UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $3 Tier 2 Rx, $0 Insulin, No Referrals) - 69842LA0240023 Health Insurance Plan
UnitedHealthcare Insurance Company health insurance plan with the Plan ID 69842LA0240023. The plan is called UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $3 Tier 2 Rx, $0 Insulin, No Referrals).
Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.01% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.99% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 69842LA0240023 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Louisiana | ||||||||||||||||||
| Health Insurance Issuer | UnitedHealthcare Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 69842LA0240023-03 | ||||||||||||||||||
| 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 - 69842LA0240023-00 Standard On Exchange Plan - 69842LA0240023-01 |
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| Last Plan Update Date | Sat, 16 Dec 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $3 Tier 2 Rx, $0 Insulin, No Referrals) Health Insurance Plan, 69842LA0240023-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 45.00% |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $60.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
Benefit limitations may apply to individual services. |
YES | 45.00% |
100.00% |
| Chemotherapy
|
YES | 45.00% |
100.00% |
| Chiropractic Care
|
YES | 45.00% |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Childbirth/delivery professional services follow inpatient physician/surgeon fees |
YES | $2,000.00 |
100.00% |
| Dental Check-Up for Children
Limit: 1.0 Visit(s) per 6 Months |
YES | No Charge |
100.00% |
| Diabetes Education
|
YES | 45.00% |
100.00% |
| Dialysis
|
YES | 45.00% |
100.00% |
| Durable Medical Equipment
|
YES | 45.00% |
100.00% |
| Emergency Room Services
|
YES | $600.00 |
$600.00 |
| Emergency Transportation/Ambulance
|
YES | 45.00% |
45.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | 45.00% |
100.00% |
| Gender Affirming Care
|
NO | ||
| 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. See SBC for non-preferred generic cost shares. Generic medications are available in 90-day supplies through 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. |
YES | $3.00 |
100.00% |
| Habilitation Services
Visit limits do not apply for physical therapy, occupational therapy, and speech therapy. |
YES | $60.00 |
100.00% |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years Benefits are limited to one hearing aid, per hearing impaired ear, in a thirty-six (36) month period. |
YES | 45.00% |
100.00% |
| Home Health Care Services
Limit: 60.0 Visit(s) per Year |
YES | 45.00% |
100.00% |
| Hospice Services
|
YES | 45.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $300.00 |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 45.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | $2000 Copay per Day |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 45.00% |
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
|
NO | ||
| Major Dental Care - Child
Benefit limitations may apply to individual services. |
YES | 45.00% |
100.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | $2000 Copay per Day |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $60.00 |
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. Non-preferred brand medications are available in 90-day supplies through 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. |
YES | 45% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
|
YES | 45.00% |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Coverage is for medically necessary orthodontia only. |
YES | 50.00% |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | 45.00% |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $300.00 |
100.00% |
| Outpatient Rehabilitation Services
Visit limits do not apply for physical therapy, occupational therapy, and speech therapy. |
YES | $60.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $300.00 |
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. Preferred brand medications are available in 90-day supplies through 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. |
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 | $5.00 |
100.00% |
| Private-Duty Nursing
Limit: 22.0 Visit(s) per Year Exclusions: Inpatient Private Duty Nursing Service is not covered. Private Duty Nursing services covered as a part of the Home Health Care benefit. |
YES | 45.00% |
100.00% |
| Prosthetic Devices
|
YES | 45.00% |
100.00% |
| Radiation
|
YES | 45.00% |
100.00% |
| Reconstructive Surgery
|
YES | $300.00 |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
|
YES | $60.00 |
100.00% |
| Rehabilitative Speech Therapy
|
YES | $60.00 |
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 | $2000 Copay per Day |
100.00% |
| Specialist Visit
|
YES | $60.00 |
100.00% |
| Specialty Drugs
Limit: 30.0 Days per Month Covers outpatient self-administered prescription legend drugs from a participating network pharmacy. Quantity limits per prescription may apply. |
YES | 50% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | $2000 Copay per Day |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $60.00 |
100.00% |
| Transplant
|
YES | $2,000.00 |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| 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-B Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $3 Tier 2 Rx, $0 Insulin, No Referrals) Health Insurance Plan Variant 69842LA0240023-03 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 | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Limited Cost Sharing Plan Variation |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $1000 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $500 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $500 |
| Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | LAF011 |
| Formulary URL | URL |
| HIOS Product ID | 69842LA024 |
| Import Date | 2023-12-16 01:02:09 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 3 |
| HSA Eligible | No |
| New/Existing Plan | New |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 81.01% |
| Issuer ID | 69842 |
| Issuer Marketplace Marketing Name | UnitedHealthcare |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | No |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 45.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $0 |
| Medical EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | LAN001 |
| 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 |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan ID (Standard Component ID with Variant) | 69842LA0240023-03 |
| Plan Marketing Name | UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $3 Tier 2 Rx, $0 Insulin, No Referrals) |
| Plan Type | EPO |
| Plan Variant Marketing Name | UHC Gold-B Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $3 Tier 2 Rx, $0 Insulin, No Referrals) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $100 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $200 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,100 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | LAS001 |
| Source Name | HIOS |
| Plan ID | 69842LA0240023 |
| State Code | LA |
| 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 |
| 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 Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $3 Tier 2 Rx, $0 Insulin, No Referrals) Health Insurance Plan, 69842LA0240023
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $3 Tier 2 Rx, $0 Insulin, No Referrals), 69842LA0240023 Health Insurance Plan, 69842LA0240023
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Does UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $3 Tier 2 Rx, $0 Insulin, No Referrals) Health Insurance Plan, 69842LA0240023 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (69842LA0240023) Health Insurance Plan, Variant (69842LA0240023-03) have Out Of Country Coverage?
Does (69842LA0240023) Health Insurance Plan, Variant (69842LA0240023-03) 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