March 21, 2010

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UnitedHealthcare Administered by Golden Rule – Plan 100 – LOUISIANA

A comparison of the Plan 100 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 Plan 100 Application Plan 100 Application
Brochure Plan 100 Brochure Plan 100 Brochure
Copay N/A N/A
Office Visit Office Visit - History and Exam: No charge after deductible Office Visit - History and Exam: No charge after deductible
Deductible $5,000 (maximum 2 per family, per calendar year) $5,000 (maximum 2 per family, per calendar year)
Coinsurance 100% 100%
Coinsurance Limit Plan 100 Plan 100
Out-of-Pocket Maximum Equal to deductible Equal to deductible
Lifetime Maximum $3 million per covered person $3 million per covered person
Prescription Drugs
  • Preferred price card - No charge after deductible (Copay Card plan enhancement available)
  • Annual Maximum: $3,000 covered expense, per person, per calendar year (No Annual Max. plan enhancement available)
    		•
  • Preferred price card - No charge after deductible (Copay Card plan enhancement available)
  • Annual Maximum: $3,000 covered expense, per person, per calendar year (No Annual Max. plan enhancement available)
    		•
    Emergency Room
  • Illness: You pay: $100 copay if not admitted, then no charge after deductible
  • Injury: No charge after deductible
    		•
  • Illness: You pay: $100 copay if not admitted, then no charge after deductible
  • Injury: No charge after deductible
    		•
    Adult Preventative Care
  • Doctor Office Visit: No charge after deductible (No waiting period)
  • X-ray and Lab: No charge after deductible (in conjunction with the preventive office visit, performed in the doctor's office or a network facility, no waiting period)
  • Preventive Mammogram, Pap Smear, PSA screening: No charge after deductible (no waiting period)
    		•
  • Doctor Office Visit: No charge after deductible (no waiting period)
  • Child Immunizations (0-18): No charge after deductible (no waiting period)
    		•
    Child Preventative Care
  • Doctor Office Visit: No charge after deductible (no waiting period)
  • Child Immunizations (0-18): No charge after deductible (no waiting period)
    		•
  • Doctor Office Visit: No charge after deductible (no waiting period)
  • Child Immunizations (0-18): No charge after deductible (no waiting period)
    		•
    Lab / X-Ray Outpatient X-ray and lab: No charge after deductible (performed in the doctor's office or a network facility) Outpatient X-ray and lab: No charge after deductible (performed in the doctor's office or a network facility)
    Maternity Optional Benefit Optional Benefit
    Physical Therapy Plan 100 Plan 100
    Skilled Nursing Plan 100 Plan 100
    Home Health Care Plan 100 Plan 100
    Mental Health Mental & Nervous Disorders (including Substance Abuse): No charge after deductible (Limited benefit) Mental & Nervous Disorders (including Substance Abuse): No charge after deductible (Limited benefit)
    Hospital Care No charge after deductible No charge after deductible
    Optional Benefits Plan 100 Plan 100