UHC Silver Advantage (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx) - 33931OH0030019 Health Insurance Plan

UnitedHealthcare of Ohio, Inc. health insurance plan with the Plan ID 33931OH0030019. The plan is called UHC Silver Advantage (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx).

Based on the data of Health Plan Issuer, this plan has an actuarial value of 71.55% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 28.45% of the costs of all covered benefits (according to the Issuer).

Health Insurance Plan ID 33931OH0030019
Health Insurance Plan Year 2023
State Ohio
Health Insurance Issuer UnitedHealthcare of Ohio, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 33931OH0030019-00
Provider Network(s) ['OHN001']
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 Ohio 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 - 33931OH0030019-00

Standard On Exchange Plan - 33931OH0030019-01

Open to Indians below 300% FPL - 33931OH0030019-02

Open to Indians above 300% FPL - 33931OH0030019-03

73% AV Silver Plan - 33931OH0030019-04

87% AV Silver Plan - 33931OH0030019-05

94% AV Silver Plan - 33931OH0030019-06

Last Plan Update Date Tue, 16 Aug 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of UHC Silver Advantage (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx) Health Insurance Plan, 33931OH0030019-00

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

Limit: 3000.0 Dollars per Episode

YES

50% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

50% Coinsurance after deductible

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

Benefit limitations may apply to individual services.

YES

50% Coinsurance after deductible

100.00%
Chemotherapy
YES

50% Coinsurance after deductible

100.00%
Chiropractic Care

Limit: 12.0 Visit(s) per Benefit Period

YES

50% Coinsurance after deductible

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

Coverage for the Inpatient postpartum stay for mother and newborn child in a hospital will be, at a minimum, 48 hours for a vaginal delivery and 96 hours for a cesarean section. Coverage will be for the length of stay recommended by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists in their Guidelines for Prenatal Care. Childbirth/delivery professional services follow inpatient physician/surgeon fees.

YES

$1500 Copay after deductible

100.00%
Dental Check-Up for Children

Limit: 1.0 Exam(s) per 6 Months

YES

No Charge

100.00%
Diabetes Education

Diabetes Self-Management Training for an individual with insulin dependent diabetes, non-insulin dependent diabetes, or elevated blood glucose levels induced by pregnancy or another medical condition

YES

50% Coinsurance after deductible

100.00%
Dialysis

Benefits include supportive use of an artificial kidney machine

YES

50% Coinsurance after deductible

100.00%
Durable Medical Equipment

Covered services include durable medical equipment, medical devices and supplies, prosthetics and appliances, including cochlear implants and eyeglasses/contact lenses (for cataract surgery or injury), and medical/surgical supplies and equipment that serve only a medical purpose for the management of disease. Benefit limits: Wigs are limited to the first one following cancer treatment not to exceed one per Benefit Period; limit of four (4) surgical bras following mastectomy per benefit period; (as required by the Women's Health and Cancer Rights Act); Left Ventricular Artificial Devices (LVAD) covered only as bridge to heart transplant.

YES

50% Coinsurance after deductible

100.00%
Emergency Room Services
YES

$1000 Copay after deductible

$1000 Copay after deductible
Emergency Transportation/Ambulance

Ambulance Services are transportation by a vehicle (including ground, water, fixed wing and rotary wing air transportation) designed, equipped and used only to transport the sick and injured and staffed by Emergency Medical Technicians (EMT), paramedics, or other certified medical professionals: from home, scene of accident or medical emergency to a hospital; between hospitals; between a hospital and skilled nursing facility; or from a hospital or skilled nursing facility to home; ambulance trips must be made to the closest facility that can give covered services appropriate for the member's condition

YES

50% Coinsurance after deductible

50% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

50% Coinsurance after deductible

100.00%
Gender Affirming Care
NO
Generic Drugs

Lowest cost shares are available at preferred retail pharmacies and home delivery. See the Summary of Benefits and Coverage 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

Limits may apply to some services; includes benefits for health care services and devices that help a person keep, learn or improve skills and functioning for daily living, including treatment of Autism Spectrum Disorders to children (0 - 21), which at a minimum shall include: (1) Out-Patient Physical Rehabilitation Services including (a) Speech and Language therapy and/or Occupational therapy, 20 visits per year of each service; and (b) Clinical Therapeutic Intervention, which include but are not limited to Applied Behavioral Analysis, 20 hours per week; and (2) Mental/Behavioral Health Outpatient Services to provide consultation, assessment, development and oversight of treatment plans

YES

$85 Copay after deductible

100.00%
Hearing Aids
NO
Home Health Care Services

Limit: 100.0 Visit(s) per Benefit Period

When therapy services are provided in the home (including physical, speech, and occupational therapy) as part of home health care services, they are not subject to separate visit limits for therapy services. The 100 visit/year limit is also not applicable to home infusion therapy or private duty nursing rendered in the home setting

YES

50% Coinsurance after deductible

100.00%
Hospice Services

To be eligible for Hospice benefits, the patient must have a life expectancy of six months or less, as confirmed by the attending Physician

YES

50% Coinsurance after deductible

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

$200 Copay after deductible

100.00%
Infertility Treatment

Includes services to diagnose and treat medical conditions resulting in infertility. Excludes: Artificial insemination, in vitro fertilization, other types of artificial or surgical means of conception including drugs administered in connection with these procedures

YES

50% Coinsurance after deductible

100.00%
Infusion Therapy

Home IV therapy includes but is not limited to: injections (intra-muscular, subcutaneous, continuous subcutaneous), Total Parenteral Nutrition (TPN), Enteral nutrition therapy, antibiotic therapy, pain management and chemotherapy

YES

50% Coinsurance after deductible

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

There are specific exceptions to certain exclusions and/or additional exclusions that are detailed in plan document; inpatient hospital services include charges from a hospital, skilled nursing facility or other provider for room, board, general nursing services; and ancillary (related) services

YES

$1500 Copay per Day after deductible

100.00%
Inpatient Physician and Surgical Services

There are specific exceptions to certain exclusions and/or additional exclusions that are detailed in plan document; inpatient medical care visits limited to one visit per day by any one physician.

YES

50% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

$15 Copay 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

50% Coinsurance after deductible

100.00%
Mental/Behavioral Health Inpatient Services
YES

$1500 Copay per Day after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

$85 Copay after deductible

100.00%
Non-Preferred Brand Drugs

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

40% Coinsurance after deductible

100.00%
Nutritional Counseling

Covered benefit under home health services and covered as USPSTF A or B recommendation under preventive health services (includes diet counseling for adults at higher risk for chronic disease, obesity screening and counseling for all adults, and healthy diet counseling for adults with cardiovascular risk factors)

YES

50% Coinsurance after deductible

100.00%
Orthodontia - Adult
NO
Orthodontia - Child

Coverage is for medically necessary orthodontia only.

YES

50% Coinsurance after deductible

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

50% Coinsurance after deductible

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

See specific exceptions to these exclusions and/or additional exclusions that are detailed in plan document; benefits for facility charges for Outpatient Services are payable for the removal of teeth or for other dental processes only if the patient's medical condition or the dental procedure requires a Hospital setting to ensure the safety of the patient

YES

$375 Copay after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 116.0 Visit(s) per Benefit Period

Limited to 20 visits per year for Speech Therapy, 20 visits per year for Occupational Therapy, 20 visits per year for Physical Therapy, 36 visits per year for Cardiac, and 20 visits per year for Pulmonary.

YES

$85 Copay after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

$375 Copay after deductible

100.00%
Preferred Brand Drugs

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

$85 Copay after deductible

100.00%
Prenatal and Postnatal Care

Includes post-delivery follow-up care performed, by a physician or nurse, within 72 hours of discharge, through home health care visits or, at patient's discretion, in a medical setting. This coverage includes, but is not limited to parent education; assistance and training in breast or bottle feeding; and routine maternal or neonatal tests and screening (including collection of sample for hereditary and metabolic newborn screening)

YES

No Charge

100.00%
Preventive Care/Screening/Immunization

Services with an 'A' or 'B' rating from the United States Preventive Services Task Force (USPSTF); Immunizations for children, adolescents, and adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; Preventive care and screenings for infants, children and adolescents as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. Additional preventive care and screening for women provided for in the guidelines supported by the Health Resources and Services Administration including: women's contraceptives, sterilization procedures, and counseling; breastfeeding support, supplies, and counseling (benefits for breast pumps are limited to one pump per benefit period); and gestational diabetes screening; routine screening mammograms; routine cytologic screening; child health supervision services from birth to age 9

YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness

Virtual urgent care visits via a Designated virtual provider unlimited $0

YES

No Charge

100.00%
Private-Duty Nursing

Limit: 90.0 Visit(s) per Benefit Period

Private Duty Nursing Services are Covered Services only when provided through the Home Care Services benefit

YES

50% Coinsurance after deductible

100.00%
Prosthetic Devices

Benefits for artificial substitutes for body parts and tissues and materials inserted into tissue for functional or therapeutic purposes. Covered Services include purchase, fitting, needed adjustment, repairs, and replacements of prosthetic devices and supplies that 1) Replace all or part of a missing body part and its adjoining tissues; or 2) Replace all or part of the function of a permanently useless or malfunctioning body part.

YES

50% Coinsurance after deductible

100.00%
Radiation
YES

50% Coinsurance after deductible

100.00%
Reconstructive Surgery

Benefits include reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance. Benefits include surgery performed to restore symmetry after a mastectomy.

YES

50% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 40.0 Visit(s) per Benefit Period

Limited to 20 visits per year for Occupational Therapy and 20 visits per year for Physical Therapy.

YES

$85 Copay after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Benefit Period

YES

$85 Copay 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

Not Covered except for preventive foot care due to conditions associated with metabolic, neurologic, or peripheral vascular disease.

NO
Skilled Nursing Facility

Limit: 90.0 Days per Benefit Period

Benefits include Items and services provided as an inpatient in a skilled nursing bed of skilled nursing facility or hospital, including room and board in semi-private accommodations; rehabilitative services; and drugs, biologicals, and supplies furnished

YES

$1500 Copay per Day after deductible

100.00%
Specialist Visit
YES

$85.00

100.00%
Specialty Drugs

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.

YES

50% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

$1500 Copay per Day after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

$85 Copay after deductible

100.00%
Transplant

Includes coverage for unrelated donor search services ($30,000 per transplant) and travel/lodging as approved by the plan ($10,000 per transplant). Transplant benefits apply to any medically necessary human organ and stem cell/bone marrow transplants (except cornea and kidney transplants) and transfusions including necessary acquisition procedures, harvest and storage, necessary preparatory myeloablative therapy, and initial evaluation/testing to determine eligibility as a transplant candidate.

YES

50% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders

Benefits provided for temporomandibular (joint connecting the lower jaw to the temporal bone at the side of the head) and craniomandibular (head and neck muscle) disorders

YES

50% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

$75.00

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

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

$35 Copay after deductible

100.00%

UHC Silver-X Advantage (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx) Health Insurance Plan Variant 33931OH0030019-00 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 Silver Off Exchange Plan
Dental Only Plan No
Design Type Not Applicable
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID OHF008
Formulary URL URL
HIOS Product ID 33931OH003
Import Date 8/16/2022 20:01
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 3
HSA Eligible No
New/Existing Plan New
Notice Required for Pregnancy No
Is a Referral Required for Specialist? Yes
Issuer Actuarial Value 71.55%
Issuer ID 33931
Issuer Marketplace Marketing Name UnitedHealthcare
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Silver
Multiple In Network Tiers No
National Network No
Network ID OHN001
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) 33931OH0030019-00
Plan Level Exclusions 0
Plan Marketing Name UHC Silver Advantage (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)
Plan Type HMO
Plan Variant Marketing Name UHC Silver-X Advantage (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $3,100
SBC Scenario, Having a Baby, Deductible $2,000
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $30
SBC Scenario, Having Diabetes, Copayment $900
SBC Scenario, Having Diabetes, Deductible $2,000
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $500
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,000
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID OHS001
Source Name SERFF
Specialist Requiring a Referral All, except OBGYN and as state mandated
Plan ID 33931OH0030019
State Code OH
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 50.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $4000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $2000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $2,000
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 Silver Advantage (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx) Health Insurance Plan, 33931OH0030019

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

Frequently Asked Questions(FAQ) about UHC Silver Advantage (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx), 33931OH0030019 Health Insurance Plan, 33931OH0030019

  • Does UHC Silver Advantage (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx) Health Insurance Plan, 33931OH0030019 support Mail Ordering?

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

  • Does (33931OH0030019) Health Insurance Plan, Variant (33931OH0030019-00) have Out Of Country Coverage?

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

    Does (33931OH0030019) Health Insurance Plan, Variant (33931OH0030019-00) 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