UHC Bronze Essential ($3 T1 Preferred Rx)

33931OH0030022
Bronze
HMO

UHC Bronze Essential ($3 T1 Preferred Rx) is a Bronze HMO plan by UnitedHealthcare.

IMPORTANT: You are viewing the 2023 version of UHC Bronze Essential ($3 T1 Preferred Rx) 33931OH0030022. You can enroll in this plan during open enrollment 2023, which started November 1st and ends January 15th, 2023, in most states.

Locations

UHC Bronze Essential ($3 T1 Preferred Rx) is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of UHC Bronze Essential ($3 T1 Preferred Rx) 33931OH0030022.
Insurer: UnitedHealthcare
Network Type: HMO
Metal Type: Bronze
HSA Eligible?: No
Plan ID: 33931OH0030022

Cost-Sharing Overview

UHC Bronze Essential ($3 T1 Preferred Rx) offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for UHC Bronze Essential ($3 T1 Preferred Rx)?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

UHC Bronze Essential ($3 T1 Preferred Rx) offers the following features and referral requirements.

Wellness Program: No
Disease Program:
Notice Pregnancy: No
Referral Specialist: Yes
Specialist Requiring Referral: All, except OBGYN and as state mandated
Plan Exclusions: 0
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what UHC Bronze Essential ($3 T1 Preferred Rx) covers when you are out of the service area or out of the country.

Out of Country Coverage: No
Out of Country Coverage Description:
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.
National Network: No

Additional Benefits and Cost-Sharing

UHC Bronze Essential ($3 T1 Preferred Rx) includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
No Charge after deductible 100.00%
Specialist Visit
Covered
No Charge after deductible 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
No Charge after deductible 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
No Charge after deductible 100.00% See specific exceptions to these exclusions and/or additional exclusions that are detailed in plan document; benefits for facility charges for Outpatient Services are payable for the removal of teeth or for other dental processes only if the patient’s medical condition or the dental procedure requires a Hospital setting to ensure the safety of the patient
Outpatient Surgery Physician/Surgical Services
Covered
No Charge after deductible 100.00%
Hospice Services
Covered
No Charge after deductible 100.00% To be eligible for Hospice benefits, the patient must have a life expectancy of six months or less, as confirmed by the attending Physician
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Covered
No Charge after deductible 100.00% Includes services to diagnose and treat medical conditions resulting in infertility. Excludes: Artificial insemination, in vitro fertilization, other types of artificial or surgical means of conception including drugs administered in connection with these procedures
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
No Charge after deductible 100.00%90 Visit(s) per Benefit Period Private Duty Nursing Services are Covered Services only when provided through the Home Care Services benefit
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
No Charge after deductible 100.00%
Home Health Care Services
Covered
No Charge after deductible 100.00%100 Visit(s) per Benefit Period When therapy services are provided in the home (including physical, speech, and occupational therapy) as part of home health care services, they are not subject to separate visit limits for therapy services. The 100 visit/year limit is also not applicable to home infusion therapy or private duty nursing rendered in the home setting
Emergency Room Services
Covered
No Charge after deductible No Charge after deductible
Emergency Transportation/Ambulance
Covered
No Charge after deductible No Charge after deductible Ambulance Services are transportation by a vehicle (including ground, water, fixed wing and rotary wing air transportation) designed, equipped and used only to transport the sick and injured and staffed by Emergency Medical Technicians (EMT), paramedics, or other certified medical professionals: from home, scene of accident or medical emergency to a hospital; between hospitals; between a hospital and skilled nursing facility; or from a hospital or skilled nursing facility to home; ambulance trips must be made to the closest facility that can give covered services appropriate for the member’s condition
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
No Charge after deductible 100.00% There are specific exceptions to certain exclusions and/or additional exclusions that are detailed in plan document; inpatient hospital services include charges from a hospital, skilled nursing facility or other provider for room, board, general nursing services; and ancillary (related) services.
Inpatient Physician and Surgical Services
Covered
No Charge after deductible 100.00% There are specific exceptions to certain exclusions and/or additional exclusions that are detailed in plan document; inpatient medical care visits limited to one visit per day by any one physician.
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
No Charge after deductible 100.00%90 Days per Benefit Period Benefits include Items and services provided as an inpatient in a skilled nursing bed of skilled nursing facility or hospital, including room and board in semi-private accommodations; rehabilitative services; and drugs, biologicals, and supplies furnished
Prenatal and Postnatal Care
Covered
No Charge 100.00% Includes post-delivery follow-up care performed, by a physician or nurse, within 72 hours of discharge, through home health care visits or, at patient’s discretion, in a medical setting. This coverage includes, but is not limited to parent education; assistance and training in breast or bottle feeding; and routine maternal or neonatal tests and screening (including collection of sample for hereditary and metabolic newborn screening)
Delivery and All Inpatient Services for Maternity Care
Covered
No Charge after deductible 100.00% Coverage for the Inpatient postpartum stay for mother and newborn child in a hospital will be, at a minimum, 48 hours for a vaginal delivery and 96 hours for a cesarean section. Coverage will be for the length of stay recommended by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists in their Guidelines for Prenatal Care. Childbirth/delivery professional services follow inpatient physician/surgeon fees.
Mental/Behavioral Health Outpatient Services
Covered
No Charge after deductible 100.00%
Mental/Behavioral Health Inpatient Services
Covered
No Charge after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
No Charge after deductible 100.00%
Substance Abuse Disorder Inpatient Services
Covered
No Charge after deductible 100.00%
Generic Drugs
Covered
$3.00 100.00% Lowest cost shares are available at preferred retail pharmacies and home delivery. See the Summary of Benefits and Coverage 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.
Preferred Brand Drugs
Covered
No Charge after deductible 100.00% 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.
Non-Preferred Brand Drugs
Covered
No Charge after deductible 100.00% 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.
Specialty Drugs
Covered
No Charge after deductible 100.00% 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.
Outpatient Rehabilitation Services
Covered
No Charge after deductible 100.00%116 Visit(s) per Benefit Period 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, and 20 visits per year for Pulmonary.
Habilitation Services
Covered
No Charge after deductible 100.00% Limits may apply to some services; includes benefits for health care services and devices that help a person keep, learn or improve skills and functioning for daily living, including treatment of Autism Spectrum Disorders to children (0 – 21), which at a minimum shall include: (1) Out-Patient Physical Rehabilitation Services including (a) Speech and Language therapy and/or Occupational therapy, 20 visits per year of each service; and (b) Clinical Therapeutic Intervention, which include but are not limited to Applied Behavioral Analysis, 20 hours per week; and (2) Mental/Behavioral Health Outpatient Services to provide consultation, assessment, development and oversight of treatment plans
Chiropractic Care
Covered
No Charge after deductible 100.00%12 Visit(s) per Benefit Period
Durable Medical Equipment
Covered
No Charge after deductible 100.00% Covered services include durable medical equipment, medical devices and supplies, prosthetics and appliances, including cochlear implants and eyeglasses/contact lenses (for cataract surgery or injury), and medical/surgical supplies and equipment that serve only a medical purpose for the management of disease. Benefit limits: Wigs are limited to the first one following cancer treatment not to exceed one per Benefit Period; limit of four (4) surgical bras following mastectomy per benefit period; (as required by the Women’s Health and Cancer Rights Act); Left Ventricular Artificial Devices (LVAD) covered only as bridge to heart transplant.
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
No Charge after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge 100.00% Services with an ‘A’ or ‘B’ rating from the United States Preventive Services Task Force (USPSTF); Immunizations for children, adolescents, and adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; Preventive care and screenings for infants, children and adolescents as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. Additional preventive care and screening for women provided for in the guidelines supported by the Health Resources and Services Administration including: women’s contraceptives, sterilization procedures, and counseling; breastfeeding support, supplies, and counseling (benefits for breast pumps are limited to one pump per benefit period); and gestational diabetes screening; routine screening mammograms; routine cytologic screening; child health supervision services from birth to age 9
Routine Foot Care
Not Covered
Not Covered except for preventive foot care due to conditions associated with metabolic, neurologic, or peripheral vascular disease.
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge 100.00%1 Exam(s) per Year
Eye Glasses for Children
Covered
No Charge after deductible 100.00%1 Item(s) per Year
Dental Check-Up for Children
Covered
No Charge 100.00%1 Exam(s) per 6 Months
Rehabilitative Speech Therapy
Covered
No Charge after deductible 100.00%20 Visit(s) per Benefit Period
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
No Charge after deductible 100.00%40 Visit(s) per Benefit Period Limited to 20 visits per year for Occupational Therapy and 20 visits per year for Physical Therapy.
Well Baby Visits and Care
Covered
No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
No Charge after deductible 100.00%
X-rays and Diagnostic Imaging
Covered
No Charge after deductible 100.00%
Basic Dental Care – Child
Covered
No Charge after deductible 100.00% Benefit limitations may apply to individual services.
Orthodontia – Child
Covered
No Charge after deductible 100.00% Coverage is for medically necessary orthodontia only.
Major Dental Care – Child
Covered
No Charge after deductible 100.00% Benefit limitations may apply to individual services.
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
No Charge after deductible 100.00% Includes coverage for unrelated donor search services ($30,000 per transplant) and travel/lodging as approved by the plan ($10,000 per transplant). Transplant benefits apply to any medically necessary human organ and stem cell/bone marrow transplants (except cornea and kidney transplants) and transfusions including necessary acquisition procedures, harvest and storage, necessary preparatory myeloablative therapy, and initial evaluation/testing to determine eligibility as a transplant candidate.
Accidental Dental
Covered
No Charge after deductible 100.00%3000 Dollars per Episode
Dialysis
Covered
No Charge after deductible 100.00% Benefits include supportive use of an artificial kidney machine
Allergy Testing
Covered
No Charge after deductible 100.00%
Chemotherapy
Covered
No Charge after deductible 100.00%
Radiation
Covered
No Charge after deductible 100.00%
Diabetes Education
Covered
No Charge after deductible 100.00% Diabetes Self-Management Training for an individual with insulin dependent diabetes, non-insulin dependent diabetes, or elevated blood glucose levels induced by pregnancy or another medical condition
Prosthetic Devices
Covered
No Charge after deductible 100.00% Benefits for artificial substitutes for body parts and tissues and materials inserted into tissue for functional or therapeutic purposes. Covered Services include purchase, fitting, needed adjustment, repairs, and replacements of prosthetic devices and supplies that 1) Replace all or part of a missing body part and its adjoining tissues; or 2) Replace all or part of the function of a permanently useless or malfunctioning body part.
Infusion Therapy
Covered
No Charge after deductible 100.00% Home IV therapy includes but is not limited to: injections (intra-muscular, subcutaneous, continuous subcutaneous), Total Parenteral Nutrition (TPN), Enteral nutrition therapy, antibiotic therapy, pain management and chemotherapy
Treatment for Temporomandibular Joint Disorders
Covered
No Charge after deductible 100.00% Benefits provided for temporomandibular (joint connecting the lower jaw to the temporal bone at the side of the head) and craniomandibular (head and neck muscle) disorders
Nutritional Counseling
Covered
No Charge after deductible 100.00% Covered benefit under home health services and covered as USPSTF A or B recommendation under preventive health services (includes diet counseling for adults at higher risk for chronic disease, obesity screening and counseling for all adults, and healthy diet counseling for adults with cardiovascular risk factors)
Reconstructive Surgery
Covered
No Charge after deductible 100.00% Benefits include reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance. Benefits include surgery performed to restore symmetry after a mastectomy.
Gender Affirming Care
Not Covered

Free Preventive Services

There is no copayment or coinsurance for any of the following UHC Bronze Essential ($3 T1 Preferred Rx) preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for UHC Bronze Essential ($3 T1 Preferred Rx) including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for UHC Bronze Essential ($3 T1 Preferred Rx)?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Table of Contents