UHC Silver Copay Focus $0 Indiv Med Ded - 33764SC0030006 Health Insurance Plan
UnitedHealthcare of South Carolina, Inc. health insurance plan with the Plan ID 33764SC0030006. The plan is called UHC Silver Copay Focus $0 Indiv Med Ded.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 73.89% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 26.11% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 33764SC0030006 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | South Carolina | ||||||||||||||||||
| Health Insurance Issuer | UnitedHealthcare of South Carolina, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 33764SC0030006-04 | ||||||||||||||||||
| 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). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 33764SC0030006-00 Standard On Exchange Plan - 33764SC0030006-01 Open to Indians below 300% FPL - 33764SC0030006-02 Open to Indians above 300% FPL - 33764SC0030006-03 73% AV Silver Plan - 33764SC0030006-04 |
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| Last Plan Update Date | Tue, 24 Oct 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of UHC Silver Copay Focus $0 Indiv Med Ded Health Insurance Plan, 33764SC0030006-04
| 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 | $100.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
YES | 30.00% |
100.00% |
| Chemotherapy
|
YES | 30.00% |
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
Diabetes self-management training and education will be provided on an outpatient basis when done by a registered or licensed health care professional that is certified in diabetes. |
YES | 30.00% |
100.00% |
| Dialysis
|
YES | 30.00% |
100.00% |
| Durable Medical Equipment
|
YES | 30.00% |
100.00% |
| Emergency Room Services
|
YES | $1,500.00 |
$1,500.00 |
| Emergency Transportation/Ambulance
|
YES | 30.00% |
30.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | 30.00% |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Limit: 30.0 Days per Month 90-day supplies are available through retail pharmacies 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
Supplementing with the federal definition of habilitative services. Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. |
YES | $100.00 |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 60.0 Visit(s) per Benefit Period |
YES | 30.00% |
100.00% |
| Hospice Services
Limit: 6.0 Months per Episode |
YES | 30.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $200.00 |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 30.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | $2500 Copay per Day |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 30.00% |
100.00% |
| Laboratory Outpatient and Professional Services
Limit: 18.0 Visit(s) per Year Limited to 18 Presumptive Drug Tests per year. Limited to 18 Definitive Drug Tests per year. |
YES | $20.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
YES | 30.00% |
100.00% |
| Mental/Behavioral Health Inpatient Services
Removed limits to meet Mental Health Parity |
YES | $2500 Copay per Day |
100.00% |
| Mental/Behavioral Health Outpatient Services
Removed limits to meet Mental Health Parity |
YES | $100.00 |
100.00% |
| Non-Preferred Brand Drugs
Limit: 30.0 Days per Month 90-day supplies are available through retail pharmacies or home delivery.? Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information. |
YES | 40% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
|
YES | 30.00% |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
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 | $100.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $375.00 |
100.00% |
| Preferred Brand Drugs
Limit: 30.0 Days per Month 90-day supplies are available through retail pharmacies or home delivery.? Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information. |
YES | $85 Copay after deductible |
100.00% |
| Prenatal and Postnatal Care
Exclusions: Maternity Benefits aren?t payable for Dependent children. |
YES | No Charge |
100.00% |
| Preventive Care/Screening/Immunization
Mammography services, OBGYN exams (limit 2 per year), pap smear services, prostate services, and routine colorectal cancer screening/testing |
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. See SBC for additional cost share details. |
YES | $5.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 30.00% |
100.00% |
| Radiation
|
YES | 30.00% |
100.00% |
| Reconstructive Surgery
Reconstructive Surgery that is considered a Covered Expense is limited to Surgery: To correct a functional defect that results from a birth defect, disease and anomaly; or Performed to correct a seriously disfiguring condition resulting from injury; or For breast reconstruction after a mastectomy. |
YES | $375.00 |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year |
YES | $100.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year |
YES | $100.00 |
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
|
NO | ||
| Skilled Nursing Facility
Limit: 60.0 Days per Benefit Period |
YES | $2500 Copay per Day |
100.00% |
| Specialist Visit
|
YES | $100.00 |
100.00% |
| Specialty Drugs
Limit: 30.0 Days per Month Specialty medications are limited to a 30-day supply. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information. |
YES | 50% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Removed limits to meet Mental Health Parity |
YES | $2500 Copay per Day |
100.00% |
| Substance Abuse Disorder Outpatient Services
Removed limits to meet Mental Health Parity |
YES | $100.00 |
100.00% |
| Transplant
|
YES | $2,500.00 |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
|
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 | $65.00 |
100.00% |
UHC Silver 73% Copay Focus $0 Indiv Med Ded Health Insurance Plan Variant 33764SC0030006-04 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 | 2024 |
| 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 | 30.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $5000 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $2500 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $2,500 |
| 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 | SCF008 |
| Formulary URL | URL |
| HIOS Product ID | 33764SC003 |
| Import Date | 2023-10-24 01:01:46 |
| 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 | 73.89% |
| Issuer ID | 33764 |
| 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 | SCN001 |
| 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 | 2024-01-01 |
| Plan ID (Standard Component ID with Variant) | 33764SC0030006-04 |
| Plan Marketing Name | UHC Silver Copay Focus $0 Indiv Med Ded |
| Plan Type | HMO |
| Plan Variant Marketing Name | UHC Silver 73% Copay Focus $0 Indiv Med Ded |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $200 |
| 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 | $300 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,600 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | SCS001 |
| Source Name | HIOS |
| Plan ID | 33764SC0030006 |
| State Code | SC |
| 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 | $15100 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7550 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,550 |
| 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 Health Insurance Plan, 33764SC0030006
| 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, 33764SC0030006 Health Insurance Plan, 33764SC0030006
-
Does UHC Silver Copay Focus $0 Indiv Med Ded Health Insurance Plan, 33764SC0030006 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (33764SC0030006) Health Insurance Plan, Variant (33764SC0030006-04) have Out Of Country Coverage?
Does (33764SC0030006) Health Insurance Plan, Variant (33764SC0030006-04) 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