UHC Gold Value $2,100 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx, No Referrals)

24251VA0060031
Gold
HMO

UHC Gold Value $2,100 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx, No Referrals) is a Gold HMO plan by UnitedHealthcare.

IMPORTANT: You are viewing the 2023 version of UHC Gold Value $2,100 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx, No Referrals) 24251VA0060031. You can enroll in this plan during open enrollment 2023, which started November 1st and ends January 15th, 2023, in most states.

Locations

UHC Gold Value $2,100 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx, No Referrals) is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of UHC Gold Value $2,100 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx, No Referrals) 24251VA0060031.
Insurer: UnitedHealthcare
Network Type: HMO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 24251VA0060031

Cost-Sharing Overview

UHC Gold Value $2,100 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx, 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 Value $2,100 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx, No Referrals)?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
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Plan Features

UHC Gold Value $2,100 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx, 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: 0
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what UHC Gold Value $2,100 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx, 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 Value $2,100 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx, 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
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% Benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is Medically Necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Includes coverage for blood and blood products, anesthesia and anesthesia supplies and services given by the Hospital or other Facility, medical and surgical dressings and supplies, casts, and splints. Includes coverage for general anesthesia and hospitalization services when determined by dentist and treating physician that such services are required to effectively and safely provide dental care for (i) children under the age of 5, (ii) covered persons who are severely disabled, or (iii) covered persons who have a medical condition that requires admission to a hospital or Outpatient surgery facility. Surgeries and procedures to correct congenital abnormalities that cause functional impairment and congenital abnormalities in newborn children; other invasive procedures, such as angiogram, arteriogram, amniocentesis, tap or puncture of brain or spine; endoscopic exams, such as arthroscopy, bronchoscopy, colonoscopy, laparoscopy; treatment of fractures and dislocations; anesthesia and surgical support when Medically Necessary; Medically Necessary pre-operative and post-operative care. Benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is Medically Necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Includes surgical treatment of injuries and illnesses of the eye.
Outpatient Surgery Physician/Surgical Services
Covered
20% Coinsurance after deductible 100.00% Benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is Medically Necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Includes coverage for blood and blood products, anesthesia and anesthesia supplies and services given by the Hospital or other Facility, medical and surgical dressings and supplies, casts, and splints. Includes coverage for general anesthesia and hospitalization services when determined by dentist and treating physician that such services are required to effectively and safely provide dental care for (i) children under the age of 5, (ii) covered persons who are severely disabled, or (iii) covered persons who have a medical condition that requires admission to a hospital or Outpatient surgery facility. Surgeries and procedures to correct congenital abnormalities that cause functional impairment and congenital abnormalities in newborn children; other invasive procedures, such as angiogram, arteriogram, amniocentesis, tap or puncture of brain or spine; endoscopic exams, such as arthroscopy, bronchoscopy, colonoscopy, laparoscopy; treatment of fractures and dislocations; anesthesia and surgical support when Medically Necessary; Medically Necessary pre-operative and post-operative care. Benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is Medically Necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Includes surgical treatment of injuries and illnesses of the eye.
Hospice Services
Covered
20% Coinsurance after deductible 100.00%
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Assisted reproductive technologies (ART) such as artificial insemination, in-vitro fertilization, zygote intrafallopian transfer (ZIFT), or gamete intrafallopian transfer (GIFT) are NOT covered. Covered Services include diagnostic tests to find the cause of infertility, such as diagnostic laparoscopy, endometrial biopsy, and semen analysis. Benefits also include services to treat the underlying medical conditions that cause infertility (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency).
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
20% Coinsurance after deductible 100.00%16 Hours per Benefit Period Coverage does not include benefits for private duty nursing in the inpatient setting.
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%100 Visit(s) per Benefit Period The Home Care visit limit will apply instead of the Therapy Services limits for physical, occupational, speech therapy, or cardiac rehabilitation for therapy in the home
Emergency Room Services
Covered
$500 Copay after deductible $500 Copay 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% Benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is Medically Necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Benefits for room, board, and nursing services include: a room with two or more beds; a private room when medically necessary for isolation and no isolation facilities are available; a room in an approved special care unit; meals, special diets; general nursing services; operating, childbirth, and treatment rooms and equipment; prescribed drugs; anesthesia, anesthesia supplies and services given by the hospital or other provider; medical and surgical dressings and supplies, casts, and splints; blood and blood products; diagnostic services. Includes coverage for general anesthesia and hospitalization services when determined by dentist and treating physician that such services are required to effectively and safely provide dental care for (i) children under the age of 5, (ii) covered persons who are severely disabled, or (iii) covered persons who have a medical condition that requires admission to a hospital or Outpatient surgery facility.
Inpatient Physician and Surgical Services
Covered
20% Coinsurance after deductible 100.00% Benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is Medically Necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Includes medical care visits; intensive medical care when medically necessary; treatment for a health problem by a Doctor who is not your surgeon while you are in the Hospital for surgery; treatment by two or more Doctors during one Hospital stay when the nature or severity of your health problem calls for the skill of separate Doctors; a personal bedside exam by another Doctor when asked for by your Doctor; surgery and general anesthesia; professional charges to interpret diagnostic tests such as imaging, pathology reports, and cardiology. Surgeries and procedures to correct congenital abnormalities that cause functional impairment and congenital abnormalities in newborn children; other invasive procedures, such as angiogram, arteriogram, amniocentesis, tap or puncture of brain or spine; endoscopic exams, such as arthroscopy, bronchoscopy, colonoscopy, laparoscopy; treatment of fractures and dislocations; anesthesia and surgical support when medically necessary; medically necessary pre-operative and post-operative care. Medical benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is medically necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Includes surgical treatment of injuries and illnesses of the eye.
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
20% Coinsurance after deductible 100.00%100 Days per Stay Custodial care even if it is recommended by a professional or performed in a facility, such as a Skilled Nursing Facility. Includes Inpatient Rehab Services. Includes room and board in semi-private accommodations; rehabilitative services; and drugs, biologicals, and supplies furnished for use in the skilled nursing facility and other medically necessary services and supplies. Your Plan will cover the private room charge when medically necessary.
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. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply.
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. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply.
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. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply.
Specialty Drugs
Covered
40% Coinsurance after deductible 100.00%30 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. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply.
Outpatient Rehabilitation Services
Covered
20% Coinsurance after deductible 100.00%30 Visit(s) per Benefit Period Limited to 30 visits per year combined for Physical and Occupational Therapy, 30 visits per year for Speech Therapy. Limits will not apply if care is part of the hospice care benefit. When you get physical, occupational or speech therapy, in the home, the home health care visit limit will apply instead of the therapy services limits listed above. Limit does not apply when received as part of the hospice, early intervention benefit, and for the treatment of autism spectrum disorders.
Habilitation Services
Covered
20% Coinsurance after deductible 100.00%30 Visit(s) per Benefit Period Limited to 30 visits per year combined for Physical and Occupational Therapy, 30 visits per year for Speech Therapy. These limits do not apply for the treatment of autism and autism spectrum disorders, for early intervention services, and if care is part of the hospice care benefit. When you get physical, occupational or speech therapy, in the home, the home health care visit limit will apply instead of the therapy services limits listed above.
Chiropractic Care
Covered
20% Coinsurance after deductible 100.00%30 Visit(s) per Benefit Period Includes therapy to treat problems of the bones, joints, joints of the spine, the nervous system, and the back, and osteopathic therapy which focuses on the joints and surrounding muscles, tendons and ligaments. Visit limits apply to habilitative and rehabilitative services separately.
Durable Medical Equipment
Covered
20% Coinsurance after deductible 100.00%
Hearing Aids
Not Covered
This Exclusion does not apply to cochlear implants.
Imaging (CT/PET Scans, MRIs)
Covered
20% Coinsurance after deductible 100.00% Includes x-rays/regular imaging services; radiology (including mammograms), ultrasound or nuclear medicine; and advanced imaging, including CT scan, CTA scan, Magnetic Resonance Imaging (MRI); Magnetic Resonance Angiography (MRA); Magnetic Resonance Spectroscopy (MRS); Nuclear Cardiology; PET scans; PET/CT Fusion scans; QCT Bone Densitometry; Diagnostic CT Colonography; Single photon emission computed tomography (SPCECT) scans.
Preventive Care/Screening/Immunization
Covered
No Charge 100.00% Covers: (1) Services with an ‘A’ or ‘B’ rating from the United States Preventive Services Task Force; (2) Immunizations for children, adolescents, and adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; (3) Preventive care and screenings for infants, children and adolescents as listed in the guidelines supported by the Health Resources and Services Administration (including infant hearing screening); (4) Preventive care and screening for women as listed in the guidelines supported by the Health Resources and Services Administration; and (5) Counseling services related to smoking and tobacco use cessation. Prescription drugs that help you stop smoking or reduce your dependence on tobacco products are also covered preventive services. Smoking cessation products and over the counter nicotine replacement products (limited to nicotine patches and gum) are covered when obtained with a prescription. Additionally, state law requires coverage for routine screening mammograms and routine prostate specific antigen testing and digital rectal exams.
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%2 Visit(s) per Year
Rehabilitative Speech Therapy
Covered
20% Coinsurance after deductible 100.00%30 Visit(s) per Benefit Period Includes services to identify, assess, and treat speech, language, and swallowing disorders in children and adults. Therapy will develop or treat communication or swallowing skills to correct a speech impairment. Limit does not apply when received as part of hospice benefit, early intervention benefit or for the treatment autism spectrum disorder. Limit applies separately to habilitative and rehabilitative service.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
20% Coinsurance after deductible 100.00%30 Visit(s) per Benefit Period Occupational therapy does not include recreational or vocational therapies, such as hobbies, arts and crafts. Non-covered providers include, but are not limited to, masseurs or masseuses (massage therapists), and physical therapist technicians. Limited to 30 visits per year combined for Physical and Occupational Therapy. The limit applies separately to habilitative and rehabilitative services. Limit does not apply when received as part of hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders.
Well Baby Visits and Care
Covered
No Charge 100.00% Includes immunizations for children recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; Preventive care and screenings for infants as listed in the guidelines supported by the Health Resources and Services Administration (including infant hearing screening).
Laboratory Outpatient and Professional Services
Covered
20% Coinsurance after deductible 100.00%
X-rays and Diagnostic Imaging
Covered
20% Coinsurance after deductible 100.00% Includes benefits for tests or procedures to find or check a condition when specific symptoms exist, as well as benefits for interpretation of diagnostic tests such as imaging, and cardiology. Tests must be ordered by a Provider and include diagnostic services ordered before a surgery or Hospital admission. Benefits include the following services: x-rays/regular imaging services; radiology (including mammograms), ultrasound or nuclear medicine.
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
Pursuant to Virginia law no QHP sold or offered on an exchange shall provide coverage for abortions, provided that this limitation shall not apply to an abortion performed (i) when the life of the mother is endangered by a physical disorder, physical illness, or physical injury, including a life endangering physical condition relating to the pregnancy, or (ii) when the pregnancy is the result of rape or incest.
Transplant
Covered
20% Coinsurance after deductible 100.00% Includes coverage for medically necessary human organ, tissue, and stem cell/bone marrow transplants and infusions including necessary acquisition procedures, mobilization, harvest and storage. It also includes medically necessary myeloablative or reduced intensity preparative chemotherapy, radiation therapy, or a combination of these therapies.
Accidental Dental
Covered
20% Coinsurance after deductible 100.00% An injury that results from chewing or biting is not considered an accidental injury and is not covered. Includes dental work, to include oral/surgical correction needed to treat injuries to the jaw, sound natural teeth, mouth or face as a result of an accident. Dental appliances required to diagnose or treat an accidental injury to the teeth, and the repair of dental appliances damaged as a result of accidental injury to the jaw, mouth or face, are also covered. Treatment must begin within 12 months of the injury, or as soon after that as possible to be a covered service.
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% Includes benefits for prosthetics and components when they are medically necessary for activities of daily living. A prosthetic device is an artificial substitute to replace, in whole or in part, a limb or body part, such as an arm, leg, foot or eye. Includes benefits for prosthetics and components when they are medically necessary for activities of daily living. A prosthetic device is an artificial substitute to replace, in whole or in part, a limb or body part, such as an arm, leg, foot or eye. Coverage is also included for the repair, fitting, adjustments and replacement of a prosthetic device. In additional, components for artificial limbs are covered. Components are the materials and equipment needed to ensure the comfort and functioning of the prosthetic device. Covered services may include: 1) Artificial limbs and components (the materials and equipment needed to ensure the comfort and functioning of the prosthetic device); 2) Breast prosthesis (whether internal or external) after a mastectomy, as required by the Women?s Health and Cancer Rights Act. 3). Colostomy and other ostomy (surgical construction of an artificial opening) supplies directly related to ostomy care. 4) Restoration prosthesis (composite facial prosthesis) 5) Wigs needed after cancer treatment (limited to one wig per benefit period).
Infusion Therapy
Covered
20% Coinsurance after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
20% Coinsurance after deductible 100.00% The medical benchmark benefits exclude fixed or removable appliances that involve movement or repositioning of the teeth, repair of teeth (fillings), or prosthetics (crowns, bridges, dentures).
Nutritional Counseling
Covered
20% Coinsurance after deductible 100.00%
Reconstructive Surgery
Covered
20% Coinsurance after deductible 100.00% Includes benefits for prosthetics and components when they are medically necessary for activities of daily living. A prosthetic device is an artificial substitute to replace, in whole or in part, a limb or body part, such as an arm, leg, foot or eye. Includes benefits for prosthetics and components when they are medically necessary for activities of daily living. A prosthetic device is an artificial substitute to replace, in whole or in part, a limb or body part, such as an arm, leg, foot or eye. Coverage is also included for the repair, fitting, adjustments and replacement of a prosthetic device. In additional, components for artificial limbs are covered. Components are the materials and equipment needed to ensure the comfort and functioning of the prosthetic device. Covered services may include: 1) Artificial limbs and components (the materials and equipment needed to ensure the comfort and functioning of the prosthetic device); 2) Breast prosthesis (whether internal or external) after a mastectomy, as required by the Women?s Health and Cancer Rights Act. 3) Colostomy and other ostomy (surgical construction of an artificial opening) supplies directly related to ostomy care. 4) Restoration prosthesis (composite facial prosthesis) 5) Wigs needed after cancer treatment (limited to one wig per benefit period).
Gender Affirming Care
20% Coinsurance after deductible 100.00%
Eye Glasses – Adult
Not Covered

Free Preventive Services

There is no copayment or coinsurance for any of the following UHC Gold Value $2,100 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx, 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 Value $2,100 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx, 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 Value $2,100 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx, 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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