UnitedHealthOne – Copay Saver Plan Benefits

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.	$6,000
Lifetime Maximum Benefit	$3 million per person ($5 million plan enhancement available)
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 3 month waiting period, not subject to deductible unless otherwise indicated
Doctor Office Visit Adult, child, in-network only.	$35 copay (no deductible) (Subject to visit limit stated above)
X-Ray and Lab In conjunction with the preventive office visit, performed in doctor’s office or network facility.	Not covered
Child Immunizations Ages 0-18.	Not covered
Preventive Mammorgram, Pap Smear, PSA screening No waiting period.	You pay: 30% after deductible
Outpatient Expense Benefits
X-Ray and Lab Must be performed within 14 days of surgery of confinement.	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!