UHC Silver Value $3,000 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

40702AZ0060011
Silver
HMO

UHC Silver Value $3,000 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx) is a Silver HMO plan by UnitedHealthcare.

IMPORTANT: You are viewing the 2023 version of UHC Silver Value $3,000 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx) 40702AZ0060011. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

UHC Silver Value $3,000 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx) is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of UHC Silver Value $3,000 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx) 40702AZ0060011.
Insurer: UnitedHealthcare
Network Type: HMO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 40702AZ0060011

Cost-Sharing Overview

UHC Silver Value $3,000 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 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 Silver Value $3,000 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 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 Silver Value $3,000 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 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 Silver Value $3,000 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 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 Silver Value $3,000 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 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
50% Coinsurance after deductible 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
50% Coinsurance after deductible 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
50% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
50% Coinsurance after deductible 100.00%
Hospice Services
Covered
50% Coinsurance after deductible 100.00% Services of a person who is a member of your family or your dependent’s family or who normally resides in your house or your dependent’s house; Services and supplies for curative or life prolonging procedures; Services and supplies for which any other benefits are payable under the Plan; Services and supplies that are primarily to aid you or your dependent in daily living; Services and supplies for respite (custodial) care; and Nutritional supplements, non-prescription drugs or substances, medical supplies, vitamins or minerals. The Plan covers hospice care services which are provided under an approved hospice care program when provided to a Member who has been diagnosed by a Participating Provider as having a terminal illness with a prognosis of six (6) months or less to live.
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
50% Coinsurance after deductible 100.00% Private Duty Nursing services provided in the home. Private duty nursing are only available during inpatient stays and determined to be medically appropriate by the Plan. Private duty nursing is available only in an inpatient setting when skilled nursing is not available from the facility. Custodial Nursing is not covered by the Plan.
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$75.00 100.00%
Home Health Care Services
Covered
50% Coinsurance after deductible 100.00%42 Visit(s) per Year Home health services do not include services of a person who is a member of your family or your dependent?s family or who normally resides in your house or your dependent?s house. 1. The physician must have determined a medical need for home health care and developed a plan of care that is reviewed at thirty day intervals by the physician.; 2. The care described in the plan of care must be for intermittent skilled nursing, therapy, or speech services.; 3. The patient must be homebound unless services are determined to be medically necessary.; 4. The home health agency delivering care must be certified within the state the care is received.; 5. The care that is being provided is not custodial care. A Home Health visit is considered to be up to four hours of services.
Emergency Room Services
Covered
50% Coinsurance after deductible 50% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
50% Coinsurance after deductible 50% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
50% Coinsurance after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
50% Coinsurance after deductible 100.00%
Bariatric Surgery
Covered
50% Coinsurance after deductible 100.00% The plan covers surgical treatment of morbid obesity provided certain criteria is met.
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
50% Coinsurance after deductible 100.00%90 Days per Year Limit will be any combination of Skilled Nursing Facility or Inpatient Rehabilitation Facility Services.
Prenatal and Postnatal Care
Covered
No Charge 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
50% Coinsurance after deductible 100.00% Newborn benefits do not apply to the newly born child of an Eligible Dependent daughter unless placement with the Employee is confirmed through a court order or legal guardianship. Childbirth/delivery professional services follow inpatient physician/surgeon fees.
Mental/Behavioral Health Outpatient Services
Covered
50% Coinsurance after deductible 100.00% 1. Any court ordered treatment or therapy, or any treatment or therapy ordered as a condition of parole, probation or custody or visitation evaluations unless Medically Appropriate and otherwise covered under this Plan; 2. Treatment of mental disorders that have been diagnosed as organic mental disorders associated with permanent dysfunction of the brain; 3. Treatment of Chronic Conditions not subject to favorable modification according to generally accepted standards of medical practice; 4. Developmental disorders, including but not limited to: developmental reading disorders; developmental arithmetic disorders; developmental language disorders; or articulation disorders. 5. Counseling for activities of an educational nature; 6. Counseling for borderline intellectual functioning; 7. Counseling for occupational problems; 8. Counseling related to consciousness raising; 9. Vocational or religious counseling; 10. I.Q. testing; 11. Marriage counseling; 12. Custodial care, including but not limited to geriatric day care; 13. Psychological testing on children requested by or for a school system; 14. Occupational/recreational therapy programs even if combined with supportive therapy forage-related cognitive decline; and 15. Biofeedback is not covered for reasons other than pain management.
Mental/Behavioral Health Inpatient Services
Covered
50% Coinsurance after deductible 100.00% 1. Any court ordered treatment or therapy, or any treatment or therapy ordered as a condition of parole, probation or custody or visitation evaluations unless Medically Appropriate and otherwise covered under this Plan; 2. Treatment of mental disorders that have been diagnosed as organic mental disorders associated with permanent dysfunction of the brain; 3. Treatment of Chronic Conditions not subject to favorable modification according to generally accepted standards of medical practice; 4. Developmental disorders, including but not limited to: developmental reading disorders; developmental arithmetic disorders; developmental language disorders; or articulation disorders. 5. Counseling for activities of an educational nature; 6. Counseling for borderline intellectual functioning; 7. Counseling for occupational problems; 8. Counseling related to consciousness raising; 9. Vocational or religious counseling; 10. I.Q. testing; 11. Marriage counseling; 12. Custodial care, including but not limited to geriatric day care; 13. Psychological testing on children requested by or for a school system; 14. Occupational/recreational therapy programs even if combined with supportive therapy forage-related cognitive decline; and 15. Biofeedback is not covered for reasons other than pain management.
Substance Abuse Disorder Outpatient Services
Covered
50% Coinsurance after deductible 100.00% 1. Any court ordered treatment or therapy, or any treatment or therapy ordered as a condition of parole, probation or custody or visitation evaluations unless Medically Appropriate and otherwise covered under this Plan; 2. Treatment of mental disorders that have been diagnosed as organic mental disorders associated with permanent dysfunction of the brain; 3. Treatment of Chronic Conditions not subject to favorable modification according to generally accepted standards of medical practice; 4. Developmental disorders, including but not limited to: developmental reading disorders; developmental arithmetic disorders; developmental language disorders; or articulation disorders. 5. Counseling for activities of an educational nature; 6. Counseling for borderline intellectual functioning; 7. Counseling for occupational problems; 8. Counseling related to consciousness raising; 9. Vocational or religious counseling; 10. I.Q. testing; 11. Marriage counseling; 12. Custodial care, including but not limited to geriatric day care; 13. Psychological testing on children requested by or for a school system; 14. Occupational/recreational therapy programs even if combined with supportive therapy forage-related cognitive decline; and 15. Biofeedback is not covered for reasons other than pain management.
Substance Abuse Disorder Inpatient Services
Covered
50% Coinsurance after deductible 100.00% 1. Any court ordered treatment or therapy, or any treatment or therapy ordered as a condition of parole, probation or custody or visitation evaluations unless Medically Appropriate and otherwise covered under this Plan; 2. Treatment of mental disorders that have been diagnosed as organic mental disorders associated with permanent dysfunction of the brain; 3. Treatment of Chronic Conditions not subject to favorable modification according to generally accepted standards of medical practice; 4. Developmental disorders, including but not limited to: developmental reading disorders; developmental arithmetic disorders; developmental language disorders; or articulation disorders. 5. Counseling for activities of an educational nature; 6. Counseling for borderline intellectual functioning; 7. Counseling for occupational problems; 8. Counseling related to consciousness raising; 9. Vocational or religious counseling; 10. I.Q. testing; 11. Marriage counseling; 12. Custodial care, including but not limited to geriatric day care; 13. Psychological testing on children requested by or for a school system; 14. Occupational/recreational therapy programs even if combined with supportive therapy forage-related cognitive decline; and 15. Biofeedback is not covered for reasons other than pain management.
Generic Drugs
Covered
$3.00 100.00%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
$60 Copay after deductible 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
40% 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
50% 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
50% Coinsurance after deductible 100.00%60 Visit(s) per Year The following limitations apply to short-term rehabilitative therapy except as required for the treatment for Autism Spectrum Disorder: 1. Occupational therapy is provided only for purposes of training Members to perform the activities of daily living. 2. Speech therapy is not covered when: a. Used to improve speech skills that have not fully developed; b. Considered custodial or educational; c. Intended to maintain speech communication; or d. Not restorative in nature. 3. Phase 3 cardiac rehabilitation is not covered. If multiple services are provided on the same day by different Providers, a separate co-payment will apply to each Provider. 60 visits per year for any combination of physical therapy, occupational therapy, and speech therapy. Short-term rehabilitative therapy includes services in an outpatient facility or physician?s office that is part of a rehabilitation program. Limits do not apply to pulmonary rehabilitation therapy and cardiac rehabilitation therapy.
Habilitation Services
Covered
50% Coinsurance after deductible 100.00%60 Visit(s) per Year 60 visits per year for any combination of physical therapy, occupational therapy and speech therapy. Visit limits do not apply for therapies for covered persons with a primary diagnoses of autism spectrum disorder. Visit limits do not apply if the primary diagnosis code for the outpatient habilitative services being provided is one for a covered mental disorder or for treatment of substance-related and addictive disorders.
Chiropractic Care
Covered
50% Coinsurance after deductible 100.00%20 Visit(s) per Year
Durable Medical Equipment
Covered
50% Coinsurance after deductible 100.00% 1. Hygienic or self-help items or equipment; 2. Items or equipment primarily used for comfort or convenience such as bathtub chairs, safety grab bars, stair gliders or elevators, over-the-bed tables, saunas or exercise equipment; 3. Environmental control equipment, such as air purifiers, humidifiers and electrostatic machines; 4. Institutional equipment, such as air fluidized beds and diathermy machines; 5. Elastic stockings and wigs (except were indicated for coverage); 6. Equipment used for the purpose of participation in sports or other recreational activities including, but not limited to, braces and splints; 7. Items, such as auto tilt chairs, paraffin bath units and whirlpool baths, which are not generally accepted by the medical profession as being therapeutically effective; 8. Items which under normal use would constitute a fixture to real property, such as lifts, ramps, railings, and grab bars; and 9. Hearing aid batteries (except those for cochlear implants) and chargers.
Hearing Aids
Covered
50% Coinsurance after deductible 100.00%1 Item(s) per Year
Imaging (CT/PET Scans, MRIs)
Covered
50% Coinsurance after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge 100.00% Well Woman and Well Man examinations are limited to 1 visit per year.
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
50% 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
50% Coinsurance after deductible 100.00%60 Visit(s) per Year Visit limit is for all therapy types combined (PT, OT, ST).
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
50% Coinsurance after deductible 100.00%60 Visit(s) per Year Visit limit is for all therapy types combined (PT, OT, ST).
Well Baby Visits and Care
Covered
No Charge 100.00% Well Child visits and immunizations are covered through 47 months as recommended by the American Academy of Pediatrics.
Laboratory Outpatient and Professional Services
Covered
50% Coinsurance after deductible 100.00%
X-rays and Diagnostic Imaging
Covered
50% Coinsurance after deductible 100.00%
Basic Dental Care – Child
Covered
50% 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
50% 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
50% Coinsurance after deductible 100.00% Benefits are available for transplants when the transplant meets the definition of a Covered Health Care Service, and is not an Experimental or Investigational or Unproven Service. Donor costs related to transplantation are Covered Health Care Services and are payable through the organ recipient’s coverage under this Policy, limited to donor: Identification, Evaluation, Organ removal, and Direct follow-up care.
Accidental Dental
Covered
50% Coinsurance after deductible 100.00%
Dialysis
Covered
50% Coinsurance after deductible 100.00%
Allergy Testing
Covered
50% Coinsurance after deductible 100.00%
Chemotherapy
Covered
50% Coinsurance after deductible 100.00%
Radiation
Covered
50% Coinsurance after deductible 100.00%
Diabetes Education
Covered
50% Coinsurance after deductible 100.00%
Prosthetic Devices
Covered
50% Coinsurance after deductible 100.00% Replacement of external prosthetic appliance due to loss or theft. The Plan covers the initial purchase and fitting of external prosthetic devices which are used as a replacement or substitute for a missing body part and are necessary for the alleviation or correction of illness, injury, congenital defect, or alopecia as a result of chemotherapy, radiation therapy, and second or third degree burns. Limited to one wig or hairpiece per covered person per calendar year.
Infusion Therapy
Covered
50% Coinsurance after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
50% Coinsurance after deductible 100.00% Benefits are payable for covered services and supplies which are necessary to treat TMJ disorder which is a result of: 1. An accident; 2. Trauma; 3. A congenital defect; 4. A developmental defect; or 5. A pathology.
Nutritional Counseling
Covered
50% Coinsurance after deductible 100.00%
Reconstructive Surgery
Covered
50% Coinsurance after deductible 100.00%
Gender Affirming Care
Not Covered

Free Preventive Services

There is no copayment or coinsurance for any of the following UHC Silver Value $3,000 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 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 Silver Value $3,000 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 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 Silver Value $3,000 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 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

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