UnitedHealthOne – Copay Saver Plan Benefits


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Plan Feature In-Network
Deductible
Per individual, per calendar year. Maximum 2 per family)
$1,500 per individual / $3,000 per family
$2,500 per individual / $7,500 per family
$5,000 per individual / $15,000 per family
$7,500 per individual / $15,000 per family
$10,000 per individual / $20,000 per family
Coinsurance Choices
The level of coverage provided by the plan after the calendar year Deductible has been satisfied.
You pay 30%
Coinsurance Out-of-Pocket Maximum
The amount of money an individual pays toward covered hospital and medical expenses during any one calendar year after deductible.
Choice of $5,000 or $10,000
Lifetime Maximum Benefit Unlimited
Physicians (illness and injury)
Office Visits
Primary Care or Specialist
$35 copay – no deductible, 2 visits per person per calendar year including wellness office visits
(2 additional visits plan enhancement available)
Wellness/Preventive Care Benefits Covered at 100%, not subject to deductible
Doctor Office Visit
Adult, child, in-network only.
$35 copay (no deductible)
(Subject to visit limit stated above)
X-Ray and Lab You pay: 30% after deductible
Child Immunizations Covered at 100%, not subject to deductible
Preventive Mammogram, Pap Smear, PSA screening Covered at 100%, not subject to deductible
Outpatient Expense Benefits
X-Ray and Lab You pay: 30% after deductible
Facility/Hospital for Outpatient Surgery You pay: 30% after deductible
Surgeon, Assistant Surgeon, and Facility Fees
Surgery in doctor’s office not covered.
You pay: 30% after deductible
Hemodialysis, Radiation, Chemotherapy, Organ Transplant Drugs, and CAT Scans, MRIs You pay: 30% after deductible
Emergency Room Fees – Illness You pay: $500 copay if not admitted, then 30% after deductible
Emergency Room Fees – Injury You pay: $500 copay if not admitted, then 30% after deductible
Spine and Back Disorders
CAT scan and MRI tests not subject to this limitation.
Not covered
Mental and Nervous Disorders
Including substance abuse.
Not covered
Other Outpatient Expenses Not covered
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: 30% after deductible
Other Inpatient Services You pay: 30% after deductible
Prescription Drug Benefit1 You Pay
Generic $15 co-payment (no deductible)
Brand Drugs Not covered
Annual Maximum
Covered expense, per person per calendar year.
Not applicable

1 Only generic drugs are covered under the Copay Saver Plan.

>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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