UHC Gold Advantage (Virtual Urgent Care + PCP Visits, Rx Copay) - 42529IL0070026 Health Insurance Plan
UnitedHealthcare of Illinois, Inc. health insurance plan with the Plan ID 42529IL0070026. The plan is called UHC Gold Advantage (Virtual Urgent Care + PCP Visits, Rx Copay).
Based on the data of Health Plan Issuer, this plan has an actuarial value of 78.73% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 21.27% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 42529IL0070026 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Illinois | ||||||||||||||||||
| Health Insurance Issuer | UnitedHealthcare of Illinois, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 42529IL0070026-00 | ||||||||||||||||||
| Provider Network(s) | NETWORK NON-PREFERRED | ||||||||||||||||||
| 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 - 42529IL0070026-00 Standard On Exchange Plan - 42529IL0070026-01 |
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| Last Plan Update Date | Thu, 30 Nov 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of UHC Gold Advantage (Virtual Urgent Care + PCP Visits, Rx Copay) Health Insurance Plan, 42529IL0070026-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
YES | $300.00 |
100.00% |
| Accidental Dental
|
YES | 20% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $50.00 |
100.00% |
| Bariatric Surgery
|
YES | $300.00 |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| 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: 25.0 Visit(s) per Year |
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
|
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 for Children
Limit: 1.0 Item(s) per Year |
YES | 20% Coinsurance after deductible |
100.00% |
| Gender Affirming Care
|
YES | $300.00 |
100.00% |
| 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
|
YES | $50.00 |
100.00% |
| Hearing Aids
Limit: 1.0 Item(s) per 2 Years Benefits will be provided for hearing aids for children age 18 and under and are limited to one hearing instrument per hearing imparied ear every 24 months. For covered persons age 19 and older, benefits are limited to one hearing instrument per hearing impaired ear every 24 months, up to $2,500 per hearing impaired ear. Benefits for bone anchored hearing aids are covered for all ages and not subject to benefit limit. |
YES | 20% Coinsurance after deductible |
100.00% |
| Home Health Care Services
|
YES | 20% Coinsurance after deductible |
100.00% |
| Hospice Services
|
YES | 20% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $250.00 |
100.00% |
| Infertility Treatment
Limit: 6.0 Procedure(s) per Lifetime The maximum number of completed oocyte retrievals that are eligible for coverage under this Certificate in your lifetime is six. Following the final completed oocyte retrieval, benefits will be provided for one subsequent procedure to transfer the oocytes or sperm to you.Thereafter, you will have no benefits for infertility treatment. |
YES | 20% Coinsurance after deductible |
100.00% |
| 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
|
YES | $10.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| 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 | $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 | $75.00 |
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)
|
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
|
YES | No Charge |
100.00% |
| Preventive Care/Screening/Immunization
|
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 | No Charge |
100.00% |
| Private-Duty Nursing
Exclusions: Inpatient Private Duty Nursing Service is not covered. Private Duty Nursing services will be covered as a part of the Home Health Care benefit. |
YES | 20% Coinsurance after deductible |
100.00% |
| Prosthetic Devices
|
YES | 20% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 20% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
|
YES | $300.00 |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
|
YES | $50.00 |
100.00% |
| Rehabilitative Speech Therapy
|
YES | $50.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year |
YES | No Charge |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
|
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 | $250.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 20% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $50.00 |
100.00% |
| Transplant
|
YES | 20% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 20% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
$0 Virtual Urgent Care visits. See SBC for additional cost share details. |
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-X Advantage (Virtual Urgent Care + PCP Visits, Rx Copay) Health Insurance Plan Variant 42529IL0070026-00 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 Off Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| EHB Percent of Total Premium | 0.998371706975779 |
| First Tier Utilization | 100% |
| Formulary ID | ILF010 |
| Formulary URL | URL |
| HIOS Product ID | 42529IL007 |
| Import Date | 2023-11-30 20:02:19 |
| 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? | Yes |
| Issuer Actuarial Value | 78.73% |
| Issuer ID | 42529 |
| 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 | ILN001 |
| 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) | 42529IL0070026-00 |
| Plan Marketing Name | UHC Gold Advantage (Virtual Urgent Care + PCP Visits, Rx Copay) |
| Plan Type | HMO |
| Plan Variant Marketing Name | UHC Gold-X Advantage (Virtual Urgent Care + PCP Visits, Rx Copay) |
| 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 | $1,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $200 |
| SBC Scenario, Having Diabetes, Deductible | $1,500 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $90 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $400 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | ILS001 |
| Source Name | SERFF |
| Specialist Requiring a Referral | All, except OBGYN and as state mandated |
| Plan ID | 42529IL0070026 |
| State Code | IL |
| 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 | $3000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,500 |
| 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 | $14000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,000 |
| 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 (Virtual Urgent Care + PCP Visits, Rx Copay) Health Insurance Plan, 42529IL0070026
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about UHC Gold Advantage (Virtual Urgent Care + PCP Visits, Rx Copay), 42529IL0070026 Health Insurance Plan, 42529IL0070026
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Does UHC Gold Advantage (Virtual Urgent Care + PCP Visits, Rx Copay) Health Insurance Plan, 42529IL0070026 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (42529IL0070026) Health Insurance Plan, Variant (42529IL0070026-00) have Out Of Country Coverage?
Does (42529IL0070026) Health Insurance Plan, Variant (42529IL0070026-00) 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