UHC Silver Advantage+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, Dental + Vision, No Referrals) - 49714WY0210002 Health Insurance Plan
UnitedHealthcare Insurance Company health insurance plan with the Plan ID 49714WY0210002. The plan is called UHC Silver Advantage+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, Dental + Vision, No Referrals).
Based on the data of Health Plan Issuer, this plan has an actuarial value of 73.84% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 26.16% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 49714WY0210002 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Wyoming | ||||||||||||||||||
| Health Insurance Issuer | UnitedHealthcare Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 49714WY0210002-04 | ||||||||||||||||||
| 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 - 49714WY0210002-00 Standard On Exchange Plan - 49714WY0210002-01 Open to Indians below 300% FPL - 49714WY0210002-02 Open to Indians above 300% FPL - 49714WY0210002-03 73% AV Silver Plan - 49714WY0210002-04 |
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| Last Plan Update Date | Fri, 16 Aug 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of UHC Silver Advantage+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, Dental + Vision, No Referrals) Health Insurance Plan, 49714WY0210002-04
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Pediatric only - Restorations of the mouth, tooth, or jaw which are necessary due to an accidental injury are limited to those services, supplies, and appliances appropriate for dental needs. These are not pediatric only benefits. The section refers to some excluded services that are covered under Pediatric Dental but this section applies to all enrollees under the product. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
NO | ||
| Bariatric Surgery
Pre-certification is required. Surgery for obesity will be a Covered Service only when required due to morbid obesity. The participant meets the current NIH (National Institutes of Health) surgical criteria. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| 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 | 30.00% Coinsurance after deductible |
100.00% |
| Chemotherapy
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 15.0 Visit(s) per Year Limited to 15 visits per calendar year. |
YES | $30.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Childbirth/delivery professional services follow inpatient physician/surgeon fees. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
Limit: 1.0 Visit(s) per 6 Months Limited to one every six months. |
YES | No Charge |
100.00% |
| Diabetes Education
Covered Outpatient self-management training and education are limited to a one-time evaluation and training program when Medically Necessary, within one (1) year of diagnosis. |
YES | $70.00 |
100.00% |
| Dialysis
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
Some items require Pre-Certification. The rental or the purchase of durable medical equipment, whichever is less expensive, is a Covered Service. When a purchase is authorized, Benefits will also be provided for repair, maintenance, replacement, and adjustment of the equipment. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | $500.00 Copay after deductible |
$500.00 Copay after deductible |
| Emergency Transportation/Ambulance
|
YES | $500.00 Copay after deductible |
$500.00 Copay after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Covers one pair of eyeglasses or 12 month supply of contacts per calendar year. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Gender Affirming Care
Covered when medically necessary. |
YES | 30.00% 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 | $5.00 |
100.00% |
| Habilitation Services
Limit: 20.0 Visit(s) per Year Outpatient Habilitative Benefits are limited to a maximum of twenty (20) visits per calendar year per Participant. |
YES | $70.00 |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Pre-Certification is required. The need for Home Healthcare must be directly related to the Condition for which the Participant's hospitalization was required. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Hospice Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | $20.00 |
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 | 30.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Cost share applies to office visits, please see SBC for Mental Health Outpatient Services. |
YES | $20.00 |
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 | $300.00 |
100.00% |
| Nutritional Counseling
|
NO | ||
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Coverage is for medically necessary orthodontia only. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 60.0 Visit(s) per Year Outpatient is limited to 40 visits per calendar year for physical therapy and combined 20 visit per calendar year maximum for occupational therapy & speech therapy. |
YES | $70.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 30.00% 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 | $75.00 |
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 | $20.00 |
100.00% |
| Private-Duty Nursing
Inpatient Private Duty Nursing Services are Covered Services only in certain circumstances such as: The Participant's Condition would ordinarily require that the Participant be placed in an intensive or coronary care unit, but the Hospital does not have such facilities. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Prosthetic Devices
Some items require Pre-Certification. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 30.00% Coinsurance after deductible |
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 | 30.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 60.0 Visit(s) per Year Outpatient is limited to 40 visits per calendar year for physical therapy and combined 20 visit per calendar year maximum for occupational therapy & speech therapy. |
YES | $70.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year Outpatient is limited to 40 visits per calendar year for physical therapy and combined 20 visit per calendar year maximum for occupational therapy & speech therapy. |
YES | $70.00 |
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 Exam(s) per Year Covers one exam per calendar 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
Pre-Certification Required and subject to approval by Case Benefit Management. Care must begin within 14 days after discharge from the hospital or skilled nursing facility. Inpatient Rehabilitation Facility services limited to 45 days per year. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
No referral needed for a specialist. |
YES | $70.00 |
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 | $500.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $20.00 |
100.00% |
| Transplant
Pre-Admission Review is required prior to obtaining non-maternity and non-emergency Inpatient Human Organ Transplant services. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| 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 | $55.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 30.00% Coinsurance after deductible |
100.00% |
UHC Silver-E Advantage+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, Dental + Vision, No Referrals) Health Insurance Plan Variant 49714WY0210002-04 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 | 73% AV Level Silver Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| EHB Percent of Total Premium | 0.98230004 |
| First Tier Utilization | 100% |
| Formulary ID | WYF030 |
| Formulary URL | URL |
| HIOS Product ID | 49714WY021 |
| Import Date | 2024-08-16 01:01:20 |
| 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 | 73.84% |
| Issuer ID | 49714 |
| Issuer Marketplace Marketing Name | UnitedHealthcare |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Silver |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | WYN011 |
| 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) | 49714WY0210002-04 |
| Plan Level Exclusions | Some exclusions may apply. See the applicable Certificate of Coverage for details. |
| Plan Marketing Name | UHC Silver Advantage+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, Dental + Vision, No Referrals) |
| Plan Type | EPO |
| Plan Variant Marketing Name | UHC Silver-E Advantage+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, Dental + Vision, No Referrals) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,900 |
| SBC Scenario, Having a Baby, Copayment | $200 |
| SBC Scenario, Having a Baby, Deductible | $3,600 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $300 |
| SBC Scenario, Having Diabetes, Deductible | $200 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $400 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,100 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | WYS011 |
| Source Name | HIOS |
| Plan ID | 49714WY0210002 |
| State Code | WY |
| 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 | 30.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $7200 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $3600 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $3,600 |
| 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 | $14400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,200 |
| 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 Silver Advantage+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, Dental + Vision, No Referrals) Health Insurance Plan, 49714WY0210002
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about UHC Silver Advantage+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, Dental + Vision, No Referrals), 49714WY0210002 Health Insurance Plan, 49714WY0210002
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Does UHC Silver Advantage+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, Dental + Vision, No Referrals) Health Insurance Plan, 49714WY0210002 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (49714WY0210002) Health Insurance Plan, Variant (49714WY0210002-04) have Out Of Country Coverage?
Does (49714WY0210002) Health Insurance Plan, Variant (49714WY0210002-04) 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