Standard High Bronze: UHC Navigate HSA Bronze 3600 Plan Details for 2021- HealthPocket

Standard High Bronze: UHC Navigate HSA Bronze 3600

$442.67/mo

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Zip Code02128
Applicant9/18/1986 Male
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameStandard High Bronze: UHC Navigate HSA Bronze 3600
Plan IDhhs-31779MA0110005
Plan Year2021
Insurance ProviderGolden Rule Insurance
Metal LevelExpanded Bronze
Plan TypeEPO
Deductible$3,600
Out-of-Pocket Maximum$7,000
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$100 Copay after deductible
Specialist Visit$150 Copay after deductible
Laboratory Outpatient and Professional Services$55 Copay after deductible
X-rays and Diagnostic Imaging$140 Copay after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans$1000 Copay after deductible
Deductible - Family$7200 per group
Out-of-Pocket Maximum - Family$14000 per group

Prescription drug coverage

Generic Drugs$30 Copay after deductible
Preferred Brand Drugs$150 Copay after deductible
Non-Preferred Brand Drugs$225 Copay after deductible
Specialty Drugs$225 Copay after deductible

Access to doctors and hospitals

Provider directory URLhttp://bitly.com/uhcfad
Does this plan have access to a national provider network?No
Is a referral required to see a Specialist?Yes - Yes, enter All, except OBGYN and as state mandated
Does this plan cover services outside plan service area?Not Covered
Does this plan cover services outside the country?Not Covered

Hospital services

Emergency Room Services$1750 Copay after deductible
Inpatient Hospital Services (e.g., Hospital Stay)$2000 Copay per Stay after deductible
Inpatient Physician and Surgical ServicesNo Charge after deductible
Emergency Transportation or Ambulance ServiceNot Applicable

Maternity

Prenatal and Postnatal CareNo Charge
Delivery and all inpatient services for maternity care$2000 Copay after deductible

Mental Health

Mental/Behavioral Health Outpatient Services$100 Copay after deductible
Mental/Behavioral Health Inpatient Services$2000 Copay per Stay after deductible
Substance use disorder outpatient services$100 Copay after deductible
Substance use disorder inpatient services$2000 Copay per Stay after deductible

Medical Management Programs

Does this plan offer disease managment programs?Diabetes, Heart Disease, Pregnancy
Does this plan offer a wellness program?Not Covered

Vision Coverage

Routine Eye Exam for ChildrenIncluded
Eye Glasses for ChildrenIncluded
Routine Eye Exam for AdultsNot Covered

Child Dental Coverage

Child Dental Coverage - Routine Dental CareIncluded
Child Dental Coverage - Basic Dental CareIncluded
Child Dental Coverage - OrthodontiaIncluded
Child Dental Coverage - Major Dental CareIncluded

Adult Dental Coverage

Adult Dental Coverage - Routine Dental CareNot Covered
Adult Dental Coverage - Basic Dental CareNot Covered
Adult Dental Coverage - OrthodontiaNot Covered
Adult Dental Coverage - Major Dental CareNot Covered

Exclusions and Limitations

More Included BenefitsOther Practitioner Office Visit (Nurse, Physician Assistant)
Preventive Care/Screening/Immunization
Bariatric Surgery
Infertility Treatment
Imaging (CT/PET Scans, MRIs)
Outpatient Surgery Physician/Surgical Services
Urgent Care Centers or Facilities
Inpatient Physician and Surgical Services
Home Health Care Services
Durable Medical Equipment
Hospice Services
Chiropractic Care
Abortion for Which Public Funding is Prohibited
Allergy Testing
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Nutritional Counseling
Prosthetic Devices
Radiation
Reconstructive Surgery
Rehabilitative Speech Therapy
Transplant
Treatment for Temporomandibular Joint Disorders
Well Baby Visits and Care
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
More Limited BenefitsSkilled Nursing Facility
Hearing Aids
Weight Loss Programs
Outpatient Rehabilitation Services
Habilitation Services
Dental Check-Up for Children
Rehabilitative Occupational and Rehabilitative Physical Therapy
More Excluded BenefitsAcupuncture
Cosmetic Surgery
Private-Duty Nursing
Routine Foot Care
Accidental Dental
Long-Term/Custodial Nursing Home Care
PremiumPlan NameDeductible
from $342Focus HMO HSA 3400$3,400.00Select
from $354Premier Bronze Saver 3600$3,600.00Select
from $378Advantage HMO Saver 3600$3,600.00Select
from $393HMO 3500 - Flex$3,500.00Select
from $400HMO HSA 3400 - Flex$3,400.00Select
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  • Phone Number
    (617) 569-5800
  • Office Locations
    10 Gove St
    East Boston, MA 02128
10 Gove St East Boston MA, 02128

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HealthPocket.com is a free information source. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. While on our site, if you click on a plan or link, you may be directed to one of our partners who offers health insurance products. HealthPocket, Inc. is part of the Benefytt Technologies, Inc. family of companies.