UHC Bronze Essential ($3 Generic Rx Pref Pharm, No Referrals) - 45480OK0050025 Health Insurance Plan

UnitedHealthcare of Oklahoma, Inc. health insurance plan with the Plan ID 45480OK0050025. The plan is called UHC Bronze Essential ($3 Generic Rx Pref Pharm, No Referrals).

Based on the data of Health Plan Issuer, this plan has an actuarial value of 61.05% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 38.95% of the costs of all covered benefits (according to the Issuer).

Health Insurance Plan ID 45480OK0050025
Health Insurance Plan Year 2023
State Oklahoma
Health Insurance Issuer UnitedHealthcare of Oklahoma, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 45480OK0050025-00
Provider Network(s) ['OKN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Wed, 27 Mar 2024 12:10 GMT).

Providers Oklahoma All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 45480OK0050025-00

Standard On Exchange Plan - 45480OK0050025-01

Open to Indians below 300% FPL - 45480OK0050025-02

Open to Indians above 300% FPL - 45480OK0050025-03

Last Plan Update Date Wed, 17 Aug 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of UHC Bronze Essential ($3 Generic Rx Pref Pharm, No Referrals) Health Insurance Plan, 45480OK0050025-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited

Exclusions: This exclusion does not apply when the mother's life is endangered.

NO
Accidental Dental
YES

No Charge after deductible

100.00%
Acupuncture
NO
Allergy Testing

Issuer clarifies this is a covered benefit but stipulated under the Medical Policy and not written in the member materials.

YES

No Charge after deductible

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child

Benefit limitations may apply to individual services.

YES

No Charge after deductible

100.00%
Chemotherapy
YES

No Charge after deductible

100.00%
Chiropractic Care
YES

No Charge after deductible

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care

Childbirth/delivery professional services follow inpatient physician/surgeon fees

YES

No Charge after deductible

100.00%
Dental Check-Up for Children

Limit: 1.0 Visit(s) per Year

YES

No Charge

100.00%
Diabetes Education
YES

No Charge after deductible

100.00%
Dialysis
YES

No Charge after deductible

100.00%
Durable Medical Equipment
YES

No Charge after deductible

100.00%
Emergency Room Services
YES

No Charge after deductible

No Charge after deductible
Emergency Transportation/Ambulance
YES

No Charge after deductible

No Charge after deductible
Eye Glasses - Adult
NO
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

No Charge after deductible

100.00%
Gender Affirming Care
NO
Generic Drugs

Limit: 30.0 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.

YES

$3.00

100.00%
Habilitation Services

Limit: 25.0 Visit(s) per Year

Limited to 25 visits per year combined for Physical, Occupational and Speech Therapy. Treatment of Autism and Autism Spectrum Disorders are limited to an additional 390 visits per year combined for Physical, Occupational and Speech Therapy.

YES

No Charge after deductible

100.00%
Hearing Aids

One hearing aid per hearing impaired ear every 48 months for Covered Persons

YES

No Charge after deductible

100.00%
Home Health Care Services

Limit: 30.0 Visit(s) per Benefit Period

YES

No Charge after deductible

100.00%
Hospice Services
YES

No Charge after deductible

100.00%
Imaging (CT/PET Scans, MRIs)
YES

No Charge after deductible

100.00%
Infertility Treatment

Exclusions: This exclusion does not apply to diagnosis and services required to treat or correct underlying causes of infertility.

NO
Infusion Therapy

Limit: 25.0 Visit(s) per Benefit Period

Covered under Outpatient Therapy Services.

YES

No Charge after deductible

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)
YES

No Charge after deductible

100.00%
Inpatient Physician and Surgical Services
YES

No Charge after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

No Charge after deductible

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child

Benefit limitations may apply to individual services.

YES

No Charge after deductible

100.00%
Mental/Behavioral Health Inpatient Services
YES

No Charge after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

No Charge after deductible

100.00%
Non-Preferred Brand Drugs

Limit: 30.0 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.

YES

No Charge after deductible

100.00%
Nutritional Counseling

Diabetes self-management training and training related to medical nutrition therapy.

YES

No Charge after deductible

100.00%
Orthodontia - Adult
NO
Orthodontia - Child

Coverage is for medically necessary orthodontia only.

YES

No Charge after deductible

100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

No Charge after deductible

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

No Charge after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 25.0 Visit(s) per Year

Limited to 25 visits per year combined for Physical, Occupational and Speech Therapy.

YES

No Charge after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

No Charge after deductible

100.00%
Preferred Brand Drugs

Limit: 30.0 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.

YES

No Charge after deductible

100.00%
Prenatal and Postnatal Care
YES

No Charge

100.00%
Preventive Care/Screening/Immunization
YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness
YES

No Charge after deductible

100.00%
Private-Duty Nursing

Limit: 85.0 Visit(s) per Benefit Period

YES

No Charge after deductible

100.00%
Prosthetic Devices
YES

No Charge after deductible

100.00%
Radiation
YES

No Charge after deductible

100.00%
Reconstructive Surgery

Breast reconstruction or implantation or removal of breast prostheses is a Covered Service only when performed solely and directly as a result of mastectomy which is Medically Necessary.

YES

No Charge after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 25.0 Visit(s) per Benefit Period

Limited to 25 visits per year combined for Physical, Occupational and Speech Therapy.

YES

No Charge after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 25.0 Visit(s) per Benefit Period

Limited to 25 visits per year combined for Physical, Occupational and Speech Therapy.

YES

No Charge after deductible

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Year

YES

No Charge

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 30.0 Days per Year

Limit will be any combination of Skilled Nursing Facility or Inpatient Rehabilitation Facility Services.

YES

No Charge after deductible

100.00%
Specialist Visit
YES

No Charge after deductible

100.00%
Specialty Drugs

Limit: 30.0 Days per Month

Covers outpatient self-administered prescription legend drugs from a participating network pharmacy. Quantity limits per prescription may apply.

YES

No Charge after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

No Charge after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

No Charge after deductible

100.00%
Transplant
YES

No Charge after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
NO
Urgent Care Centers or Facilities
YES

No Charge after deductible

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

No Charge after deductible

100.00%

UHC Bronze-X Essential ($3 Generic Rx Pref Pharm, No Referrals) Health Insurance Plan Variant 45480OK0050025-00 Attributes

Plan Attribute Value
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2023
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Bronze Off Exchange Plan
Dental Only Plan No
Design Type Not Applicable
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID OKF001
Formulary URL URL
HIOS Product ID 45480OK005
Import Date 8/17/2022 1:01
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible No
New/Existing Plan Existing
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer Actuarial Value 61.05%
Issuer ID 45480
Issuer Marketplace Marketing Name UnitedHealthcare
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Bronze
Multiple In Network Tiers No
National Network No
Network ID OKN001
Out of Country Coverage No
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.
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan ID (Standard Component ID with Variant) 45480OK0050025-00
Plan Level Exclusions 0
Plan Marketing Name UHC Bronze Essential ($3 Generic Rx Pref Pharm, No Referrals)
Plan Type HMO
Plan Variant Marketing Name UHC Bronze-X Essential ($3 Generic Rx Pref Pharm, No Referrals)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $9,100
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $0
SBC Scenario, Having Diabetes, Deductible $5,300
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $0
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,800
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID OKS001
Source Name HIOS
Plan ID 45480OK0050025
State Code OK
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 0.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $18200 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $9100 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $9,100
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person per person not applicable
Combined Medical and Drug EHB Deductible, Out of Network, Individual Not Applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $18200 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $9100 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $9,100
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual Not Applicable
Unique Plan Design Yes
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of UHC Bronze Essential ($3 Generic Rx Pref Pharm, No Referrals) Health Insurance Plan, 45480OK0050025

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about UHC Bronze Essential ($3 Generic Rx Pref Pharm, No Referrals), 45480OK0050025 Health Insurance Plan, 45480OK0050025

  • Does UHC Bronze Essential ($3 Generic Rx Pref Pharm, No Referrals) Health Insurance Plan, 45480OK0050025 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (45480OK0050025) Health Insurance Plan, Variant (45480OK0050025-00) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan).

    Does (45480OK0050025) Health Insurance Plan, Variant (45480OK0050025-00) have Out of Service Area Coverage?

    Yes. Details: Plan covers eligible expenses provided by a Network Physician or other provider or facility within the Network Area.

 

Disclaimer: This is based on the import(Date: Wed, 27 Mar 2024 12:10 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API