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This plan uses a provider network. You will pay less if you use a provider in
Yes. See the network. You will pay the most if you use a non-participating provider,
Will you pay less if www.welcometouhc.com/uhcwest and you might receive a bill from a provider for the difference between the
you use a network or call 1-800-624-8822 for a list of charge and what your plan pays (balance billing). Be aware, your
provider?
participating providers. participating provider might use a non-participating provider for some services
(such as lab work). Check with your provider before you get services.
Yes, written or oral approval
Do you need a referral is required, based upon This plan will pay some or all of the costs to see a specialist for covered services
to see a specialist? but only if you have a referral before you see the specialist.
medical policies.
AHQ/4CZ

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Subject to Regulatory Approval

Common Services You May What You Will Pay Limitations, Exceptions, & Other
Medical Event Need Participating Non-Participating Important
Provider (You will Provider (You will Information
pay the least) pay the most)
$20 copay / office visit
Primary care visit to and $5 copay / Virtual If you receive services in addition to
treat an injury or visits by a designated Not covered office visit, additional copayments or
illness virtual participating coinsurance may apply.
provider
If you visit a health Member is required to obtain a
care referral to specialist or other
office or licensed health care practitioner,
clinic except for OB/GYN Physician
Specialist visit $40 copay / visit Not covered services, reproductive health care
services within the Participating
Medical Group and Emergency /
Urgently needed services. If you
receive services in addition to office

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