UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $3 Tier 2 Rx) - 40702AZ0060047 Health Insurance Plan
UnitedHealthcare of Arizona, Inc. health insurance plan with the Plan ID 40702AZ0060047. The plan is called UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $3 Tier 2 Rx).
Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.39% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.61% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 40702AZ0060047 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Arizona | ||||||||||||||||||
| Health Insurance Issuer | UnitedHealthcare of Arizona, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 40702AZ0060047-00 | ||||||||||||||||||
| Provider Network(s) | NON-PREFERRED NETWORK | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 24 Dec 2024 06:21 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 40702AZ0060047-00 Standard On Exchange Plan - 40702AZ0060047-01 |
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| Last Plan Update Date | Fri, 16 Aug 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 24 Dec 2024 06:21 GMT |
Benefits of UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $3 Tier 2 Rx) Health Insurance Plan, 40702AZ0060047-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 30.00% |
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 | 30.00% |
100.00% |
| Chemotherapy
|
YES | $500.00 |
100.00% |
| Chiropractic Care
Limit: 20.0 Visit(s) per Year |
YES | $10.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
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 | 30.00% |
100.00% |
| Dialysis
|
YES | $500.00 |
100.00% |
| Durable Medical Equipment
|
YES | 30.00% |
100.00% |
| Emergency Room Services
|
YES | $650.00 |
$650.00 |
| Emergency Transportation/Ambulance
|
YES | $650.00 |
$650.00 |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | 30.00% |
100.00% |
| Gender Affirming Care
Covered when medically necessary. |
YES | $300.00 |
100.00% |
| Generic Drugs
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. |
YES | $3.00 |
100.00% |
| Habilitation Services
Limit: 60.0 Visit(s) per Year Visit limit applies to any combination of PT, OT, and ST. Limit does not apply for therapies to treat autism, mental health disorders, or substance-related and addictive disorders. |
YES | $60.00 |
100.00% |
| Hearing Aids
Limit: 1.0 Item(s) per Year Limited to one per hearing impaired ear per year. |
YES | 30.00% |
100.00% |
| Home Health Care Services
Limit: 42.0 Visit(s) per Year |
YES | 30.00% |
100.00% |
| Hospice Services
|
YES | 30.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $300.00 |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | $75.00 |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | $2000.00 Copay per Day |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | No Charge |
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 | 30.00% |
100.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | $2000.00 Copay per Day |
100.00% |
| Mental/Behavioral Health Outpatient Services
Cost share applies to office visits, please see SBC for Mental Health Outpatient Services. |
YES | $30.00 |
100.00% |
| Non-Preferred Brand Drugs
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. |
YES | 45.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
Medical or behavioral/mental health related nutritional education services that are provided as part of treatment for a disease are covered |
YES | 30.00% |
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 | 30.00% |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $300.00 |
100.00% |
| Outpatient Rehabilitation Services
Limit: 60.0 Visit(s) per Year Visit limit applies to any combination of PT, OT, and ST. Limit does not apply to pulmonary or cardiac rehabilitation therapy. |
YES | $60.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $300.00 |
100.00% |
| Preferred Brand Drugs
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. |
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. |
YES | $10.00 |
100.00% |
| Private-Duty Nursing
Private duty nursing is only available during inpatient stays and when determined to be medically necessary. |
YES | 30.00% |
100.00% |
| Prosthetic Devices
|
YES | 30.00% |
100.00% |
| Radiation
|
YES | $75.00 |
100.00% |
| Reconstructive Surgery
Reconstructive procedures are covered when the primary purpose of the procedure is either treatment of a medical condition or required to improve or restore physiologic function. |
YES | $300.00 |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 60.0 Visit(s) per Year Visit limit applies to any combination of PT, OT, and ST. |
YES | $60.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 60.0 Visit(s) per Year Visit limit applies to any combination of PT, OT, and ST. |
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
Covered as medically necessary for the prevention of complications associated with metabolic, neurologic, or peripheral vascular disease |
NO | ||
| Skilled Nursing Facility
Limit: 90.0 Days per Year Limit of 90 days will be any combination of Skilled Nursing Facility or Inpatient Rehabilitation Facility Services. |
YES | $2000.00 Copay per Day |
100.00% |
| Specialist Visit
|
YES | $50.00 |
100.00% |
| Specialty Drugs
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. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | $2000.00 Copay per Day |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $30.00 |
100.00% |
| Transplant
|
YES | $2,000.00 |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 30.00% |
100.00% |
| Urgent Care Centers or Facilities
$0 Virtual Urgent Care visits are available through vendor. See SBC for additional cost share details for in-person urgent care visits. |
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 Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $3 Tier 2 Rx) Health Insurance Plan Variant 40702AZ0060047-00 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 | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold Off Exchange Plan |
| 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 | $500 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $250 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $250 |
| 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 | AZF033 |
| Formulary URL | URL |
| HIOS Product ID | 40702AZ006 |
| Import Date | 2024-08-16 01:01:20 |
| 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? | Yes |
| Issuer Actuarial Value | 81.39% |
| Issuer ID | 40702 |
| 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 | 30.00% |
| 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 | AZN011 |
| 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 plan also covers emergency health care services received outside the service area. |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan ID (Standard Component ID with Variant) | 40702AZ0060047-00 |
| Plan Level Exclusions | Some exclusions may apply. See the applicable Certificate of Coverage for details. |
| Plan Marketing Name | UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $3 Tier 2 Rx) |
| Plan Type | HMO |
| Plan Variant Marketing Name | UHC Gold-X Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $3 Tier 2 Rx) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $2,400 |
| 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 | $400 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $10 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,800 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | AZS011 |
| Source Name | HIOS |
| Specialist Requiring a Referral | All, except OBGYN and as state mandated. |
| Plan ID | 40702AZ0060047 |
| State Code | AZ |
| 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 | $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 Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $3 Tier 2 Rx) Health Insurance Plan, 40702AZ0060047
| 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), 40702AZ0060047 Health Insurance Plan, 40702AZ0060047
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Does UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $3 Tier 2 Rx) Health Insurance Plan, 40702AZ0060047 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (40702AZ0060047) Health Insurance Plan, Variant (40702AZ0060047-00) have Out Of Country Coverage?
Does (40702AZ0060047) Health Insurance Plan, Variant (40702AZ0060047-00) have Out of Service Area Coverage?
Disclaimer: This is based on the import(Date: Tue, 24 Dec 2024 06:21 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