UHC Bronze Standard $9,100 Deductible - 40702AZ0060020 Health Insurance Plan

UnitedHealthcare of Arizona, Inc. health insurance plan with the Plan ID 40702AZ0060020. The plan is called UHC Bronze Standard $9,100 Deductible.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 59.86% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 40.14% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.

Health Insurance Plan ID 40702AZ0060020
Health Insurance Plan Year 2023
State Arizona
Health Insurance Issuer UnitedHealthcare of Arizona, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 40702AZ0060020-00
Provider Network(s) ['AZN001']
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 Arizona 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 - 40702AZ0060020-00

Standard On Exchange Plan - 40702AZ0060020-01

Open to Indians below 300% FPL - 40702AZ0060020-02

Open to Indians above 300% FPL - 40702AZ0060020-03

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 Standard $9,100 Deductible Health Insurance Plan, 40702AZ0060020-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental
YES

No Charge after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

No Charge after deductible

100.00%
Bariatric Surgery

The plan covers surgical treatment of morbid obesity provided certain criteria is met.

YES

No Charge after deductible

100.00%
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

Limit: 20.0 Visit(s) per Year

YES

No Charge after deductible

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

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.

YES

No Charge after deductible

100.00%
Dental Check-Up for Children

Limit: 1.0 Visit(s) per 6 Months

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

Exclusions: 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.

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 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

No Charge after deductible

100.00%
Habilitation Services

Limit: 60.0 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.

YES

No Charge after deductible

100.00%
Hearing Aids

Limit: 1.0 Item(s) per Year

YES

No Charge after deductible

100.00%
Home Health Care Services

Limit: 42.0 Visit(s) per Year

Exclusions: 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.

YES

No Charge after deductible

100.00%
Hospice Services

Exclusions: 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.

YES

No Charge after deductible

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

No Charge after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
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

Exclusions: 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.

YES

No Charge after deductible

100.00%
Mental/Behavioral Health Outpatient Services

Exclusions: 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.

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
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: 60.0 Visit(s) per Year

Exclusions: 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.

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

Well Woman and Well Man examinations are limited to 1 visit per year.

YES

0.00%

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

No Charge after deductible

100.00%
Private-Duty Nursing

Exclusions: 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.

YES

No Charge after deductible

100.00%
Prosthetic Devices

Exclusions: 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.

YES

No Charge after deductible

100.00%
Radiation
YES

No Charge after deductible

100.00%
Reconstructive Surgery
YES

No Charge after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 60.0 Visit(s) per Year

Visit limit is for all therapy types combined (PT, OT, ST).

YES

No Charge after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 60.0 Visit(s) per Year

Visit limit is for all therapy types combined (PT, OT, ST).

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 Visit(s) per Year

YES

No Charge

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 90.0 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

Exclusions: 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.

YES

No Charge after deductible

100.00%
Substance Abuse Disorder Outpatient Services

Exclusions: 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.

YES

No Charge after deductible

100.00%
Transplant

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.

YES

No Charge after deductible

100.00%
Treatment for Temporomandibular Joint Disorders

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.

YES

No Charge after deductible

100.00%
Urgent Care Centers or Facilities
YES

No Charge after deductible

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care

Well Child visits and immunizations are covered through 47 months as recommended by the American Academy of Pediatrics.

YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

No Charge after deductible

100.00%

UHC Bronze-X Standard $9,100 Deductible Health Insurance Plan Variant 40702AZ0060020-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.5986
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 Design 1
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID AZF007
Formulary URL URL
HIOS Product ID 40702AZ006
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 New
Notice Required for Pregnancy No
Is a Referral Required for Specialist? Yes
Issuer ID 40702
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 AZN001
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) 40702AZ0060020-00
Plan Level Exclusions 0
Plan Marketing Name UHC Bronze Standard $9,100 Deductible
Plan Type HMO
Plan Variant Marketing Name UHC Bronze-X Standard $9,100 Deductible
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $2,700
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 AZS001
Source Name HIOS
Specialist Requiring a Referral All, except OBGYN and as state mandated
Plan ID 40702AZ0060020
State Code AZ
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 No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of UHC Bronze Standard $9,100 Deductible Health Insurance Plan, 40702AZ0060020

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

Frequently Asked Questions(FAQ) about UHC Bronze Standard $9,100 Deductible, 40702AZ0060020 Health Insurance Plan, 40702AZ0060020

  • Does UHC Bronze Standard $9,100 Deductible Health Insurance Plan, 40702AZ0060020 support Mail Ordering?

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

  • Does (40702AZ0060020) Health Insurance Plan, Variant (40702AZ0060020-00) have Out Of Country Coverage?

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

    Does (40702AZ0060020) Health Insurance Plan, Variant (40702AZ0060020-00) 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