UHC Bronze-X Value HSA (Off-Exchange Only)

Health Insurance Plan Details (2025 Plan)

SBC doc

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HMO

HSA

Bronze

Deductible (per individual)	$7,500 /yr
Deductible (per family)	$15,000 /yr
Max Out-of-Pocket (per individual)	$8,050 /yr
Max Out-of-Pocket (per family)	$16,100 /yr
Drug Deductible (per individual)
Drug Deductible (per family)
Drug Max Out-of-Pocket (per individual)
Drug Max Out-of-Pocket (per family)
Plan Type	HMO
Includes Child Dental?	Yes
Includes Adult Dental?	No

Medical Services
Preventive Care	No Charge
Primary Care Visit	Not Applicable
Specialist Visit	30.00% Coinsurance after deductible
Emergency Room	30.00% Coinsurance after deductible
Inpatient Facility	30.00% Coinsurance after deductible
Inpatient Physician	30.00% Coinsurance after deductible

Drug Costs
Generic Drugs	$20 Copay after deductible
Preferred Brand Drugs	30.00% Coinsurance after deductible
Non-preferred Brand Drugs	45.00% Coinsurance after deductible
Specialty Drugs	50.00% Coinsurance after deductible

Summary of Benefits and Coverage	SBC doc
Provider Directory	Doctor lookup
Drug Formulary List	n/a

* Figures shown are only for in-network medical costs

** Please check with insurance company if Copay and Coinsurance rates are before or after the deductible

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