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

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 Office Visit: $30 Copay (Ded waived). Specialist Visit: $40 (Ded. Waived) (Maternity and pregnancy related expenses are not covered).	Non-Specialist Office Visit: 70% after deductible. Specialist Visit: 70% after deductible (Maternity and pregnancy related expenses are not covered).
Copay	Non-Specialist Office Visit: $30 Copay (Ded waived). Specialist Visit: $40 (Ded. Waived) (Maternity and pregnancy related expenses are not covered).	Non-Specialist Office Visit: 70% after deductible. Specialist Visit: 70% after deductible (Maternity and pregnancy related expenses are not covered).
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	50% after deductible
Office Visit	Non-Specialist Office Visit: $40 Copay (deductible waived). Specialist Visit: $50 Copay (deductible waived) (Maternity and pregnancy related expenses are not covered).	Non-Specialist Office Visit: 70% Specialist Visit: 70% after deductible (Maternity and pregnancy related expenses are not covered, except for complications of pregnancy).
Copay	Non-Specialist Office Visit: $40 Copay (deductible waived). Specialist Visit: $50 Copay (deductible waived) (Maternity and pregnancy related expenses are not covered).	Non-Specialist Office Visit: 70% Specialist Visit: 70% after deductible (Maternity and pregnancy related expenses are not covered, except for complications of pregnancy).
Deductible	Individual: $5,000, Family: $10,000	Individual: $10,000, Family: $20,000

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 — 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	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 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	50% after deductible
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	50% after deductible
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 3500

A comparison of the PPO 3500 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 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 Office Visit: $30 Copay (Ded waived). Specialist Visit: $40 (Ded. Waived) (Maternity and pregnancy related expenses are not covered).	Non-Specialist Office Visit: 70% after deductible. Specialist Visit: 70% after deductible (Maternity and pregnancy related expenses are not covered).
Copay	Non-Specialist Office Visit: $30 Copay (Ded waived). Specialist Visit: $40 (Ded. Waived) (Maternity and pregnancy related expenses are not covered).	Non-Specialist Office Visit: 70% after deductible. Specialist Visit: 70% after deductible (Maternity and pregnancy related expenses are not covered).
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	50% after deductible
Office Visit	Non-Specialist Office Visit: $40 Copay (deductible waived). Specialist Visit: $50 Copay (deductible waived) (Maternity and pregnancy related expenses are not covered).	Non-Specialist Office Visit: 70% Specialist Visit: 70% after deductible (Maternity and pregnancy related expenses are not covered, except for complications of pregnancy).
Copay	Non-Specialist Office Visit: $40 Copay (deductible waived). Specialist Visit: $50 Copay (deductible waived) (Maternity and pregnancy related expenses are not covered).	Non-Specialist Office Visit: 70% Specialist Visit: 70% after deductible (Maternity and pregnancy related expenses are not covered, except for complications of pregnancy).
Deductible	Individual: $5,000, Family: $10,000	Individual: $10,000, Family: $20,000

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 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	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 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	50% after deductible
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	100% after deductible	50% after deductible
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 — PPO 3500 with Dental

A comparison of the PPO 3500 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 Select Value Care - Plan I

A comparison of the PPO Select Value Care - Plan I 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	50%	50%
Office Visit	50% of Allowable Amount	50% of Allowable Amount
Copay	N/A	N/A
Deductible	N/A	N/A

UnitedHealthcare Administered by Golden Rule — PPO Select Value Care - Plan II

A comparison of the PPO Select Value Care - Plan II 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	50%	50%
Office Visit	50% of Allowable Amount	50% of Allowable Amount
Copay	N/A	N/A
Deductible	N/A	N/A

UnitedHealthcare Administered by Golden Rule — PPO Select Value Care - Plan III

A comparison of the PPO Select Value Care - Plan III 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	50%	50%
Office Visit	50% of Allowable Amount	50% of Allowable Amount
Copay	N/A	N/A
Deductible	N/A	N/A

UnitedHealthcare Administered by Golden Rule — Foundation Hospital Care

A comparison of the Foundation Hospital Care 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	BCBSTX pays 80%, insured pays 20%	BCBSTX pays 60%, insured pays 40%
Office Visit	Not Covered	Not Covered
Copay	N/A	N/A
Deductible	Individual: $5,000, Family: $15,000	Individual: $10,000, Family: $30,000

UnitedHealthcare Administered by Golden Rule — Select Blue Advantage - Plan I

A comparison of the Select Blue Advantage - Plan I 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	85% of the Allowable Amount for Eligible Expenses	75% of the Allowable Amount for Eligible Expenses
Office Visit	$25 office visit copay includes same day lab and x-ray, up to annual max of $750	Physician office visits subject to deductible and coinsurance
Copay	$25	None
Deductible	$250 Individual/$750 Family	$500 Individual/$1,500 Family

UnitedHealthcare Administered by Golden Rule — Select Blue Advantage - Plan II

A comparison of the Select Blue Advantage - Plan II 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	85% of the Allowable Amount for Eligible Expenses	75% of the Allowable Amount for Eligible Expenses
Office Visit	$25 office visit copay includes same day lab and x-ray, up to annual max of $750	Physician office visits subject to deductible and coinsurance
Copay	$25	None
Deductible	$500 Individual/$1,500 Family	$1,000 Individual/$3,000 Family

UnitedHealthcare Administered by Golden Rule — Select Blue Advantage - Plan III

A comparison of the Select Blue Advantage - Plan III 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	85% of the Allowable Amount for Eligible Expenses	75% of the Allowable Amount for Eligible Expenses
Office Visit	$25 office visit copay includes same day lab and x-ray, up to annual max of $750	Physician office visits subject to deductible and coinsurance
Copay	$25	None
Deductible	$1,000 Individual/$3,000 Family	$2,000 Individual/$6,000 Family

UnitedHealthcare Administered by Golden Rule — Select Blue Advantage - Plan IV

A comparison of the Select Blue Advantage - Plan IV 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	85% of the Allowable Amount for Eligible Expenses	75% of the Allowable Amount for Eligible Expenses
Office Visit	$25 office visit copay includes same day lab and x-ray, up to annual max of $750	Physician office visits subject to deductible and coinsurance
Copay	$25	None
Deductible	$1,500 Individual/$4,500 Family	$3,000 Individual/$9,000 Family

UnitedHealthcare Administered by Golden Rule — Select Blue Advantage - Plan V

A comparison of the Select Blue Advantage - Plan V 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	85% of the Allowable Amount for Eligible Expenses	75% of the Allowable Amount for Eligible Expenses
Office Visit	$25 office visit copay includes same day lab and x-ray, up to annual max of $750	Physician office visits subject to deductible and coinsurance
Copay	$25	None
Deductible	$2,500 Individual/$7,500 Family	$5,000 Individual/$15,000 Family

UnitedHealthcare Administered by Golden Rule — Select Blue Advantage - Plan VI

A comparison of the Select Blue Advantage - Plan VI 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	85% of the Allowable Amount for Eligible Expenses	75% of the Allowable Amount for Eligible Expenses
Office Visit	$25 office visit copay includes same day lab and x-ray, up to annual max of $750	Physician office visits subject to deductible and coinsurance
Copay	$25	None
Deductible	$3,500 Individual/$10,500 Family	$7,000 Individual/$21,000 Family

UnitedHealthcare Administered by Golden Rule — Select Blue Advantage - Plan VII

A comparison of the Select Blue Advantage - Plan VII 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	85% of the Allowable Amount for Eligible Expenses	75% of the Allowable Amount for Eligible Expenses
Office Visit	$25 office visit copay includes same day lab and x-ray, up to annual max of $750	Physician office visits subject to deductible and coinsurance
Copay	$25	None
Deductible	$5,000 Individual/$15,000 Family	$10,000 Individual/$30,000 Family

UnitedHealthcare Administered by Golden Rule — Select Blue Advantage - Plan VIII

A comparison of the Select Blue Advantage - Plan VIII 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	85% of the Allowable Amount for Eligible Expenses	75% of the Allowable Amount for Eligible Expenses
Office Visit	$25 office visit copay includes same day lab and x-ray, up to annual max of $750	Physician office visits subject to deductible and coinsurance
Copay	$25	None
Deductible	$10,000 Individual/$30,000 Family	$20,000 Individual/$60,000 Family

UnitedHealthcare Administered by Golden Rule — PPO Select Choice - Plan I

A comparison of the PPO Select Choice - Plan I 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% of the Allowable Amount for Eligible Expenses	70% of the Allowable Amount for Eligible Expenses
Office Visit	$25 copayment applies to office visit/consultation only	Physician office visits subject to deductible and coinsurance
Copay	$25	None
Deductible	$250 Individual/$750 Family	$500 Individual/$1,500 Family

UnitedHealthcare Administered by Golden Rule — PPO Select Choice - Plan II

A comparison of the PPO Select Choice - Plan II 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% of the Allowable Amount for Eligible Expenses	70% of the Allowable Amount for Eligible Expenses
Office Visit	$25 copayment applies to office visit/consultation only	Physician office visits subject to deductible and coinsurance
Copay	$25	None
Deductible	$500 Individual/$1,500 Family	$1,000 Individual/$3,000 Family

UnitedHealthcare Administered by Golden Rule — PPO Select Choice - Plan III

A comparison of the PPO Select Choice - Plan III 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% of the Allowable Amount for Eligible Expenses	70% of the Allowable Amount for Eligible Expenses
Office Visit	$25 copayment applies to office visit/consultation only	Physician office visits subject to deductible and coinsurance
Copay	$25	None
Deductible	$1,000 Individual/$3,000 Family	$2,000 Individual/$6,000 Family

UnitedHealthcare Administered by Golden Rule — PPO Select Choice - Plan IV

A comparison of the PPO Select Choice - Plan IV 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% of the Allowable Amount for Eligible Expenses	70% of the Allowable Amount for Eligible Expenses
Office Visit	$25 copayment applies to office visit/consultation only	Physician office visits subject to deductible and coinsurance
Copay	$25	None
Deductible	$1,500 Individual/$4,500 Family	$3,000 Individual/$9,000 Family

UnitedHealthcare Administered by Golden Rule — PPO Select Choice - Plan V

A comparison of the PPO Select Choice - Plan V 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% of the Allowable Amount for Eligible Expenses	70% of the Allowable Amount for Eligible Expenses
Office Visit	$25 copayment applies to office visit/consultation only	Physician office visits subject to deductible and coinsurance
Copay	$25	None
Deductible	$2,500 Individual/$7,500 Family	$5,000 Individual/$15,000 Family

UnitedHealthcare Administered by Golden Rule — PPO Select Choice - Plan VI

A comparison of the PPO Select Choice - Plan VI 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% of the Allowable Amount for Eligible Expenses	70% of the Allowable Amount for Eligible Expenses
Office Visit	$25 copayment applies to office visit/consultation only	Physician office visits subject to deductible and coinsurance
Copay	$25	None
Deductible	$3,500 Individual/$10,500 Family	$7,000 Individual/$21,000 Family

UnitedHealthcare Administered by Golden Rule — PPO Select Choice - Plan VII

A comparison of the PPO Select Choice - Plan VII 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% of the Allowable Amount for Eligible Expenses	70% of the Allowable Amount for Eligible Expenses
Office Visit	$25 copayment applies to office visit/consultation only	Physician office visits subject to deductible and coinsurance
Copay	$25	None
Deductible	$5,000 Individual/$15,000 Family	$10,000 Individual/$30,000 Family

UnitedHealthcare Administered by Golden Rule — PPO Select Choice - Plan VIII

A comparison of the PPO Select Choice - Plan VIII 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% of the Allowable Amount for Eligible Expenses	70% of the Allowable Amount for Eligible Expenses
Office Visit	$25 copayment applies to office visit/consultation only	Physician office visits subject to deductible and coinsurance
Copay	$25	None
Deductible	$10,000 Individual/$30,000 Family	$20,000 Individual/$60,000 Family

UnitedHealthcare Administered by Golden Rule — PPO Select Saver - Plan I

A comparison of the PPO Select Saver - Plan I 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	75% of the AllowableAmount for Eligible Expenses	60% of the Allowable Amount for Eligible Expenses
Office Visit	All physician office visits will be subject to deductible and coinsurance	All physician office visits will be subject to deductible and coinsurance
Copay	N/A	N/A
Deductible	$500 Individual/$1,500 Family	$1,000 Individual/$3,000 Family

UnitedHealthcare Administered by Golden Rule — PPO Select Saver - Plan II

A comparison of the PPO Select Saver - Plan II 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	75% of the AllowableAmount for Eligible Expenses	60% of the Allowable Amount for Eligible Expenses
Office Visit	All physician office visits will be subject to deductible and coinsurance	All physician office visits will be subject to deductible and coinsurance
Copay	N/A	N/A
Deductible	$1,000 Individual/$3,000 Family	$2,000 Individual/$6,000 Family

UnitedHealthcare Administered by Golden Rule — PPO Select Saver - Plan III

A comparison of the PPO Select Saver - Plan III 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	75% of the AllowableAmount for Eligible Expenses	60% of the Allowable Amount for Eligible Expenses
Office Visit	All physician office visits will be subject to deductible and coinsurance	All physician office visits will be subject to deductible and coinsurance
Copay	N/A	N/A
Deductible	$1,500 Individual/$4,500 Family	$3,000 Individual/$9,000 Family

UnitedHealthcare Administered by Golden Rule — PPO Select Saver - Plan IV

A comparison of the PPO Select Saver - Plan IV 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	75% of the AllowableAmount for Eligible Expenses	60% of the Allowable Amount for Eligible Expenses
Office Visit	All physician office visits will be subject to deductible and coinsurance	All physician office visits will be subject to deductible and coinsurance
Copay	N/A	N/A
Deductible	$2,500 Individual/$7,500 Family	$5,000 Individual/$15,000 Family

UnitedHealthcare Administered by Golden Rule — PPO Select Saver - Plan V

A comparison of the PPO Select Saver - Plan V 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	75% of the AllowableAmount for Eligible Expenses	60% of the Allowable Amount for Eligible Expenses
Office Visit	All physician office visits will be subject to deductible and coinsurance	All physician office visits will be subject to deductible and coinsurance
Copay	N/A	N/A
Deductible	$3,500 Individual/$10,500 Family	$7,000 Individual/$21,000 Family

UnitedHealthcare Administered by Golden Rule — PPO Select Saver - Plan VI

A comparison of the PPO Select Saver - Plan VI 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	75% of the AllowableAmount for Eligible Expenses	60% of the Allowable Amount for Eligible Expenses
Office Visit	All physician office visits will be subject to deductible and coinsurance	All physician office visits will be subject to deductible and coinsurance
Copay	N/A	N/A
Deductible	$5,000 Individual/$15,000 Family	$10,000 Individual/$30,000 Family

UnitedHealthcare Administered by Golden Rule — PPO Select Saver - Plan VII

A comparison of the PPO Select Saver - Plan VII 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	75% of the AllowableAmount for Eligible Expenses	60% of the Allowable Amount for Eligible Expenses
Office Visit	All physician office visits will be subject to deductible and coinsurance	All physician office visits will be subject to deductible and coinsurance
Copay	N/A	N/A
Deductible	$10,000 Individual/$30,000 Family	$20,000 Individual/$60,000 Family

UnitedHealthcare Administered by Golden Rule — BlueEdge Individual HSA - Plan I

A comparison of the BlueEdge Individual HSA - Plan I 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	90% of allowable amount after calendar year deductible	70% of allowable amount after calendar year deductible
Office Visit	Deductible and coinsurance	Deductible and coinsurance
Copay	N/A	N/A
Deductible	$1,150 Individual $2,300 Family	$2,300 Individual $4,600 Family

UnitedHealthcare Administered by Golden Rule — BlueEdge Individual HSA - Plan II

A comparison of the BlueEdge Individual HSA - Plan II 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	90% of allowable amount after calendar year deductible	70% of allowable amount after calendar year deductible
Office Visit	Deductible and coinsurance	Deductible and coinsurance
Copay	N/A	N/A
Deductible	$1,750 Individual $3,500 Family	$3,500 Individual $7,000 Family

UnitedHealthcare Administered by Golden Rule — BlueEdge Individual HSA - Plan III

A comparison of the BlueEdge Individual HSA - Plan III 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	90% of allowable amount after calendar year deductible	70% of allowable amount after calendar year deductible
Office Visit	Deductible and coinsurance	Deductible and coinsurance
Copay	N/A	N/A
Deductible	$2,500 Individual $5,000 Family	$5,000 Individual $10,000 Family

UnitedHealthcare Administered by Golden Rule — BlueEdge Individual HSA - Plan IV

A comparison of the BlueEdge Individual HSA - Plan IV 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	75% of allowable amount after calendar year deductible	60% of allowable amount after calendar year deductible
Office Visit	Deductible and coinsurance	Deductible and coinsurance
Copay	N/A	N/A
Deductible	$1,150 Individual $2,300 Family	$2,300 Individual $4,600 Family

UnitedHealthcare Administered by Golden Rule — BlueEdge Individual HSA - Plan V

A comparison of the BlueEdge Individual HSA - Plan V 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	75% of allowable amount after calendar year deductible	60% of allowable amount after calendar year deductible
Office Visit	Deductible and coinsurance	Deductible and coinsurance
Copay	N/A	N/A
Deductible	$1,750 Individual $3,500 Family	$3,500 Individual $7,000 Family

UnitedHealthcare Administered by Golden Rule — BlueEdge Individual HSA - Plan VI

A comparison of the BlueEdge Individual HSA - Plan VI 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	75% of allowable amount after calendar year deductible	60% of allowable amount after calendar year deductible
Office Visit	Deductible and coinsurance	Deductible and coinsurance
Copay	N/A	N/A
Deductible	$2,500 Individual $5,000 Family	$5,000 Individual $10,000 Family

UnitedHealthcare Administered by Golden Rule — BlueEdge Individual HSA - Plan VII

A comparison of the BlueEdge Individual HSA - Plan VII 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% of allowable amount after calendar year deductible	70% of allowable amount after calendar year deductible
Office Visit	Deductible and coinsurance	Deductible and coinsurance
Copay	N/A	N/A
Deductible	$5,000 Individual $10,000 Family	$10,000 Individual $20,000 Family

UnitedHealthcare Administered by Golden Rule — SelecTemp PPO - Plan I

A comparison of the SelecTemp PPO - Plan I 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	60% after deductible
Office Visit	80% of Allowable Amount after deductible	60% of Allowable Amount after deductible
Copay	N/A	N/A
Deductible	$500 Individual, $1,500 Family	$1,000, Individual, $3,000 Family

UnitedHealthcare Administered by Golden Rule — SelecTemp PPO - Plan II

A comparison of the SelecTemp PPO - Plan II 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	60% after deductible
Office Visit	80% of Allowable Amount after deductible	60% of Allowable Amount after deductible
Copay	N/A	N/A
Deductible	$1,000, Individual, $3,000 Family	$2,000, Individual, $6,000 Family

UnitedHealthcare Administered by Golden Rule — SelecTemp PPO - Plan III

A comparison of the SelecTemp PPO - Plan III 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	60% after deductible
Office Visit	80% of Allowable Amount after deductible	60% of Allowable Amount after deductible
Copay	N/A	N/A
Deductible	$1,500, Individual, $4,500 Family	$3,000, Individual, $9,000 Family

UnitedHealthcare Administered by Golden Rule — SelecTemp PPO - Plan IV

A comparison of the SelecTemp PPO - Plan IV 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	60% after deductible
Office Visit	80% of Allowable Amount after deductible	60% of Allowable Amount after deductible
Copay	N/A	N/A
Deductible	$2,000, Individual, $6,000 Family	$4,000, Individual, $12,000 Family

UnitedHealthcare Administered by Golden Rule — SelecTemp PPO - Plan V

A comparison of the SelecTemp PPO - Plan V 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	60% after deductible
Office Visit	80% of Allowable Amount after deductible	60% of Allowable Amount after deductible
Copay	N/A	N/A
Deductible	$2,500, Individual, $7,500 Family	$5,000, Individual, $15,000 Family

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	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 — Autograph Share 70 Plus Rx

A comparison of the Autograph Share 70 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	70%	50%
Office Visit	70% after deductible	50% after deductible
Copay	N/A	N/A
Deductible	$2,500	$5,000

UnitedHealthcare Administered by Golden Rule — Autograph Share 70 Plus Rx and Dental

A comparison of the Autograph Share 70 Plus Rx 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	70%	50%
Office Visit	70% after deductible	50% after deductible
Copay	N/A	N/A
Deductible	$2,500	$5,000

UnitedHealthcare Administered by Golden Rule — Autograph Share 70 Plus Rx

A comparison of the Autograph Share 70 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	70%	50%
Office Visit	70% after deductible	50% after deductible
Copay	N/A	N/A
Deductible	$5,000	$10,000

UnitedHealthcare Administered by Golden Rule — Autograph Share 70 Plus Rx and Dental

A comparison of the Autograph Share 70 Plus Rx 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	70%	50%
Office Visit	70% after deductible	50% after deductible
Copay	N/A	N/A
Deductible	$5,000	$10,000