UHC Gold Standard (No Referrals) - 45480OK0050028 Health Insurance Plan
UnitedHealthcare of Oklahoma, Inc. health insurance plan with the Plan ID 45480OK0050028. The plan is called UHC Gold Standard (No Referrals).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 100.00% (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 0.00% 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 | 45480OK0050028 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Oklahoma | ||||||||||||||||||
| Health Insurance Issuer | UnitedHealthcare of Oklahoma, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 45480OK0050028-02 | ||||||||||||||||||
| Provider Network(s) | NETWORK NON-PREFERRED | ||||||||||||||||||
| 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 - 45480OK0050028-00 Standard On Exchange Plan - 45480OK0050028-01 |
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| Last Plan Update Date | Tue, 12 Dec 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 24 Dec 2024 06:21 GMT |
Benefits of UHC Gold Standard (No Referrals) Health Insurance Plan, 45480OK0050028-02
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Exclusions: This exclusion does not apply when the mother's life is endangered. |
NO | ||
| Accidental Dental
|
YES | $0.00, 0.00% |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $0.00, 0.00% |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
Benefit limitations may apply to individual services. |
YES | $0.00, 0.00% |
100.00% |
| Chemotherapy
|
YES | $0.00, 0.00% |
100.00% |
| Chiropractic Care
|
YES | $0.00, 0.00% |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Childbirth/delivery professional services follow inpatient physician/surgeon fees. |
YES | $0.00, 0.00% |
100.00% |
| Dental Check-Up for Children
Limit: 1.0 Visit(s) per 6 Months |
YES | $0.00, 0.00% |
100.00% |
| Diabetes Education
|
YES | $0.00, 0.00% |
100.00% |
| Dialysis
|
YES | $0.00, 0.00% |
100.00% |
| Durable Medical Equipment
|
YES | $0.00, 0.00% |
100.00% |
| Emergency Room Services
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Emergency Transportation/Ambulance
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Eye Glasses - Adult
|
NO | ||
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | $0.00, 0.00% |
100.00% |
| Gender Affirming Care
|
NO | ||
| 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 | $0.00, 0.00% |
100.00% |
| Habilitation Services
Limit: 25.0 Visit(s) per Year Limited to 25 visits per year combined for Physical, Occupational and Speech Therapy. Treatment of Autism and Autism Spectrum Disorders are unlimited. |
YES | $0.00, 0.00% |
100.00% |
| Hearing Aids
One hearing aid per hearing impaired ear every 48 months for Covered Persons. |
YES | $0.00, 0.00% |
100.00% |
| Home Health Care Services
Limit: 30.0 Visit(s) per Year |
YES | $0.00, 0.00% |
100.00% |
| Hospice Services
|
YES | $0.00, 0.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $0.00, 0.00% |
100.00% |
| Infertility Treatment
Exclusions: This exclusion does not apply to diagnosis and services required to treat or correct underlying causes of infertility. |
NO | ||
| Infusion Therapy
Limit: 25.0 Visit(s) per Year |
YES | $0.00, 0.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | $0.00, 0.00% |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | $0.00, 0.00% |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | $0.00, 0.00% |
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 | $0.00, 0.00% |
100.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | $0.00, 0.00% |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $0.00, 0.00% |
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 | $0.00, 0.00% |
100.00% |
| Nutritional Counseling
Diabetes self-management training and training related to medical nutrition therapy. |
YES | $0.00, 0.00% |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Coverage is for medically necessary orthodontia only. |
YES | $0.00, 0.00% |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $0.00, 0.00% |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $0.00, 0.00% |
100.00% |
| Outpatient Rehabilitation Services
Limit: 25.0 Visit(s) per Year Limited to 25 visits per year combined for Physical, Occupational and Speech Therapy. |
YES | $0.00, 0.00% |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $0.00, 0.00% |
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 | $0.00, 0.00% |
100.00% |
| Prenatal and Postnatal Care
|
YES | $0.00, 0.00% |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | $0.00, 0.00% |
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 | $0.00, 0.00% |
100.00% |
| Private-Duty Nursing
Limit: 85.0 Visit(s) per Year |
YES | $0.00, 0.00% |
100.00% |
| Prosthetic Devices
|
YES | $0.00, 0.00% |
100.00% |
| Radiation
|
YES | $0.00, 0.00% |
100.00% |
| Reconstructive Surgery
Breast reconstruction or implantation or removal of breast prostheses is a Covered Service only when performed solely and directly as a result of mastectomy which is Medically Necessary. |
YES | $0.00, 0.00% |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 25.0 Visit(s) per Year Limited to 25 visits per year combined for Physical, Occupational and Speech Therapy. |
YES | $0.00, 0.00% |
100.00% |
| Rehabilitative Speech Therapy
Limit: 25.0 Visit(s) per Year Limited to 25 visits per year combined for Physical, Occupational and Speech Therapy. |
YES | $0.00, 0.00% |
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 | $0.00, 0.00% |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 30.0 Days per Year |
YES | $0.00, 0.00% |
100.00% |
| Specialist Visit
|
YES | $0.00, 0.00% |
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 | $0.00, 0.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | $0.00, 0.00% |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $0.00, 0.00% |
100.00% |
| Transplant
|
YES | $0.00, 0.00% |
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 | $0.00, 0.00% |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | $0.00, 0.00% |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | $0.00, 0.00% |
100.00% |
UHC Gold-A Standard (No Referrals) Health Insurance Plan Variant 45480OK0050028-02 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 1.0 |
| 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 | Zero Cost Sharing Plan Variation |
| Dental Only Plan | No |
| Design Type | Design 1 |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | OKF011 |
| Formulary URL | URL |
| HIOS Product ID | 45480OK005 |
| Import Date | 2023-12-12 01:02:02 |
| 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? | No |
| Issuer ID | 45480 |
| 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 | OKN001 |
| 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) | 45480OK0050028-02 |
| Plan Level Exclusions | 0 |
| Plan Marketing Name | UHC Gold Standard (No Referrals) |
| Plan Type | HMO |
| Plan Variant Marketing Name | UHC Gold-A Standard (No Referrals) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| 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 | $0 |
| 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 | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | OKS001 |
| Source Name | HIOS |
| Plan ID | 45480OK0050028 |
| State Code | OK |
| 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 | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| 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 | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $0 |
| 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 |
Copay & Coinsurance of UHC Gold Standard (No Referrals) Health Insurance Plan, 45480OK0050028
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about UHC Gold Standard (No Referrals), 45480OK0050028 Health Insurance Plan, 45480OK0050028
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Does UHC Gold Standard (No Referrals) Health Insurance Plan, 45480OK0050028 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (45480OK0050028) Health Insurance Plan, Variant (45480OK0050028-02) have Out Of Country Coverage?
Does (45480OK0050028) Health Insurance Plan, Variant (45480OK0050028-02) 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