UHC Bronze Value HSA $6,700 Indiv Ded

94968KS0090012
Expanded Bronze
EPO

UHC Bronze Value HSA $6,700 Indiv Ded is an Expanded Bronze EPO plan by UnitedHealthcare.

IMPORTANT: You are viewing the 2023 version of UHC Bronze Value HSA $6,700 Indiv Ded 94968KS0090012. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

UHC Bronze Value HSA $6,700 Indiv Ded is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of UHC Bronze Value HSA $6,700 Indiv Ded 94968KS0090012.
Insurer: UnitedHealthcare
Network Type: EPO
Metal Type: Expanded Bronze
HSA Eligible?: Yes
Plan ID: 94968KS0090012

Cost-Sharing Overview

UHC Bronze Value HSA $6,700 Indiv Ded 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 Value HSA $6,700 Indiv Ded?

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 Value HSA $6,700 Indiv Ded offers the following features and referral requirements.

Wellness Program: No
Disease Program:
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what UHC Bronze Value HSA $6,700 Indiv Ded 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. The Network Area may include select Network providers located in a neighboring state.
National Network: No

Additional Benefits and Cost-Sharing

UHC Bronze Value HSA $6,700 Indiv Ded 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
$50 Copay after deductible 100.00%
Specialist Visit
Covered
30% Coinsurance after deductible 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
30% Coinsurance after deductible 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
30% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
30% Coinsurance after deductible 100.00%
Hospice Services
Covered
30% Coinsurance after deductible 100.00%
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Covered
30% Coinsurance after deductible 100.00% Plan covers Diagnosis and treatment of cause of infertility. Benefits are available for covered services such as office visits, laboratory tests, and radiological studies to diagnose the cause of infertility. Benefits are also provided for the necessary treatment of the condition unless the treatment is identified as non-covered (see exclusions). For example, corrective surgical procedures, therapeutic injections, and drug therapy regimens (Pregnyl, Clomid, Clomiphene, Ovidrel, Gonal, Follistim and Cetrotide) are all covered services when medically necessary. Benefits are also available for tests, such as ultrasound, performed to monitor the effectiveness of the fertility drug therapy. Also for any necessary pregnancy testing performed as an integral part of the overall infertility treatment program. Benefits are excluded, however, for any procedures, tests, or other services that are exclusively provided to monitor the effectiveness of non-covered fertilization procedures.
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
30% Coinsurance after deductible 100.00%
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$75 Copay after deductible 100.00%
Home Health Care Services
Covered
30% Coinsurance after deductible 100.00%
Emergency Room Services
Covered
30% Coinsurance after deductible 30% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
30% Coinsurance after deductible 30% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
30% Coinsurance after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
30% Coinsurance after deductible 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Not Covered
Prenatal and Postnatal Care
Covered
No Charge 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
30% Coinsurance after deductible 100.00% Childbirth/delivery professional services follow inpatient physician/surgeon fees
Mental/Behavioral Health Outpatient Services
Covered
30% Coinsurance after deductible 100.00%
Mental/Behavioral Health Inpatient Services
Covered
30% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
30% Coinsurance after deductible 100.00%
Substance Abuse Disorder Inpatient Services
Covered
30% Coinsurance after deductible 100.00%
Generic Drugs
Covered
$5 Copay after deductible 100.00%34 Days per Month See SBC for non-preferred generic cost shares. Generic medications are available in 102-day supplies through home delivery. Limited to 34 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
40% Coinsurance after deductible 100.00%34 Days per Month Preferred brand medications are available in 102-day supplies through home delivery. Limited to 34 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
50% Coinsurance after deductible 100.00%34 Days per Month Non-preferred brand medications are available in 102-day supplies through home delivery. Limited to 34 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
50% Coinsurance after deductible 100.00%34 Days per Month Specialty medications are limited to a 34-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
30% Coinsurance after deductible 100.00%90 Days per Year Speech Therapy limited to 1 visit per day, up to 90 days.
Habilitation Services
Covered
30% Coinsurance after deductible 100.00%
Chiropractic Care
Covered
30% Coinsurance after deductible 100.00%
Durable Medical Equipment
Covered
30% Coinsurance after deductible 100.00%
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
30% Coinsurance after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge 100.00%
Routine Foot Care
Covered
30% Coinsurance after deductible 100.00% 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%
Eye Glasses for Children
Covered
30% Coinsurance after deductible 100.00%3 Item(s) per Year
Dental Check-Up for Children
Covered
No Charge 100.00%1 Visit(s) per 6 Months
Rehabilitative Speech Therapy
Covered
30% Coinsurance after deductible 100.00%90 Days per Year Speech Therapy limited to 1 visit per day, up to 90 days.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
30% Coinsurance after deductible 100.00%
Well Baby Visits and Care
Covered
No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
30% Coinsurance after deductible 100.00%18 Visit(s) per Year Limited to 18 Presumptive Drug Tests per year. Limited to 18 Definitive Drug Tests per year.
X-rays and Diagnostic Imaging
Covered
30% Coinsurance after deductible 100.00%
Basic Dental Care – Child
Covered
30% Coinsurance after deductible 100.00% Benefit limitations may apply to individual services.
Orthodontia – Child
Covered
50% Coinsurance after deductible 100.00% Coverage is for medically necessary orthodontia only.
Major Dental Care – Child
Covered
30% Coinsurance 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
30% Coinsurance after deductible 100.00%
Accidental Dental
Covered
30% Coinsurance after deductible 100.00%
Dialysis
Covered
30% Coinsurance after deductible 100.00%
Allergy Testing
Covered
30% Coinsurance after deductible 100.00%
Chemotherapy
Covered
30% Coinsurance after deductible 100.00%
Radiation
Covered
30% Coinsurance after deductible 100.00%
Diabetes Education
Covered
30% Coinsurance after deductible 100.00%
Prosthetic Devices
Covered
30% Coinsurance after deductible 100.00%
Infusion Therapy
Covered
30% Coinsurance after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
30% Coinsurance after deductible 100.00%
Nutritional Counseling
Covered
30% Coinsurance after deductible 100.00%
Reconstructive Surgery
Covered
30% Coinsurance after deductible 100.00%
Gender Affirming Care
Not Covered

Free Preventive Services

There is no copayment or coinsurance for any of the following UHC Bronze Value HSA $6,700 Indiv Ded 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 Value HSA $6,700 Indiv Ded 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 Value HSA $6,700 Indiv Ded?

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

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