Optimum Choice, Inc health insurance plan with the Plan ID 24251VA0060001. The plan is called UHC Gold Value+ ($3 Walgreens T1 Preferred Rx + 3 $0 Virtual Urgent Care Visits).
Based on the data of Health Plan Issuer, this plan has an actuarial value of 76.00% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 24.00% of the costs of all covered benefits (according to the Issuer).
Health Insurance Plan ID | 24251VA0060001 | ||||||||||||||||||
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Health Insurance Plan Year | 2022 | ||||||||||||||||||
State | Virginia | ||||||||||||||||||
Health Insurance Issuer | Optimum Choice, Inc | ||||||||||||||||||
Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
Health Insurance Plan Variant | 24251VA0060001-00 | ||||||||||||||||||
Provider Network(s) | ['VAN001'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 20 Aug 2024 06:14 GMT). |
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Available Variants of the Health Plan | Standard Off Exchange Plan - 24251VA0060001-00 Standard On Exchange Plan - 24251VA0060001-01 |
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Last Plan Update Date | Fri, 18 Feb 2022 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 20 Aug 2024 06:14 GMT |
Plan Attribute | Value |
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Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
Business Year | 2022 |
Child-Only Offering | Allows Adult and Child-Only |
Composite Rating Offered | No |
CSR Variation Type | Standard Gold Off Exchange Plan |
Dental Only Plan | No |
EHB Percent of Total Premium | 1 |
First Tier Utilization | 100% |
Formulary ID | VAF010 |
Formulary URL | URL |
HIOS Product ID | 24251VA006 |
Import Date | 2/18/2022 20:01 |
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? | Yes |
Issuer Actuarial Value | 76.00% |
Issuer ID | 24251 |
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 | VAN001 |
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. |
Plan Brochure | URL |
Plan Effective Date | 1/1/2022 |
Plan ID (Standard Component ID with Variant) | 24251VA0060001-00 |
Plan Level Exclusions | 0 |
Plan Marketing Name | UHC Gold Value+ ($3 Walgreens T1 Preferred Rx + 3 $0 Virtual Urgent Care Visits) |
Plan Type | HMO |
Plan Variant Marketing Name | UHC Gold-X Value+ ($3 Walgreens T1 Preferred Rx + 3 $0 Virtual Urgent Care Visits) |
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 | $100 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $20 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,000 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | VAS001 |
Source Name | SERFF |
Specialist Requiring a Referral | All, except OBGYN and as state mandated |
Plan ID | 24251VA0060001 |
State Code | VA |
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 | Yes |
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, 20 Aug 2024 06:14 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