital or other Facility, medical and surgical dressings and supplies, casts, and splints. Includes coverage for general anesthesia and hospitalization services when determined by dentist and treating physician that such services are required to effectively and safely provide dental care for (i) children under the age of 5, (ii) covered persons who are severely disabled, or (iii) covered persons who have a medical condition that requires admission to a hospital or Outpatient surgery facility. Surgeries and procedures to correct congenital abnormalities that cause functional impairment and congenital abnormalities in newborn children; other invasive procedures, such as angiogram, arteriogram, amniocentesis, tap or puncture of brain or spine; endoscopic exams, such as arthroscopy, bronchoscopy, colonoscopy, laparoscopy; treatment of fractures and dislocations; anesthesia and surgical support when Medically Necessary; Medically Necessary pre-operative and post-operative care. Benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is Medically Necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Includes surgical treatment of injuries and illnesses of the eye. |
YES | 20% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
Limit: 30.0 Days per Month Preferred brand medications are available in 90-day supplies through preferred retail pharmacies or home delivery. Limited to 30 day supplies at all other pharmacies. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply. |
YES | $45.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge |
100.00% |
| Preventive Care/Screening/Immunization
Covers: (1) Services with an 'A' or 'B' rating from the United States Preventive Services Task Force; (2) Immunizations for children, adolescents, and adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; (3) Preventive care and screenings for infants, children and adolescents as listed in the guidelines supported by the Health Resources and Services Administration (including infant hearing screening); (4) Preventive care and screening for women as listed in the guidelines supported by the Health Resources and Services Administration; and (5) Counseling services related to smoking and tobacco use cessation. Prescription drugs that help you stop smoking or reduce your dependence on tobacco products are also covered preventive services. Smoking cessation products and over the counter nicotine replacement products (limited to nicotine patches and gum) are covered when obtained with a prescription. Additionally, state law requires coverage for routine screening mammograms and routine prostate specific antigen testing and digital rectal exams. |
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Virtual urgent care visits via a Designated virtual provider unlimited $0 |
YES | No Charge |
100.00% |
| Private-Duty Nursing
Limit: 16.0 Hours per Benefit Period Exclusions: Coverage does not include benefits for private duty nursing in the inpatient setting. |
YES | 20% Coinsurance after deductible |
100.00% |
| Prosthetic Devices
Includes benefits for prosthetics and components when they are medically necessary for activities of daily living. A prosthetic device is an artificial substitute to replace, in whole or in part, a limb or body part, such as an arm, leg, foot or eye. Includes benefits for prosthetics and components when they are medically necessary for activities of daily living. A prosthetic device is an artificial substitute to replace, in whole or in part, a limb or body part, such as an arm, leg, foot or eye. Coverage is also included for the repair, fitting, adjustments and replacement of a prosthetic device. In additional, components for artificial limbs are covered. Components are the materials and equipment needed to ensure the comfort and functioning of the prosthetic device. Covered services may include: 1) Artificial limbs and components (the materials and equipment needed to ensure the comfort and functioning of the prosthetic device); 2) Breast prosthesis (whether internal or external) after a mastectomy, as required by the Women?s Health and Cancer Rights Act. 3). Colostomy and other ostomy (surgical construction of an artificial opening) supplies directly related to ostomy care. 4) Restoration prosthesis (composite facial prosthesis) 5) Wigs needed after cancer treatment (limited to one wig per benefit period). |
YES | 20% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 20% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Includes benefits for prosthetics and components when they are medically necessary for activities of daily living. A prosthetic device is an artificial substitute to replace, in whole or in part, a limb or body part, such as an arm, leg, foot or eye. Includes benefits for prosthetics and components when they are medically necessary for activities of daily living. A prosthetic device is an artificial substitute to replace, in whole or in part, a limb or body part, such as an arm, leg, foot or eye. Coverage is also included for the repair, fitting, adjustments and replacement of a prosthetic device. In additional, components for artificial limbs are covered. Components are the materials and equipment needed to ensure the comfort and functioning of the prosthetic device. Covered services may include: 1) Artificial limbs and components (the materials and equipment needed to ensure the comfort and functioning of the prosthetic device); 2) Breast prosthesis (whether internal or external) after a mastectomy, as required by the Women?s Health and Cancer Rights Act. 3) Colostomy and other ostomy (surgical construction of an artificial opening) supplies directly related to ostomy care. 4) Restoration prosthesis (composite facial prosthesis) 5) Wigs needed after cancer treatment (limited to one wig per benefit period). |
YES | 20% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Benefit Period Exclusions: Occupational therapy does not include recreational or vocational therapies, such as hobbies, arts and crafts. Non-covered providers include, but are not limited to, masseurs or masseuses (massage therapists), and physical therapist technicians. Limited to 30 visits per year combined for Physical and Occupational Therapy. The limit applies separately to habilitative and rehabilitative services. Limit does not apply when received as part of hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders. |
YES | 20% Coinsurance after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Benefit Period Includes services to identify, assess, and treat speech, language, and swallowing disorders in children and adults. Therapy will develop or treat communication or swallowing skills to correct a speech impairment. Limit does not apply when received as part of hospice benefit, early intervention benefit or for the treatment autism spectrum disorder. Limit applies separately to habilitative and rehabilitative service. |
YES | 20% Coinsurance after deductible |
100.00% |
| Routine Dental Services (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 | 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: 100.0 Days per Stay Exclusions: Custodial care even if it is recommended by a professional or performed in a facility, such as a Skilled Nursing Facility. Includes Inpatient Rehab Services. Includes room and board in semi-private accommodations; rehabilitative services; and drugs, biologicals, and supplies furnished for use in the skilled nursing facility and other medically necessary services and supplies. Your Plan will cover the private room charge when medically necessary. |
YES | 20% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | 20% Coinsurance after deductible |
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. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply. |
YES | 40% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 20% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | 20% Coinsurance after deductible |
100.00% |
| Transplant
Includes coverage for medically necessary human organ, tissue, and stem cell/bone marrow transplants and infusions including necessary acquisition procedures, mobilization, harvest and storage. It also includes medically necessary myeloablative or reduced intensity preparative chemotherapy, radiation therapy, or a combination of these therapies. |
YES | 20% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Exclusions: The medical benchmark benefits exclude fixed or removable appliances that involve movement or repositioning of the teeth, repair of teeth (fillings), or prosthetics (crowns, bridges, dentures). |
YES | 20% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | 20% Coinsurance after deductible |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
Includes immunizations for children recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; Preventive care and screenings for infants as listed in the guidelines supported by the Health Resources and Services Administration (including infant hearing screening). |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
Includes benefits for tests or procedures to find or check a condition when specific symptoms exist, as well as benefits for interpretation of diagnostic tests such as imaging, and cardiology. Tests must be ordered by a Provider and include diagnostic services ordered before a surgery or Hospital admission. Benefits include the following services: x-rays/regular imaging services; radiology (including mammograms), ultrasound or nuclear medicine. |
YES | 20% Coinsurance after deductible |
100.00% |
UHC Gold-B Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $2 T1 Preferred Rx, Dental + Vision) Health Insurance Plan Variant 24251VA0060018-03 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 | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Limited Cost Sharing Plan Variation |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| EHB Percent of Total Premium | 0.9384 |
| First Tier Utilization | 100% |
| Formulary ID | VAF011 |
| Formulary URL | URL |
| HIOS Product ID | 24251VA006 |
| Import Date | 8/17/2022 20:01 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | Yes |
| Issuer Actuarial Value | 81.23% |
| Issuer ID | 24251 |
| 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 | VAN001 |
| 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 | 1/1/2023 |
| Plan ID (Standard Component ID with Variant) | 24251VA0060018-03 |
| Plan Level Exclusions | 0 |
| Plan Marketing Name | UHC Gold Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $2 T1 Preferred Rx, Dental + Vision) |
| Plan Type | HMO |
| Plan Variant Marketing Name | UHC Gold-B Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $2 T1 Preferred Rx, Dental + Vision) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,900 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $1,200 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $20 |
| SBC Scenario, Having Diabetes, Copayment | $600 |
| SBC Scenario, Having Diabetes, Deductible | $1,200 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $500 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,200 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | VAS001 |
| Source Name | SERFF |
| Specialist Requiring a Referral | All, except OBGYN and as state mandated |
| Plan ID | 24251VA0060018 |
| State Code | VA |
| 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+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $2 T1 Preferred Rx, Dental + Vision) Health Insurance Plan, 24251VA0060018
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about UHC Gold Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $2 T1 Preferred Rx, Dental + Vision), 24251VA0060018 Health Insurance Plan, 24251VA0060018
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Does UHC Gold Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $2 T1 Preferred Rx, Dental + Vision) Health Insurance Plan, 24251VA0060018 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (24251VA0060018) Health Insurance Plan, Variant (24251VA0060018-03) have Out Of Country Coverage?
Does (24251VA0060018) Health Insurance Plan, Variant (24251VA0060018-03) have Out of Service Area Coverage?
Disclaimer: This is based on the import(Date: Tue, 22 Oct 2024 06:47 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