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

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 — 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).

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	$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