UCare Minnesota - UCare M Health Fairview Silver HSA
Yearly Deductible
Out-of-Pocket Maximum
Primary Care Visit
25% Coinsurance after deductible
50% Coinsurance after deductible
Specialist Visit
25% Coinsurance after deductible
50% Coinsurance after deductible
Other Practitioner Office Visit
25% Coinsurance after deductible
50% Coinsurance after deductible
Preventive Care/Screening/Immunization
No Charge
50% Coinsurance after deductible
X-rays and Diagnostic Imaging
25% Coinsurance after deductible
50% Coinsurance after deductible
Imaging (CT/PET scans, MRIs)
25% Coinsurance after deductible
50% Coinsurance after deductible
Generic Drugs
25% Coinsurance after deductible
100% Coinsurance
Preferred Brand Drugs
25% Coinsurance after deductible
100% Coinsurance
Non-Preferred Brand Drugs
25% Coinsurance after deductible
100% Coinsurance
Specialty Drugs
25% Coinsurance after deductible
100% Coinsurance
Outpatient Services
25% Coinsurance after deductible
50% Coinsurance after deductible
Emergency Room
25% Coinsurance after deductible
25% Coinsurance after deductible
Ambulance Services
25% Coinsurance after deductible
25% Coinsurance after deductible
Urgent Care Services
25% Coinsurance after deductible
50% Coinsurance after deductible
Inpatient Hospital Services
25% Coinsurance after deductible
50% Coinsurance after deductible
Inpatient Physician and Surgical Services
25% Coinsurance after deductible
50% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services
25% Coinsurance after deductible
50% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services
25% Coinsurance after deductible
50% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services
25% Coinsurance after deductible
50% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services
25% Coinsurance after deductible
50% Coinsurance after deductible
Prenatal and Postnatal Care
No Charge
50% Coinsurance after deductible
Delivery and All Inpatient Services for Maternity Care
25% Coinsurance after deductible
50% Coinsurance after deductible
Home Healthcare Services
25% Coinsurance after deductible
50% Coinsurance after deductible
Outpatient Rehabilitation Services
25% Coinsurance after deductible
50% Coinsurance after deductible
Habilitation Services
25% Coinsurance after deductible
50% Coinsurance after deductible
Skilled Nursing Facility
25% Coinsurance after deductible
50% Coinsurance after deductible
Durable Medical Equipment
25% Coinsurance after deductible
50% Coinsurance after deductible
Hospice Services
25% Coinsurance after deductible
50% Coinsurance after deductible
Acupuncture
Not covered
Not covered
Rehabilitative Occupational and Rehabilitative Physical Therapy
25% Coinsurance after deductible
50% Coinsurance after deductible
Well Baby Visits and Care
No Charge
50% Coinsurance after deductible
Allergy Testing
25% Coinsurance after deductible
50% Coinsurance after deductible
Diabetes Education
No Charge
50% Coinsurance after deductible
Nutritional Counseling
No Charge
50% Coinsurance after deductible
Eye Exam for Children
No Charge
50% Coinsurance after deductible
Eyeglasses for Children
25% Coinsurance after deductible
100% Coinsurance
Hearing Aids for Children
25% Coinsurance after deductible
100% Coinsurance
Basic Dental Care (Adult)
Not covered
Not covered
Basic Dental (Child)
25% Coinsurance after deductible
100% Coinsurance
Dental Checkup (Child)
No Charge
50% Coinsurance after deductible
Major Dental Care (Adult)
Not covered
Not covered
Major Dental Care (Child)
25% Coinsurance after deductible
100% Coinsurance