UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) - 33931OH0030030 Health Insurance Plan
UnitedHealthcare of Ohio, Inc. health insurance plan with the Plan ID 33931OH0030030. The plan is called UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals).
Based on the data of Health Plan Issuer, this plan has an actuarial value of 87.12% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 12.88% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 33931OH0030030 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Ohio | ||||||||||||||||||
| Health Insurance Issuer | UnitedHealthcare of Ohio, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 33931OH0030030-05 | ||||||||||||||||||
| Provider Network(s) | NETWORK NON-PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 10 Dec 2024 06:32 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 33931OH0030030-00 Standard On Exchange Plan - 33931OH0030030-01 Open to Indians below 300% FPL - 33931OH0030030-02 Open to Indians above 300% FPL - 33931OH0030030-03 73% AV Silver Plan - 33931OH0030030-04 |
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| Last Plan Update Date | Fri, 13 Sep 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 10 Dec 2024 06:32 GMT |
Benefits of UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Health Insurance Plan, 33931OH0030030-05
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 30.00% |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $60.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
Benefit limitations may apply to individual services. |
YES | 30.00% |
100.00% |
| Chemotherapy
|
YES | $500.00 |
100.00% |
| Chiropractic Care
Limit: 12.0 Visit(s) per Benefit Period |
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 | $1,000.00 |
100.00% |
| Dental Check-Up for Children
Limit: 1.0 Exam(s) per 6 Months |
YES | No Charge |
100.00% |
| Diabetes Education
|
YES | 30.00% |
100.00% |
| Dialysis
|
YES | $500.00 |
100.00% |
| Durable Medical Equipment
|
YES | 30.00% |
100.00% |
| Emergency Room Services
|
YES | $300.00 |
$300.00 |
| Emergency Transportation/Ambulance
|
YES | $300.00 |
$300.00 |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | 30.00% |
100.00% |
| Gender Affirming Care
Covered when medically necessary. |
YES | $180.00 |
100.00% |
| Generic Drugs
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
Limit: 60.0 Visit(s) per Year Limited to 20 visits per year for Speech Therapy, 20 visits per year for Occupational Therapy, and 20 visits per year for Physical Therapy. Visit limits do not apply for therapies for covered persons with a primary diagnosis of Autism Spectrum Disorder. |
YES | $60.00 |
100.00% |
| Hearing Aids
Cochlear implants are covered as durable medical equipment. |
NO | ||
| Home Health Care Services
Limit: 100.0 Visit(s) per Year The 100 visit/year limit is not applicable to home infusion therapy or private duty nursing rendered in the home setting. |
YES | 30.00% |
100.00% |
| Hospice Services
|
YES | 30.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Cost sharing may differ based on the location where services are provided. Please refer to the Certificate of Coverage for more information. |
YES | $50.00 |
100.00% |
| Infertility Treatment
Exclusions: Health care services and related expenses for infertility treatments, including assisted reproductive technology, in vitro fertilization, in vivo fertilization, or any other medically-aided insemination procedure, regardless of the reason for the treatment, except when performed for the diagnosis, treatment and correction of the underlying causes of infertility. Plan covers Diagnosis and treatment of cause of infertility. Benefits are available for covered services such as office visits, laboratory tests, and radiological studies to diagnose the cause of infertility. Benefits are also provided for the necessary treatment of the condition unless the treatment is identified as non-covered (see exclusions). Depending upon where the covered service is provided, benefits will be the same as those stated under each health care service category. |
YES | 30.00% |
100.00% |
| Infusion Therapy
|
YES | $75.00 |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | $1000.00 Copay per Day |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | No Charge |
100.00% |
| Laboratory Outpatient and Professional Services
Cost sharing may differ based on the location where services are provided. Please refer to the Certificate of Coverage for more information. |
YES | $10.00 |
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 | 30.00% |
100.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | $1000.00 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 | $20.00 |
100.00% |
| Non-Preferred Brand Drugs
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 | $180.00 |
100.00% |
| Outpatient Rehabilitation Services
Limit: 60.0 Visit(s) per Year Limited to 20 visits per year for Speech Therapy, 20 visits per year for Occupational Therapy, 20 visits per year for Physical Therapy, 36 visits per year for Cardiac rehabilitation Therapy, and 20 visits per year for Pulmonary rehabilitation therapy. |
YES | $60.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $375.00 |
100.00% |
| Preferred Brand Drugs
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 | $20.00 |
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
Limit: 90.0 Visit(s) per Year Private Duty Nursing Services are Covered Services only when provided through the Home Health Care Services benefit. |
YES | 30.00% |
100.00% |
| Prosthetic Devices
|
YES | 30.00% |
100.00% |
| Radiation
|
YES | $75.00 |
100.00% |
| Reconstructive Surgery
|
YES | $180.00 |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 40.0 Visit(s) per Year Limited to 20 visits per year for Occupational Therapy and 20 visits per year for Physical Therapy. |
YES | $60.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year Limited to 20 visits per year for Speech Therapy |
YES | $60.00 |
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 | No Charge |
100.00% |
| Routine Foot Care
Covered when done for the prevention of complications associated with metabolic, neurologic, or peripheral vascular disease |
NO | ||
| Skilled Nursing Facility
Limit: 90.0 Days per Year Limit will be 90 days per benefit period for Skilled Nursing Facility. Limits will be 60 days per benefit period for inpatient physical medicine and rehabilitation. |
YES | $1000.00 Copay per Day |
100.00% |
| Specialist Visit
|
YES | $60.00 |
100.00% |
| Specialty Drugs
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 | $1000.00 Copay per Day |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $20.00 |
100.00% |
| Transplant
|
YES | $1,000.00 |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 30.00% |
100.00% |
| 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 | $60.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
Cost sharing may differ based on the location where services are provided. Please refer to the Certificate of Coverage for more information. |
YES | $15.00 |
100.00% |
UHC Silver-D Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Health Insurance Plan Variant 33931OH0030030-05 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 | 87% 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 | $1000 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $500 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $500 |
| 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 | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | OHF032 |
| Formulary URL | URL |
| HIOS Product ID | 33931OH003 |
| Import Date | 2024-09-13 20:01:37 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 3 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 87.12% |
| Issuer ID | 33931 |
| 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 | OHN011 |
| 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) | 33931OH0030030-05 |
| 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, No Referrals) |
| Plan Type | HMO |
| Plan Variant Marketing Name | UHC Silver-D Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $1,500 |
| 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 | $1,100 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | OHS011 |
| Source Name | SERFF |
| Plan ID | 33931OH0030030 |
| State Code | OH |
| 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 | $6100 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $3050 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $3,050 |
| 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, No Referrals) Health Insurance Plan, 33931OH0030030
| 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, No Referrals), 33931OH0030030 Health Insurance Plan, 33931OH0030030
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Does UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Health Insurance Plan, 33931OH0030030 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (33931OH0030030) Health Insurance Plan, Variant (33931OH0030030-05) have Out Of Country Coverage?
Does (33931OH0030030) Health Insurance Plan, Variant (33931OH0030030-05) have Out of Service Area Coverage?
Disclaimer: This is based on the import(Date: Tue, 10 Dec 2024 06:32 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