UHC Gold Value ($0 Virtual Urgent Care, $3 Tier 2 Rx)

80180WI0100011
Gold
HMO

UHC Gold Value ($0 Virtual Urgent Care, $3 Tier 2 Rx) is a Gold HMO plan by UnitedHealthcare.

IMPORTANT: You are viewing the 2024 version of UHC Gold Value ($0 Virtual Urgent Care, $3 Tier 2 Rx) 80180WI0100011. 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 Value ($0 Virtual Urgent Care, $3 Tier 2 Rx) is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of UHC Gold Value ($0 Virtual Urgent Care, $3 Tier 2 Rx) 80180WI0100011.
Insurer: UnitedHealthcare
Network Type: HMO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 80180WI0100011

Cost-Sharing Overview

UHC Gold Value ($0 Virtual Urgent Care, $3 Tier 2 Rx) 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 Value ($0 Virtual Urgent Care, $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

Plan Features

UHC Gold Value ($0 Virtual Urgent Care, $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:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what UHC Gold Value ($0 Virtual Urgent Care, $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. The Network Area may include select Network providers located in a neighboring state.
National Network: No

Additional Benefits and Cost-Sharing

UHC Gold Value ($0 Virtual Urgent Care, $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
$5.00 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
$75.00 Not ApplicableNot Applicable 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Hospice Services
Covered
Not Applicable 20.00% 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
$75.00 Not ApplicableNot Applicable 100.00% $0 Virtual Urgent Care visits. See SBC for additional cost share details.
Home Health Care Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%60.0 Visit(s) per Year One visit equals up to four hours of skilled care services. This visit limit does not include any service which is billed only for the administration of intravenous infusion.
Emergency Room Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 20.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 20.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Inpatient Physician and Surgical Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%30.0 Days per Stay
Prenatal and Postnatal Care
Covered
Not Applicable No ChargeNot Applicable 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00% Childbirth/delivery professional services follow inpatient physician/surgeon fees.
Mental/Behavioral Health Outpatient Services
Covered
$75.00 Not ApplicableNot Applicable 100.00%
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$75.00 Not ApplicableNot Applicable 100.00%
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Generic Drugs
Covered
$3.00 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
$60.00 Copay after deductible 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
Not Applicable 40.00% Coinsurance after deductibleNot 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 50.00% Coinsurance after deductibleNot Applicable 100.00%30.0 Days per Month Up to a consecutive 31-day supply of a Specialty Prescription Drug Product, unless adjusted based on the drug manufacturer?s packaging size, or based on supply limits.
Outpatient Rehabilitation Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00% Rehabilitative services must be short term.
Habilitation Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00% Supplementing with the federal definition of habilitative services: 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 20.00% Coinsurance after deductibleNot Applicable 100.00% Rehabilitative services must be short term. Visit limits do not apply to Manipulative Therapy.
Durable Medical Equipment
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Hearing Aids
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%1.0 Item(s) per 3 Years Benefits are limited to a single purchase (including repair/replacement) per hearing impaired ear every three years.
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Preventive Care/Screening/Immunization
Covered
Not Applicable No ChargeNot 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 20.00% 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
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%20.0 Visit(s) per Year Rehabilitative services must be short term.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%20.0 Visit(s) per Year Separate limits for OT and PT.
Well Baby Visits and Care
Covered
Not Applicable No ChargeNot Applicable 100.00%
Laboratory Outpatient and Professional Services
Covered
$10.00 Not ApplicableNot Applicable 100.00%
X-rays and Diagnostic Imaging
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Basic Dental Care – Child
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00% Benefit limitations may apply to individual services.
Orthodontia – Child
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Coverage is for medically necessary orthodontia only.
Major Dental Care – Child
Covered
Not Applicable 20.00% 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 20.00% Coinsurance after deductibleNot Applicable 100.00%
Accidental Dental
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Dialysis
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Allergy Testing
Not Covered
Chemotherapy
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00% Intravenous chemotherapy is covered.
Radiation
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Diabetes Education
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Prosthetic Devices
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Infusion Therapy
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Nutritional Counseling
Not Covered
Medical nutritional education services that are provided by appropriately licensed or registered health care professionals are covered when both of the following are true: Nutritional education is required for a disease in which patient self-management is an important component of treatment. There exists a knowledge deficit regarding the disease which requires the intervention of a trained health professional.
Reconstructive Surgery
Covered
Not Applicable 20.00% 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 Value ($0 Virtual Urgent Care, $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.

Additional Resources

Below are additional resources for UHC Gold Value ($0 Virtual Urgent Care, $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 Value ($0 Virtual Urgent Care, $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

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