UHC Silver Value ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 Rx, No Referrals)

54332NC0030012
Silver
HMO

UHC Silver Value ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 Rx, No Referrals) is a Silver HMO plan by UnitedHealthcare.

IMPORTANT: You are viewing the 2024 version of UHC Silver Value ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 Rx, No Referrals) 54332NC0030012. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

UHC Silver Value ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 Rx, No Referrals) is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of UHC Silver Value ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 Rx, No Referrals) 54332NC0030012.
Insurer: UnitedHealthcare
Network Type: HMO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 54332NC0030012

Cost-Sharing Overview

UHC Silver Value ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 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 Silver Value ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 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

Plan Features

UHC Silver Value ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 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:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what UHC Silver Value ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 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 Silver Value ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 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
Not Applicable No ChargeNot Applicable 100.00% Cost sharing for Virtual Primary Care matches in-person office visit. See SBC for additional cost share details.
Specialist Visit
Covered
Not Applicable 50% Coinsurance after deductibleNot Applicable 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
Not Applicable 50% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 50% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 50% Coinsurance after deductibleNot Applicable 100.00%
Hospice Services
Covered
Not Applicable 50% Coinsurance after deductibleNot Applicable 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
Not Applicable 50% Coinsurance after deductibleNot Applicable 100.00%3.0 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 medical 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. The lifetime maximums are described in BCBSNC medical policies, which are guides considered by BCBSNC when making coverage determinations.
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
Not Applicable 50% Coinsurance after deductibleNot Applicable 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
$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 50% Coinsurance after deductibleNot Applicable 100.00%60.0 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
Not Applicable 50% Coinsurance after deductibleNot Applicable 50% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
Not Applicable 50% Coinsurance after deductibleNot Applicable 50% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 50% Coinsurance after deductibleNot Applicable 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
Not Applicable 50% Coinsurance after deductibleNot Applicable 100.00%
Bariatric Surgery
Covered
Not Applicable 50% Coinsurance after deductibleNot Applicable 100.00%1.0 Procedure(s) per Lifetime Excludes removal of excess skin from the abdomen, arms or thighs. For surgical treatment of morbid obesity.
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
Not Applicable 50% Coinsurance after deductibleNot Applicable 100.00%60.0 Days per Benefit Period Limit will be any combination of Skilled Nursing Facility or Inpatient Rehabilitation Facility Services.
Prenatal and Postnatal Care
Covered
Not Applicable No ChargeNot Applicable 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 50% Coinsurance after deductibleNot Applicable 100.00% Childbirth/delivery professional services follow inpatient physician/surgeon fees.
Mental/Behavioral Health Outpatient Services
Covered
Not Applicable 50% Coinsurance after deductibleNot Applicable 100.00% Excludes marriage and family therapy.
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 50% Coinsurance after deductibleNot Applicable 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
Not Applicable 50% Coinsurance after deductibleNot Applicable 100.00% Excludes marriage and family therapy.
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 50% Coinsurance after deductibleNot Applicable 100.00% Excludes, “Inpatient confinements that are primarily intended as a change of environment”; Counseling with relatives of a patient.
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
$100 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 45% 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% Coinsurance after deductibleNot Applicable 100.00%30.0 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
Not Applicable 50% Coinsurance after deductibleNot Applicable 100.00%30.0 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
Not Applicable 50% Coinsurance after deductibleNot Applicable 100.00%30.0 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
Not Applicable 50% Coinsurance after deductibleNot Applicable 100.00%30.0 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
Not Applicable 50% Coinsurance after deductibleNot Applicable 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.
Hearing Aids
Covered
Not Applicable 50% Coinsurance after deductibleNot Applicable 100.00%
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 50% Coinsurance after deductibleNot Applicable 100.00% Lab tests that are not ordered by Doctor of Other Provider.
Preventive Care/Screening/Immunization
Covered
Not Applicable No ChargeNot Applicable 100.00% All preventive care that is not state mandated is not covered OON.
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 50% 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 50% Coinsurance after deductibleNot Applicable 100.00%30.0 Visit(s) per Year Excludes speech therapy for stammering or stuttering.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Not Applicable 50% Coinsurance after deductibleNot Applicable 100.00%30.0 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
Not Applicable No ChargeNot Applicable 100.00%
Laboratory Outpatient and Professional Services
Covered
$15.00 Not ApplicableNot Applicable 100.00%18.0 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
Not Applicable 50% Coinsurance after deductibleNot Applicable 100.00%
Basic Dental Care – Child
Covered
Not Applicable 50% 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 50% 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 50% Coinsurance after deductibleNot Applicable 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. Benefits are provided for reasonable and necessary services related to the search for a donor up to a maximum of $10,000 per transplant; Both the recipient and the donor are entitled to benefits of this coverage when the recipient is a MEMBER. Benefits provided to the donor will be charged against the recipient’s coverage.
Accidental Dental
Covered
Not Applicable 50% Coinsurance after deductibleNot Applicable 100.00%
Dialysis
Covered
Not Applicable 50% Coinsurance after deductibleNot Applicable 100.00%
Allergy Testing
Covered
Not Applicable 50% Coinsurance after deductibleNot Applicable 100.00%
Chemotherapy
Covered
Not Applicable 50% Coinsurance after deductibleNot Applicable 100.00%
Radiation
Covered
Not Applicable 50% Coinsurance after deductibleNot Applicable 100.00%
Diabetes Education
Covered
Not Applicable 50% Coinsurance after deductibleNot Applicable 100.00%
Prosthetic Devices
Covered
Not Applicable 50% Coinsurance after deductibleNot Applicable 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
Not Applicable 50% Coinsurance after deductibleNot Applicable 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
Not Applicable 50% Coinsurance after deductibleNot Applicable 100.00% Excludes Treatment for periodontal disease; Dental implants or root canals; Crowns and bridges; Orthodontic brace; Occlusal (bite) adjustments; Extractions. Therapeutic benefits for TMJ disease include splinting and use of intra-oral PROSTHETIC APPLIANCES to reposition the bones. Surgical benefits for TMJ disease are limited to SURGERY performed on the temporomandibular joint. If TMJ is caused by malocclusion, benefits are provided for surgical correction of malocclusion when surgical management of the TMJ is MEDICALLY NECESSARY.
Nutritional Counseling
Covered
Not Applicable 50% Coinsurance after deductibleNot Applicable 100.00% Nutritional counseling visits are separate from the obesity-related office visits.
Reconstructive Surgery
Covered
Not Applicable 50% Coinsurance after deductibleNot Applicable 100.00% Benefits include coverage for congenital defects of newborn, adopted, and foster children; reconstruction following a mastectomy.
Gender Affirming Care
Not Covered

Free Preventive Services

There is no copayment or coinsurance for any of the following UHC Silver Value ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 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 Silver Value ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 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 Silver Value ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 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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