UHC Medical Plan – HMO Gold Navigate (CO Only) – Summary of Benefits

1. Overview

The UnitedHealthcare HMO Gold Navigate (Colorado Only) plan provides comprehensive medical coverage to eligible employees and their families. This is a referral‑based HMO plan, meaning you must select a Primary Care Physician (PCP) and obtain referrals for most specialist visits. Coverage is provided in‑network only.

This article summarizes the key features, costs, and covered services under this plan.

2. Key Plan Features

Plan Type

• HMO (Health Maintenance Organization)
• In‑network only
• Referrals required for most specialists
• OB/GYN providers may be accessed without referral

Provider Network

• Must use UnitedHealthcare Navigate network providers
• Out‑of‑network services are not covered

3. Costs & Deductibles

Annual Deductible

• Individual: $1,250
• Family: $2,500
• Applies to most medical services except those with a flat copay or preventive care

Out‑of‑Pocket Maximum

• Individual: $6,600
• Family: $13,200
• Once you reach this amount, covered services are paid at 100% for the remainder of the plan year

Costs Not Counted Toward Out‑of‑Pocket Max

• Premiums
• Non‑covered services
• Balance billing (when applicable)

4. Office Visits & Preventive Care

Primary Care Visits

• $25 copay per visit
• Deductible does not apply

Specialist Visits

• $50 copay per visit
• Referral required (except OB/GYN)

Preventive Care

• No charge
• Must be preventive and in‑network
• Includes screenings, immunizations, wellness exams

5. Diagnostic Testing & Imaging

Lab Work & X‑Rays

• 10% coinsurance
• Additional per‑occurrence deductibles for hospital‑based services may apply

CT, PET, MRI

• 10% coinsurance
• $500 per‑occurrence hospital‑based deductible applies before coinsurance

6. Prescription Drug Coverage

Retail (31‑day supply) & Mail Order (90‑day)

Copays per prescription:

• Certain drugs require prior authorization
• Preventive medications may be available at no cost
• The plan requires use of network pharmacies

7. Emergency & Urgent Care

Emergency Room

• 10% coinsurance
• Covered nationwide

Emergency Transportation

• 10% coinsurance

Urgent Care

• $50 copay per visit
• Additional services (e.g., imaging) may apply

8. Hospitalization & Surgery

Outpatient Surgery

• Ambulatory Surgery Center: 10% coinsurance
• Hospital Facility: 10% coinsurance
• Hospital surgery subject to $500 per‑occurrence deductible before coinsurance

Inpatient Hospital Stay

• 10% coinsurance
• $500 inpatient per‑occurrence deductible applies

9. Mental Health & Substance Abuse

Outpatient Therapy

• $30 copay per visit
• Deductible does not apply
• Some intensive services use 10% coinsurance

Inpatient Treatment

• 10% coinsurance

10. Maternity Care

Office Visits

• No charge for prenatal preventive services
• Other services subject to cost‑share

Delivery

• Professional Services: 10% coinsurance
• Facility Services: 10% coinsurance + $500 per‑occurrence inpatient deductible

11. Rehabilitation & Skilled Care

Home Health Care

• 10% coinsurance
• Limited to 364 visits per year

Outpatient Therapy

• $25 copay per visit
• Limits per year:
  • Physical Therapy: 20 visits
  • Occupational Therapy: 20 visits
  • Speech Therapy: 20 visits

Skilled Nursing Facility

• 10% coinsurance
• Up to 100 days per year

12. Pediatric Vision & Dental (Medical Plan Only)

Children’s Eye Exam

• $10 copay
• 1 exam every 12 months

Children’s Glasses

• $25 copay for frames
• 1 pair every 12 months

Children’s Dental Cleanings

• Covered at 0% coinsurance
• 2 cleanings per 12 months

13. Excluded Services

The following are not covered under this medical plan:

• Adult dental care
• Long‑term care
• Routine foot care
• Cosmetic surgery
• Out‑of‑country non‑emergency care
• Weight loss programs

14. Other Covered Services (with limits)

• Acupuncture (6 visits/year)
• Bariatric surgery (when medically necessary)
• Hearing aids
• Infertility treatment
• Private duty nursing
• Adult routine eye exam (1 exam/year)
• Chiropractic adjustments (20 visits/year)

15. Referrals & Navigate Program Rules

• You must select a Primary Care Physician (PCP)
• Referrals are required for most specialists
• Without a referral:
  • Many services will not be covered
  • Claims may be denied in full

16. Continuation of Coverage

If your coverage ends, continuation options may include:

• COBRA
• Marketplace coverage

Assistance is available through U.S. Department of Labor and Colorado Division of Insurance.