UnitedHealthcare of Arizona, Inc. health insurance plan with the Plan ID 40702AZ0060016. The plan is called UHC Gold Standard.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.00% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 22.00% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
Health Insurance Plan ID | 40702AZ0060016 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
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 | 40702AZ0060016-01 | ||||||||||||||||||
Provider Network(s) | ['AZN001'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 01 Oct 2024 06:11 GMT). |
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Available Variants of the Health Plan | Standard Off Exchange Plan - 40702AZ0060016-00 Standard On Exchange Plan - 40702AZ0060016-01 |
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Last Plan Update Date | Wed, 17 Aug 2022 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 01 Oct 2024 06:11 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
|
NO | ||
Accidental Dental
|
YES | 25% Coinsurance after deductible |
100.00% |
Acupuncture
|
NO | ||
Allergy Testing
|
YES | 25% Coinsurance after deductible |
100.00% |
Bariatric Surgery
The plan covers surgical treatment of morbid obesity provided certain criteria is met. |
YES | 25% Coinsurance after deductible |
100.00% |
Basic Dental Care - Adult
|
NO | ||
Basic Dental Care - Child
Benefit limitations may apply to individual services. |
YES | 25% Coinsurance after deductible |
100.00% |
Chemotherapy
|
YES | 25% Coinsurance after deductible |
100.00% |
Chiropractic Care
Limit: 20.0 Visit(s) per Year |
YES | 25% Coinsurance after deductible |
100.00% |
Cosmetic Surgery
|
NO | ||
Delivery and All Inpatient Services for Maternity Care
Newborn benefits do not apply to the newly born child of an Eligible Dependent daughter unless placement with the Employee is confirmed through a court order or legal guardianship. Childbirth/delivery professional services follow inpatient physician/surgeon fees. |
YES | 25% 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 | 25% Coinsurance after deductible |
100.00% |
Dialysis
|
YES | 25% Coinsurance after deductible |
100.00% |
Durable Medical Equipment
Exclusions: 1. Hygienic or self-help items or equipment; 2. Items or equipment primarily used for comfort or convenience such as bathtub chairs, safety grab bars, stair gliders or elevators, over-the-bed tables, saunas or exercise equipment; 3. Environmental control equipment, such as air purifiers, humidifiers and electrostatic machines; 4. Institutional equipment, such as air fluidized beds and diathermy machines; 5. Elastic stockings and wigs (except were indicated for coverage); 6. Equipment used for the purpose of participation in sports or other recreational activities including, but not limited to, braces and splints; 7. Items, such as auto tilt chairs, paraffin bath units and whirlpool baths, which are not generally accepted by the medical profession as being therapeutically effective; 8. Items which under normal use would constitute a fixture to real property, such as lifts, ramps, railings, and grab bars; and 9. Hearing aid batteries (except those for cochlear implants) and chargers. |
YES | 25% Coinsurance after deductible |
100.00% |
Emergency Room Services
|
YES | 25.00% Coinsurance after deductible |
25% Coinsurance after deductible |
Emergency Transportation/Ambulance
|
YES | 25% Coinsurance after deductible |
25% Coinsurance after deductible |
Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | 25% Coinsurance after deductible |
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. |
YES | $15.00 |
100.00% |
Habilitation Services
Limit: 60.0 Visit(s) per Year 60 visits per year for any combination of physical therapy, occupational therapy and speech therapy. Visit limits do not apply for therapies for covered persons with a primary diagnoses of autism spectrum disorder. Visit limits do not apply if the primary diagnosis code for the outpatient habilitative services being provided is one for a covered mental disorder or for treatment of substance-related and addictive disorders. |
YES | $30.00 |
100.00% |
Hearing Aids
Limit: 1.0 Item(s) per Year |
YES | 25% Coinsurance after deductible |
100.00% |
Home Health Care Services
Limit: 42.0 Visit(s) per Year Exclusions: Home health services do not include services of a person who is a member of your family or your dependent?s family or who normally resides in your house or your dependent?s house. 1. The physician must have determined a medical need for home health care and developed a plan of care that is reviewed at thirty day intervals by the physician.; 2. The care described in the plan of care must be for intermittent skilled nursing, therapy, or speech services.; 3. The patient must be homebound unless services are determined to be medically necessary.; 4. The home health agency delivering care must be certified within the state the care is received.; 5. The care that is being provided is not custodial care. A Home Health visit is considered to be up to four hours of services. |
YES | 25% Coinsurance after deductible |
100.00% |
Hospice Services
Exclusions: Services of a person who is a member of your family or your dependent's family or who normally resides in your house or your dependent's house; Services and supplies for curative or life prolonging procedures; Services and supplies for which any other benefits are payable under the Plan; Services and supplies that are primarily to aid you or your dependent in daily living; Services and supplies for respite (custodial) care; and Nutritional supplements, non-prescription drugs or substances, medical supplies, vitamins or minerals. The Plan covers hospice care services which are provided under an approved hospice care program when provided to a Member who has been diagnosed by a Participating Provider as having a terminal illness with a prognosis of six (6) months or less to live. |
YES | 25% Coinsurance after deductible |
100.00% |
Imaging (CT/PET Scans, MRIs)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Infertility Treatment
|
NO | ||
Infusion Therapy
|
YES | 25% Coinsurance after deductible |
100.00% |
Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Inpatient Physician and Surgical Services
|
YES | 25% Coinsurance after deductible |
100.00% |
Laboratory Outpatient and Professional Services
|
YES | 25.00% Coinsurance after deductible |
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 | 25% Coinsurance after deductible |
100.00% |
Mental/Behavioral Health Inpatient Services
Exclusions: 1. Any court ordered treatment or therapy, or any treatment or therapy ordered as a condition of parole, probation or custody or visitation evaluations unless Medically Appropriate and otherwise covered under this Plan; 2. Treatment of mental disorders that have been diagnosed as organic mental disorders associated with permanent dysfunction of the brain; 3. Treatment of Chronic Conditions not subject to favorable modification according to generally accepted standards of medical practice; 4. Developmental disorders, including but not limited to: developmental reading disorders; developmental arithmetic disorders; developmental language disorders; or articulation disorders. 5. Counseling for activities of an educational nature; 6. Counseling for borderline intellectual functioning; 7. Counseling for occupational problems; 8. Counseling related to consciousness raising; 9. Vocational or religious counseling; 10. I.Q. testing; 11. Marriage counseling; 12. Custodial care, including but not limited to geriatric day care; 13. Psychological testing on children requested by or for a school system; 14. Occupational/recreational therapy programs even if combined with supportive therapy forage-related cognitive decline; and 15. Biofeedback is not covered for reasons other than pain management. |
YES | 25.00% Coinsurance after deductible |
100.00% |
Mental/Behavioral Health Outpatient Services
Exclusions: 1. Any court ordered treatment or therapy, or any treatment or therapy ordered as a condition of parole, probation or custody or visitation evaluations unless Medically Appropriate and otherwise covered under this Plan; 2. Treatment of mental disorders that have been diagnosed as organic mental disorders associated with permanent dysfunction of the brain; 3. Treatment of Chronic Conditions not subject to favorable modification according to generally accepted standards of medical practice; 4. Developmental disorders, including but not limited to: developmental reading disorders; developmental arithmetic disorders; developmental language disorders; or articulation disorders. 5. Counseling for activities of an educational nature; 6. Counseling for borderline intellectual functioning; 7. Counseling for occupational problems; 8. Counseling related to consciousness raising; 9. Vocational or religious counseling; 10. I.Q. testing; 11. Marriage counseling; 12. Custodial care, including but not limited to geriatric day care; 13. Psychological testing on children requested by or for a school system; 14. Occupational/recreational therapy programs even if combined with supportive therapy forage-related cognitive decline; and 15. Biofeedback is not covered for reasons other than pain management. |
YES | $30.00 |
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. |
YES | $60.00 |
100.00% |
Nutritional Counseling
|
YES | 25% 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 | 25% Coinsurance after deductible |
100.00% |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Outpatient Rehabilitation Services
Limit: 60.0 Visit(s) per Year Exclusions: The following limitations apply to short-term rehabilitative therapy except as required for the treatment for Autism Spectrum Disorder: 1. Occupational therapy is provided only for purposes of training Members to perform the activities of daily living. 2. Speech therapy is not covered when: a. Used to improve speech skills that have not fully developed; b. Considered custodial or educational; c. Intended to maintain speech communication; or d. Not restorative in nature. 3. Phase 3 cardiac rehabilitation is not covered. If multiple services are provided on the same day by different Providers, a separate co-payment will apply to each Provider. 60 visits per year for any combination of physical therapy, occupational therapy, and speech therapy. Short-term rehabilitative therapy includes services in an outpatient facility or physician?s office that is part of a rehabilitation program. Limits do not apply to pulmonary rehabilitation therapy and cardiac rehabilitation therapy. |
YES | $30.00 |
100.00% |
Outpatient Surgery Physician/Surgical Services
|
YES | 25.00% 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. |
YES | $30.00 |
100.00% |
Prenatal and Postnatal Care
|
YES | No Charge |
100.00% |
Preventive Care/Screening/Immunization
Well Woman and Well Man examinations are limited to 1 visit per year. |
YES | 0.00% |
100.00% |
Primary Care Visit to Treat an Injury or Illness
|
YES | $30.00 |
100.00% |
Private-Duty Nursing
Exclusions: Private Duty Nursing services provided in the home. Private duty nursing are only available during inpatient stays and determined to be medically appropriate by the Plan. Private duty nursing is available only in an inpatient setting when skilled nursing is not available from the facility. Custodial Nursing is not covered by the Plan. |
YES | 25% Coinsurance after deductible |
100.00% |
Prosthetic Devices
Exclusions: Replacement of external prosthetic appliance due to loss or theft. The Plan covers the initial purchase and fitting of external prosthetic devices which are used as a replacement or substitute for a missing body part and are necessary for the alleviation or correction of illness, injury, congenital defect, or alopecia as a result of chemotherapy, radiation therapy, and second or third degree burns. Limited to one wig or hairpiece per covered person per calendar year. |
YES | 25% Coinsurance after deductible |
100.00% |
Radiation
|
YES | 25% Coinsurance after deductible |
100.00% |
Reconstructive Surgery
|
YES | 25% Coinsurance after deductible |
100.00% |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 60.0 Visit(s) per Year Visit limit is for all therapy types combined (PT, OT, ST). |
YES | $30.00 |
100.00% |
Rehabilitative Speech Therapy
Limit: 60.0 Visit(s) per Year Visit limit is for all therapy types combined (PT, OT, ST). |
YES | $30.00 |
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
Limit: 90.0 Days per Year Limit will be any combination of Skilled Nursing Facility or Inpatient Rehabilitation Facility Services. |
YES | 25.00% Coinsurance after deductible |
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 | $250.00 |
100.00% |
Substance Abuse Disorder Inpatient Services
Exclusions: 1. Any court ordered treatment or therapy, or any treatment or therapy ordered as a condition of parole, probation or custody or visitation evaluations unless Medically Appropriate and otherwise covered under this Plan; 2. Treatment of mental disorders that have been diagnosed as organic mental disorders associated with permanent dysfunction of the brain; 3. Treatment of Chronic Conditions not subject to favorable modification according to generally accepted standards of medical practice; 4. Developmental disorders, including but not limited to: developmental reading disorders; developmental arithmetic disorders; developmental language disorders; or articulation disorders. 5. Counseling for activities of an educational nature; 6. Counseling for borderline intellectual functioning; 7. Counseling for occupational problems; 8. Counseling related to consciousness raising; 9. Vocational or religious counseling; 10. I.Q. testing; 11. Marriage counseling; 12. Custodial care, including but not limited to geriatric day care; 13. Psychological testing on children requested by or for a school system; 14. Occupational/recreational therapy programs even if combined with supportive therapy forage-related cognitive decline; and 15. Biofeedback is not covered for reasons other than pain management. |
YES | 25.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Outpatient Services
Exclusions: 1. Any court ordered treatment or therapy, or any treatment or therapy ordered as a condition of parole, probation or custody or visitation evaluations unless Medically Appropriate and otherwise covered under this Plan; 2. Treatment of mental disorders that have been diagnosed as organic mental disorders associated with permanent dysfunction of the brain; 3. Treatment of Chronic Conditions not subject to favorable modification according to generally accepted standards of medical practice; 4. Developmental disorders, including but not limited to: developmental reading disorders; developmental arithmetic disorders; developmental language disorders; or articulation disorders. 5. Counseling for activities of an educational nature; 6. Counseling for borderline intellectual functioning; 7. Counseling for occupational problems; 8. Counseling related to consciousness raising; 9. Vocational or religious counseling; 10. I.Q. testing; 11. Marriage counseling; 12. Custodial care, including but not limited to geriatric day care; 13. Psychological testing on children requested by or for a school system; 14. Occupational/recreational therapy programs even if combined with supportive therapy forage-related cognitive decline; and 15. Biofeedback is not covered for reasons other than pain management. |
YES | $30.00 |
100.00% |
Transplant
Benefits are available for transplants when the transplant meets the definition of a Covered Health Care Service, and is not an Experimental or Investigational or Unproven Service. Donor costs related to transplantation are Covered Health Care Services and are payable through the organ recipient's coverage under this Policy, limited to donor: Identification, Evaluation, Organ removal, and Direct follow-up care. |
YES | 25% Coinsurance after deductible |
100.00% |
Treatment for Temporomandibular Joint Disorders
Benefits are payable for covered services and supplies which are necessary to treat TMJ disorder which is a result of: 1. An accident; 2. Trauma; 3. A congenital defect; 4. A developmental defect; or 5. A pathology. |
YES | 25% Coinsurance after deductible |
100.00% |
Urgent Care Centers or Facilities
|
YES | $45.00 |
100.00% |
Weight Loss Programs
|
NO | ||
Well Baby Visits and Care
Well Child visits and immunizations are covered through 47 months as recommended by the American Academy of Pediatrics. |
YES | No Charge |
100.00% |
X-rays and Diagnostic Imaging
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 0.78 |
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 | Standard Gold On Exchange Plan |
Dental Only Plan | No |
Design Type | Design 1 |
EHB Percent of Total Premium | 1 |
First Tier Utilization | 100% |
Formulary ID | AZF013 |
Formulary URL | URL |
HIOS Product ID | 40702AZ006 |
Import Date | 8/17/2022 1:01 |
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 ID | 40702 |
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 | AZN001 |
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 | 1/1/2023 |
Plan ID (Standard Component ID with Variant) | 40702AZ0060016-01 |
Plan Level Exclusions | 0 |
Plan Marketing Name | UHC Gold Standard |
Plan Type | HMO |
Plan Variant Marketing Name | UHC Gold Standard |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $2,200 |
SBC Scenario, Having a Baby, Copayment | $10 |
SBC Scenario, Having a Baby, Deductible | $2,000 |
SBC Scenario, Having a Baby, Limit | $60 |
SBC Scenario, Having Diabetes, Coinsurance | $20 |
SBC Scenario, Having Diabetes, Copayment | $700 |
SBC Scenario, Having Diabetes, Deductible | $2,000 |
SBC Scenario, Having Diabetes, Limit | $0 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $50 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $100 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,000 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | AZS001 |
Source Name | HIOS |
Specialist Requiring a Referral | All, except OBGYN and as state mandated |
Plan ID | 40702AZ0060016 |
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 |
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 | 25.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $4000 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $2000 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $2,000 |
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 | $17400 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8700 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,700 |
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 | No |
URL for Enrollment Payment | URL |
URL for Summary of Benefits & Coverage | URL |
Wellness Program Offered | No |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 01 Oct 2024 06:11 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