UHC Gold Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $2 T1 Preferred Rx, Dental + Vision)
24251VA0060018
Gold
HMO
UHC Gold Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $2 T1 Preferred Rx, Dental + Vision) is a Gold HMO plan by UnitedHealthcare.
IMPORTANT: You are viewing the 2023 version of UHC Gold Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $2 T1 Preferred Rx, Dental + Vision) 24251VA0060018. You can enroll in this plan if you qualify for special enrollment until the end of 2023.
Locations
UHC Gold Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $2 T1 Preferred Rx, Dental + Vision) is offered in the following counties.
Plan Overview
This is a plan overview for 2023 version of UHC Gold Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $2 T1 Preferred Rx, Dental + Vision) 24251VA0060018.
| Insurer: | UnitedHealthcare |
| Network Type: | HMO |
| Metal Type: | Gold |
| HSA Eligible?: | No |
| Plan ID: | 24251VA0060018 |
Cost-Sharing Overview
UHC Gold Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $2 T1 Preferred Rx, Dental + Vision) offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for UHC Gold Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $2 T1 Preferred Rx, Dental + Vision) includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $7,500.00 | $7500 per person | $15000 per group |
| Deductible: | $1,200.00 | $1200 per person | $2400 per group |
| Coinsurance: | 20.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for UHC Gold Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $2 T1 Preferred Rx, Dental + Vision) will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | Not Applicable | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | Not Applicable | per person not applicable | per group not applicable |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | $1,200.00 |
| Copayment: | $0.00 |
| Coinsurance: | $1,900.00 |
| Limit: | $60.00 |
| Deductible: | $1,200.00 |
| Copayment: | $600.00 |
| Coinsurance: | $20.00 |
| Limit: | $0.00 |
| Deductible: | $1,200.00 |
| Copayment: | $0.00 |
| Coinsurance: | $500.00 |
| Limit: | $0.00 |
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 Gold Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $2 T1 Preferred Rx, Dental + Vision)?
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 Gold Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $2 T1 Preferred Rx, Dental + Vision) 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 Gold Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $2 T1 Preferred Rx, Dental + Vision) 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 Gold Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $2 T1 Preferred Rx, Dental + Vision) 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 | 100.00% | Virtual urgent care visits via a Designated virtual provider unlimited $0 |
| Specialist Visit Covered | 20% Coinsurance after deductible | 100.00% | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | 20% Coinsurance after deductible | 100.00% | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | 20% Coinsurance after deductible | 100.00% | Benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is Medically Necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Includes coverage for blood and blood products, anesthesia and anesthesia supplies and services given by the Hospital or other Facility, medical and surgical dressings and supplies, casts, and splints. Includes coverage for general anesthesia and hospitalization services when determined by dentist and treating physician that such services are required to effectively and safely provide dental care for (i) children under the age of 5, (ii) covered persons who are severely disabled, or (iii) covered persons who have a medical condition that requires admission to a hospital or Outpatient surgery facility. Surgeries and procedures to correct congenital abnormalities that cause functional impairment and congenital abnormalities in newborn children; other invasive procedures, such as angiogram, arteriogram, amniocentesis, tap or puncture of brain or spine; endoscopic exams, such as arthroscopy, bronchoscopy, colonoscopy, laparoscopy; treatment of fractures and dislocations; anesthesia and surgical support when Medically Necessary; Medically Necessary pre-operative and post-operative care. Benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is Medically Necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Includes surgical treatment of injuries and illnesses of the eye. |
| Outpatient Surgery Physician/Surgical Services Covered | 20% Coinsurance after deductible | 100.00% | Benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is Medically Necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Includes coverage for blood and blood products, anesthesia and anesthesia supplies and services given by the Hospital or other Facility, medical and surgical dressings and supplies, casts, and splints. Includes coverage for general anesthesia and hospitalization services when determined by dentist and treating physician that such services are required to effectively and safely provide dental care for (i) children under the age of 5, (ii) covered persons who are severely disabled, or (iii) covered persons who have a medical condition that requires admission to a hospital or Outpatient surgery facility. Surgeries and procedures to correct congenital abnormalities that cause functional impairment and congenital abnormalities in newborn children; other invasive procedures, such as angiogram, arteriogram, amniocentesis, tap or puncture of brain or spine; endoscopic exams, such as arthroscopy, bronchoscopy, colonoscopy, laparoscopy; treatment of fractures and dislocations; anesthesia and surgical support when Medically Necessary; Medically Necessary pre-operative and post-operative care. Benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is Medically Necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Includes surgical treatment of injuries and illnesses of the eye. |
| Hospice Services Covered | 20% Coinsurance after deductible | 100.00% | |
| Routine Dental Services (Adult) Covered | No Charge | 100.00% | 1000 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults; Excluded from In-Network Out-of-Pocket Limit |
| Infertility Treatment Not Covered | Assisted reproductive technologies (ART) such as artificial insemination, in-vitro fertilization, zygote intrafallopian transfer (ZIFT), or gamete intrafallopian transfer (GIFT) are NOT covered. Covered Services include diagnostic tests to find the cause of infertility, such as diagnostic laparoscopy, endometrial biopsy, and semen analysis. Benefits also include services to treat the underlying medical conditions that cause infertility (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency). | ||
| Long-Term/Custodial Nursing Home Care Not Covered | |||
| Private-Duty Nursing Covered | 20% Coinsurance after deductible | 100.00% | 16 Hours per Benefit Period Coverage does not include benefits for private duty nursing in the inpatient setting. |
| Routine Eye Exam (Adult) Covered | No Charge | 100.00% | 1 Visit(s) per Year |
| Urgent Care Centers or Facilities Covered | 20% Coinsurance after deductible | 100.00% | |
| Home Health Care Services Covered | 20% Coinsurance after deductible | 100.00% | 100 Visit(s) per Benefit Period The Home Care visit limit will apply instead of the Therapy Services limits for physical, occupational, speech therapy, or cardiac rehabilitation for therapy in the home |
| Emergency Room Services Covered | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | |
| Emergency Transportation/Ambulance Covered | 20% Coinsurance after deductible | 20% Coinsurance after deductible | |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | 20% Coinsurance after deductible | 100.00% | Benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is Medically Necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Benefits for room, board, and nursing services include: a room with two or more beds; a private room when medically necessary for isolation and no isolation facilities are available; a room in an approved special care unit; meals, special diets; general nursing services; operating, childbirth, and treatment rooms and equipment; prescribed drugs; anesthesia, anesthesia supplies and services given by the hospital or other provider; medical and surgical dressings and supplies, casts, and splints; blood and blood products; diagnostic services. Includes coverage for general anesthesia and hospitalization services when determined by dentist and treating physician that such services are required to effectively and safely provide dental care for (i) children under the age of 5, (ii) covered persons who are severely disabled, or (iii) covered persons who have a medical condition that requires admission to a hospital or Outpatient surgery facility. |
| Inpatient Physician and Surgical Services Covered | 20% Coinsurance after deductible | 100.00% | Benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is Medically Necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Includes medical care visits; intensive medical care when medically necessary; treatment for a health problem by a Doctor who is not your surgeon while you are in the Hospital for surgery; treatment by two or more Doctors during one Hospital stay when the nature or severity of your health problem calls for the skill of separate Doctors; a personal bedside exam by another Doctor when asked for by your Doctor; surgery and general anesthesia; professional charges to interpret diagnostic tests such as imaging, pathology reports, and cardiology. Surgeries and procedures to correct congenital abnormalities that cause functional impairment and congenital abnormalities in newborn children; other invasive procedures, such as angiogram, arteriogram, amniocentesis, tap or puncture of brain or spine; endoscopic exams, such as arthroscopy, bronchoscopy, colonoscopy, laparoscopy; treatment of fractures and dislocations; anesthesia and surgical support when medically necessary; medically necessary pre-operative and post-operative care. Medical benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is medically necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Includes surgical treatment of injuries and illnesses of the eye. |
| Bariatric Surgery Not Covered | |||
| Cosmetic Surgery Not Covered | |||
| Skilled Nursing Facility Covered | 20% Coinsurance after deductible | 100.00% | 100 Days per Stay Custodial care even if it is recommended by a professional or performed in a facility, such as a Skilled Nursing Facility. Includes Inpatient Rehab Services. Includes room and board in semi-private accommodations; rehabilitative services; and drugs, biologicals, and supplies furnished for use in the skilled nursing facility and other medically necessary services and supplies. Your Plan will cover the private room charge when medically necessary. |
| Prenatal and Postnatal Care Covered | No Charge | 100.00% | |
| Delivery and All Inpatient Services for Maternity Care Covered | 20% Coinsurance after deductible | 100.00% | Childbirth/delivery professional services follow inpatient physician/surgeon fees |
| Mental/Behavioral Health Outpatient Services Covered | 20% Coinsurance after deductible | 100.00% | |
| Mental/Behavioral Health Inpatient Services Covered | 20% Coinsurance after deductible | 100.00% | |
| Substance Abuse Disorder Outpatient Services Covered | 20% Coinsurance after deductible | 100.00% | |
| Substance Abuse Disorder Inpatient Services Covered | 20% Coinsurance after deductible | 100.00% | |
| Generic Drugs Covered | $2.00 | 100.00% | 30 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. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply. |
| Preferred Brand Drugs Covered | $45.00 | 100.00% | 30 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. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply. |
| Non-Preferred Brand Drugs Covered | 30% Coinsurance after deductible | 100.00% | 30 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. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply. |
| Specialty Drugs Covered | 40% Coinsurance after deductible | 100.00% | 30 Days per Month 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. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply. |
| Outpatient Rehabilitation Services Covered | 20% Coinsurance after deductible | 100.00% | 30 Visit(s) per Benefit Period Limited to 30 visits per year combined for Physical and Occupational Therapy, 30 visits per year for Speech Therapy. Limits will not apply if care is part of the hospice care benefit. When you get physical, occupational or speech therapy, in the home, the home health care visit limit will apply instead of the therapy services limits listed above. Limit does not apply when received as part of the hospice, early intervention benefit, and for the treatment of autism spectrum disorders. |
| Habilitation Services Covered | 20% Coinsurance after deductible | 100.00% | 30 Visit(s) per Benefit Period Limited to 30 visits per year combined for Physical and Occupational Therapy, 30 visits per year for Speech Therapy. These limits do not apply for the treatment of autism and autism spectrum disorders, for early intervention services, and if care is part of the hospice care benefit. When you get physical, occupational or speech therapy, in the home, the home health care visit limit will apply instead of the therapy services limits listed above. |
| Chiropractic Care Covered | 20% Coinsurance after deductible | 100.00% | 30 Visit(s) per Benefit Period Includes therapy to treat problems of the bones, joints, joints of the spine, the nervous system, and the back, and osteopathic therapy which focuses on the joints and surrounding muscles, tendons and ligaments. Visit limits apply to habilitative and rehabilitative services separately. |
| Durable Medical Equipment Covered | 20% Coinsurance after deductible | 100.00% | |
| Hearing Aids Not Covered | This Exclusion does not apply to cochlear implants. | ||
| Imaging (CT/PET Scans, MRIs) Covered | 20% Coinsurance after deductible | 100.00% | Includes x-rays/regular imaging services; radiology (including mammograms), ultrasound or nuclear medicine; and advanced imaging, including CT scan, CTA scan, Magnetic Resonance Imaging (MRI); Magnetic Resonance Angiography (MRA); Magnetic Resonance Spectroscopy (MRS); Nuclear Cardiology; PET scans; PET/CT Fusion scans; QCT Bone Densitometry; Diagnostic CT Colonography; Single photon emission computed tomography (SPCECT) scans. |
| Preventive Care/Screening/Immunization Covered | No Charge | 100.00% | Covers: (1) Services with an ‘A’ or ‘B’ rating from the United States Preventive Services Task Force; (2) Immunizations for children, adolescents, and adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; (3) Preventive care and screenings for infants, children and adolescents as listed in the guidelines supported by the Health Resources and Services Administration (including infant hearing screening); (4) Preventive care and screening for women as listed in the guidelines supported by the Health Resources and Services Administration; and (5) Counseling services related to smoking and tobacco use cessation. Prescription drugs that help you stop smoking or reduce your dependence on tobacco products are also covered preventive services. Smoking cessation products and over the counter nicotine replacement products (limited to nicotine patches and gum) are covered when obtained with a prescription. Additionally, state law requires coverage for routine screening mammograms and routine prostate specific antigen testing and digital rectal exams. |
| Routine Foot Care Not Covered | |||
| Acupuncture Not Covered | |||
| Weight Loss Programs Not Covered | |||
| Routine Eye Exam for Children Covered | No Charge | 100.00% | 1 Visit(s) per Year |
| Eye Glasses for Children Covered | 20% Coinsurance after deductible | 100.00% | 1 Item(s) per Year |
| Dental Check-Up for Children Covered | No Charge | 100.00% | 2 Visit(s) per Year |
| Rehabilitative Speech Therapy Covered | 20% Coinsurance after deductible | 100.00% | 30 Visit(s) per Benefit Period Includes services to identify, assess, and treat speech, language, and swallowing disorders in children and adults. Therapy will develop or treat communication or swallowing skills to correct a speech impairment. Limit does not apply when received as part of hospice benefit, early intervention benefit or for the treatment autism spectrum disorder. Limit applies separately to habilitative and rehabilitative service. |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | 20% Coinsurance after deductible | 100.00% | 30 Visit(s) per Benefit Period Occupational therapy does not include recreational or vocational therapies, such as hobbies, arts and crafts. Non-covered providers include, but are not limited to, masseurs or masseuses (massage therapists), and physical therapist technicians. Limited to 30 visits per year combined for Physical and Occupational Therapy. The limit applies separately to habilitative and rehabilitative services. Limit does not apply when received as part of hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders. |
| Well Baby Visits and Care Covered | No Charge | 100.00% | Includes immunizations for children recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; Preventive care and screenings for infants as listed in the guidelines supported by the Health Resources and Services Administration (including infant hearing screening). |
| Laboratory Outpatient and Professional Services Covered | 20% Coinsurance after deductible | 100.00% | |
| X-rays and Diagnostic Imaging Covered | 20% Coinsurance after deductible | 100.00% | Includes benefits for tests or procedures to find or check a condition when specific symptoms exist, as well as benefits for interpretation of diagnostic tests such as imaging, and cardiology. Tests must be ordered by a Provider and include diagnostic services ordered before a surgery or Hospital admission. Benefits include the following services: x-rays/regular imaging services; radiology (including mammograms), ultrasound or nuclear medicine. |
| Basic Dental Care – Child Covered | 20% 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 | 20% Coinsurance after deductible | 100.00% | Benefit limitations may apply to individual services. |
| Basic Dental Care – Adult Covered | 50.00% | 100.00% | 1000 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults; Excluded from In-Network Out-of-Pocket Limit |
| Orthodontia – Adult Not Covered | |||
| Major Dental Care – Adult Covered | 50.00% | 100.00% | 1000 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults; Excluded from In-Network Out-of-Pocket Limit |
| Abortion for Which Public Funding is Prohibited Not Covered | Pursuant to Virginia law no QHP sold or offered on an exchange shall provide coverage for abortions, provided that this limitation shall not apply to an abortion performed (i) when the life of the mother is endangered by a physical disorder, physical illness, or physical injury, including a life endangering physical condition relating to the pregnancy, or (ii) when the pregnancy is the result of rape or incest. | ||
| Transplant Covered | 20% Coinsurance after deductible | 100.00% | Includes coverage for medically necessary human organ, tissue, and stem cell/bone marrow transplants and infusions including necessary acquisition procedures, mobilization, harvest and storage. It also includes medically necessary myeloablative or reduced intensity preparative chemotherapy, radiation therapy, or a combination of these therapies. |
| Accidental Dental Covered | 20% Coinsurance after deductible | 100.00% | An injury that results from chewing or biting is not considered an accidental injury and is not covered. Includes dental work, to include oral/surgical correction needed to treat injuries to the jaw, sound natural teeth, mouth or face as a result of an accident. Dental appliances required to diagnose or treat an accidental injury to the teeth, and the repair of dental appliances damaged as a result of accidental injury to the jaw, mouth or face, are also covered. Treatment must begin within 12 months of the injury, or as soon after that as possible to be a covered service. |
| Dialysis Covered | 20% Coinsurance after deductible | 100.00% | |
| Allergy Testing Covered | 20% Coinsurance after deductible | 100.00% | |
| Chemotherapy Covered | 20% Coinsurance after deductible | 100.00% | |
| Radiation Covered | 20% Coinsurance after deductible | 100.00% | |
| Diabetes Education Covered | 20% Coinsurance after deductible | 100.00% | |
| Prosthetic Devices Covered | 20% Coinsurance after deductible | 100.00% | Includes benefits for prosthetics and components when they are medically necessary for activities of daily living. A prosthetic device is an artificial substitute to replace, in whole or in part, a limb or body part, such as an arm, leg, foot or eye. Includes benefits for prosthetics and components when they are medically necessary for activities of daily living. A prosthetic device is an artificial substitute to replace, in whole or in part, a limb or body part, such as an arm, leg, foot or eye. Coverage is also included for the repair, fitting, adjustments and replacement of a prosthetic device. In additional, components for artificial limbs are covered. Components are the materials and equipment needed to ensure the comfort and functioning of the prosthetic device. Covered services may include: 1) Artificial limbs and components (the materials and equipment needed to ensure the comfort and functioning of the prosthetic device); 2) Breast prosthesis (whether internal or external) after a mastectomy, as required by the Women?s Health and Cancer Rights Act. 3). Colostomy and other ostomy (surgical construction of an artificial opening) supplies directly related to ostomy care. 4) Restoration prosthesis (composite facial prosthesis) 5) Wigs needed after cancer treatment (limited to one wig per benefit period). |
| Infusion Therapy Covered | 20% Coinsurance after deductible | 100.00% | |
| Treatment for Temporomandibular Joint Disorders Covered | 20% Coinsurance after deductible | 100.00% | The medical benchmark benefits exclude fixed or removable appliances that involve movement or repositioning of the teeth, repair of teeth (fillings), or prosthetics (crowns, bridges, dentures). |
| Nutritional Counseling Covered | 20% Coinsurance after deductible | 100.00% | |
| Reconstructive Surgery Covered | 20% Coinsurance after deductible | 100.00% | Includes benefits for prosthetics and components when they are medically necessary for activities of daily living. A prosthetic device is an artificial substitute to replace, in whole or in part, a limb or body part, such as an arm, leg, foot or eye. Includes benefits for prosthetics and components when they are medically necessary for activities of daily living. A prosthetic device is an artificial substitute to replace, in whole or in part, a limb or body part, such as an arm, leg, foot or eye. Coverage is also included for the repair, fitting, adjustments and replacement of a prosthetic device. In additional, components for artificial limbs are covered. Components are the materials and equipment needed to ensure the comfort and functioning of the prosthetic device. Covered services may include: 1) Artificial limbs and components (the materials and equipment needed to ensure the comfort and functioning of the prosthetic device); 2) Breast prosthesis (whether internal or external) after a mastectomy, as required by the Women?s Health and Cancer Rights Act. 3) Colostomy and other ostomy (surgical construction of an artificial opening) supplies directly related to ostomy care. 4) Restoration prosthesis (composite facial prosthesis) 5) Wigs needed after cancer treatment (limited to one wig per benefit period). |
| Gender Affirming Care | 20% Coinsurance after deductible | 100.00% | |
| Eye Glasses – Adult Covered | $25.00 | 100.00% | 1 Item(s) per Year Excluded from In-Network Out-of-Pocket Limit |
Free Preventive Services
There is no copayment or coinsurance for any of the following UHC Gold Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $2 T1 Preferred Rx, Dental + Vision) 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.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for UHC Gold Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $2 T1 Preferred Rx, Dental + Vision) 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 Gold Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $2 T1 Preferred Rx, Dental + Vision)?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
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