United Healthcare of Illinois Copay Select Plan Information
Copay Select
Deductible $500 $1,000 $1,500 $2,500 $5,000 $7,500 $10,000
Maximum Family Deductible Maximum two deductibles per family per calendar year
Coinsurance 80/20 70/30 100/0
Coinsurance Out-of-Pocket Maximum After Deductible $5,000
Plan Enhancements
Lifetime Maximum $3 Million $5 Million
Initial Rate Guarantee 12 Month 24 Month
Prescription Drug $3,000 Annual Maximum No Annual Maximum
Office Visit $35 Copay $25 Copay
Physicians (Illness & Injury)
Office Visit - History & Exam (Primary Care, Specialist) $35 copay - not subject to deductible ($25 copay available)
Primary Care Physician / Specialist Referrals Required No
Prescription Drug
Prescription Drugs Tier 1 - $15 copay, no deductible; Tier 2-4 – combined $200 calendar-year deductible, then Tier 2 - $35 copay; Tier 3 - $65 copay; Tier 4 – you pay 25% coinsurance (If you choose name-brand when generic is available, you pay your generic copay plus the additional cost above the generic price)
Annual Maximum $3000 covered (not paid) per person per calendar year (No annual maximum available)
Wellness/Preventive Care
Doctor Office Visit (adult or child) $35 copay (3 month waiting period)
X-ray & Lab You pay: chosen coinsurance (in conjunction with the preventive office visit, performed in the doctor’s office or a network facility; 3 month waiting period, not subject to deductible)
Child Immunizations You pay: chosen coinsurance - not subject to deductible (3 month waiting period)
Preventive Mammogram & PSA Testing You pay: chosen coinsurance - not subject to deductible (no waiting period)
Outpatient Expense Benefits
X-ray & Lab You pay: chosen coinsurance after deductible (performed in the doctor’s office or a network facility)
Facility/Hospital for Outpatient Surgery You pay: chosen coinsurance after deductible
Surgeon, Assistant Surgeon, & Facility Fees You pay: chosen coinsurance after deductible
Hemodialysis, Radiation, Chemotherapy, Organ Transplant Drugs, & CAT Scans, MRIs You pay: chosen coinsurance after deductible
Emergency Room Fees - Illness You pay: $100 copay if not admitted, then chosen coinsurance after deductible
Emergency Room Fees - Injury You pay: chosen coinsurance after deductible
Other Covered Outpatient Expenses You pay: chosen coinsurance after deductible
Spine & Back Disorders You pay: chosen coinsurance after deductible (Limited benefit; CAT scan and MRI tests are not subject to this limitation)
Mental & Nervous Disorders (including substance abuse) You pay: chosen coinsurance after deductible (Limited benefit)
Inpatient Expense Benefits
Room & Board, Intensive Care Unit, Operating Room, Recovery Room, Physician Visit, & Professional Fees of Doctors, Surgeons, Nurses You pay: chosen coinsurance after deductible
Other Covered Inpatient Services You pay: chosen coinsurance after deductible
Other United Healthcare of Illinois health insurance plans:
