UnitedHealthcare of North Carolina, Inc health insurance plan with the Plan ID 54332NC0030028. The plan is called UHC Bronze Essential $9,100 Indiv Ded ($3 Generic Rx Pref Pharm, No Referrals).
Based on the data of Health Plan Issuer, this plan has an actuarial value of 61.05% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 38.95% of the costs of all covered benefits (according to the Issuer).
Health Insurance Plan ID | 54332NC0030028 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | North Carolina | ||||||||||||||||||
Health Insurance Issuer | UnitedHealthcare of North Carolina, Inc | ||||||||||||||||||
Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
Health Insurance Plan Variant | 54332NC0030028-00 | ||||||||||||||||||
Provider Network(s) | ['NCN001'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 30 Apr 2024 06:06 GMT). |
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Available Variants of the Health Plan | Standard Off Exchange Plan - 54332NC0030028-00 Standard On Exchange Plan - 54332NC0030028-01 |
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Last Plan Update Date | Wed, 25 Jan 2023 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 30 Apr 2024 06:06 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
|
NO | ||
Accidental Dental
|
YES | No Charge after deductible |
100.00% |
Acupuncture
|
NO | ||
Allergy Testing
|
YES | No Charge after deductible |
100.00% |
Bariatric Surgery
Limit: 1.0 Procedure(s) per Lifetime Exclusions: Excludes removal of excess skin from the abdomen, arms or thighs. |
YES | No Charge after deductible |
100.00% |
Basic Dental Care - Adult
|
NO | ||
Basic Dental Care - Child
Benefit limitations may apply to individual services. |
YES | No Charge after deductible |
100.00% |
Chemotherapy
|
YES | No Charge after deductible |
100.00% |
Chiropractic Care
Limit: 30.0 Visit(s) per Year Limited to 30 visits for any combination of physical therapy, occupational therapy, and manipulative treatment including chiropractic care. |
YES | No Charge after deductible |
100.00% |
Cosmetic Surgery
|
NO | ||
Delivery and All Inpatient Services for Maternity Care
Childbirth/delivery professional services follow inpatient physician/surgeon fees |
YES | No Charge after deductible |
100.00% |
Dental Check-Up for Children
Limit: 1.0 Visit(s) per 6 Months |
YES | No Charge |
100.00% |
Diabetes Education
|
YES | No Charge after deductible |
100.00% |
Dialysis
|
YES | No Charge after deductible |
100.00% |
Durable Medical Equipment
Exclusions: Appliances and accessories that serve no medical purpose or that are primarily for comfort or convenience; repair or replacement of equipment due to abuse or desire for new equipment. |
YES | No Charge after deductible |
100.00% |
Emergency Room Services
|
YES | No Charge after deductible |
No Charge after deductible |
Emergency Transportation/Ambulance
Exclusions: Excludes services provided primarily for the convenience of travel, transportation to or from a doctor's office or dialysis center, transportation for the purpose of receiving services that are not considered "covered services.? |
YES | No Charge after deductible |
No Charge after deductible |
Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | No Charge after deductible |
100.00% |
Gender Affirming Care
|
NO | ||
Generic Drugs
Limit: 30.0 Days per Month Lowest cost shares are available at preferred retail pharmacies and home delivery. See SBC for cost shares at other retail pharmacies and for non-preferred generics. 90-day supplies are available through preferred retail pharmacies or home delivery. Limited to 30 day supplies at all other pharmacies. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information. |
YES | $3.00 |
100.00% |
Habilitation Services
Limit: 30.0 Visit(s) per Year Exclusions: Group classes for pulmonary rehabilitation. Limited to 30 visits for any combination of physical therapy, occupational therapy, and manipulative treatment including chiropractic care. |
YES | No Charge after deductible |
100.00% |
Hearing Aids
|
YES | No Charge after deductible |
100.00% |
Home Health Care Services
Limit: 60.0 Visit(s) per Year Exclusions: Excludes homemaker services, such as cooking and housekeeping; Dietitian services or meals; Services that are provided by a close relative or a member of the household. |
YES | No Charge after deductible |
100.00% |
Hospice Services
Exclusions: Excludes homemaker services, such as cooking, housekeeping, and food or meal preparation. Benefits for Hospice services for care of a terminally ill Member with a life expectancy of six months or less. |
YES | No Charge after deductible |
100.00% |
Imaging (CT/PET Scans, MRIs)
Exclusions: Lab tests that are not ordered by Doctor of Other Provider. |
YES | No Charge after deductible |
100.00% |
Infertility Treatment
Limit: 3.0 Treatment(s) per Lifetime Infertility Services- Benefits are provided for certain services related to the diagnosis, treatment and correction of any underlying causes of infertility for all members. Benefits are limited to three pharmaceutical ovulation induction cycles per lifetime per member. Prescription Drug Benefits- Certain prescription drugs related to treatment of infertility. Infertility drugs are limited to benefit lifetime maximums per member. |
YES | No Charge after deductible |
100.00% |
Infusion Therapy
|
YES | No Charge after deductible |
100.00% |
Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: Admissions primarily for the purpose of receiving diagnostic services or a physical examination; admissions primarily for the purpose of receiving therapy services, except when the admission is a continuation of treatment following care at an inpatient facility for an illness or accident requiring therapy. |
YES | No Charge after deductible |
100.00% |
Inpatient Physician and Surgical Services
|
YES | No Charge after deductible |
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 | No Charge after deductible |
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 | No Charge after deductible |
100.00% |
Mental/Behavioral Health Inpatient Services
Exclusions: Excludes, "Inpatient confinements that are primarily intended as a change of environment"; Counseling with relatives of a patient. |
YES | No Charge after deductible |
100.00% |
Mental/Behavioral Health Outpatient Services
Exclusions: Excludes marriage and family therapy. |
YES | No Charge after deductible |
100.00% |
Non-Preferred Brand Drugs
Limit: 30.0 Days per Month Non-preferred brand medications are available in 90-day supplies through preferred retail pharmacies or home delivery. Limited to 30 day supplies at all other pharmacies. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information. |
YES | No Charge after deductible |
100.00% |
Nutritional Counseling
|
YES | No Charge after deductible |
100.00% |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
Coverage is for medically necessary orthodontia only. |
YES | No Charge after deductible |
100.00% |
Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | No Charge after deductible |
100.00% |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | No Charge after deductible |
100.00% |
Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Year Exclusions: Applied Behavior Analysis (ABA) therapy; Speech therapy for stammering or stuttering; Group classes for pulmonary rehabilitation; music therapy, remedial reading, recreational or activity therapy, all forms or special education and supplies or equipment used similarly; maintenance therapy; massage therapy. Limited to 30 visits for any combination of physical therapy, occupational therapy, and manipulative treatment including chiropractic care. |
YES | No Charge after deductible |
100.00% |
Outpatient Surgery Physician/Surgical Services
|
YES | No Charge after deductible |
100.00% |
Preferred Brand Drugs
Limit: 30.0 Days per Month Preferred brand medications are available in 90-day supplies through preferred retail pharmacies or home delivery. Limited to 30 day supplies at all other pharmacies. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information. |
YES | No Charge 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
|
YES | No Charge after deductible |
100.00% |
Private-Duty Nursing
Exclusions: Excludes services provided by a close relative or a member of the household. |
YES | No Charge after deductible |
100.00% |
Prosthetic Devices
Exclusions: Dental appliances except when medically necessary for the treatment of temporomandibular joint disease or obstructive sleep apnea; cosmetic improvements, such as implants of hair follicles and skin tone enhancements; lenses for keratoconus or any other eye procedure except as specifically covered under the health plan. Prosthetic appliance must replace all or part of a body part or its function. |
YES | No Charge after deductible |
100.00% |
Radiation
|
YES | No Charge after deductible |
100.00% |
Reconstructive Surgery
|
YES | No Charge after deductible |
100.00% |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year Limited to 30 visits for any combination of physical therapy, occupational therapy, and manipulative treatment including chiropractic care. |
YES | No Charge after deductible |
100.00% |
Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year Exclusions: Excludes speech therapy for stammering or stuttering. |
YES | No Charge after deductible |
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 Year Limit will be any combination of Skilled Nursing Facility or Inpatient Rehabilitation Facility Services. |
YES | No Charge after deductible |
100.00% |
Specialist Visit
|
YES | No Charge after deductible |
100.00% |
Specialty Drugs
Limit: 30.0 Days per Month Covers outpatient self-administered prescription legend drugs from a participating network pharmacy. Quantity limits per prescription may apply. |
YES | No Charge after deductible |
100.00% |
Substance Abuse Disorder Inpatient Services
Exclusions: Excludes, "Inpatient confinements that are primarily intended as a change of environment"; Counseling with relatives of a patient. |
YES | No Charge after deductible |
100.00% |
Substance Abuse Disorder Outpatient Services
Exclusions: Excludes marriage and family therapy. |
YES | No Charge after deductible |
100.00% |
Transplant
Exclusions: The purchase price of organs or tissue if any organ or tissue is sold rather than donated to the recipient member; the procurement of organs, tissue, bone marrow, or peripheral blood stem cells or any other donor services if a recipient is not a member; transplants, including high dose chemotherapy, considered experimental or investigational; services for or related to the transplantation of animal or artificial organs or tissues. |
YES | No Charge after deductible |
100.00% |
Treatment for Temporomandibular Joint Disorders
Exclusions: Excludes Treatment for periodontal disease; Dental implants or root canals; Crowns and bridges; Orthodontic brace; Occlusal (bite) adjustments; Extractions. |
YES | No Charge after deductible |
100.00% |
Urgent Care Centers or Facilities
|
YES | No Charge after deductible |
100.00% |
Weight Loss Programs
|
NO | ||
Well Baby Visits and Care
|
YES | No Charge |
100.00% |
X-rays and Diagnostic Imaging
|
YES | No Charge after deductible |
100.00% |
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 | 2023 |
Child-Only Offering | Allows Adult and Child-Only |
Composite Rating Offered | No |
CSR Variation Type | Standard Bronze Off Exchange Plan |
Dental Only Plan | No |
Design Type | Not Applicable |
EHB Percent of Total Premium | 1 |
First Tier Utilization | 100% |
Formulary ID | NCF012 |
Formulary URL | URL |
HIOS Product ID | 54332NC003 |
Import Date | 1/25/2023 1:00 |
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? | No |
Issuer Actuarial Value | 61.05% |
Issuer ID | 54332 |
Issuer Marketplace Marketing Name | UnitedHealthcare |
Market Coverage | Individual |
Medical Drug Deductibles Integrated | Yes |
Medical Drug Maximum Out of Pocket Integrated | Yes |
Metal Level | Bronze |
Multiple In Network Tiers | No |
National Network | No |
Network ID | NCN001 |
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 | 1/1/2023 |
Plan ID (Standard Component ID with Variant) | 54332NC0030028-00 |
Plan Marketing Name | UHC Bronze Essential $9,100 Indiv Ded ($3 Generic Rx Pref Pharm, No Referrals) |
Plan Type | HMO |
Plan Variant Marketing Name | UHC Bronze-X Essential $9,100 Indiv Ded ($3 Generic Rx Pref Pharm, No Referrals) |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $0 |
SBC Scenario, Having a Baby, Copayment | $0 |
SBC Scenario, Having a Baby, Deductible | $9,100 |
SBC Scenario, Having a Baby, Limit | $60 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $0 |
SBC Scenario, Having Diabetes, Deductible | $5,300 |
SBC Scenario, Having Diabetes, Limit | $0 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,800 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | NCS001 |
Source Name | HIOS |
Plan ID | 54332NC0030028 |
State Code | NC |
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 | 0.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $18200 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $9100 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $9,100 |
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 | $18200 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9100 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,100 |
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, 30 Apr 2024 06:06 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