| Plan Feature | In-Network |
|---|---|
| Deductible Per individual, per calendar year. Family deductible is 2x individual. | $2,500 single / $5,000 family $3,000 single / $6,000 family $4,000 single / $8,000 family $5,000 single / $15,000 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 In network per calendar year, after deductible. Number in (parentheses) is the corresponding plan deductible. | $3,000 single ($2,500) / $6,000 family ($5,000) $2,600 single ($3,000) / $5,200 family ($6,000) $1,600 single ($4,000) / $3,200 family ($8,000) $600 single ($5,000) / $1,200 family ($10,000) |
| Lifetime Maximum Benefit | Unlmited |
| Physicians (illness and injury) | |
| Office Visits Primary Care or Specialist | You pay 30% 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, child, in-network only. | You pay 30% after deductible |
| X-Ray and Lab In conjunction with the preventive office visit, performed in doctor’s office or network facility. | You pay 30% |
| Child Immunizations Ages 0-18. | You pay 30% |
| Preventive Mammorgram, Pap Smear, PSA screening No waiting period. | You pay 30% |
| Outpatient Expense Benefits | |
| X-Ray and Lab Performed in doctor’s office or a network facility. | You pay 30% after deductible |
| Facility/Hospital for Outpatient Surgery | You pay 30% after deductible |
| Surgeon, Assistant Surgeon, and Facility Fees | You pay 30% after deductible |
| Hemodialysis, Radiation, Chemotherapy, Organ Transplant Drugs, and CAT Scans, MRIs | You pay 30% after deductible |
| Emergency Room Fees | You pay 30% after deductible |
| Spine and Back Disorders CAT scan and MRI tests not subject to this limitation. | You pay 30% after deductible (Limited benefit) |
| Mental and Nervous Disorders Including substance abuse. | You pay 30% after deductible (Limited benefit) |
| Other Outpatient Expenses | You pay 30% 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 30% after deductible |
| Other Inpatient Services | You pay 30% 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. | Preferred price card, you pay 30% after deductible |
| 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!
