UHC Gold Standard (No Referrals) - 69842LA0240012 Health Insurance Plan

UnitedHealthcare Insurance Company health insurance plan with the Plan ID 69842LA0240012. The plan is called UHC Gold Standard (No Referrals).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.10% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 21.90% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.

Health Insurance Plan ID 69842LA0240012
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 69842LA0240012-00
Provider Network(s) NON-PREFERRED NETWORK
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 10 Dec 2024 06:32 GMT).

Providers Louisiana All US States
All 11806 13062
PCP 1583 1698
Allergy 6 6
OB/GYN 63 68
Dentists 11 12
Available Variants of the Health Plan

Standard Off Exchange Plan - 69842LA0240012-00

Standard On Exchange Plan - 69842LA0240012-01

Open to Indians below 300% FPL - 69842LA0240012-02

Open to Indians above 300% FPL - 69842LA0240012-03

Last Plan Update Date Fri, 16 Aug 2024 00:00 GMT
Last Import Date Tue, 10 Dec 2024 06:32 GMT

Benefits of UHC Gold Standard (No Referrals) Health Insurance Plan, 69842LA0240012-00

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

25.00% Coinsurance after deductible

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

25.00% Coinsurance after deductible

100.00%
Chemotherapy
YES

25.00% Coinsurance after deductible

100.00%
Chiropractic Care
YES

25.00% Coinsurance 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

25.00% Coinsurance 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

25.00% Coinsurance after deductible

100.00%
Dialysis
YES

25.00% Coinsurance after deductible

100.00%
Durable Medical Equipment
YES

25.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

25.00% Coinsurance after deductible

100.00%
Gender Affirming Care

Covered when medically necessary.

YES

25.00% 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

$15.00

100.00%
Habilitation Services
YES

$30.00

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

25.00% Coinsurance after deductible

100.00%
Home Health Care Services
YES

25.00% Coinsurance after deductible

100.00%
Hospice Services
YES

25.00% Coinsurance after deductible

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

25.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

25.00% Coinsurance after deductible

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

25.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

25.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

25.00% Coinsurance 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

25.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Inpatient Services
YES

25.00% 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

$30.00

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

$60.00

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

25.00% Coinsurance after deductible

100.00%
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

25.00% Coinsurance after deductible

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

25.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services
YES

$30.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

25.00% 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

$30.00

100.00%
Prenatal and Postnatal Care
YES

No Charge

100.00%
Preventive Care/Screening/Immunization
YES

0.00%

100.00%
Primary Care Visit to Treat an Injury or Illness

Cost sharing for Virtual Primary Care matches in-person office visit.

YES

$30.00

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

25.00% Coinsurance after deductible

100.00%
Prosthetic Devices
YES

25.00% Coinsurance after deductible

100.00%
Radiation
YES

25.00% 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

25.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy
YES

$30.00

100.00%
Rehabilitative Speech Therapy
YES

$30.00

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 as medically necessary for the prevention of complications associated with metabolic, neurologic, or peripheral vascular disease

NO
Skilled Nursing Facility
YES

25.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$60.00

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

$100.00

100.00%
Substance Abuse Disorder Inpatient Services
YES

25.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

$30.00

100.00%
Transplant
YES

25.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
NO
Urgent Care Centers or Facilities
YES

$45.00

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

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

25.00% Coinsurance after deductible

100.00%

UHC Gold-X Standard (No Referrals) Health Insurance Plan Variant 69842LA0240012-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.781023925816989
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 Standard Gold Off Exchange Plan
Dental Only Plan No
Design Type Design 2
EHB Percent of Total Premium 1.0
First Tier Utilization 100%
Formulary ID LAF032
Formulary URL URL
HIOS Product ID 69842LA024
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 Existing
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer ID 69842
Issuer Marketplace Marketing Name UnitedHealthcare
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Gold
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) 69842LA0240012-00
Plan Level Exclusions Some exclusions may apply. See the applicable Certificate of Coverage for details.
Plan Marketing Name UHC Gold Standard (No Referrals)
Plan Type EPO
Plan Variant Marketing Name UHC Gold-X Standard (No Referrals)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,400
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $1,500
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $200
SBC Scenario, Having Diabetes, Deductible $300
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $200
SBC Scenario, Treatment of a Simple Fracture, Copayment $200
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,500
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID LAS011
Source Name HIOS
Specialty Drug Maximum Coinsurance $150
Plan ID 69842LA0240012
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
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 25.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $3000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $1500 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $1,500
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 $15600 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $7800 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $7,800
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 No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of UHC Gold Standard (No Referrals) Health Insurance Plan, 69842LA0240012

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

Frequently Asked Questions(FAQ) about UHC Gold Standard (No Referrals), 69842LA0240012 Health Insurance Plan, 69842LA0240012

  • Does UHC Gold Standard (No Referrals) Health Insurance Plan, 69842LA0240012 support Mail Ordering?

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

  • Does (69842LA0240012) Health Insurance Plan, Variant (69842LA0240012-00) have Out Of Country Coverage?

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

    Does (69842LA0240012) Health Insurance Plan, Variant (69842LA0240012-00) 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: 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