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UHC Gold Standard (No Referrals)

54332NC0030022
Gold
HMO

UHC Gold Standard (No Referrals) is a Gold HMO plan by UnitedHealthcare.

IMPORTANT: You are viewing the 2023 version of UHC Gold Standard (No Referrals) 54332NC0030022. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

UHC Gold Standard (No Referrals) is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of UHC Gold Standard (No Referrals) 54332NC0030022.
Insurer: UnitedHealthcare
Network Type: HMO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 54332NC0030022

Cost-Sharing Overview

UHC Gold Standard (No Referrals) 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 Standard (No Referrals)?

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 Standard (No Referrals) offers the following features and referral requirements.

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

Network Details

The following network details will help you understand what UHC Gold Standard (No Referrals) 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 Standard (No Referrals) includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Hearing Aids
Covered
25% Coinsurance after deductible 100.00%
Imaging (CT/PET Scans, MRIs)
Covered
25.00% Coinsurance after deductible 100.00% Lab tests that are not ordered by Doctor of Other Provider.
Preventive Care/Screening/Immunization
Covered
0.00% 100.00%
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
25% Coinsurance after deductible 100.00%1 Item(s) per Year
Dental Check-Up for Children
Covered
No Charge 100.00%1 Visit(s) per 6 Months
Rehabilitative Speech Therapy
Covered
$30.00 100.00%30 Visit(s) per Year Excludes speech therapy for stammering or stuttering.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$30.00 100.00%30 Visit(s) per Year Limited to 30 visits for any combination of physical therapy, occupational therapy, and manipulative treatment including chiropractic care.
Well Baby Visits and Care
Covered
No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
25.00% Coinsurance after deductible 100.00%18 Visit(s) per Year Limited to 18 Presumptive Drug Tests per year. Limited to 18 Definitive Drug Tests per year.
X-rays and Diagnostic Imaging
Covered
25.00% Coinsurance after deductible 100.00%
Basic Dental Care – Child
Covered
25% 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
25% Coinsurance after deductible 100.00% Benefit limitations may apply to individual services.
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Primary Care Visit to Treat an Injury or Illness
Covered
$30.00 100.00%
Specialist Visit
Covered
$60.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
25% Coinsurance after deductible 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
25.00% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
25.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
25% Coinsurance after deductible 100.00% Excludes homemaker services, such as cooking, housekeeping, and food or meal preparation. Benefits for Hospice services for care of a terminally ill Member with a life expectancy of six months or less.
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Covered
25% Coinsurance after deductible 100.00%3 Treatment(s) per Lifetime Infertility Services- Benefits are provided for certain services related to the diagnosis, treatment and correction of any underlying causes of infertility for all members. Benefits are limited to three pharmaceutical ovulation induction cycles per lifetime per member. Prescription Drug Benefits- Certain prescription drugs related to treatment of infertility. Infertility drugs are limited to benefit lifetime maximums per member.
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
25% Coinsurance after deductible 100.00% Excludes services provided by a close relative or a member of the household.
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$45.00 100.00%
Home Health Care Services
Covered
25% Coinsurance after deductible 100.00%60 Visit(s) per Year Excludes homemaker services, such as cooking and housekeeping; Dietitian services or meals; Services that are provided by a close relative or a member of the household.
Emergency Room Services
Covered
25.00% Coinsurance after deductible 25% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
25% Coinsurance after deductible 25% Coinsurance after deductible Excludes services provided primarily for the convenience of travel, transportation to or from a doctor’s office or dialysis center, transportation for the purpose of receiving services that are not considered “covered services.?
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
25.00% Coinsurance after deductible 100.00% Admissions primarily for the purpose of receiving diagnostic services or a physical examination; admissions primarily for the purpose of receiving therapy services, except when the admission is a continuation of treatment following care at an inpatient facility for an illness or accident requiring therapy.
Inpatient Physician and Surgical Services
Covered
25% Coinsurance after deductible 100.00%
Bariatric Surgery
Covered
25% Coinsurance after deductible 100.00%1 Procedure(s) per Lifetime Excludes removal of excess skin from the abdomen, arms or thighs.
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
25.00% Coinsurance after deductible 100.00%60 Days per Year Limit will be any combination of Skilled Nursing Facility or Inpatient Rehabilitation Facility Services.
Prenatal and Postnatal Care
Covered
No Charge 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
25% Coinsurance after deductible 100.00% Childbirth/delivery professional services follow inpatient physician/surgeon fees
Mental/Behavioral Health Outpatient Services
Covered
$30.00 100.00% Excludes marriage and family therapy.
Mental/Behavioral Health Inpatient Services
Covered
25.00% Coinsurance after deductible 100.00% Excludes, “Inpatient confinements that are primarily intended as a change of environment”; Counseling with relatives of a patient.
Substance Abuse Disorder Outpatient Services
Covered
$30.00 100.00% Excludes marriage and family therapy.
Substance Abuse Disorder Inpatient Services
Covered
25.00% Coinsurance after deductible 100.00% Excludes, “Inpatient confinements that are primarily intended as a change of environment”; Counseling with relatives of a patient.
Generic Drugs
Covered
$15.00 100.00%30 Days per Month See SBC for non-preferred generic cost shares. Generic medications are available in 90-day supplies through home delivery. Limited to 30 day supplies at all other pharmacies. Other quantity limits may apply. Check the plan’s Summary of Benefits or Prescription Drug List for more information.
Preferred Brand Drugs
Covered
$30.00 100.00%30 Days per Month Preferred brand medications are available in 90-day supplies through home delivery. Limited to 30 day supplies at all other pharmacies. Other quantity limits may apply. Check the plan’s Summary of Benefits or Prescription Drug List for more information.
Non-Preferred Brand Drugs
Covered
$60.00 100.00%30 Days per Month Non-preferred brand medications are available in 90-day supplies through home delivery. Limited to 30 day supplies at all other pharmacies. Other quantity limits may apply. Check the plan’s Summary of Benefits or Prescription Drug List for more information.
Specialty Drugs
Covered
$250.00 100.00%30 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
$30.00 100.00%30 Visit(s) per Year Applied Behavior Analysis (ABA) therapy; Speech therapy for stammering or stuttering; Group classes for pulmonary rehabilitation; music therapy, remedial reading, recreational or activity therapy, all forms or special education and supplies or equipment used similarly; maintenance therapy; massage therapy. Limited to 30 visits for any combination of physical therapy, occupational therapy, and manipulative treatment including chiropractic care.
Habilitation Services
Covered
$30.00 100.00%30 Visit(s) per Year Group classes for pulmonary rehabilitation. Limited to 30 visits for any combination of physical therapy, occupational therapy, and manipulative treatment including chiropractic care.
Chiropractic Care
Covered
25% Coinsurance after deductible 100.00%30 Visit(s) per Year Limited to 30 visits for any combination of physical therapy, occupational therapy, and manipulative treatment including chiropractic care.
Durable Medical Equipment
Covered
25% Coinsurance after deductible 100.00% Appliances and accessories that serve no medical purpose or that are primarily for comfort or convenience; repair or replacement of equipment due to abuse or desire for new equipment.
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
25% Coinsurance after deductible 100.00% The purchase price of organs or tissue if any organ or tissue is sold rather than donated to the recipient member; the procurement of organs, tissue, bone marrow, or peripheral blood stem cells or any other donor services if a recipient is not a member; transplants, including high dose chemotherapy, considered experimental or investigational; services for or related to the transplantation of animal or artificial organs or tissues.
Accidental Dental
Covered
25% Coinsurance after deductible 100.00%
Dialysis
Covered
25% Coinsurance after deductible 100.00%
Allergy Testing
Covered
25% Coinsurance after deductible 100.00%
Chemotherapy
Covered
25% Coinsurance after deductible 100.00%
Radiation
Covered
25% Coinsurance after deductible 100.00%
Diabetes Education
Covered
25% Coinsurance after deductible 100.00%
Prosthetic Devices
Covered
25% Coinsurance after deductible 100.00% Dental appliances except when medically necessary for the treatment of temporomandibular joint disease or obstructive sleep apnea; cosmetic improvements, such as implants of hair follicles and skin tone enhancements; lenses for keratoconus or any other eye procedure except as specifically covered under the health plan. Prosthetic appliance must replace all or part of a body part or its function.
Infusion Therapy
Covered
25% Coinsurance after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
25% Coinsurance after deductible 100.00% Excludes Treatment for periodontal disease; Dental implants or root canals; Crowns and bridges; Orthodontic brace; Occlusal (bite) adjustments; Extractions.
Nutritional Counseling
Covered
25% Coinsurance after deductible 100.00%
Reconstructive Surgery
Covered
25% Coinsurance after deductible 100.00%
Gender Affirming Care
Not Covered

Free Preventive Services

There is no copayment or coinsurance for any of the following UHC Gold Standard (No Referrals) preventive services. This is true even if you haven’t met your yearly deductible.

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

Additional Resources

Below are additional resources for UHC Gold Standard (No Referrals) 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 Standard (No Referrals)?

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

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