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UnitedHealthcare Administered by Golden Rule Health Insurance in ILLINOIS – Health Plan Options

UnitedHealthcare Administered by Golden Rule — PPO First Dollar 30 with Dental

A comparison of the PPO First Dollar 30 with Dental offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	see brochure	see brochure
Office Visit	see brochure	see brochure
Copay	see brochure	see brochure
Deductible	see brochure	see brochure

UnitedHealthcare Administered by Golden Rule — PPO 2500 with Dental

A comparison of the PPO 2500 with Dental offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80% after deductible	50% after deductible
Office Visit	Non-specialist: $30 copay deductible waived, Specialist: $40 copay deductible waived	Non-Specialist Office Visit: 50% after deductible, Specialist Visit: 50% after deductible
Copay	Non-specialist: $30 copay deductible waived, Specialist: $40 copay deductible waived	Non-Specialist Office Visit: 50% after deductible, Specialist Visit: 50% after deductible
Deductible	Individual: $2,500, Family: $5,000	Individual: $5,000, Family: $10,000

UnitedHealthcare Administered by Golden Rule — PPO 5000 with Dental

A comparison of the PPO 5000 with Dental offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80% after deductible up to out of pocket max. $0 once out of pocket max. is satisfied.	50% after deductible up to out of pocket max. $0 once out of pocket max. is satisfied.
Office Visit	Non-specialist: $40 copay deductible waived,Specialist: $50 copay deductible waived	Non-Specialist Office Visit: 50% after deductible, Specialist Visit: 50% after deductible
Copay	Non-specialist: $40 copay deductible waived, Specialist: $50 copay deductible waived	Non-Specialist Office Visit: 50% after deductible, Specialist Visit: 50% after deductible
Deductible	Individual: $5,000, Family: $10,000	Individual: $10,000, Family: $20,000

UnitedHealthcare Administered by Golden Rule — PPO Value 2500 with Dental

A comparison of the PPO Value 2500 with Dental offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	see brochure	see brochure
Office Visit	see brochure	see brochure
Copay	see brochure	see brochure
Deductible	see brochure	see brochure

UnitedHealthcare Administered by Golden Rule — PPO Value 5000 with Dental

A comparison of the PPO Value 5000 with Dental offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	70% after deductible up to out of pocket max. $0 once out of pocket max. is satisfied.	50% after deductible up to out of pocket max. $0 once out of pocket max. is satisfied.
Office Visit	Non-Specialist: Visits 1-2 $30 copay, ded. Waived; Visits 3+ 70% after ded., Specialist: Visits 1-2 $30 copay, ded. Waived; Visits 3+ 70% after ded. Specialist and Non-Specialist share visit max.	Non-Specialist Office Visit: 50% after deductible, Specialist Visit: 50% after deductible
Copay	Non-Specialist: Visits 1-2 $30 copay, ded. Waived; Visits 3+ 70% after ded., Specialist: Visits 1-2 $30 copay, ded. Waived; Visits 3+ 70% after ded. Specialist and Non-Specialist share visit max.	Non-Specialist Office Visit: 50% after deductible, Specialist Visit: 50% after deductible
Deductible	Individual: $5,000, Family: $10,000	Individual: $10,000, Family: $20,000

UnitedHealthcare Administered by Golden Rule — PPO High Deductible 3000 (HSA Compatible) with Dental

A comparison of the PPO High Deductible 3000 (HSA Compatible) with Dental offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	100% after deductible up to out of pocket max. $0 once out of pocket max. is satisfied.	50% after deductible up to out of pocket max. $0 once out of pocket max. is satisfied.
Office Visit	Non-Specialist Office Visit: 100% after deductible, Specialist Visit: 100% after deductible	Non-Specialist Office Visit: 50% after deductible, Specialist Visit: 50% after deductible
Copay	Non-Specialist Office Visit: 100% after deductible, Specialist Visit: 100% after deductible	Non-Specialist Office Visit: 50% after deductible, Specialist Visit: 50% after deductible
Deductible	Individual: $3,000, Family: $6,000	Individual: $6,000, Family: $12,000

UnitedHealthcare Administered by Golden Rule — PPO High Deductible 5000 (HSA Compatible) with Dental

A comparison of the PPO High Deductible 5000 (HSA Compatible) with Dental offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	see brochure	see brochure
Office Visit	see brochure	see brochure
Copay	see brochure	see brochure
Deductible	see brochure	see brochure

UnitedHealthcare Administered by Golden Rule — PPO Value 1500 with Dental

A comparison of the PPO Value 1500 with Dental offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	see brochure	see brochure
Office Visit	see brochure	see brochure
Copay	see brochure	see brochure
Deductible	see brochure	see brochure

UnitedHealthcare Administered by Golden Rule — PPO First Dollar 30

A comparison of the PPO First Dollar 30 offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	see brochure	see brochure
Office Visit	see brochure	see brochure
Copay	see brochure	see brochure
Deductible	see brochure	see brochure

UnitedHealthcare Administered by Golden Rule — PPO 2500

A comparison of the PPO 2500 offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80% after deductible	50% after deductible
Office Visit	Non-specialist: $30 copay deductible waived, Specialist: $40 copay deductible waived	Non-Specialist Office Visit: 50% after deductible, Specialist Visit: 50% after deductible
Copay	Non-specialist: $30 copay deductible waived, Specialist: $40 copay deductible waived	Non-Specialist Office Visit: 50% after deductible, Specialist Visit: 50% after deductible
Deductible	Individual: $2,500, Family: $5,000	Individual: $5,000, Family: $10,000

UnitedHealthcare Administered by Golden Rule — PPO 5000

A comparison of the PPO 5000 offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80% after deductible up to out of pocket max. $0 once out of pocket max. is satisfied.	50% after deductible up to out of pocket max. $0 once out of pocket max. is satisfied.
Office Visit	Non-specialist: $40 copay deductible waived,Specialist: $50 copay deductible waived	Non-Specialist Office Visit: 50% after deductible, Specialist Visit: 50% after deductible
Copay	Non-specialist: $40 copay deductible waived, Specialist: $50 copay deductible waived	Non-Specialist Office Visit: 50% after deductible, Specialist Visit: 50% after deductible
Deductible	Individual: $5,000, Family: $10,000	Individual: $10,000, Family: $20,000

UnitedHealthcare Administered by Golden Rule — PPO Value 2500

A comparison of the PPO Value 2500 offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	see brochure	see brochure
Office Visit	see brochure	see brochure
Copay	see brochure	see brochure
Deductible	see brochure	see brochure

UnitedHealthcare Administered by Golden Rule — PPO Value 5000

A comparison of the PPO Value 5000 offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	70% after deductible up to out of pocket max. $0 once out of pocket max. is satisfied.	50% after deductible up to out of pocket max. $0 once out of pocket max. is satisfied.
Office Visit	Non-Specialist: Visits 1-2 $30 copay, ded. Waived; Visits 3+ 70% after ded., Specialist: Visits 1-2 $30 copay, ded. Waived; Visits 3+ 70% after ded. Specialist and Non-Specialist share visit max.	Non-Specialist Office Visit: 50% after deductible, Specialist Visit: 50% after deductible
Copay	Non-Specialist: Visits 1-2 $30 copay, ded. Waived; Visits 3+ 70% after ded., Specialist: Visits 1-2 $30 copay, ded. Waived; Visits 3+ 70% after ded. Specialist and Non-Specialist share visit max.	Non-Specialist Office Visit: 50% after deductible, Specialist Visit: 50% after deductible
Deductible	Individual: $5,000, Family: $10,000	Individual: $10,000, Family: $20,000

UnitedHealthcare Administered by Golden Rule — PPO High Deductible 3000 (HSA Compatible)

A comparison of the PPO High Deductible 3000 (HSA Compatible) offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	100% after deductible up to out of pocket max. $0 once out of pocket max. is satisfied.	50% after deductible up to out of pocket max. $0 once out of pocket max. is satisfied.
Office Visit	Non-Specialist Office Visit: 100% after deductible, Specialist Visit: 100% after deductible	Non-Specialist Office Visit: 50% after deductible, Specialist Visit: 50% after deductible
Copay	Non-Specialist Office Visit: 100% after deductible, Specialist Visit: 100% after deductible	Non-Specialist Office Visit: 50% after deductible, Specialist Visit: 50% after deductible
Deductible	Individual: $3,000, Family: $6,000	Individual: $6,000, Family: $12,000

UnitedHealthcare Administered by Golden Rule — PPO High Deductible 5000 (HSA Compatible)

A comparison of the PPO High Deductible 5000 (HSA Compatible) offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	100% after deductible up to out of pocket max. $0 once out of pocket max. is satisfied.	50% after deductible up to out of pocket max. $0 once out of pocket max. is satisfied.
Office Visit	Non-Specialist Office Visit: 100% after deductible, Specialist Visit: 100% after deductible	Non-Specialist Office Visit: 50% after deductible, Specialist Visit: 50% after deductible
Copay	Non-Specialist Office Visit: 100% after deductible, Specialist Visit: 100% after deductible	Non-Specialist Office Visit: 50% after deductible, Specialist Visit: 50% after deductible
Deductible	Individual: $5,000, Family: $10,000	Individual: $10,000, Family: $20,000

UnitedHealthcare Administered by Golden Rule — Preventive and Hospital Care 3000 (HSA Compatible)

A comparison of the Preventive and Hospital Care 3000 (HSA Compatible) offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	see brochure	see brochure
Office Visit	see brochure	see brochure
Copay	see brochure	see brochure
Deductible	see brochure	see brochure

UnitedHealthcare Administered by Golden Rule — PPO Value 1500

A comparison of the PPO Value 1500 offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	see brochure	see brochure
Office Visit	see brochure	see brochure
Copay	see brochure	see brochure
Deductible	see brochure	see brochure

UnitedHealthcare Administered by Golden Rule — Copay Saver

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
Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	History and exam: $35 copay (maximum 2 visits per person per year)	History and exam: $35 copay (maximum 2 visits per person per year)
Copay	$35	$35
Deductible	$1,500 (Maximum 2 per family, per calendar year)	$1,500 (Maximum 2 per family, per calendar year)

UnitedHealthcare Administered by Golden Rule — Copay Saver

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
Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	History and exam: $35 copay (maximum 2 visits per person per year)	History and exam: $35 copay (maximum 2 visits per person per year)
Copay	$35	$35
Deductible	$2,500 (Maximum 2 per family, per calendar year)	$2,500 (Maximum 2 per family, per calendar year)

UnitedHealthcare Administered by Golden Rule — Copay Saver

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
Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	History and exam: $35 copay (maximum 2 visits per person per year)	History and exam: $35 copay (maximum 2 visits per person per year)
Copay	$35	$35
Deductible	$5,000 (Maximum 2 per family, per calendar year)	$5,000 (Maximum 2 per family, per calendar year)

UnitedHealthcare Administered by Golden Rule — Copay Saver

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
Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	History and exam: $35 copay (maximum 2 visits per person per year)	History and exam: $35 copay (maximum 2 visits per person per year)
Copay	$35	$35
Deductible	$7,500	$7,500

UnitedHealthcare Administered by Golden Rule — Copay Saver

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
Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	History and exam: $35 copay (maximum 2 visits per person per year)	History and exam: $35 copay (maximum 2 visits per person per year)
Copay	$35	$35
Deductible	$10,000	$10,000

UnitedHealthcare Administered by Golden Rule — Single HSA 100

A comparison of the Single HSA 100 offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	100%	100%
Office Visit	100% after deductible	100% after deductible
Copay	N/A	N/A
Deductible	$1,250	$1,250

UnitedHealthcare Administered by Golden Rule — Single HSA 100

A comparison of the Single HSA 100 offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	100%	100%
Office Visit	100% after deductible	100% after deductible
Copay	N/A	N/A
Deductible	$2,500	$2,500

UnitedHealthcare Administered by Golden Rule — Single HSA 100

A comparison of the Single HSA 100 offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	100%	100%
Office Visit	100% after deductible	100% after deductible
Copay	N/A	N/A
Deductible	$3,000	$3,000

UnitedHealthcare Administered by Golden Rule — Single HSA 100

A comparison of the Single HSA 100 offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	100%	100%
Office Visit	100% after deductible	100% after deductible
Copay	N/A	N/A
Deductible	$3,500	$3,500

UnitedHealthcare Administered by Golden Rule — Single HSA 100

A comparison of the Single HSA 100 offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	100%	100%
Office Visit	100% after deductible	100% after deductible
Copay	N/A	N/A
Deductible	$5,000	$5,000

UnitedHealthcare Administered by Golden Rule — Plan 100

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
Network	See Provider	See Provider
Coinsurance	100%	100%
Office Visit	100% after deductible	100% after deductible
Copay	N/A	N/A
Deductible	$1,500 (maximum 2 per family, per calendar year)	$1,500 (maximum 2 per family, per calendar year)

UnitedHealthcare Administered by Golden Rule — Plan 100

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
Network	See Provider	See Provider
Coinsurance	100%	100%
Office Visit	100% after deductible	100% after deductible
Copay	N/A	N/A
Deductible	$2,500 (maximum 2 per family, per calendar year)	$2,500 (maximum 2 per family, per calendar year)

UnitedHealthcare Administered by Golden Rule — Plan 100

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
Network	See Provider	See Provider
Coinsurance	100%	100%
Office Visit	100% after deductible	100% after deductible
Copay	N/A	N/A
Deductible	$5,000 (maximum 2 per family, per calendar year)	$5,000 (maximum 2 per family, per calendar year)

UnitedHealthcare Administered by Golden Rule — Plan 100

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
Network	See Provider	See Provider
Coinsurance	100%	100%
Office Visit	100% after deductible	100% after deductible
Copay	N/A	N/A
Deductible	$7,500	$7,500

UnitedHealthcare Administered by Golden Rule — Plan 100

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
Network	See Provider	See Provider
Coinsurance	100%	100%
Office Visit	100% after deductible	100% after deductible
Copay	N/A	N/A
Deductible	$10,000	$10,000

UnitedHealthcare Administered by Golden Rule — Plan 80

A comparison of the Plan 80 offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	80% after deductible	80% after deductible
Copay	N/A	N/A
Deductible	$1,500 (maximum 2 per family, per calendar year)	$1,500 (maximum 2 per family, per calendar year)

UnitedHealthcare Administered by Golden Rule — Plan 80

A comparison of the Plan 80 offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	80% after deductible	80% after deductible
Copay	N/A	N/A
Deductible	$2,500 (maximum 2 per family, per calendar year)	$2,500 (maximum 2 per family, per calendar year)

UnitedHealthcare Administered by Golden Rule — Plan 80

A comparison of the Plan 80 offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	80% after deductible	80% after deductible
Copay	N/A	N/A
Deductible	$5,000 (maximum 2 per family, per calendar year)	$5,000 (maximum 2 per family, per calendar year)

UnitedHealthcare Administered by Golden Rule — Plan 80

A comparison of the Plan 80 offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	80% after deductible	80% after deductible
Copay	N/A	N/A
Deductible	$7,500	$7,500

UnitedHealthcare Administered by Golden Rule — Plan 80

A comparison of the Plan 80 offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	80% after deductible	80% after deductible
Copay	N/A	N/A
Deductible	$10,000	$10,000

UnitedHealthcare Administered by Golden Rule — Saver 80

A comparison of the Saver 80 offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	Office Visit - History and Exam: Not covered	Office Visit - History and Exam: Not covered
Copay	N/A	N/A
Deductible	$500 (maximum 2 per family, per calendar year)	$500 (maximum 2 per family, per calendar year)

UnitedHealthcare Administered by Golden Rule — Saver 80

A comparison of the Saver 80 offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	Office Visit - History and Exam: Not covered	Office Visit - History and Exam: Not covered
Copay	N/A	N/A
Deductible	$1,000 (maximum 2 per family, per calendar year)	$1,000 (maximum 2 per family, per calendar year)

UnitedHealthcare Administered by Golden Rule — Saver 80

A comparison of the Saver 80 offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	Office Visit - History and Exam: Not covered	Office Visit - History and Exam: Not covered
Copay	N/A	N/A
Deductible	$1,500 (maximum 2 per family, per calendar year)	$1,500 (maximum 2 per family, per calendar year)

UnitedHealthcare Administered by Golden Rule — Saver 80

A comparison of the Saver 80 offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	Office Visit - History and Exam: Not covered	Office Visit - History and Exam: Not covered
Copay	N/A	N/A
Deductible	$2,500 (maximum 2 per family, per calendar year)	$2,500 (maximum 2 per family, per calendar year)

UnitedHealthcare Administered by Golden Rule — Saver 80

A comparison of the Saver 80 offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	Office Visit - History and Exam: Not covered	Office Visit - History and Exam: Not covered
Copay	N/A	N/A
Deductible	$5,000 (maximum 2 per family, per calendar year)	$5,000 (maximum 2 per family, per calendar year)

UnitedHealthcare Administered by Golden Rule — Saver 80

A comparison of the Saver 80 offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	Office Visit - History and Exam: Not covered	Office Visit - History and Exam: Not covered
Copay	N/A	N/A
Deductible	$7,500 (maximum 2 per family, per calendar year)	$7,500 (maximum 2 per family, per calendar year)

UnitedHealthcare Administered by Golden Rule — Saver 80

A comparison of the Saver 80 offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	Office Visit - History and Exam: Not covered	Office Visit - History and Exam: Not covered
Copay	N/A	N/A
Deductible	$10,000 (maximum 2 per family, per calendar year)	$10,000 (maximum 2 per family, per calendar year)

UnitedHealthcare Administered by Golden Rule — Copay Select

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

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	100%	100%
Office Visit	$35 copay -not subject to deductible ($25 copay available)	$35 copay -not subject to deductible ($25 copay available)
Copay	$35	$35
Deductible	$500 (maximum 2 per family, per calendar year)	$500 (maximum 2 per family, per calendar year)

UnitedHealthcare Administered by Golden Rule — Copay Select

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

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	$35 copay -not subject to deductible ($25 copay available)	$35 copay -not subject to deductible ($25 copay available)
Copay	$35	$35
Deductible	$500 (maximum 2 per family, per calendar year)	$500 (maximum 2 per family, per calendar year)

UnitedHealthcare Administered by Golden Rule — Copay Select

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

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	70%	70%
Office Visit	$35 copay -not subject to deductible ($25 copay available)	$35 copay -not subject to deductible ($25 copay available)
Copay	$35	$35
Deductible	$500 (maximum 2 per family, per calendar year)	$500 (maximum 2 per family, per calendar year)

UnitedHealthcare Administered by Golden Rule — Copay Select

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

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	100%	100%
Office Visit	$35 copay -not subject to deductible ($25 copay available)	$35 copay -not subject to deductible ($25 copay available)
Copay	$35	$35
Deductible	$1,000 (maximum 2 per family, per calendar year)	$1,000 (maximum 2 per family, per calendar year)

UnitedHealthcare Administered by Golden Rule — Copay Select

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

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	$35 copay -not subject to deductible ($25 copay available)	$35 copay -not subject to deductible ($25 copay available)
Copay	$35	$35
Deductible	$1,000 (maximum 2 per family, per calendar year)	$1,000 (maximum 2 per family, per calendar year)

UnitedHealthcare Administered by Golden Rule — Copay Select

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

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	70%	70%
Office Visit	$35 copay -not subject to deductible ($25 copay available)	$35 copay -not subject to deductible ($25 copay available)
Copay	$35	$35
Deductible	$1,000 (maximum 2 per family, per calendar year)	$1,000 (maximum 2 per family, per calendar year)

UnitedHealthcare Administered by Golden Rule — Copay Select

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

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	100%	100%
Office Visit	$35 copay -not subject to deductible ($25 copay available)	$35 copay -not subject to deductible ($25 copay available)
Copay	$35	$35
Deductible	$1,500 (maximum 2 per family, per calendar year)	$1,500 (maximum 2 per family, per calendar year)

UnitedHealthcare Administered by Golden Rule — Copay Select

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

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	$35 copay -not subject to deductible ($25 copay available)	$35 copay -not subject to deductible ($25 copay available)
Copay	$35	$35
Deductible	$1,500 (maximum 2 per family, per calendar year)	$1,500 (maximum 2 per family, per calendar year)

UnitedHealthcare Administered by Golden Rule — Copay Select

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

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	70%	70%
Office Visit	$35 copay -not subject to deductible ($25 copay available)	$35 copay -not subject to deductible ($25 copay available)
Copay	$35	$35
Deductible	$1,500 (maximum 2 per family, per calendar year)	$1,500 (maximum 2 per family, per calendar year)

UnitedHealthcare Administered by Golden Rule — Copay Select

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

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	100%	100%
Office Visit	$35 copay -not subject to deductible ($25 copay available)	$35 copay -not subject to deductible ($25 copay available)
Copay	$35	$35
Deductible	$2,500 (maximum 2 per family, per calendar year)	$2,500 (maximum 2 per family, per calendar year)

UnitedHealthcare Administered by Golden Rule — Copay Select

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

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	$35 copay -not subject to deductible ($25 copay available)	$35 copay -not subject to deductible ($25 copay available)
Copay	$35	$35
Deductible	$2,500 (maximum 2 per family, per calendar year)	$2,500 (maximum 2 per family, per calendar year)

UnitedHealthcare Administered by Golden Rule — Copay Select

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

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	70%	70%
Office Visit	$35 copay -not subject to deductible ($25 copay available)	$35 copay -not subject to deductible ($25 copay available)
Copay	$35	$35
Deductible	$2,500 (maximum 2 per family, per calendar year)	$2,500 (maximum 2 per family, per calendar year)

UnitedHealthcare Administered by Golden Rule — Copay Select

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

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	100%	100%
Office Visit	$35 copay -not subject to deductible ($25 copay available)	$35 copay -not subject to deductible ($25 copay available)
Copay	$35	$35
Deductible	$3,500	$3,500

UnitedHealthcare Administered by Golden Rule — Copay Select

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

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	$35 copay -not subject to deductible ($25 copay available)	$35 copay -not subject to deductible ($25 copay available)
Copay	$35	$35
Deductible	$3,500	$3,500

UnitedHealthcare Administered by Golden Rule — Copay Select

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

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	70%	70%
Office Visit	$35 copay -not subject to deductible ($25 copay available)	$35 copay -not subject to deductible ($25 copay available)
Copay	$35	$35
Deductible	$3,500	$3,500

UnitedHealthcare Administered by Golden Rule — Copay Select

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

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	100%	100%
Office Visit	$35 copay -not subject to deductible ($25 copay available)	$35 copay -not subject to deductible ($25 copay available)
Copay	$35	$35
Deductible	$5,000 (maximum 2 per family, per calendar year)	$5,000 (maximum 2 per family, per calendar year)

UnitedHealthcare Administered by Golden Rule — Copay Select

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

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	$35 copay -not subject to deductible ($25 copay available)	$35 copay -not subject to deductible ($25 copay available)
Copay	$35	$35
Deductible	$5,000 (maximum 2 per family, per calendar year)	$5,000 (maximum 2 per family, per calendar year)

UnitedHealthcare Administered by Golden Rule — Copay Select

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

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	70%	70%
Office Visit	$35 copay -not subject to deductible ($25 copay available)	$35 copay -not subject to deductible ($25 copay available)
Copay	$35	$35
Deductible	$5,000 (maximum 2 per family, per calendar year)	$5,000 (maximum 2 per family, per calendar year)

UnitedHealthcare Administered by Golden Rule — Copay Select

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

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	100%	100%
Office Visit	$35 copay -not subject to deductible ($25 copay available)	$35 copay -not subject to deductible ($25 copay available)
Copay	$35	$35
Deductible	$7,500	$7,500

UnitedHealthcare Administered by Golden Rule — Copay Select

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

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	$35 copay -not subject to deductible ($25 copay available)	$35 copay -not subject to deductible ($25 copay available)
Copay	$35	$35
Deductible	$7,500	$7,500

UnitedHealthcare Administered by Golden Rule — Copay Select

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

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	70%	70%
Office Visit	$35 copay -not subject to deductible ($25 copay available)	$35 copay -not subject to deductible ($25 copay available)
Copay	$35	$35
Deductible	$7,500	$7,500

UnitedHealthcare Administered by Golden Rule — Copay Select

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

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	100%	100%
Office Visit	$35 copay -not subject to deductible ($25 copay available)	$35 copay -not subject to deductible ($25 copay available)
Copay	$35	$35
Deductible	$10,000	$10,000

UnitedHealthcare Administered by Golden Rule — Copay Select

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

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	80%
Office Visit	$35 copay -not subject to deductible ($25 copay available)	$35 copay -not subject to deductible ($25 copay available)
Copay	$35	$35
Deductible	$10,000	$10,000

UnitedHealthcare Administered by Golden Rule — Copay Select

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

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	70%	70%
Office Visit	$35 copay -not subject to deductible ($25 copay available)	$35 copay -not subject to deductible ($25 copay available)
Copay	$35	$35
Deductible	$10,000	$10,000

UnitedHealthcare Administered by Golden Rule — Autograph Total Plus Rx/HSA

A comparison of the Autograph Total Plus Rx/HSA offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	100%	70%
Office Visit	100% after deductible	70% after deductible
Copay	N/A	N/A
Deductible	$1,500	$3,000

UnitedHealthcare Administered by Golden Rule — Autograph Total Plus Rx/HSA and Dental

A comparison of the Autograph Total Plus Rx/HSA and Dental offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	100%	70%
Office Visit	100% after deductible	70% after deductible
Copay	N/A	N/A
Deductible	$1,500	$3,000

UnitedHealthcare Administered by Golden Rule — Autograph Total Plus Rx/HSA

A comparison of the Autograph Total Plus Rx/HSA offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	100%	70%
Office Visit	100% after deductible	70% after deductible
Copay	N/A	N/A
Deductible	$2,500	$5,000

UnitedHealthcare Administered by Golden Rule — Autograph Total Plus Rx/HSA and Dental

A comparison of the Autograph Total Plus Rx/HSA and Dental offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	100%	70%
Office Visit	100% after deductible	70% after deductible
Copay	N/A	N/A
Deductible	$2,500	$5,000

UnitedHealthcare Administered by Golden Rule — Autograph Total Plus Rx/HSA

A comparison of the Autograph Total Plus Rx/HSA offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	100%	70%
Office Visit	100% after deductible	70% after deductible
Copay	N/A	N/A
Deductible	$3,500	$7,000

UnitedHealthcare Administered by Golden Rule — Autograph Total Plus Rx/HSA and Dental

A comparison of the Autograph Total Plus Rx/HSA and Dental offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	100%	70%
Office Visit	100% after deductible	70% after deductible
Copay	N/A	N/A
Deductible	$3,500	$7,000

UnitedHealthcare Administered by Golden Rule — Autograph Total Plus Rx/HSA

A comparison of the Autograph Total Plus Rx/HSA offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	100%	70%
Office Visit	100% after deductible	70% after deductible
Copay	N/A	N/A
Deductible	$5,000	$10,000

UnitedHealthcare Administered by Golden Rule — Autograph Total Plus Rx/HSA and Dental

A comparison of the Autograph Total Plus Rx/HSA and Dental offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	100%	70%
Office Visit	100% after deductible	70% after deductible
Copay	N/A	N/A
Deductible	$5,000	$10,000

UnitedHealthcare Administered by Golden Rule — Autograph Total/HSA

A comparison of the Autograph Total/HSA offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	100%	70%
Office Visit	100% after deductible	70% after deductible
Copay	N/A	N/A
Deductible	$2,000	$4,000

UnitedHealthcare Administered by Golden Rule — Autograph Total/HSA with Dental

A comparison of the Autograph Total/HSA with Dental offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	100%	70%
Office Visit	100% after deductible	70% after deductible
Copay	N/A	N/A
Deductible	$2,000	$4,000

UnitedHealthcare Administered by Golden Rule — Autograph Total/HSA

A comparison of the Autograph Total/HSA offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	100%	70%
Office Visit	100% after deductible	70% after deductible
Copay	N/A	N/A
Deductible	$3,000	$6,000

UnitedHealthcare Administered by Golden Rule — Autograph Total/HSA with Dental

A comparison of the Autograph Total/HSA with Dental offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	100%	70%
Office Visit	100% after deductible	70% after deductible
Copay	N/A	N/A
Deductible	$3,000	$6,000

UnitedHealthcare Administered by Golden Rule — Autograph Total/HSA

A comparison of the Autograph Total/HSA offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	100%	70%
Office Visit	100% after deductible	70% after deductible
Copay	N/A	N/A
Deductible	$4,000	$8,000

UnitedHealthcare Administered by Golden Rule — Autograph Total/HSA with Dental

A comparison of the Autograph Total/HSA with Dental offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	100%	70%
Office Visit	100% after deductible	70% after deductible
Copay	N/A	N/A
Deductible	$4,000	$8,000

UnitedHealthcare Administered by Golden Rule — Autograph Total/HSA

A comparison of the Autograph Total/HSA offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	100%	70%
Office Visit	100% after deductible	70% after deductible
Copay	N/A	N/A
Deductible	$5,200	$10,400

UnitedHealthcare Administered by Golden Rule — Autograph Total/HSA with Dental

A comparison of the Autograph Total/HSA with Dental offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	100%	70%
Office Visit	100% after deductible	70% after deductible
Copay	N/A	N/A
Deductible	$5,200	$10,400

UnitedHealthcare Administered by Golden Rule — Portrait Share 80 Plus Rx Unlimited (with $0 Rx Deductible)

A comparison of the Portrait Share 80 Plus Rx Unlimited (with $0 Rx Deductible) offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	60%
Office Visit	Primary Care (unlimited visits): $35 copayment. Specialty Care (unlimited visits): $50 copayment.	60% after deductible
Copay	Primary Care (unlimited visits): $35 copayment. Specialty Care (unlimited visits): $50 copayment.	N/A
Deductible	$1,000 (Two members must meet their deductible).	$2,000 (Two members must meet their deductible).

UnitedHealthcare Administered by Golden Rule — Portrait Share 80 Plus Rx Unlimited

A comparison of the Portrait Share 80 Plus Rx Unlimited offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	60%
Office Visit	Primary Care (unlimited visits): $35 copayment. Specialty Care (unlimited visits): $50 copayment.	60% after deductible
Copay	Primary Care (unlimited visits): $35 copayment. Specialty Care (unlimited visits): $50 copayment.	N/A
Deductible	$1,000 (Two members must meet their deductible).	$2,000 (Two members must meet their deductible).

UnitedHealthcare Administered by Golden Rule — Portrait Share 80 Plus Rx Unlimited and Dental

A comparison of the Portrait Share 80 Plus Rx Unlimited and Dental offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	60%
Office Visit	Primary Care (unlimited visits): $35 copayment. Specialty Care (unlimited visits): $50 copayment.	60% after deductible
Copay	Primary Care (unlimited visits): $35 copayment. Specialty Care (unlimited visits): $50 copayment.	N/A
Deductible	$1,000 (Two members must meet their deductible).	$2,000 (Two members must meet their deductible).

UnitedHealthcare Administered by Golden Rule — Portrait Share 80 Plus Rx Unlimited (with $0 Rx Deductible) with Dental

A comparison of the Portrait Share 80 Plus Rx Unlimited (with $0 Rx Deductible) with Dental offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	60%
Office Visit	Primary Care (unlimited visits): $35 copayment. Specialty Care (unlimited visits): $50 copayment.	60% after deductible
Copay	Primary Care (unlimited visits): $35 copayment. Specialty Care (unlimited visits): $50 copayment.	N/A
Deductible	$1,000 (Two members must meet their deductible).	$2,000 (Two members must meet their deductible).

UnitedHealthcare Administered by Golden Rule — Portrait Share 80 Plus Rx Unlimited (with $0 Rx Deductible)

A comparison of the Portrait Share 80 Plus Rx Unlimited (with $0 Rx Deductible) offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	60%
Office Visit	Primary Care (unlimited visits): $35 copayment. Specialty Care (unlimited visits): $50 copayment.	60% after deductible
Copay	Primary Care (unlimited visits): $35 copayment. Specialty Care (unlimited visits): $50 copayment.	N/A
Deductible	$2,500 (Two members must meet their deductible).	$5,000 (Two members must meet their deductible).

UnitedHealthcare Administered by Golden Rule — Portrait Share 80 Plus Rx Unlimited

A comparison of the Portrait Share 80 Plus Rx Unlimited offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	60%
Office Visit	Primary Care (unlimited visits): $35 copayment. Specialty Care (unlimited visits): $50 copayment.	60% after deductible
Copay	Primary Care (unlimited visits): $35 copayment. Specialty Care (unlimited visits): $50 copayment.	N/A
Deductible	$2,500 (Two members must meet their deductible).	$5,000 (Two members must meet their deductible).

UnitedHealthcare Administered by Golden Rule — Portrait Share 80 Plus Rx Unlimited and Dental

A comparison of the Portrait Share 80 Plus Rx Unlimited and Dental offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	60%
Office Visit	Primary Care (unlimited visits): $35 copayment. Specialty Care (unlimited visits): $50 copayment.	60% after deductible
Copay	Primary Care (unlimited visits): $35 copayment. Specialty Care (unlimited visits): $50 copayment.	N/A
Deductible	$2,500 (Two members must meet their deductible).	$5,000 (Two members must meet their deductible).

UnitedHealthcare Administered by Golden Rule — Portrait Share 80 Plus Rx Unlimited (with $0 Rx Deductible) with Dental

A comparison of the Portrait Share 80 Plus Rx Unlimited (with $0 Rx Deductible) with Dental offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	60%
Office Visit	Primary Care (unlimited visits): $35 copayment. Specialty Care (unlimited visits): $50 copayment.	60% after deductible
Copay	Primary Care (unlimited visits): $35 copayment. Specialty Care (unlimited visits): $50 copayment.	N/A
Deductible	$2,500 (Two members must meet their deductible).	$5,000 (Two members must meet their deductible).

UnitedHealthcare Administered by Golden Rule — Autograph Share 80 Plus Rx

A comparison of the Autograph Share 80 Plus Rx offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	60%
Office Visit	Primary Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $35 copayment for 6 visits, then 80% after deductible. Specialty Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $50 copayment for 6 visits, then 80% after deductible.	60% after deductible
Copay	Primary Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $35 copayment for 6 visits, then 80% after deductible. Specialty Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $50 copayment for 6 visits, then 80% after deductible.	N/A
Deductible	see brochure	see brochure

UnitedHealthcare Administered by Golden Rule — Autograph Share 80 Plus Rx (with $500 Deductible Rx)

A comparison of the Autograph Share 80 Plus Rx (with $500 Deductible Rx) offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	60%
Office Visit	Primary Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $35 copayment for 6 visits, then 80% after deductible. Specialty Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $50 copayment for 6 visits, then 80% after deductible.	60% after deductible
Copay	Primary Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $35 copayment for 6 visits, then 80% after deductible. Specialty Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $50 copayment for 6 visits, then 80% after deductible.	N/A
Deductible	see brochure	see brochure

UnitedHealthcare Administered by Golden Rule — Autograph Share 80 Plus Rx with Dental

A comparison of the Autograph Share 80 Plus Rx with Dental offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	60%
Office Visit	Primary Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $35 copayment for 6 visits, then 80% after deductible. Specialty Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $50 copayment for 6 visits, then 80% after deductible.	60% after deductible
Copay	Primary Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $35 copayment for 6 visits, then 80% after deductible. Specialty Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $50 copayment for 6 visits, then 80% after deductible.	N/A
Deductible	see brochure	see brochure

UnitedHealthcare Administered by Golden Rule — Autograph Share 80 Plus Rx

A comparison of the Autograph Share 80 Plus Rx offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	60%
Office Visit	Primary Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $35 copayment for 6 visits, then 80% after deductible. Specialty Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $50 copayment for 6 visits, then 80% after deductible.	60% after deductible
Copay	Primary Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $35 copayment for 6 visits, then 80% after deductible. Specialty Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $50 copayment for 6 visits, then 80% after deductible.	N/A
Deductible	$5,000	$10,000

UnitedHealthcare Administered by Golden Rule — Autograph Share 80 Plus Rx (with $500 Deductible Rx)

A comparison of the Autograph Share 80 Plus Rx (with $500 Deductible Rx) offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	60%
Office Visit	Primary Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $35 copayment for 6 visits, then 80% after deductible. Specialty Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $50 copayment for 6 visits, then 80% after deductible.	60% after deductible
Copay	Primary Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $35 copayment for 6 visits, then 80% after deductible. Specialty Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $50 copayment for 6 visits, then 80% after deductible.	N/A
Deductible	$5,000	$10,000

UnitedHealthcare Administered by Golden Rule — Autograph Share 80 Plus Rx with Dental

A comparison of the Autograph Share 80 Plus Rx with Dental offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	60%
Office Visit	Primary Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $35 copayment for 6 visits, then 80% after deductible. Specialty Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $50 copayment for 6 visits, then 80% after deductible.	60% after deductible
Copay	Primary Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $35 copayment for 6 visits, then 80% after deductible. Specialty Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $50 copayment for 6 visits, then 80% after deductible.	N/A
Deductible	$5,000	$10,000

UnitedHealthcare Administered by Golden Rule — Autograph Share 80 Plus Rx

A comparison of the Autograph Share 80 Plus Rx offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	60%
Office Visit	Primary Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $35 copayment for 6 visits, then 80% after deductible. Specialty Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $50 copayment for 6 visits, then 80% after deductible.	60% after deductible
Copay	Primary Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $35 copayment for 6 visits, then 80% after deductible. Specialty Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $50 copayment for 6 visits, then 80% after deductible.	N/A
Deductible	$6,000	$12,000

UnitedHealthcare Administered by Golden Rule — Autograph Share 80 Plus Rx (with $500 Deductible Rx)

A comparison of the Autograph Share 80 Plus Rx (with $500 Deductible Rx) offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	60%
Office Visit	Primary Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $35 copayment for 6 visits, then 80% after deductible. Specialty Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $50 copayment for 6 visits, then 80% after deductible.	60% after deductible
Copay	Primary Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $35 copayment for 6 visits, then 80% after deductible. Specialty Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $50 copayment for 6 visits, then 80% after deductible.	N/A
Deductible	$6,000	$12,000

UnitedHealthcare Administered by Golden Rule — Autograph Share 80 Plus Rx with Dental

A comparison of the Autograph Share 80 Plus Rx with Dental offered by UnitedHealthcare Administered by Golden Rule is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	80%	60%
Office Visit	Primary Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $35 copayment for 6 visits, then 80% after deductible. Specialty Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $50 copayment for 6 visits, then 80% after deductible.	60% after deductible
Copay	Primary Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $35 copayment for 6 visits, then 80% after deductible. Specialty Care (limited to 6 combined (Primary and Specialty Care) visits/calendar year)(includes allergy injections)- $50 copayment for 6 visits, then 80% after deductible.	N/A
Deductible	$6,000	$12,000

UnitedHealthcare Administered by Golden Rule — Monogram

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

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	100%	75%
Office Visit	100% after deductible	75% after deductible
Copay	N/A	N/A
Deductible	$7,500 (Two family members must meet their deductible).	$15,000 (Two family members must meet their deductible).

UnitedHealthcare Administered by Golden Rule — Monogram with Dental

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

	Network	Non-Network
Network	See Provider	See Provider
Coinsurance	100%	75%
Office Visit	100% after deductible	75% after deductible
Copay	N/A	N/A
Deductible	$7,500 (Two family members must meet their deductible).	$15,000 (Two family members must meet their deductible).