UHC Gold Value ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)

Health Insurance Plan Details (2025 Plan)

SBC doc

doctor lookup

drug list

EPO

Gold

Deductible (per individual)	$2,000 /yr
Deductible (per family)	$4,000 /yr
Max Out-of-Pocket (per individual)	$8,500 /yr
Max Out-of-Pocket (per family)	$17,000 /yr
Drug Deductible (per individual)	Included in Medical
Drug Deductible (per family)	Included in Medical
Drug Max Out-of-Pocket (per individual)	Included in Medical
Drug Max Out-of-Pocket (per family)	Included in Medical
Plan Type	EPO
Includes Child Dental?	Yes
Includes Adult Dental?	No

Medical Services
Preventive Care	No Charge
Primary Care Visit	$10 Copay
Specialist Visit	20% Coinsurance after deductible
Emergency Room	20% Coinsurance after deductible
Inpatient Facility	20% Coinsurance after deductible
Inpatient Physician	20% Coinsurance after deductible

Drug Costs
Generic Drugs	$1 Copay
Preferred Brand Drugs	$15 Copay
Non-preferred Brand Drugs	40% Coinsurance after deductible
Specialty Drugs	50% Coinsurance after deductible

Summary of Benefits and Coverage	SBC doc
Provider Directory	Doctor lookup
Drug Formulary List	drug list

* 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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