UHC Bronze-X Virtual First ($3 Rx + Unlimited Free App-based Care) (Disponible en espaol) Plan Details for 2021- HealthPocket

UHC Bronze-X Virtual First ($3 Rx + Unlimited Free App-based Care) (Disponible en espaol)

$283.31/mo

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Zip Code60629
Applicant7/3/1987 Male
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameUHC Bronze-X Virtual First ($3 Rx + Unlimited Free App-based Care) (Disponible en espaol)
Plan IDhhs-42529IL0070003
Plan Year2021
Insurance ProviderGolden Rule Insurance
Metal LevelExpanded Bronze
Plan TypeHMO
Deductible$7,250
Out-of-Pocket Maximum$8,700
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$75 Copay
Specialist Visit50.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services$40 Copay
X-rays and Diagnostic Imaging50.00% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans50.00% Coinsurance after deductible
Deductible - Family$14500 per group
Out-of-Pocket Maximum - Family$17400 per group

Prescription drug coverage

Generic Drugs$3 Copay
Preferred Brand Drugs50.00% Coinsurance after deductible
Non-Preferred Brand Drugs50.00% Coinsurance after deductible
Specialty Drugs50.00% Coinsurance after deductible

Access to doctors and hospitals

Provider directory URLhttp://www.uhc.com/find-a-physician
Does this plan have access to a national provider network?No
Is a referral required to see a Specialist?Yes - All, except OBGYN and as state mandated
Does this plan cover services outside plan service area?Yes - Plan covers eligible expenses provided by a Network Physician or other provider or facility within the Network Area.
Does this plan cover services outside the country?Not Covered

Hospital services

Emergency Room Services50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services50.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service50.00% Coinsurance after deductible

Maternity

Prenatal and Postnatal CareNo Charge
Delivery and all inpatient services for maternity care50.00% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services50.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services50.00% Coinsurance after deductible
Substance use disorder outpatient services50.00% Coinsurance after deductible
Substance use disorder inpatient services50.00% Coinsurance after deductible

Medical Management Programs

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
Private-Duty Nursing
Imaging (CT/PET Scans, MRIs)
Outpatient Surgery Physician/Surgical Services
Urgent Care Centers or Facilities
Inpatient Physician and Surgical Services
Home Health Care Services
Hospice Services
Abortion for Which Public Funding is Prohibited
Accidental Dental
Allergy Testing
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Nutritional Counseling
Radiation
Reconstructive Surgery
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
Infertility Treatment
Outpatient Rehabilitation Services
Habilitation Services
Durable Medical Equipment
Dental Check-Up for Children
Chiropractic Care
Prosthetic Devices
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
More Excluded BenefitsAcupuncture
Cosmetic Surgery
Weight Loss Programs
Routine Foot Care
Long-Term/Custodial Nursing Home Care
Eye Glasses - Adult
PremiumPlan NameDeductible
from $256Blue FocusCare Bronze? 209$7,400.00Select
from $334Cigna Connect 7150$7,150.00Select
from $352Ambetter Balanced Care 4 (2021)$7,200.00Select
from $356Cigna Plus with Northwestern Medicine 7150$7,150.00Select
from $371Blue Precision Bronze HMO? 205$7,400.00Select
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  • Phone Number
    (773) 884-1662
  • Office Locations
    2701 W 68th St
    Chicago, IL 60629
2701 W 68th St Chicago IL, 60629

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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.