UnitedHealthOne – Plan 80 Plan Benefits


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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 20%
Coinsurance Out-of-Pocket Maximum
In-network, per person, per calendar year, after deductible.
$3,000
Lifetime Maximum Benefit Unlimited
Initial Rate Guarantee 12 Months
Physicians (illness and injury)
Office Visits
Primary Care or Specialist
You pay 20% 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.
You pay 20% after deductible
Child Immunizations
Ages 0-18.
Covered at 100%, not subject to deductible
Preventive Mammogram, Pap Smear, PSA screening
No waiting period.
Covered at 100%, not subject to deductible
Outpatient Expense Benefits
X-Ray and Lab You pay 20% after deductible
Facility/Hospital for Outpatient Surgery You pay 20% after deductible
Surgeon, Assistant Surgeon, and Facility Fees You pay 20% after deductible
Hemodialysis, Radiation, Chemotherapy, Organ Transplant Drugs, and CAT Scans, MRIs You pay 20% after deductible
Emergency Room Fees – Illness You pay $100 copay if not admitted, then 20% after deductible
Emergency Room Fees – Injury You pay 20% after deductible
Spine and Back Disorders
CAT scan and MRI tests not subject to this limitation.
You pay 20% after deductible
(Limited benefit)
Mental and Nervous Disorders
Including substance abuse.
You pay 20% after deductible
(Limited, optional benefit)
Other Outpatient Expenses You pay 20% 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 You pay 20% after deductible
Other Inpatient Services You pay 20% 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 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, you pay 20% after deductible

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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