Find Health Plans

UHC Gold Value $1,800 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx)

40220TX0080021
Gold
HMO

UHC Gold Value $1,800 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx) is a Gold HMO plan by UnitedHealthcare.

IMPORTANT: You are viewing the 2023 version of UHC Gold Value $1,800 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx) 40220TX0080021. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

UHC Gold Value $1,800 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx) is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of UHC Gold Value $1,800 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx) 40220TX0080021.
Insurer: UnitedHealthcare
Network Type: HMO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 40220TX0080021

Cost-Sharing Overview

UHC Gold Value $1,800 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred 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 $1,800 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred 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 $1,800 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred 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 Value $1,800 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred 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 Value $1,800 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred 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
No Charge 100.00% Virtual urgent care visits via a Designated virtual provider unlimited $0
Specialist Visit
Covered
20% Coinsurance after deductible 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
20% Coinsurance after deductible 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
20% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
20% Coinsurance after deductible 100.00%
Hospice Services
Covered
20% Coinsurance after deductible 100.00%
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
20% Coinsurance after deductible 100.00% Covered inpatient only when medically necessary.
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$50.00 100.00%
Home Health Care Services
Covered
20% Coinsurance after deductible 100.00%60 Visit(s) per Year
Emergency Room Services
Covered
40% Coinsurance after deductible 40% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
20% Coinsurance after deductible 20% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
20% Coinsurance after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
20% Coinsurance after deductible 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
20% Coinsurance after deductible 100.00%25 Days per Year Limit will be any combination of Skilled Nursing or Inpatient Rehabilitation Services. Visit limits do not apply to ABI services.
Prenatal and Postnatal Care
Covered
No Charge 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
20% Coinsurance after deductible 100.00% Childbirth/delivery professional services follow inpatient physician/surgeon fees
Mental/Behavioral Health Outpatient Services
Covered
20% Coinsurance after deductible 100.00%
Mental/Behavioral Health Inpatient Services
Covered
20% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
20% Coinsurance after deductible 100.00%
Substance Abuse Disorder Inpatient Services
Covered
20% Coinsurance after deductible 100.00%
Generic Drugs
Covered
$1.00 100.00%30 Days per Month Lowest cost shares are available at preferred retail pharmacies and home delivery. See SBC for cost shares at other retail pharmacies and for non-preferred generics. 90-day supplies are available through preferred retail pharmacies or 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
$50.00 100.00%30 Days per Month Preferred brand medications are available in 90-day supplies through preferred retail pharmacies or 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
30% Coinsurance after deductible 100.00%30 Days per Month Non-preferred brand medications are available in 90-day supplies through preferred retail pharmacies or 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
40% Coinsurance after deductible 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
20% Coinsurance after deductible 100.00%35 Visit(s) per Year 35 visits per year for any combination of physical therapy, occupational therapy, speech therapy, and manipulative treatment.
Habilitation Services
Covered
20% Coinsurance after deductible 100.00%35 Visit(s) per Year 35 visits per year for any combination of physical therapy, occupational therapy, speech therapy, and manipulative treatment. Visit limits do not apply if the primary diagnosis code for the outpatient habilitative services being provided is a covered mental health or substance use disorder.
Chiropractic Care
Covered
20% Coinsurance after deductible 100.00%35 Visit(s) per Year 35 visits per year for any combination of physical therapy, occupational therapy, speech therapy, and manipulative treatment.
Durable Medical Equipment
Covered
20% Coinsurance after deductible 100.00%
Hearing Aids
Covered
20% Coinsurance after deductible 100.00%1 Item(s) per 3 Years Benefits are limited to a single purchase per hearing impaired ear every 36 months.
Imaging (CT/PET Scans, MRIs)
Covered
20% Coinsurance after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge 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
20% 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
20% Coinsurance after deductible 100.00%35 Visit(s) per Year 35 visits for any combination of physical therapy, occupational therapy, speech therapy and manipulative treatments.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
20% Coinsurance after deductible 100.00%35 Visit(s) per Year 35 visits for any combination of physical therapy, occupational therapy, speech therapy and manipulative treatments.
Well Baby Visits and Care
Covered
No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
20% 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
20% Coinsurance after deductible 100.00%
Basic Dental Care – Child
Covered
20% 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
20% 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
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
20% Coinsurance after deductible 100.00%
Accidental Dental
Covered
20% Coinsurance after deductible 100.00%
Dialysis
Covered
20% Coinsurance after deductible 100.00%
Allergy Testing
Covered
20% Coinsurance after deductible 100.00%
Chemotherapy
Covered
20% Coinsurance after deductible 100.00%
Radiation
Covered
20% Coinsurance after deductible 100.00%
Diabetes Education
Covered
20% Coinsurance after deductible 100.00%
Prosthetic Devices
Covered
20% Coinsurance after deductible 100.00%
Infusion Therapy
Covered
20% Coinsurance after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
20% Coinsurance after deductible 100.00%
Nutritional Counseling
Not Covered
Reconstructive Surgery
Covered
20% Coinsurance after deductible 100.00%
Gender Affirming Care
Not Covered
Eye Glasses – Adult
Not Covered

Free Preventive Services

There is no copayment or coinsurance for any of the following UHC Gold Value $1,800 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred 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 $1,800 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred 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 $1,800 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred 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

Table of Contents