UHC Gold Value+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) - 72850IN0170005 Health Insurance Plan
UnitedHealthcare Insurance Company health insurance plan with the Plan ID 72850IN0170005. The plan is called UHC Gold Value+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals).
Based on the data of Health Plan Issuer, this plan has an actuarial value of 78.05% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 21.95% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 72850IN0170005 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Indiana | ||||||||||||||||||
| Health Insurance Issuer | UnitedHealthcare Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 72850IN0170005-00 | ||||||||||||||||||
| Provider Network(s) | 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 - 72850IN0170005-00 Standard On Exchange Plan - 72850IN0170005-01 |
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| Last Plan Update Date | Thu, 31 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of UHC Gold Value+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) Health Insurance Plan, 72850IN0170005-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Per Indiana law, abortion only covered if performed because a woman becomes pregnant through an act of rape or incest; or an abortion is necessary to avert the pregnant woman?s death or a substantial and irreversible impairment of a major bodily function of the pregnant woman. |
NO | ||
| Accidental Dental
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
Cost share driven by provider/setting. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
Limit: 1000.0 Dollars per Year 1,000 annual benefit maximum includes all Dental Services (Routine, Basic and Major) for Adults; Excluded from In-Network Deductible and Out-of-Pocket Limit |
YES | 50.00% |
100.00% |
| Basic Dental Care - Child
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Chemotherapy
Cost share driven by provider/setting. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 12.0 Visit(s) per Benefit Period Cost share driven by provider/setting. |
YES | 20.00% 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 | 20.00% 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 | 20.00% Coinsurance after deductible |
100.00% |
| Dialysis
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
One wig per benefit period. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Gender Affirming Care
Covered when medically necessary. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Generic Drugs
Limit: 30.0 Days per Month 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 | $1.00 |
100.00% |
| Habilitation Services
Limit: 60.0 Visit(s) per Benefit Period Includes 20 visits each of PT, OT and ST. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 100.0 Visit(s) per Benefit Period Maximum does not include Home Infusion Therapy or Private Duty Nursing rendered in the home. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Hospice Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
Cost share driven by provider/setting. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Maximum 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis). |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
Cost share driven by provider/setting. |
YES | $15.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
Limit: 1000.0 Dollars per Year 1,000 annual benefit maximum includes all Dental Services (Routine, Basic and Major) for Adults; Excluded from In-Network Deductible and Out-of-Pocket Limit |
YES | 50.00% |
100.00% |
| Major Dental Care - Child
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Cost share driven by provider/setting. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Non-Preferred Brand Drugs
Limit: 30.0 Days per Month 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 | 40.00% 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 | 20.00% Coinsurance after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 60.0 Visit(s) per Benefit Period Cost share is driven by provider/setting. Coverage for Speech Therapy is limited to 20 visits per benefit period, Occupational Therapy is limited to 20 visits per benefit period, and Physical Therapy is limited to 20 visits per benefit period. Benefit includes an Inpatient maximum of 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis). Cardiac Rehabilitation limited to 36 visits when rendered as Physician Home Visits and Office Services or Outpatient Services, when rendered in the home, Home Care Services limits apply.Pulmonary Rehabilitation limited to 20 visits when rendered as Physician Home Visits and Office Services or Outpatient Services. When rendered in the home, Home Care Services limits apply. When rendered as part of physical therapy, the Physical Therapy limit will apply instead of the limit indicated. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
Limit: 30.0 Days per Month 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 | $15.00 |
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
Limit: 82.0 Visit(s) per Year |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Prosthetic Devices
Must be medically necessary. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Radiation
Cost share driven by provider/setting. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Certain reconstructive services required to correct a deformity caused by disease, trauma, congenital anomalies, or previous therapeutic process are covered. Coverage includes breast reconstruction on which a mastectomy has been performed. Reconstructive services required due to prior therapeutic process are payable only if the original procedure would have been a covered service under this plan. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 40.0 Visit(s) per Benefit Period Cost share is driven by provider/setting. Occupational Therapy is limited to 20 visits per benefit period, and Physical Therapy is limited to a separate 20 visits per benefit period. Coverage also includes an additional 20 visits each for habilitative services. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Benefit Period Cost share driven by provider/setting. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Routine Dental Services (Adult)
Limit: 2.0 Visit(s) per Year 1,000 annual benefit maximum includes all Dental Services (Routine, Basic and Major) for Adults; Excluded from In-Network Deductible and Out-of-Pocket Limit |
YES | No Charge |
100.00% |
| Routine Eye Exam (Adult)
Limit: 1.0 Visit(s) per Year Benefit also includes 1 pair of eyeglasses or contact lenses every 12 months. Eyeglass lenses have a $25 copay and frames are covered up to $150. Formulary contact lenses are covered in lieu of glasses with a $25 copay. |
YES | No Charge |
100.00% |
| 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 Benefit Period Benefit includes an Inpatient maximum of 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis). |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Specialty Drugs
Limit: 30.0 Days per Month 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 | 20.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Cost share driven by provider/setting. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Transplant
Includes coverage for unrelated donor search services ($30,000 per transplant) and travel/lodging as approved by the plan ($10,000 per transplant). |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
$0 Virtual Urgent Care visits are available through telehealth vendor only. 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
Cost share driven by provider/setting. |
YES | 20.00% Coinsurance after deductible |
100.00% |
UHC Gold-X Value+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) Health Insurance Plan Variant 72850IN0170005-00 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 |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| EHB Percent of Total Premium | 0.9679 |
| First Tier Utilization | 100% |
| Formulary ID | INF033 |
| Formulary URL | URL |
| HIOS Product ID | 72850IN017 |
| Import Date | 2024-10-31 01:01:26 |
| 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? | No |
| Issuer Actuarial Value | 78.05% |
| Issuer ID | 72850 |
| 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 | INN011 |
| 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. 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) | 72850IN0170005-00 |
| Plan Level Exclusions | Some exclusions may apply. See the applicable Certificate of Coverage for details. |
| Plan Marketing Name | UHC Gold Value+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) |
| Plan Type | EPO |
| Plan Variant Marketing Name | UHC Gold-X Value+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,600 |
| SBC Scenario, Having a Baby, Copayment | $200 |
| SBC Scenario, Having a Baby, Deductible | $2,000 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $100 |
| SBC Scenario, Having Diabetes, Deductible | $500 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $40 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,000 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | INS011 |
| Source Name | HIOS |
| Plan ID | 72850IN0170005 |
| State Code | IN |
| 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 | $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 | $17000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8500 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,500 |
| 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 Value+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) Health Insurance Plan, 72850IN0170005
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about UHC Gold Value+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals), 72850IN0170005 Health Insurance Plan, 72850IN0170005
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Does UHC Gold Value+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) Health Insurance Plan, 72850IN0170005 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (72850IN0170005) Health Insurance Plan, Variant (72850IN0170005-00) have Out Of Country Coverage?
Does (72850IN0170005) Health Insurance Plan, Variant (72850IN0170005-00) 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