March 19, 2010

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UnitedHealthcare Administered by Golden Rule – Copay Saver – LOUISIANA

A comparison of the Copay Saver offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

  Network Non-Network
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Network See Provider See Provider
Application Copay Saver Application Copay Saver Application
Brochure Copay Saver Brochure Copay Saver Brochure
Copay Copay Saver Copay Saver
Office Visit Office Visit - History and Exam: You pay: $30 copay - no deductible, 2 visits per person, per calendar year, including wellness office visits (2 Additional Visits plan enhancement available) Office Visit - History and Exam: You pay: $30 copay - no deductible, 2 visits per person, per calendar year, including wellness office visits (2 Additional Visits plan enhancement available)
Deductible $5,000 (maximum 2 per family, per calendar year) $5,000 (maximum 2 per family, per calendar year)
Coinsurance 80% 80%
Coinsurance Limit Copay Saver Copay Saver
Out-of-Pocket Maximum $3,000 per covered person after deductible and copays $3,000 per covered person after deductible and copays
Lifetime Maximum $3 million per covered person $3 million per covered person
Prescription Drugs
  • Generic: $15 copay, no deductible; Brand: not covered
  • Annual Maximum: Not Applicable
    		•
  • Generic: $15 copay, no deductible; Brand: not covered
  • Annual Maximum: Not Applicable
    		•
    Emergency Room You pay: $500 copay if not admitted, then 20% after deductible You pay: $500 copay if not admitted, then 20% after deductible
    Adult Preventative Care
  • Doctor Office Visit: $35 copay - subject to visit limit (3-month waiting period, not subject to deductible)
  • X-ray and lab: Not covered
  • Preventive Mammogram, Pap Smear, PSA screening: You pay: 30% after deductible (no waiting period)
    		•
  • Doctor Office Visit: $35 copay - subject to visit limit (3-month waiting period, no subject to deductible)
  • Child Immunizations (0-18): Not covered
    		•
    Child Preventative Care
  • Doctor Office Visit: $35 copay - subject to visit limit (3-month waiting period, no subject to deductible)
  • Child Immunizations (0-18): Not covered
    		•
  • Doctor Office Visit: $35 copay - subject to visit limit (3-month waiting period, no subject to deductible)
  • Child Immunizations (0-18): Not covered
    		•
    Lab / X-Ray Outpatient X-ray and lab: You pay: 20% after deductible (performed in the doctor's office or a network facility, Must be performed within 14 days of surgery or confinement) Outpatient X-ray and lab: You pay: 20% after deductible (performed in the doctor's office or a network facility, Must be performed within 14 days of surgery or confinement)
    Maternity Optional Benefit Optional Benefit
    Physical Therapy Copay Saver Copay Saver
    Skilled Nursing Copay Saver Copay Saver
    Home Health Care Copay Saver Copay Saver
    Mental Health Not covered Not covered
    Hospital Care You pay: 20% after deductible You pay: 20% after deductible
    Optional Benefits Copay Saver Copay Saver