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UnitedHealthOne - Plan 100 Plan Benefits

Plan Feature In-Network
Deductible
Maximum 2 per family, per calendar year
$1,500 single / $3,000 family
$2,500 single / $5,000 family
$5,000 single / $10,000 family
$7,500 single / $15,000 family
$10,000 single / $20,000 family
Coinsurance Choices
The level of coverage provided by the plan after the calendar year Deductible has been satisfied.
You pay 0%
Coinsurance Out-of-Pocket Maximum
In network per calendar year, after deductible.
$0
Lifetime Maximum Benefit Unlimited
Initial Rate Guarantee 12 Months
Physicians (illness and injury)
Office Visits
Primary Care or Specialist
No charge after deductible
Wellness/Preventive Care Benefits
From age 16. Covers services associated with both an annual physical exam and an annual gynecological exam. Includes immunizations and routine diagnostic tests received or ordered on the same day as part of the exam when covered services are received in provider's office.
Covered at 100%, not subject to deductible
Wellness/Preventive Child Care
Covered at 100%, not subject to deductible
Doctor Office Visit
Adult or child, in-network only.
No charge after deductible
X-Ray and Lab
In conjunction with the preventive office visit, performed in doctor's office or network facility.
No charge after deductible
Child Immunizations
Ages 0-18.
Covered at 100%, not subject to deductible
Preventive Mammorgram, Pap Smear, PSA screening
No waiting period.
Covered at 100%, not subject to deductible
Outpatient Expense Benefits
X-Ray and Lab
Performed in doctor's office or a network facility.
No charge after deductible
Facility/Hospital for Outpatient Surgery No charge after deductible
Surgeon, Assistant Surgeon, and Facility Fees No charge after deductible
Hemodialysis, Radiation, Chemotherapy, Organ Transplant Drugs, and CAT Scans, MRIs No charge after deductible
Emergency Room Fees - Illness You pay $100 copay if not admitted, then no charge after deductible
Emergency Room Fees - Injury No charge after deductible
Spine and Back Disorders
CAT scan and MRI tests not subject to this limitation.
No charge after deductible
(Limited benefit)
Mental and Nervous Disorders
Including substance abuse.
No charge after deductible
(Limited benefit)
Other Outpatient Expenses No charge after deductible
Inpatient Expense Benefits
Room and Board, Intensive Care Unit, Operating Room, Recovery Room, Prescription Drugs, Physician Visit, and Professional Fees of Doctors, Surgeons, and Nurses No charge after deductible
Other Inpatient Services No charge after deductible

Prescription Drug Benefit You Pay
Preferred Price Card
You pay for prescriptions at the point of sale at the lowest discounted price available, and submit a claim to UnitedHealthcare/Golden Rule.
Or
Discount Card
You may obtain Rx drugs at an average savings of 20-25%. Discounts vary by pharmacy, geographic area, and drug.
Preferred price card, no charge after deductible
(Copay Card plan enhancement available)
Annual Maximum
Covered expense, per person per calendar year.
$3,000
READ YOUR POLICY CAREFULLY; This outline of coverage provides a brief description of the important features of the Policy. This is not the insurance contract, and only the actual Policy provisions will control. The Policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY CAREFULLY!

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