UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, Dental + Vision, No Referrals) - 69842LA0250003 Health Insurance Plan

UnitedHealthcare Insurance Company health insurance plan with the Plan ID 69842LA0250003. The plan is called UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, Dental + Vision, No Referrals).

Based on the data of Health Plan Issuer, this plan has an actuarial value of 73.58% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 26.42% of the costs of all covered benefits (according to the Issuer).

Health Insurance Plan ID 69842LA0250003
Health Insurance Plan Year 2025
State Louisiana
Health Insurance Issuer UnitedHealthcare Insurance Company
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 69842LA0250003-04
Provider Network(s) NON-PREFERRED NETWORK
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT).

Providers Louisiana All US States
All 11786 13028
PCP 1583 1698
Allergy 6 6
OB/GYN 62 67
Dentists 11 13
Available Variants of the Health Plan

Standard Off Exchange Plan - 69842LA0250003-00

Standard On Exchange Plan - 69842LA0250003-01

Open to Indians below 300% FPL - 69842LA0250003-02

Open to Indians above 300% FPL - 69842LA0250003-03

73% AV Silver Plan - 69842LA0250003-04

87% AV Silver Plan - 69842LA0250003-05

94% AV Silver Plan - 69842LA0250003-06

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 Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, Dental + Vision, No Referrals) Health Insurance Plan, 69842LA0250003-04

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited

Medically necessary abortions that are required to save the life of the mother are covered.

NO
Accidental Dental
YES

30.00%

100.00%
Acupuncture
NO
Allergy Testing
YES

$65.00

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

Benefit limitations may apply to individual services.

YES

30.00%

100.00%
Chemotherapy
YES

$750.00

100.00%
Chiropractic Care
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

$2,500.00

100.00%
Dental Check-Up for Children

Limit: 1.0 Visit(s) per 6 Months

YES

No Charge

100.00%
Diabetes Education
YES

30.00%

100.00%
Dialysis
YES

$750.00

100.00%
Durable Medical Equipment
YES

30.00%

100.00%
Emergency Room Services
YES

$1,500.00

$1,500.00
Emergency Transportation/Ambulance
YES

$1,500.00

$1,500.00
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

30.00%

100.00%
Gender Affirming Care

Covered when medically necessary.

YES

$375.00

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

$10.00

100.00%
Habilitation Services
YES

$65.00

100.00%
Hearing Aids

Limit: 1.0 Item(s) per 3 Years

Benefits are limited to one hearing aid, per hearing impaired ear, in a thirty-six (36) month period.

YES

30.00%

100.00%
Home Health Care Services
YES

30.00%

100.00%
Hospice Services
YES

30.00%

100.00%
Imaging (CT/PET Scans, MRIs)
YES

$200.00

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

$100.00

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)
YES

$2500.00 Copay per Day

100.00%
Inpatient Physician and Surgical Services
YES

No Charge

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

Benefit limitations may apply to individual services.

YES

30.00%

100.00%
Mental/Behavioral Health Inpatient Services
YES

$2500.00 Copay per Day

100.00%
Mental/Behavioral Health Outpatient Services

Cost share applies to office visits, please see SBC for Mental Health Outpatient Services.

YES

$50.00

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

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

30.00%

100.00%
Orthodontia - Adult
NO
Orthodontia - Child

Coverage is for medically necessary orthodontia only.

YES

50.00%

100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

30.00%

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

$375.00

100.00%
Outpatient Rehabilitation Services
YES

$65.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

$375.00

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

$85.00 Copay after deductible

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

$5.00

100.00%
Private-Duty Nursing

Limit: 19.0 Visit(s) per Year

Exclusions: Inpatient Private Duty Nursing Service is not covered.

Private Duty Nursing services covered as a part of the Home Health Care benefit.

YES

30.00%

100.00%
Prosthetic Devices
YES

30.00%

100.00%
Radiation
YES

$100.00

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

$375.00

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy
YES

$65.00

100.00%
Rehabilitative Speech Therapy
YES

$65.00

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 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
YES

$2500.00 Copay per Day

100.00%
Specialist Visit
YES

$65.00

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

50.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

$2500.00 Copay per Day

100.00%
Substance Abuse Disorder Outpatient Services
YES

$50.00

100.00%
Transplant
YES

$2,500.00

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

$75.00

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

$200.00

100.00%

UHC Silver-E Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, Dental + Vision, No Referrals) Health Insurance Plan Variant 69842LA0250003-04 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
Drug EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Drug EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 0.00%
Drug EHB Deductible, In Network (Tier 1), Family Per Group $8000 per group
Drug EHB Deductible, In Network (Tier 1), Family Per Person $4000 per person
Drug EHB Deductible, In Network (Tier 1), Individual $4,000
Drug EHB Deductible, Out of Network, Family Per Group per group not applicable
Drug EHB Deductible, Out of Network, Family Per Person per person not applicable
Drug EHB Deductible, Out of Network, Individual Not Applicable
Dental Only Plan No
Design Type Not Applicable
EHB Percent of Total Premium 0.97830003
First Tier Utilization 100%
Formulary ID LAF031
Formulary URL URL
HIOS Product ID 69842LA025
Import Date 2024-08-16 01:01:20
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 3
HSA Eligible No
New/Existing Plan New
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer Actuarial Value 73.58%
Issuer ID 69842
Issuer Marketplace Marketing Name UnitedHealthcare
Market Coverage Individual
Medical Drug Deductibles Integrated No
Medical Drug Maximum Out of Pocket Integrated Yes
Medical EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Medical EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Medical EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Medical EHB Deductible, In Network (Tier 1), Default Coinsurance 30.00%
Medical EHB Deductible, In Network (Tier 1), Family Per Group $0 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person $0 per person
Medical EHB Deductible, In Network (Tier 1), Individual $0
Medical EHB Deductible, Out of Network, Family Per Group per group not applicable
Medical EHB Deductible, Out of Network, Family Per Person per person not applicable
Medical EHB Deductible, Out of Network, Individual Not Applicable
Metal Level Silver
Multiple In Network Tiers No
National Network No
Network ID LAN011
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) 69842LA0250003-04
Plan Level Exclusions Some exclusions may apply. See the applicable Certificate of Coverage for details.
Plan Marketing Name UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, Dental + Vision, No Referrals)
Plan Type EPO
Plan Variant Marketing Name UHC Silver-E Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, Dental + Vision, No Referrals)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $3,100
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 $400
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $10
SBC Scenario, Treatment of a Simple Fracture, Copayment $2,400
SBC Scenario, Treatment of a Simple Fracture, Deductible $0
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID LAS011
Source Name HIOS
Specialty Drug Maximum Coinsurance $150
Plan ID 69842LA0250003
State Code LA
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
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $14700 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $7350 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $7,350
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 Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, Dental + Vision, No Referrals) Health Insurance Plan, 69842LA0250003

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, Dental + Vision, No Referrals), 69842LA0250003 Health Insurance Plan, 69842LA0250003

  • Does UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, Dental + Vision, No Referrals) Health Insurance Plan, 69842LA0250003 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (69842LA0250003) Health Insurance Plan, Variant (69842LA0250003-04) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan).

    Does (69842LA0250003) Health Insurance Plan, Variant (69842LA0250003-04) have Out of Service Area Coverage?

    Yes. Details: 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.

 

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