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UnitedHealthOne - HSA 100 Plan Benefits

Plan Feature In-Network
Per individual, per calendar year. Family deductible is 2x individual.
$1,250 single / $2,500 family
$2,500 single / $5,000 family
$3,000 single / $6,000 family
$3,500 single / $7,000 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 0%
Coinsurance Out-of-Pocket Maximum
In network per calendar year, after deductible.
Lifetime Maximum Benefit Unlimited
Physicians (illness and injury)
Office Visits
Primary Care or Specialist
No charge after deductible
Wellness/Preventive Care Benefits Covered at 100%, not subject to deductible
Doctor Office Visit
Adult, child, in-network only.
$35 copay
X-Ray and Lab
In conjunction with the preventive office visit, performed in doctor's office or network facility.
You pay: $0
Child Immunizations
Ages 0-18.
Covered at 100%, not subject to deductible
Preventive Mammorgram, Pap Smear, PSA screening
No waiting period.
Covered at 100%, not subject to deductible
Outpatient Expense Benefits
X-Ray and Lab
Performed in doctor's office or a network facility.
No charge after deductible
Facility/Hospital for Outpatient Surgery No charge after deductible
Surgeon, Assistant Surgeon, and Facility Fees No charge after deductible
Hemodialysis, Radiation, Chemotherapy, Organ Transplant Drugs, and CAT Scans, MRIs No charge after deductible
Emergency Room Fees No charge after deductible
Spine and Back Disorders
CAT scan and MRI tests not subject to this limitation.
No charge after deductible
(Limited benefit)
Mental and Nervous Disorders
Including substance abuse.
No charge after deductible
(Limited benefit)
Other Outpatient Expenses No charge 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 No charge after deductible
Other Inpatient Services No charge 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 Golden Rule.
Preferred price card, no charge after deductible
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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