UnitedHealthcare Insurance Company
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All supported filed details, including known conditions and limits. This is not the entire insurance contract. Unknown does not mean $0 or not covered.
NexusACO OAP is a POS plan using provider tiers: Tier 1 providers offer lower member cost sharing than other network providers. It includes out-of-network benefits at higher costs and requires a network primary care provider; the filing lists no specialist-referral requirement.
UnitedHealthcare · NexusACO · Issuer 18699. Confirm current provider participation and exact coverage in the plan documents.
| Benefit | UHC NexusACO OAP Gold 1000 |
|---|---|
Medical deductibleNotes & source2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 individual: $1,000 In-network tier 1 family: $1,000 per person | $2,000 per group In-network tier 1 coinsurance: 30.00% In-network tier 2 individual: $1,000 In-network tier 2 family: $1,000 per person | $2,000 per group In-network tier 2 coinsurance: 30.00% Out-of-network individual: $10,000 Out-of-network family: $10,000 per person | $20,000 per group Combined in/out-of-network individual: Not Applicable Combined in/out-of-network family: per person not applicable | per group not applicable |
Prescription drug deductibleNotes & source2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 individual: $50 In-network tier 1 family: $50 per person | $100 per group In-network tier 1 coinsurance: 50.00% In-network tier 2 individual: $50 In-network tier 2 family: $50 per person | $100 per group In-network tier 2 coinsurance: 50.00% Out-of-network individual: $50 Out-of-network family: $50 per person | $100 per group Combined in/out-of-network individual: Not Applicable Combined in/out-of-network family: per person not applicable | per group not applicable |
| Benefit | UHC NexusACO OAP Gold 1000 |
|---|---|
Maximum Out of Pocket for Medical and Drug Benefits (Total)Notes & source2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 individual: $8,500 In-network tier 1 family: $8,500 per person | $17,000 per group In-network tier 2 individual: $8,500 In-network tier 2 family: $8,500 per person | $17,000 per group Out-of-network individual: $20,000 Out-of-network family: $20,000 per person | $40,000 per group Combined in/out-of-network individual: Not Applicable Combined in/out-of-network family: per person not applicable | per group not applicable |
| Benefit | UHC NexusACO OAP Gold 1000 |
|---|---|
Combined medical and drug deductibleNotes & sourceWhether covered medical and prescription costs count toward the same deductible. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | No |
Combined medical and drug spending limitNotes & sourceWhether covered medical and prescription costs count toward the same out-of-pocket limit. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Yes |
Specialty drug coinsurance capNotes & sourceA filed cap on the member’s percentage-based specialty drug cost, if supplied. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Not supplied in selected filing |
Hospital copay day limitNotes & sourceThe maximum number of hospital days charged a daily copay under the filed rule. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Unknown |
Primary care visits before cost sharingNotes & sourceThe filed number of primary care visits before member charges begin. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Not supplied in selected filing |
Primary care copays before other chargesNotes & sourceThe filed number of copay visits before a deductible or coinsurance rule begins. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Unknown |
| Benefit | UHC NexusACO OAP Gold 1000 |
|---|---|
Primary Care Visit to Treat an Injury or IllnessNotes & sourceA visit with a primary care clinician for an illness or injury. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: $30.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: No In-network tier 2 copay: $60.00 Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Specialist VisitNotes & sourceA visit with a clinician who focuses on a particular condition or area of medicine. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: $55.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: No In-network tier 2 copay: $75.00 Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Other Practitioner Office Visit (Nurse, Physician Assistant)Notes & sourceAn office visit with a nurse practitioner, physician assistant, or another listed clinician. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: $30.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: No In-network tier 2 copay: $60.00 Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Preventive Care/Screening/ImmunizationNotes & sourceServices intended to prevent illness or detect health problems early. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: No Charge Coverage: Covered Service limit: No In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Well Baby Visits and CareNotes & sourceRoutine visits to check a baby’s health and development. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: No Charge Coverage: Covered Service limit: No In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
| Benefit | UHC NexusACO OAP Gold 1000 |
|---|---|
Imaging (CT/PET Scans, MRIs)Notes & sourceAdvanced scans used to examine the inside of the body. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: No In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Laboratory Outpatient and Professional ServicesNotes & sourceLaboratory testing without inpatient admission. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: No In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
X-rays and Diagnostic ImagingNotes & sourceX-rays and other listed images used to help diagnose a health problem. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: No In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Allergy TestingNotes & sourceTests used to identify substances that trigger allergic reactions. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: $55.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: No In-network tier 2 copay: $75.00 Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
| Benefit | UHC NexusACO OAP Gold 1000 |
|---|---|
Urgent Care Centers or FacilitiesNotes & sourceCare at an urgent care center for problems that need prompt attention. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: $50.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: No In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Emergency Room ServicesNotes & sourceEvaluation and treatment of a medical emergency in an emergency department. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: No In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 30.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Emergency Transportation/AmbulanceNotes & sourceAmbulance or other listed transportation for an emergency. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: No In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 30.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
| Benefit | UHC NexusACO OAP Gold 1000 |
|---|---|
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)Notes & sourceThe charge for using an outpatient facility, separate from a clinician’s professional fee. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: No In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: 40.00% Coinsurance after deductible Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Outpatient Surgery Physician/Surgical ServicesNotes & sourceThe surgeon’s or other clinician’s services for surgery without inpatient admission. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: No In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: 40.00% Coinsurance after deductible Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Inpatient Hospital Services (e.g., Hospital Stay)Notes & sourceHospital facility services after admission as an inpatient. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: No In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: 40.00% Coinsurance after deductible Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Inpatient Physician and Surgical ServicesNotes & sourceClinicians’ professional services during an inpatient hospital stay. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: No In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: 40.00% Coinsurance after deductible Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
TransplantNotes & sourceMedical care involving transplantation of an organ or tissue. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: No In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Reconstructive SurgeryNotes & sourceSurgery to restore function or repair a body part affected by injury, illness, or a birth condition. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: No Benefit details: Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: 40.00% Coinsurance after deductible Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
| Benefit | UHC NexusACO OAP Gold 1000 |
|---|---|
Mental/Behavioral Health Outpatient ServicesNotes & sourceMental or behavioral health care without inpatient admission. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: $55.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: No Benefit details: Supporting benefit crosswalk (SERFF submitted 2026-06-23): Mental Health Care and Substance-Related and Addictive Disorders Services - $55 copay. Partial Hospitalization/Day Treatment/High Intensity Outpatient/Intensive Outpatient Programs - 30% coinsurance In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Mental/Behavioral Health Inpatient ServicesNotes & sourceMental or behavioral health treatment during an inpatient stay. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: No In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Substance Abuse Disorder Outpatient ServicesNotes & sourceTreatment for substance use disorders without inpatient admission. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: $55.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: No Benefit details: Supporting benefit crosswalk (SERFF submitted 2026-06-23): Mental Health Care and Substance-Related and Addictive Disorders Services - $55 copay. Partial Hospitalization/Day Treatment/High Intensity Outpatient/Intensive Outpatient Programs - 30% coinsurance In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Substance Abuse Disorder Inpatient ServicesNotes & sourceTreatment for substance use disorders during an inpatient stay. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: No In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
| Benefit | UHC NexusACO OAP Gold 1000 |
|---|---|
Generic DrugsNotes & sourceMedicines classified by the plan as generic drugs. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: $10.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: Yes Limit amount: 30 Limit unit: Days per Month Benefit details: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. In-network tier 2 copay: Not Applicable Out-of-network copay: $10.00 In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: Not Applicable Essential health benefit: Yes Essential benefit variation: Other Law/Regulation Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Preferred Brand DrugsNotes & sourceBrand-name medicines placed in the plan’s preferred drug category. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: $40.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: Yes Limit amount: 30 Limit unit: Days per Month Benefit details: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. In-network tier 2 copay: Not Applicable Out-of-network copay: $40.00 In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: Not Applicable Essential health benefit: Yes Essential benefit variation: Other Law/Regulation Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Non-Preferred Brand DrugsNotes & sourceBrand-name medicines outside the plan’s preferred drug category. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 50.00% Coinsurance after deductible Coverage: Covered Service limit: Yes Limit amount: 30 Limit unit: Days per Month Benefit details: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Essential benefit variation: Other Law/Regulation Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Specialty DrugsNotes & sourceMedicines placed in the plan’s specialty category, often requiring special handling or monitoring. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 50.00% Coinsurance after deductible Coverage: Covered Service limit: Yes Limit amount: 30 Limit unit: Days per Month Benefit details: First fill allowed at a retail pharmacy. Additional fills must be provided at a specialty pharmacy. Coverage is limited to a 30-day supply for specialty and self-administrable cancer chemotherapy medications from a specialty pharmacy per fill or refill. In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Essential benefit variation: Other Law/Regulation Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Supply limits and coverage conditionsNotes & sourceRetail, mail-order and specialty prescription terms, with the source drug tiers and exceptions retained. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Generic Drugs; Preferred Brand Drugs; Non-Preferred Brand Drugs · Benefit details: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. Specialty Drugs · Benefit details: First fill allowed at a retail pharmacy. Additional fills must be provided at a specialty pharmacy. Coverage is limited to a 30-day supply for specialty and self-administrable cancer chemotherapy medications from a specialty pharmacy per fill or refill. |
Formulary tier 1Notes & sourceFiled formulary tier. Mail-order availability refers to three-month in-network supply; coverage, supply limits and medication requirements still apply. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Drug category: Generic, Brand, Specialty Drugs Three-month in-network mail order: Yes |
Formulary tier 2Notes & sourceFiled formulary tier. Mail-order availability refers to three-month in-network supply; coverage, supply limits and medication requirements still apply. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Drug category: Generic, Brand, Specialty Drugs Three-month in-network mail order: Yes |
Formulary tier 3Notes & sourceFiled formulary tier. Mail-order availability refers to three-month in-network supply; coverage, supply limits and medication requirements still apply. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Drug category: Generic, Brand Three-month in-network mail order: Yes |
Formulary tier 4Notes & sourceFiled formulary tier. Mail-order availability refers to three-month in-network supply; coverage, supply limits and medication requirements still apply. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Drug category: Generic, Brand Three-month in-network mail order: Yes |
Formulary tier 5Notes & sourceFiled formulary tier. Mail-order availability refers to three-month in-network supply; coverage, supply limits and medication requirements still apply. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Drug category: Specialty Drugs Three-month in-network mail order: Yes |
Formulary tier 6Notes & sourceFiled formulary tier. Mail-order availability refers to three-month in-network supply; coverage, supply limits and medication requirements still apply. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Drug category: Specialty Drugs Three-month in-network mail order: Yes |
Formulary tier 7Notes & sourceFiled formulary tier. Mail-order availability refers to three-month in-network supply; coverage, supply limits and medication requirements still apply. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Drug category: Medical Service Drugs Three-month in-network mail order: No |
| Benefit | UHC NexusACO OAP Gold 1000 |
|---|---|
Prenatal and Postnatal CareNotes & sourceCare during pregnancy and after childbirth. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: No Charge Coverage: Covered Service limit: No In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Delivery and All Inpatient Services for Maternity CareNotes & sourceCare for childbirth and related inpatient services. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: No In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: 40.00% Coinsurance after deductible Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Abortion for Which Public Funding is ProhibitedNotes & sourceThe filing’s category for abortion services that cannot receive public funding. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: No Charge Coverage: Covered Service limit: No In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
| Benefit | UHC NexusACO OAP Gold 1000 |
|---|---|
Hospice ServicesNotes & sourceCare focused on comfort and support near the end of life. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: Yes Limit amount: 14 Limit unit: Days per Lifetime Benefit details: Limited to 14 days per lifetime for Respite Care. Hospice Services are not subject to this limit. In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Home Health Care ServicesNotes & sourceMedical care delivered at home under a care plan. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: Yes Limit amount: 130 Limit unit: Visit(s) per Year In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Skilled Nursing FacilityNotes & sourceCare in a facility providing skilled nursing or rehabilitation. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: Yes Limit amount: 60 Limit unit: Days per Year In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Outpatient Rehabilitation ServicesNotes & sourceTherapy to help restore abilities after illness or injury without inpatient admission. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: $50.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: Yes Limit amount: 25 Limit unit: Visit(s) per Year Benefit details: 25 visits per year combined for Physical, Occupational and Speech Therapy. In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Habilitation ServicesNotes & sourceTherapy to help develop or maintain skills needed for daily activities. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: $50.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: Yes Limit amount: 30 Limit unit: Visit(s) per Year Benefit details: Coverage for habilitative services is limited to 30-inpatient days/year. Coverage for habilitative services is limited to 25-outpatient visits/year. In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Essential benefit variation: Other Law/Regulation Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Rehabilitative Speech TherapyNotes & sourceTherapy to restore speech, communication, or swallowing abilities. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: $50.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: Yes Limit amount: 30 Limit unit: Visit(s) per Year Benefit details: Coverage is limited to 30-inpatient days/year and 25-outpatient visits/year. Rehabilitative Speech Therapy and Rehabilitative Occupational and Rehabilitative Physical Therapy combine for 25 visits for Rehabilitative Services and 25 visits for Habilitative Services. In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Rehabilitative Occupational and Rehabilitative Physical TherapyNotes & sourceTherapy to restore movement or the ability to carry out everyday tasks. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: $50.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: Yes Limit amount: 30 Limit unit: Visit(s) per Year Benefit details: Coverage is limited to 30-inpatient days/year and 25-outpatient visits/year. Rehabilitative Speech Therapy and Rehabilitative Occupational and Rehabilitative Physical Therapy combine for 25 visits for Rehabilitative Services and 25 visits for Habilitative Services. In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Infusion TherapyNotes & sourceTreatment that delivers medicine or fluids through a needle or catheter. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: No Benefit details: Covered under applicable benefit (such as Therapeutic Treatment). In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Durable Medical EquipmentNotes & sourceMedical equipment for repeated use, such as a wheelchair or home oxygen equipment. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: No In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
| Benefit | UHC NexusACO OAP Gold 1000 |
|---|---|
Infertility TreatmentNotes & sourceMedical services to evaluate or treat difficulty becoming pregnant. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: No Benefit details: Artificial insemination is covered. The following infertility services are excluded: All Services and supplies (other than artificial insemination) related to conception by artificial means. Prescription drugs related to such Services, and donor semen and donor eggs used for such Services, such as, but not limited to: in vitro fertilization, ovum transplants, gamete intra fallopian transfer and zygote intra fallopian transfer are not covered. These exclusions apply to fertile as well as infertile individuals or couples. In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Chiropractic CareNotes & sourceCare provided by a chiropractor, including listed spinal or joint treatments. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: $50.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: Yes Limit amount: 12 Limit unit: Visit(s) per Year In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Hearing AidsNotes & sourceDevices that help improve hearing. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coverage: Covered Service limit: Yes Limit amount: 1 Limit unit: Item(s) per 3 Years Benefit details: Coverage is limited to one hearing aid per ear every 3 years. Cochlear Implants are also covered. In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Routine Foot CareNotes & sourceRegular foot care, such as listed nail or callus services. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: $55.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: No Benefit details: Coverage applies to preventive foot care for Covered Persons who are at risk of neurological or vascular disease arising from diseases such as diabetes. In-network tier 2 copay: $75.00 Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
AcupunctureNotes & sourceTreatment using thin needles placed at specific points on the body. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: $50.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: No In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
DialysisNotes & sourceTreatment that filters the blood when the kidneys cannot do so adequately. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: No In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
ChemotherapyNotes & sourceDrug treatment used for cancer and certain other conditions. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: No Benefit details: Covered under the base benchmark plan. In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
RadiationNotes & sourceTreatment using targeted radiation, commonly for cancer. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: No Benefit details: Covered under the base benchmark plan; covered under applicable benefit (such as office visit). In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Diabetes EducationNotes & sourceInstruction to help a person manage diabetes. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: $30.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: No In-network tier 2 copay: $60.00 Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Prosthetic DevicesNotes & sourceDevices that replace a missing body part. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: No In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Temporomandibular joint (TMJ) treatmentNotes & sourceTreatment for problems affecting the jaw joint and nearby muscles. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: No In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Nutritional CounselingNotes & sourceProfessional guidance on food choices and nutrition. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: $30.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: No Benefit details: USPTSF defined counseling is not subject to limitation, and the plan’s scope of coverage meets the 3 visit limitation because we do not apply visit limitations for any type of nutritional counseling. Medical necessity determines usage. In-network tier 2 copay: $60.00 Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Gender Affirming CareNotes & sourceHealth services that support a person’s gender identity. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coverage: Covered Benefit details: Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services. In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential benefit variation: Other Law/Regulation Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Diabetes Care ManagementNotes & sourceCoordinated support for managing diabetes and its treatment. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: No In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Inherited Metabolic Disorder - PKUNotes & sourceCare for phenylketonuria, an inherited condition affecting how the body processes part of dietary protein. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: No In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Hearing examsNotes & sourceAn assessment of hearing; consult the filed benefit for limits and member costs. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coverage: Covered Benefit details: Coverage is limited to an initial assessment and one annual hearing exam. In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
| Benefit | UHC NexusACO OAP Gold 1000 |
|---|---|
Routine Eye Exam for ChildrenNotes & sourceRegular vision exams for children. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: No Charge Coverage: Covered Service limit: Yes Limit amount: 1 Limit unit: Exam(s) per Year In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Eye Glasses for ChildrenNotes & sourcePrescription eyeglasses for children. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: No Charge Coverage: Covered Service limit: Yes Limit amount: 1 Limit unit: Item(s) per Year Benefit details: Coverage is limited to one frame and one pair (two lenses)/ calendar year or contacts (in lieu of glasses). In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Dental Check-Up for ChildrenNotes & sourceRoutine dental exams for children. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: No Charge Coverage: Covered Service limit: Yes Limit amount: 2 Limit unit: Visit(s) per Year In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Basic Dental Care - ChildNotes & sourceDental services classified as basic care for children, such as listed fillings. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 40.00% Coinsurance after deductible Coverage: Covered Service limit: Yes Limit amount: 1 Limit unit: Treatment(s) per 2 Years Benefit details: Scaling and Root Planing limited to 1 time per quadrant per 24 months. Perio Maintenance limited to 4 times per 12 month period in conjunction with dental prophylaxis following active and adjunctive periodontal therapy, exclusive of gross debridement. In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Orthodontia - ChildNotes & sourceTreatment to align children’s teeth or jaws, such as braces. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 50.00% Coinsurance after deductible Coverage: Covered Service limit: No Benefit details: Medically necessary orthodontia must be covered. In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Major Dental Care - ChildNotes & sourceDental services classified as major care for children. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 50.00% Coinsurance after deductible Coverage: Covered Service limit: No Benefit details: Once every 2 years for the same restoration. In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Accidental DentalNotes & sourceDental treatment needed because of an accidental injury. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: No In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 30.00% Coinsurance after deductible Essential benefit variation: Not an essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
Dental AnesthesiaNotes & sourceAnesthesia used during dental treatment. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 30.00% Coinsurance after deductible Coverage: Covered Service limit: No In-network tier 2 copay: Not Applicable Out-of-network copay: Not Applicable In-network tier 2 coinsurance: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: No |
| Benefit | UHC NexusACO OAP Gold 1000 |
|---|---|
Provider networkNotes & sourceThe insurer’s name for the network linked to this plan. Check the current provider directory to confirm a doctor or hospital participates. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | NexusACO |
Specialist referralNotes & sourceWhether the plan generally requires a referral before seeing a specialist. Check the listed exceptions. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | No |
Referral detailsNotes & sourceThe insurer’s explanation of when specialist referrals are needed. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | The selected 2027 filing says specialist referrals are not required for this NexusACO OAP plan. UHC’s Washington provider guide separately requires NexusACO members to choose an in-network primary care provider (PCP); PCP selection is different from a specialist-referral requirement. The page distinguishes OA/OAP open-access products from referral-required R/RB/RP products, but also uses broader suite-level referral wording. Confirm OAP requirements and any service-specific authorization in the issued plan. |
Provider tiersNotes & sourceWhether in-network providers are grouped into tiers with different member costs. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Yes |
National networkNotes & sourceWhether the filing lists a national provider network; this does not confirm any particular provider participates. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Yes |
Care outside the countryNotes & sourceWhether the filing lists coverage outside the country; restrictions may apply. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | No |
International care detailsNotes & sourceThe insurer’s explanation of coverage and restrictions outside the country. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Unknown |
Care outside the service areaNotes & sourceWhether the filing lists coverage away from the plan’s normal service area. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Yes |
Outside-area care detailsNotes & sourceThe insurer’s explanation of care covered away from the normal service area. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | With Network Provider, same as other Network Benefits |
| Benefit | UHC NexusACO OAP Gold 1000 |
|---|---|
HSA-compatible planNotes & sourceWhether the filing identifies the plan as HSA-compatible; your personal ability to contribute also depends on other rules. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | No |
Filed employer account contributionNotes & sourceWhether the plan filing includes an employer HSA or HRA contribution; it does not describe your employer’s actual contribution. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | No |
Filed contribution amountNotes & sourceThe employer account contribution amount included in the filing, if supplied. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Not supplied in selected filing |
HSA in source plan nameNotes & sourceSource name evidence only; this does not establish personal HSA eligibility. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | No |
| Benefit | UHC NexusACO OAP Gold 1000 |
|---|---|
Wellness programNotes & sourceWhether the filing lists a program intended to support healthy habits. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | No |
Condition support programsNotes & sourcePrograms listed to help members manage ongoing health conditions. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Heart Disease, Diabetes, Pregnancy |
Plan designNotes & sourceThe plan design description supplied by the insurer. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | UHC’s 2027 small-group lookup describes this design as OAP Tiered (carrier code FA-5F). This is the carrier’s lookup category; the filing’s plan-design field is blank. It does not replace the plan’s filed benefits or establish additional coverage. |
Unique plan designNotes & sourceWhether the insurer marked the benefit design as distinct in its filing. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Yes |
Plan exclusionsNotes & sourceServices or situations the insurer lists as excluded from coverage. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Unknown |
Pregnancy noticeNotes & sourceWhether the filing indicates a pregnancy-related notice requirement. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | No |
Adult dental waiting periodNotes & sourceWhether the filing lists a wait before adult dental benefits begin. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Not supplied in selected filing |
Waiting period lengthNotes & sourceHow long the filed waiting period lasts, if supplied. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Not supplied in selected filing |
Child-only coverageNotes & sourceHow the filing describes coverage offered for children without an enrolled adult. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Allows Adult and Child-Only |
| Benefit | UHC NexusACO OAP Gold 1000 |
|---|---|
Calculated actuarial valueNotes & sourceAn estimate of the share of covered costs the plan pays for a standard population, not your expected spending. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Unknown |
Insurer actuarial valueNotes & sourceThe insurer’s estimate of the plan’s share of covered costs for a standard population. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | 78.80% |
Tier 1 filing assumptionNotes & sourceThe use of tier 1 providers assumed in the filing, not a prediction of your care. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | 70% |
Tier 2 filing assumptionNotes & sourceThe use of tier 2 providers assumed in the filing, not a prediction of your care. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | 30% |
Essential benefit premium shareNotes & sourceThe filed portion of the premium allocated to essential health benefits. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Not supplied in selected filing |
Children’s dental allocationNotes & sourceThe filed allocation for children’s dental benefits. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Not supplied in selected filing |
Composite premium availableNotes & sourceWhether the filing offers a shared premium rate instead of separate age-based rates. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | No |
Rate descriptionNotes & sourceWhether the insurer labels its filed rate as guaranteed or estimated. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Not supplied in selected filing |
| Benefit | UHC NexusACO OAP Gold 1000 |
|---|---|
Plan IDNotes & sourceThe identifier used to distinguish this plan in the filing. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | 18699WA0420045 |
Plan variation IDNotes & sourceIdentifies this plan’s specific version of benefits and cost sharing. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | 18699WA0420045-00 |
Plan variation nameNotes & sourceThe insurer’s name for this version of the plan. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | UHC NexusACO OAP Gold 1000 |
Cost-sharing variationNotes & sourceThe filed category for this version of the plan’s member costs. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Standard Gold Off Exchange Plan |
Product IDNotes & sourceThe identifier for the product family this plan belongs to. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | 18699WA042 |
Network IDNotes & sourceIdentifies this plan’s provider network within this insurer’s filing. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | WAN002 |
Service area IDNotes & sourceIdentifies the area where the insurer offers this plan. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | WAS002 |
Drug list IDNotes & sourceIdentifies the prescription drug list referenced by this plan. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | WAF003 |
Marketplace statusNotes & sourceWhether the filing describes the plan as offered through the health insurance marketplace. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Off the Exchange |
New or existing planNotes & sourceWhether the insurer filed this as a new or continuing plan. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Existing |
Child-only plan IDNotes & sourceIdentifies a related child-only plan when one is supplied. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Not supplied in selected filing |
Tribal cost-sharing variationNotes & sourceIdentifies a special cost-sharing variation, if one is listed. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Not supplied in selected filing |
Effective dateNotes & sourceThe start date listed for this plan in the filing. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | 1/1/2027 |
Expiration dateNotes & sourceThe end date listed in the filing; a blank does not mean coverage continues indefinitely. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | Unknown |
Plan nameNotes & source2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | UHC NexusACO OAP Gold 1000 |
Legal issuerNotes & source2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | UnitedHealthcare Insurance Company |
Plan typeNotes & source2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | POS |
| Benefit | UHC NexusACO OAP Gold 1000 |
|---|---|
Virtual care optionsNotes & source2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references. | General UHC guidance describes 24/7 Virtual Visits with a Designated Virtual Network Provider by video, or audio-only where state law permits. These visits are for non-emergency care. Availability for this exact 2027 plan and the member cost share are not verified; check the issued benefits and myuhc.com. The guide’s illustrative care costs are not this plan’s copay, coinsurance, deductible or guaranteed price. |
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Search 2027 plans only. Availability depends on your county and coverage start.
2027 · Public plan ID 18699WA0420045 · Benefit variant 18699WA0420045-00
SBC unavailableYou can still review this plan’s other details.
Carrier source index; formats and available documents vary. No exact public Washington 2027 small-group SBC located. UHC directs small-business SBC access to employer/broker services. The public ACA Marketplace tool is for individual coverage. Carrier codes are recorded separately; do not substitute another state, year, funding type or federal plan.
Original identity review: General carrier reference only; no exact Washington 2027 SBC, benefit summary or booklet was located. It does not establish this plan’s coverage or cost sharing. The lookup is a Medicare Part D creditable-coverage reference, not a coverage contract. A lookup category and carrier code are shown for research; no creditability determination is made here. This macro-enabled workbook can be inspected without enabling macros. Local copy retained; extracted text is review evidence, not a reconciled coverage contract.
Original identity review: General carrier reference only; no exact Washington 2027 SBC, benefit summary or booklet was located. It does not establish this plan’s coverage or cost sharing. This 2025 educational guide’s $55/$150/$175/$1,800 examples are allowed amounts shared by sponsor and member, not member copays. Virtual-visit eligibility and member cost sharing remain unverified for this exact 2027 plan; designated-provider, state and benefit restrictions apply. Local copy retained; extracted text is review evidence, not a reconciled coverage contract.
General Washington access reference, not an exact 2027 SBC or certificate. The selected filing says No specialist referral for all 30 plans. NexusACO members must select a PCP; the page’s suite-level referral wording also covers referral-required products. Confirm OAP and service-specific authorization requirements with UHC.
Benton, Clark, Cowlitz, King, Kitsap, Klickitat, Lewis, Pierce, Skagit, Skamania, Snohomish, Spokane, Thurston, Whatcom, Yakima. Availability still depends on the coverage start and employer eligibility.
Estimate this plan and compare alternatives here, with the existing comparison PDF.