UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) - 72850IN0160006 Health Insurance Plan

UnitedHealthcare Insurance Company health insurance plan with the Plan ID 72850IN0160006. 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 71.70% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 28.30% of the costs of all covered benefits (according to the Issuer).

Health Insurance Plan ID 72850IN0160006
Health Insurance Plan Year 2025
State Indiana
Health Insurance Issuer UnitedHealthcare Insurance Company
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 72850IN0160006-00
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 Indiana All US States
All 5983 6778
PCP 697 724
Allergy N/A N/A
OB/GYN 10 11
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 72850IN0160006-00

Standard On Exchange Plan - 72850IN0160006-01

Open to Indians below 300% FPL - 72850IN0160006-02

Open to Indians above 300% FPL - 72850IN0160006-03

73% AV Silver Plan - 72850IN0160006-04

87% AV Silver Plan - 72850IN0160006-05

94% AV Silver Plan - 72850IN0160006-06

Last Plan Update Date Thu, 31 Oct 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, 72850IN0160006-00

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

Per Indiana law, abortion only covered if performed because a woman becomes pregnant through an act of rape or incest; or an abortion is necessary to avert the pregnant woman?s death or a substantial and irreversible impairment of a major bodily function of the pregnant woman.

NO
Accidental Dental
YES

40.00%

100.00%
Acupuncture
NO
Allergy Testing

Cost share driven by provider/setting.

YES

$80.00

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
YES

40.00%

100.00%
Chemotherapy

Cost share driven by provider/setting.

YES

$750.00

100.00%
Chiropractic Care

Limit: 12.0 Visit(s) per Benefit Period

Cost share driven by provider/setting.

YES

40.00%

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care

Childbirth/delivery professional services follow inpatient physician/surgeon fees.

YES

$3,000.00

100.00%
Dental Check-Up for Children

Limit: 1.0 Visit(s) per 6 Months

YES

No Charge

100.00%
Diabetes Education
YES

40.00%

100.00%
Dialysis
YES

$750.00

100.00%
Durable Medical Equipment

One wig per benefit period.

YES

40.00%

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

40.00%

100.00%
Gender Affirming Care

Covered when medically necessary.

YES

$400.00

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

$20.00

100.00%
Habilitation Services

Limit: 60.0 Visit(s) per Benefit Period

Includes 20 visits each of PT, OT and ST.

YES

$80.00

100.00%
Hearing Aids
NO
Home Health Care Services

Limit: 100.0 Visit(s) per Benefit Period

Maximum does not include Home Infusion Therapy or Private Duty Nursing rendered in the home.

YES

40.00%

100.00%
Hospice Services
YES

40.00%

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

$200.00

100.00%
Infertility Treatment
NO
Infusion Therapy

Cost share driven by provider/setting.

YES

$100.00

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

Maximum 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis).

YES

$3000.00 Copay per Day

100.00%
Inpatient Physician and Surgical Services
YES

No Charge

100.00%
Laboratory Outpatient and Professional Services

Cost share driven by provider/setting.

YES

$40.00

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
YES

40.00%

100.00%
Mental/Behavioral Health Inpatient Services
YES

$3000.00 Copay per Day

100.00%
Mental/Behavioral Health Outpatient Services

Cost share driven by provider/setting.

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

40.00%

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
YES

50.00%

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

40.00%

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

$400.00

100.00%
Outpatient Rehabilitation Services

Limit: 60.0 Visit(s) per Benefit Period

Cost share is driven by provider/setting. Coverage for Speech Therapy is limited to 20 visits per benefit period, Occupational Therapy is limited to 20 visits per benefit period, and Physical Therapy is limited to 20 visits per benefit period. Benefit includes an Inpatient maximum of 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis). Cardiac Rehabilitation limited to 36 visits when rendered as Physician Home Visits and Office Services or Outpatient Services, when rendered in the home, Home Care Services limits apply.Pulmonary Rehabilitation limited to 20 visits when rendered as Physician Home Visits and Office Services or Outpatient Services. When rendered in the home, Home Care Services limits apply. When rendered as part of physical therapy, the Physical Therapy limit will apply instead of the limit indicated.

YES

$80.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

$400.00

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

$45.00

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

$35.00

100.00%
Private-Duty Nursing

Limit: 82.0 Visit(s) per Year

YES

40.00%

100.00%
Prosthetic Devices

Must be medically necessary.

YES

40.00%

100.00%
Radiation

Cost share driven by provider/setting.

YES

$100.00

100.00%
Reconstructive Surgery

Certain reconstructive services required to correct a deformity caused by disease, trauma, congenital anomalies, or previous therapeutic process are covered. Coverage includes breast reconstruction on which a mastectomy has been performed. Reconstructive services required due to prior therapeutic process are payable only if the original procedure would have been a covered service under this plan.

YES

$400.00

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 40.0 Visit(s) per Benefit Period

Cost share is driven by provider/setting. Occupational Therapy is limited to 20 visits per benefit period, and Physical Therapy is limited to a separate 20 visits per benefit period. Coverage also includes an additional 20 visits each for habilitative services.

YES

$80.00

100.00%
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Benefit Period

Cost share driven by provider/setting.

YES

$80.00

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

Limit: 90.0 Days per Benefit Period

Benefit includes an Inpatient maximum of 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis).

YES

$3000.00 Copay per Day

100.00%
Specialist Visit
YES

$80.00

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

$3000.00 Copay per Day

100.00%
Substance Abuse Disorder Outpatient Services

Cost share driven by provider/setting.

YES

$50.00

100.00%
Transplant

Includes coverage for unrelated donor search services ($30,000 per transplant) and travel/lodging as approved by the plan ($10,000 per transplant).

YES

$3,000.00

100.00%
Treatment for Temporomandibular Joint Disorders
YES

40.00%

100.00%
Urgent Care Centers or Facilities

$0 Virtual Urgent Care visits are available through telehealth vendor only. 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 share driven by provider/setting.

YES

$65.00

100.00%

UHC Silver-X Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Health Insurance Plan Variant 72850IN0160006-00 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 Standard Silver Off Exchange 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 $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 INF031
Formulary URL URL
HIOS Product ID 72850IN016
Import Date 2024-10-31 01:01:26
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 71.70%
Issuer ID 72850
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 40.00%
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 INN011
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) 72850IN0160006-00
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 EPO
Plan Variant Marketing Name UHC Silver-X 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 $3,800
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 $600
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 $2,600
SBC Scenario, Treatment of a Simple Fracture, Deductible $0
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID INS011
Source Name HIOS
Plan ID 72850IN0160006
State Code IN
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 $18400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $9200 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $9,200
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, 72850IN0160006

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), 72850IN0160006 Health Insurance Plan, 72850IN0160006

  • Does UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Health Insurance Plan, 72850IN0160006 support Mail Ordering?

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

  • Does (72850IN0160006) Health Insurance Plan, Variant (72850IN0160006-00) have Out Of Country Coverage?

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

    Does (72850IN0160006) Health Insurance Plan, Variant (72850IN0160006-00) 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