What You Pay for Services
Copays ($) and Coinsurance (%) for Covered Health Care Services
Out-of-Network
Network
Specialist
$75 copay
50%*
Additional copays, deductible, or co-insurance may apply when you receive other services at your physician’s office. For example, surgery and lab work. Telehealth is covered at the same cost share as in the office.
Urgent Care Center Services
$50 copay
50%*
Additional copays, deductible, or co-insurance may apply when you receive other services at the urgent care facility. For example, surgery and lab work.
Virtual Care Services
No copay
50%*
Network Benefits are available only when services are delivered through a Designated Virtual Network Provider. You can find a Designated Virtual Visit Network Provider by contacting us at myuhc.com® or the telephone number on your ID card. Access to Virtual Visits and prescription services may not be available in all states or for all groups. Emergency Care
Ambulance Services - Emergency Ambulance
Air Ambulance
No copay*
No copay*
Ground Ambulance
No copay*
No copay*
Ambulance Services - Non-Emergency Ambulance¹
Air Ambulance
No copay*
No copay*
Ground Ambulance
No copay*
50%*
Dental Services - Accident Only
No copay*
50%*
Emergency Health Care Services - Outpatient¹
You pay a $300 per occurrence copay per visit prior to and in addition to paying any Annual Deductible.*
You pay a $300 per occurrence copay per visit prior to and in addition to paying any Annual Deductible.*
Inpatient Care
Habilitative Services - Inpatient
The amount you pay is based on where the covered health care service is provided.
Hospital - Inpatient Stay¹
No copay*
50%*
Skilled Nursing Facility/Inpatient Rehabilitation Facility Services¹
No copay*
50%*
Limited to 60 days per year.
Outpatient Care
Acupuncture Services
$25 copay
50%*
Limited to 10 treatments per year.
*After the Annual Medical Deductible has been met. ¹Prior Authorization Required. Refer to SPD.
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