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UHC Gold Standard (No Referrals)

69443TN0140016
Gold
EPO

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

IMPORTANT: You are viewing the 2024 version of UHC Gold Standard (No Referrals) 69443TN0140016. 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 Standard (No Referrals) is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of UHC Gold Standard (No Referrals) 69443TN0140016.
Insurer: UnitedHealthcare
Network Type: EPO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 69443TN0140016

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
Primary Care Visit to Treat an Injury or Illness
Covered
$30.00 Not ApplicableNot Applicable 100.00% Cost sharing for Virtual Primary Care matches in-person office visit. See SBC for additional cost share details.
Specialist Visit
Covered
$60.00 Not ApplicableNot Applicable 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
Not Applicable 25% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Hospice Services
Covered
Not Applicable 25% Coinsurance after deductibleNot Applicable 100.00%
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Not Covered
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$45.00 Not ApplicableNot Applicable 100.00%
Home Health Care Services
Covered
Not Applicable 25% Coinsurance after deductibleNot Applicable 100.00%60.0 Visit(s) per Year
Emergency Room Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 25% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
Not Applicable 25% Coinsurance after deductibleNot Applicable 25% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Inpatient Physician and Surgical Services
Covered
Not Applicable 25% Coinsurance after deductibleNot Applicable 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%60.0 Days per Year Limit will be any combination of Skilled Nursing or Inpatient Rehabilitation Services.
Prenatal and Postnatal Care
Covered
Not Applicable No ChargeNot Applicable 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 25% Coinsurance after deductibleNot Applicable 100.00% Childbirth/delivery professional services follow inpatient physician/surgeon fees.
Mental/Behavioral Health Outpatient Services
Covered
$30.00 Not ApplicableNot Applicable 100.00%
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$30.00 Not ApplicableNot Applicable 100.00%
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Generic Drugs
Covered
$15.00 Not ApplicableNot 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
$30.00 Not ApplicableNot 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
$60.00 Not ApplicableNot 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
$250.00 Not ApplicableNot Applicable 100.00%30.0 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.
Outpatient Rehabilitation Services
Covered
$30.00 Not ApplicableNot Applicable 100.00%132.0 Visit(s) per Year Limited to 20 visits per year for Physical Therapy, 20 visits per year for Occupational Therapy, 20 visits per year for Speech Therapy, 36 visits per year for Pulmonary Rehabilitation Therapy, and 36 visits per year for Cardiac Rehabilitation Therapy.
Habilitation Services
Covered
$30.00 Not ApplicableNot Applicable 100.00%60.0 Visit(s) per Year Limited to 20 visits per year for Physical Therapy, 20 visits per year for Occupational Therapy, and 20 visits per year for Speech Therapy.
Chiropractic Care
Covered
Not Applicable 25% Coinsurance after deductibleNot Applicable 100.00%20.0 Visit(s) per Year
Durable Medical Equipment
Covered
Not Applicable 25% Coinsurance after deductibleNot Applicable 100.00%
Hearing Aids
Covered
Not Applicable 25% Coinsurance after deductibleNot Applicable 100.00%1.0 Item(s) per 3 Years Benefits are limited to a single purchase per hearing impaired ear every three years.
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Preventive Care/Screening/Immunization
Covered
Not Applicable 0.00%Not Applicable 100.00%
Routine Foot Care
Not Covered
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
Not Applicable No ChargeNot Applicable 100.00%1.0 Visit(s) per Year
Eye Glasses for Children
Covered
Not Applicable 25% Coinsurance after deductibleNot Applicable 100.00%1.0 Item(s) per Year
Dental Check-Up for Children
Covered
Not Applicable No ChargeNot Applicable 100.00%1.0 Visit(s) per 6 Months
Rehabilitative Speech Therapy
Covered
$30.00 Not ApplicableNot Applicable 100.00%20.0 Visit(s) per Year
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$30.00 Not ApplicableNot Applicable 100.00%20.0 Visit(s) per Year 20 visits per year for Occupational Therapy and 20 visits per year for Physical Therapy.
Well Baby Visits and Care
Covered
Not Applicable No ChargeNot Applicable 100.00%
Laboratory Outpatient and Professional Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
X-rays and Diagnostic Imaging
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Basic Dental Care – Child
Covered
Not Applicable 25% Coinsurance after deductibleNot Applicable 100.00% Benefit limitations may apply to individual services.
Orthodontia – Child
Covered
Not Applicable 50% Coinsurance after deductibleNot Applicable 100.00% Coverage is for medically necessary orthodontia only.
Major Dental Care – Child
Covered
Not Applicable 25% Coinsurance after deductibleNot 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
Not Applicable 25% Coinsurance after deductibleNot Applicable 100.00%
Accidental Dental
Covered
Not Applicable 25% Coinsurance after deductibleNot Applicable 100.00%
Dialysis
Covered
Not Applicable 25% Coinsurance after deductibleNot Applicable 100.00%
Allergy Testing
Covered
$60.00 Not ApplicableNot Applicable 100.00%
Chemotherapy
Covered
Not Applicable 25% Coinsurance after deductibleNot Applicable 100.00%
Radiation
Covered
Not Applicable 25% Coinsurance after deductibleNot Applicable 100.00%
Diabetes Education
Covered
Not Applicable 25% Coinsurance after deductibleNot Applicable 100.00%
Prosthetic Devices
Covered
Not Applicable 25% Coinsurance after deductibleNot Applicable 100.00%
Infusion Therapy
Covered
Not Applicable 25% Coinsurance after deductibleNot Applicable 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
Not Applicable 25% Coinsurance after deductibleNot Applicable 100.00%
Nutritional Counseling
Covered
Not Applicable 25% Coinsurance after deductibleNot Applicable 100.00%
Reconstructive Surgery
Covered
Not Applicable 25% Coinsurance after deductibleNot Applicable 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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