UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 Rx)
40702AZ0060021
Gold
HMO
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 Rx) is a Gold HMO plan by UnitedHealthcare.
IMPORTANT: You are viewing the 2024 version of UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 Rx) 40702AZ0060021. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.
Locations
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 Rx) is offered in the following counties.
Plan Overview
This is a plan overview for 2024 version of UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 Rx) 40702AZ0060021.
| Insurer: | UnitedHealthcare |
| Network Type: | HMO |
| Metal Type: | Gold |
| HSA Eligible?: | No |
| Plan ID: | 40702AZ0060021 |
Cost-Sharing Overview
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 Rx) offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 Rx) includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $7000 per person | $14000 per group |
| Deductible: | $0 per person | $0 per group |
| Coinsurance: | $0 per group | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 Rx) will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | 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: | $0.00 |
| Copayment: | $100.00 |
| Coinsurance: | $0.00 |
| Limit: | $60.00 |
| Deductible: | $0.00 |
| Copayment: | $200.00 |
| Coinsurance: | $0.00 |
| Limit: | $0.00 |
| Deductible: | $0.00 |
| Copayment: | $1,200.00 |
| Coinsurance: | $0.00 |
| 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 Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 Rx)?
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Plan Features
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 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 Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 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 Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 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 | Not Applicable No Charge | Not Applicable 100.00% | Cost sharing for Virtual Primary Care matches in-person office visit. See SBC for additional cost share details. |
| Specialist Visit Covered | $75.00 Not Applicable | Not Applicable 100.00% | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | Not Applicable 45.00% | Not Applicable 100.00% | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | $300.00 Not Applicable | Not Applicable 100.00% | |
| Outpatient Surgery Physician/Surgical Services Covered | $300.00 Not Applicable | Not Applicable 100.00% | |
| Hospice Services Covered | Not Applicable 45.00% | Not Applicable 100.00% | Services of a person who is a member of your family or your dependent’s family or who normally resides in your house or your dependent’s house; Services and supplies for curative or life prolonging procedures; Services and supplies for which any other benefits are payable under the Plan; Services and supplies that are primarily to aid you or your dependent in daily living; Services and supplies for respite (custodial) care; and Nutritional supplements, non-prescription drugs or substances, medical supplies, vitamins or minerals. The Plan covers hospice care services which are provided under an approved hospice care program when provided to a Member who has been diagnosed by a Participating Provider as having a terminal illness with a prognosis of six (6) months or less to live. |
| Routine Dental Services (Adult) Not Covered | |||
| Infertility Treatment Not Covered | |||
| Long-Term/Custodial Nursing Home Care Not Covered | |||
| Private-Duty Nursing Covered | Not Applicable 45.00% | Not Applicable 100.00% | Private Duty Nursing services provided in the home. Private duty nursing are only available during inpatient stays and determined to be medically appropriate by the Plan. Private duty nursing is available only in an inpatient setting when skilled nursing is not available from the facility. Custodial Nursing is not covered by the Plan. |
| Routine Eye Exam (Adult) Not Covered | |||
| Urgent Care Centers or Facilities Covered | $50.00 Not Applicable | Not Applicable 100.00% | $0 Virtual Urgent Care visits. See SBC for additional cost share details. |
| Home Health Care Services Covered | Not Applicable 45.00% | Not Applicable 100.00% | 42.0 Visit(s) per Year Home health services do not include services of a person who is a member of your family or your dependent?s family or who normally resides in your house or your dependent?s house. 1. The physician must have determined a medical need for home health care and developed a plan of care that is reviewed at thirty day intervals by the physician.; 2. The care described in the plan of care must be for intermittent skilled nursing, therapy, or speech services.; 3. The patient must be homebound unless services are determined to be medically necessary.; 4. The home health agency delivering care must be certified within the state the care is received.; 5. The care that is being provided is not custodial care. A Home Health visit is considered to be up to four hours of services. |
| Emergency Room Services Covered | $650.00 Not Applicable | $650.00 Not Applicable | |
| Emergency Transportation/Ambulance Covered | Not Applicable 45.00% | Not Applicable 45.00% | |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | $2000 Copay per Day Not Applicable | Not Applicable 100.00% | |
| Inpatient Physician and Surgical Services Covered | Not Applicable 45.00% | Not Applicable 100.00% | |
| Bariatric Surgery Covered | $300.00 Not Applicable | Not Applicable 100.00% | The following bariatric procedures are excluded: 1. Open vertical banded gastroplasty; 2. Laparoscopic vertical banded gastroplasty; 3. Open sleeve gastrectomy; 4. Open adjustable gastric banding. 1. The patient must have a body-mass index (BMI) of at least 35. 2. Have at least one co-morbidity related to obesity. 3. Previously unsuccessful with medical treatment for obesity. The following medical information must be documented in the patient’s medical record: Active participation within the last two years in one physician?supervised weight-management program for a minimum of six months without significant gaps. The weight-management program must include monthly documentation of all of the following components: a. Weight b. Current dietary program c. Physical activity (e.g., exercise program) 4. In addition, the procedure must be performed at an approved Center of Excellence facility that is credentialed by your Health Network to perform bariatric surgery. 5. The member must be 18 years or older, or have reached full expected skeletal growth. |
| Cosmetic Surgery Not Covered | |||
| Skilled Nursing Facility Covered | $2000 Copay per Day Not Applicable | Not Applicable 100.00% | 90.0 Days per Year |
| Prenatal and Postnatal Care Covered | Not Applicable No Charge | Not Applicable 100.00% | |
| Delivery and All Inpatient Services for Maternity Care Covered | $2,000.00 Not Applicable | Not Applicable 100.00% | Childbirth/delivery professional services follow inpatient physician/surgeon fees. |
| Mental/Behavioral Health Outpatient Services Covered | $75.00 Not Applicable | Not Applicable 100.00% | 1. Any court ordered treatment or therapy, or any treatment or therapy ordered as a condition of parole, probation or custody or visitation evaluations unless Medically Appropriate and otherwise covered under this Plan; 2. Treatment of mental disorders that have been diagnosed as organic mental disorders associated with permanent dysfunction of the brain; 3. Treatment of Chronic Conditions not subject to favorable modification according to generally accepted standards of medical practice; 4. Developmental disorders, including but not limited to: developmental reading disorders; developmental arithmetic disorders; developmental language disorders; or articulation disorders. 5. Counseling for activities of an educational nature; 6. Counseling for borderline intellectual functioning; 7. Counseling for occupational problems; 8. Counseling related to consciousness raising; 9. Vocational or religious counseling; 10. I.Q. testing; 11. Marriage counseling; 12. Custodial care, including but not limited to geriatric day care; 13. Psychological testing on children requested by or for a school system; 14. Occupational/recreational therapy programs even if combined with supportive therapy forage-related cognitive decline; and 15. Biofeedback is not covered for reasons other than pain management. |
| Mental/Behavioral Health Inpatient Services Covered | $2000 Copay per Day Not Applicable | Not Applicable 100.00% | 1. Any court ordered treatment or therapy, or any treatment or therapy ordered as a condition of parole, probation or custody or visitation evaluations unless Medically Appropriate and otherwise covered under this Plan; 2. Treatment of mental disorders that have been diagnosed as organic mental disorders associated with permanent dysfunction of the brain; 3. Treatment of Chronic Conditions not subject to favorable modification according to generally accepted standards of medical practice; 4. Developmental disorders, including but not limited to: developmental reading disorders; developmental arithmetic disorders; developmental language disorders; or articulation disorders. 5. Counseling for activities of an educational nature; 6. Counseling for borderline intellectual functioning; 7. Counseling for occupational problems; 8. Counseling related to consciousness raising; 9. Vocational or religious counseling; 10. I.Q. testing; 11. Marriage counseling; 12. Custodial care, including but not limited to geriatric day care; 13. Psychological testing on children requested by or for a school system; 14. Occupational/recreational therapy programs even if combined with supportive therapy forage-related cognitive decline; and 15. Biofeedback is not covered for reasons other than pain management. |
| Substance Abuse Disorder Outpatient Services Covered | $75.00 Not Applicable | Not Applicable 100.00% | 1. Any court ordered treatment or therapy, or any treatment or therapy ordered as a condition of parole, probation or custody or visitation evaluations unless Medically Appropriate and otherwise covered under this Plan; 2. Treatment of mental disorders that have been diagnosed as organic mental disorders associated with permanent dysfunction of the brain; 3. Treatment of Chronic Conditions not subject to favorable modification according to generally accepted standards of medical practice; 4. Developmental disorders, including but not limited to: developmental reading disorders; developmental arithmetic disorders; developmental language disorders; or articulation disorders. 5. Counseling for activities of an educational nature; 6. Counseling for borderline intellectual functioning; 7. Counseling for occupational problems; 8. Counseling related to consciousness raising; 9. Vocational or religious counseling; 10. I.Q. testing; 11. Marriage counseling; 12. Custodial care, including but not limited to geriatric day care; 13. Psychological testing on children requested by or for a school system; 14. Occupational/recreational therapy programs even if combined with supportive therapy forage-related cognitive decline; and 15. Biofeedback is not covered for reasons other than pain management. |
| Substance Abuse Disorder Inpatient Services Covered | $2000 Copay per Day Not Applicable | Not Applicable 100.00% | 1. Any court ordered treatment or therapy, or any treatment or therapy ordered as a condition of parole, probation or custody or visitation evaluations unless Medically Appropriate and otherwise covered under this Plan; 2. Treatment of mental disorders that have been diagnosed as organic mental disorders associated with permanent dysfunction of the brain; 3. Treatment of Chronic Conditions not subject to favorable modification according to generally accepted standards of medical practice; 4. Developmental disorders, including but not limited to: developmental reading disorders; developmental arithmetic disorders; developmental language disorders; or articulation disorders. 5. Counseling for activities of an educational nature; 6. Counseling for borderline intellectual functioning; 7. Counseling for occupational problems; 8. Counseling related to consciousness raising; 9. Vocational or religious counseling; 10. I.Q. testing; 11. Marriage counseling; 12. Custodial care, including but not limited to geriatric day care; 13. Psychological testing on children requested by or for a school system; 14. Occupational/recreational therapy programs even if combined with supportive therapy forage-related cognitive decline; and 15. Biofeedback is not covered for reasons other than pain management. |
| Generic Drugs Covered | $3.00 Not Applicable | Not Applicable 100.00% | 30.0 Days per Month 90-day supplies are available through retail pharmacies or home delivery.? Other quantity limits may apply. Check the plan’s Summary of Benefits or Prescription Drug List for more information. |
| Preferred Brand Drugs Covered | $50.00 Not Applicable | Not Applicable 100.00% | 30.0 Days per Month 90-day supplies are available through retail pharmacies or home delivery.? Other quantity limits may apply. Check the plan’s Summary of Benefits or Prescription Drug List for more information. |
| Non-Preferred Brand Drugs Covered | Not Applicable 45% Coinsurance after deductible | Not Applicable 100.00% | 30.0 Days per Month 90-day supplies are available through retail pharmacies or home delivery.? Other quantity limits may apply. Check the plan’s Summary of Benefits or Prescription Drug List for more information. |
| Specialty Drugs Covered | Not Applicable 50% Coinsurance after deductible | Not Applicable 100.00% | 30.0 Days per Month Covers outpatient self-administered prescription legend drugs from a participating network pharmacy. Quantity limits per prescription may apply. |
| Outpatient Rehabilitation Services Covered | $75.00 Not Applicable | Not Applicable 100.00% | 60.0 Visit(s) per Year The following limitations apply to short-term rehabilitative therapy except as required for the treatment for Autism Spectrum Disorder: 1. Occupational therapy is provided only for purposes of training Members to perform the activities of daily living. 2. Speech therapy is not covered when: a. Used to improve speech skills that have not fully developed; b. Considered custodial or educational; c. Intended to maintain speech communication; or d. Not restorative in nature. 3. Phase 3 cardiac rehabilitation is not covered. If multiple services are provided on the same day by different Providers, a separate co-payment will apply to each Provider. Short-term rehabilitative therapy includes services in an outpatient facility or physician?s office that is part of a rehabilitation program, including physical, speech, occupational, cardiac rehabilitation and pulmonary rehabilitation therapy. Visit limit is for all therapy types combined. |
| Habilitation Services Covered | $75.00 Not Applicable | Not Applicable 100.00% | 60.0 Visit(s) per Year Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. |
| Chiropractic Care Covered | Not Applicable 45.00% | Not Applicable 100.00% | 20.0 Visit(s) per Year 1. Services of a chiropractor or osteopath which are not within his scope of practice, as defined by state law; 2. Charges for care not provided in an office setting; 3. Maintenance or preventive treatment consisting of routine, long term or Non-Medically Appropriate care provided to prevent reoccurrences or to maintain the patient?s current status; and 4. Vitamin therapy. HMOs may limit chiropractic visits to 20; PPOs must cover medically necessary chiropractic visits. |
| Durable Medical Equipment Covered | Not Applicable 45.00% | Not Applicable 100.00% | 1. Hygienic or self-help items or equipment; 2. Items or equipment primarily used for comfort or convenience such as bathtub chairs, safety grab bars, stair gliders or elevators, over-the-bed tables, saunas or exercise equipment; 3. Environmental control equipment, such as air purifiers, humidifiers and electrostatic machines; 4. Institutional equipment, such as air fluidized beds and diathermy machines; 5. Elastic stockings and wigs (except were indicated for coverage); 6. Equipment used for the purpose of participation in sports or other recreational activities including, but not limited to, braces and splints; 7. Items, such as auto tilt chairs, paraffin bath units and whirlpool baths, which are not generally accepted by the medical profession as being therapeutically effective; 8. Items which under normal use would constitute a fixture to real property, such as lifts, ramps, railings, and grab bars; and 9. Hearing aid batteries (except those for cochlear implants) and chargers. |
| Hearing Aids Covered | Not Applicable 45.00% | Not Applicable 100.00% | 1.0 Item(s) per Year |
| Imaging (CT/PET Scans, MRIs) Covered | $300.00 Not Applicable | Not Applicable 100.00% | |
| Preventive Care/Screening/Immunization Covered | Not Applicable No Charge | Not Applicable 100.00% | 1.0 Exam(s) per Year Well Woman and Well Man examinations are limited to 1 visit per year. |
| Routine Foot Care Not Covered | |||
| Acupuncture Not Covered | |||
| Weight Loss Programs Not Covered | |||
| Routine Eye Exam for Children Covered | Not Applicable No Charge | Not Applicable 100.00% | 1.0 Visit(s) per Year |
| Eye Glasses for Children Covered | Not Applicable 45.00% | Not Applicable 100.00% | 1.0 Item(s) per Year |
| Dental Check-Up for Children Covered | Not Applicable No Charge | Not Applicable 100.00% | 1.0 Visit(s) per 6 Months |
| Rehabilitative Speech Therapy Covered | $75.00 Not Applicable | Not Applicable 100.00% | 60.0 Visit(s) per Year Visit limit is for all therapy types combined (PT, OT, ST). |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | $75.00 Not Applicable | Not Applicable 100.00% | 60.0 Visit(s) per Year Visit limit is for all therapy types combined (PT, OT, ST). |
| Well Baby Visits and Care Covered | Not Applicable No Charge | Not Applicable 100.00% | Well Child visits and immunizations are covered through 47 months as recommended by the American Academy of Pediatrics. |
| Laboratory Outpatient and Professional Services Covered | $10.00 Not Applicable | Not Applicable 100.00% | |
| X-rays and Diagnostic Imaging Covered | $65.00 Not Applicable | Not Applicable 100.00% | |
| Basic Dental Care – Child Covered | Not Applicable 45.00% | Not Applicable 100.00% | Benefit limitations may apply to individual services. |
| Orthodontia – Child Covered | Not Applicable 50.00% | Not Applicable 100.00% | Coverage is for medically necessary orthodontia only. |
| Major Dental Care – Child Covered | Not Applicable 45.00% | Not Applicable 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 | $2,000.00 Not Applicable | Not Applicable 100.00% | These benefits are available when the Member is the recipient of an organ transplant. No coverage if Member is an organ donor for a recipient other than a Member enrolled under this plan. Coverage for organ procurement costs are limited to costs directly related to the procurement of an organ, from a cadaver or a live donor. Organ procurement costs shall consist of surgery necessary for organ removal, organ transportation and the transportation, hospitalization and surgery of a live donor. Compatibility testing undertaken prior to procurement is covered if Medically Necessary. Travel & lodging expenses are limited to $10,000 per transplant. Travel and lodging are not covered if the Member is a donor. Organ transplant services include the recipient?s medical, surgical and hospital services; inpatient immunosuppressive medications; and costs for organ procurement. Transplant services are covered only if they are required to perform human to human organ or tissue transplants, such as: 1. Allogeneic bone marrow/stem cell; 2. Autologous bone marrow/stem cell; 3. Cornea; 4. Heart; 5. Heart/lung; 6. Kidney; 7. Kidney/pancreas; 8. Liver; 9. Lung; 10. Pancreas; 11. Small bowel/liver; or 12. Kidney/liver. Organ transplant coverage will apply only to non-experimental transplants for the specific diagnosis. Coverage for organ procurement costs are limited to costs directly related to the procurement of an organ, from a cadaver or a live donor. Organ procurement costs shall consist of surgery necessary for organ removal, organ transportation and the transportation, hospitalization and surgery of a live donor. Compatibility testing undertaken prior to procurement is covered if Medically Necessary. |
| Accidental Dental Covered | Not Applicable 45.00% | Not Applicable 100.00% | |
| Dialysis Covered | Not Applicable 45.00% | Not Applicable 100.00% | |
| Allergy Testing Covered | $75.00 Not Applicable | Not Applicable 100.00% | |
| Chemotherapy Covered | Not Applicable 45.00% | Not Applicable 100.00% | |
| Radiation Covered | Not Applicable 45.00% | Not Applicable 100.00% | |
| Diabetes Education Covered | Not Applicable 45.00% | Not Applicable 100.00% | |
| Prosthetic Devices Covered | Not Applicable 45.00% | Not Applicable 100.00% | Replacement of external prosthetic appliance due to loss or theft. The Plan covers the initial purchase and fitting of external prosthetic devices which are used as a replacement or substitute for a missing body part and are necessary for the alleviation or correction of illness, injury, congenital defect, or alopecia as a result of chemotherapy, radiation therapy, and second or third degree burns. External prosthetic appliances shall include artificial arms and legs, wigs, hair pieces and terminal devices such as a hand or hook. Wigs and hair pieces are limited to one per Plan Year. Members must provide a valid prescription verifying diagnosis of alopecia as a result of chemotherapy, radiation therapy, second or third degree burns with a submitted claim for coverage. All other diagnosis are excluded. Replacement of artificial arms and legs and terminal devices are covered only if necessitated by normal anatomical growth or as a result of wear and tear. |
| Infusion Therapy Covered | Not Applicable 45.00% | Not Applicable 100.00% | Infusion/IV Therapy in an Outpatient setting including, but not limited to: Infliximab (Remicade), Alefacept (Amevive), and Etanercept (Enbrel). |
| Treatment for Temporomandibular Joint Disorders Covered | Not Applicable 45.00% | Not Applicable 100.00% | Benefits are payable for covered services and supplies which are necessary to treat TMJ disorder which is a result of: 1. An accident; 2. Trauma; 3. A congenital defect; 4. A developmental defect; or 5. A pathology. |
| Nutritional Counseling Covered | Not Applicable 45.00% | Not Applicable 100.00% | Covered when dietary adjustment has a therapeutic role of a diagnosed chronic disease/condition, including but not limited to: 1. Morbid obesity 2. Diabetes 3. Cardiovascular disease 4. Hypertension 5. Kidney disease 6. Eating disorders 7. Gastrointestinal disorders 8. Food allergies 9. Hyperlipidemia |
| Reconstructive Surgery Covered | $300.00 Not Applicable | Not Applicable 100.00% | Following a mastectomy, the following services and supplies are covered: 1. Surgical services for reconstruction of the breast on which the mastectomy was performed; 2. Surgical services for reconstruction of the non-diseased breast to produce symmetrical appearance; 3. Post-operative breast prostheses; and 4. Mastectomy bras/camisoles and external prosthetics that meet external prosthetic placement needs. During all stages of mastectomy, treatments of physical complications, including lymphedema, are covered. Cosmetic Surgery is covered for reconstructive surgery that constitutes necessary care and treatment of medically diagnosed services required for the prompt repair of accidental injury. Congenital defects and birth abnormalities are covered for Eligible Dependent children. |
| Gender Affirming Care Not Covered |
Free Preventive Services
There is no copayment or coinsurance for any of the following UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 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.
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 Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 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 Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 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