UHC Gold Base+ ($3 Walgreens + 6 Free Visits)

72375MD0070012
Gold
HMO

UHC Gold Base+ ($3 Walgreens + 6 Free Visits) is a Gold HMO plan by UnitedHealthcare.

Locations

UHC Gold Base+ ($3 Walgreens + 6 Free Visits) is offered in the following counties.

Plan Overview

This is a plan overview for 2022 version of UHC Gold Base+ ($3 Walgreens + 6 Free Visits) 72375MD0070012.
Insurer: UnitedHealthcare
Network Type: HMO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 72375MD0070012

Cost-Sharing Overview

UHC Gold Base+ ($3 Walgreens + 6 Free Visits) 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 Gold Base+ ($3 Walgreens + 6 Free Visits)?

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 Base+ ($3 Walgreens + 6 Free Visits) 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 Base+ ($3 Walgreens + 6 Free Visits) 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 Base+ ($3 Walgreens + 6 Free Visits) includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Dialysis
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Substantially Equal
Skilled Nursing Facility
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes100 Days per Benefit Period Includes Inpatient Rehabilitation Services.Substantially Equal
Well Baby Visits and Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Substantially Equal
Chemotherapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Substantially Equal
Prosthetic Devices
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes1 Item(s) per 3 Years Substantially Equal
Outpatient Surgery Physician/Surgical Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Substantially Equal
Eye Glasses for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes1 Item(s) per Year Substantially Equal
Orthodontia – Child
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Coverage is for medically necessary orthodontia only.Substantially Equal
Major Dental Care – Child
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Benefit limitations may apply to individual services.Substantially Equal
Preventive Care/Screening/Immunization
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Substantially Equal
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Substantially Equal
Acupuncture
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Substantially Equal
Mental/Behavioral Health Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Substantially Equal
Mental/Behavioral Health Inpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Substantially Equal
Reconstructive Surgery
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Substantially Equal
Laboratory Outpatient and Professional Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Substantially Equal
Outpatient Rehabilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes30 Visit(s) per Benefit Period Limited to 30 physical therapy visits per condition per year, 30 speech therapy visits per condition per year, 30 occupational therapy visits per condition per year, 90 cardiac rehabilitation therapy visits per year, and one program per Covered Person during the entire period of time he or she is enrolled for coverage under the Policy for pulmonary rehabilitation therapy.Substantially Equal
Cosmetic Surgery
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Delivery and All Inpatient Services for Maternity Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Substantially Equal
Bariatric Surgery
Covered
Excluded from In-Network MOOP: YesExcluded from Out-of-Network MOOP: Yes Not EHB
Eye Glasses – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Routine Eye Exam for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes1 Visit(s) per Year Substantially Equal
Hospice Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes30 Days per Year Limited to 30 days per year for Inpatient hospice.Substantially Equal
Non-Preferred Brand Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes30 Days per Month 90-day supplies available at a Network Pharmacy or Home Delivery. Covers outpatient self-administered prescription legend drugs from a participating network pharmacy. Quantity limits per prescription may apply.Substantially Equal
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Substantially Equal
Dental Check-Up for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes1 Visit(s) per 6 Months Substantially Equal
Accidental Dental
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Substantially Equal
Routine Dental Services (Adult)
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Allergy Testing
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Substantially Equal
Chiropractic Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes20 Visit(s) per Benefit Period Limited to 20 manipulative therapy services visits per condition per year.Substantially Equal
Weight Loss Programs
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Emergency Transportation/Ambulance
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Substantially Equal
Home Health Care Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes For Covered Persons that received less than 48 hours of inpatient hospitalization following a mastectomy or removal of a testicle or who undergo a mastectomy or removal of a testicle on an outpatient basis will receive the following: One home visit scheduled to occur within 24 hours after discharge from the Hospital or outpatient health care facility, and an additional home visit if prescribed by the Covered Person’s attending Physician.Substantially Equal
Basic Dental Care – Child
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Benefit limitations may apply to individual services.Substantially Equal
Nutritional Counseling
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Substantially Equal
Treatment for Temporomandibular Joint Disorders
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Substantially Equal
Imaging (CT/PET Scans, MRIs)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Substantially Equal
Infusion Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Substantially Equal
Habilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes30 Visit(s) per Benefit Period For Covered Persons age 19 or older, limited to 30 physical therapy visits per condition per year, 30 speech therapy visits per condition per year, and 30 occupational therapy visits per condition per year. Visit limits to not apply for Covered Persons up to the age of 19 or for therapies for Covered Persons with a primary diagnoses of autism spectrum disorder.Substantially Equal
Routine Eye Exam (Adult)
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Prenatal and Postnatal Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Substantially Equal
Specialist Visit
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Substantially Equal
Routine Foot Care
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Preferred Brand Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes30 Days per Month 90-day supplies available at a Network Pharmacy or Home Delivery. Covers outpatient self-administered prescription legend drugs from a participating network pharmacy. Quantity limits per prescription may apply.Substantially Equal
Long-Term/Custodial Nursing Home Care
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Substance Abuse Disorder Inpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Substantially Equal
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes30 Visit(s) per Benefit Period Limited to 30 physical therapy visits per condition per year, and 30 occupational therapy visits per condition per year.Substantially Equal
Substance Abuse Disorder Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Substantially Equal
Specialty Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes30 Days per Month Covers outpatient self-administered prescription legend drugs from a participating network pharmacy. Quantity limits per prescription may apply.Substantially Equal
Hearing Aids
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Substantially Equal
Major Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
X-rays and Diagnostic Imaging
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Substantially Equal
Orthodontia – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Abortion for Which Public Funding is Prohibited
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Substantially Equal
Primary Care Visit to Treat an Injury or Illness
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes First 3 in-person visits $0. First 3 visits via Preferred virtual provider $0. See SBC for cost share for visits 4 and beyond. Virtual Primary Care limited to age 18 and older.Substantially Equal
Transplant
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Substantially Equal
Emergency Room Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Substantially Equal
Diabetes Education
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Substantially Equal
Private-Duty Nursing
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Durable Medical Equipment
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes1 Item(s) per 3 Years Substantially Equal
Infertility Treatment
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes3 Treatment(s) per Year Benefits include diagnosis and treatment of infertility. Artificial insemination and intrauterine insemination, subject tocertain criteria and are limited to 3 attempts of artificial insemination over the course of one year.Substantially Equal
Basic Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Urgent Care Centers or Facilities
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Substantially Equal
Inpatient Physician and Surgical Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Substantially Equal
Rehabilitative Speech Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes30 Visit(s) per Benefit Period Limited to 30 speech therapy visits per condition per year.Substantially Equal
Generic Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes30 Days per Month See SBC for (non-preferred) Generic Cost Share. 90-day supplies available at a Network Pharmacy or Home Delivery. Covers outpatient self-administered prescription legend drugs from a participating network pharmacy. Quantity limits per prescription may apply.Substantially Equal
Radiation
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Substantially Equal

Free Preventive Services

There is no copayment or coinsurance for any of the following UHC Gold Base+ ($3 Walgreens + 6 Free Visits) 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.

Ready to sign up for UHC Gold Base+ ($3 Walgreens + 6 Free Visits)?

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