United Healthcare of Illinois HSA Plan 100 Plan Information
HSA 100®
Deductible $5,000
Maximum Family Deductible One deductible per family per calendar year
Coinsurance 100/0
Coinsurance Out-of-Pocket Maximum After Deductible $0
Note In-network per family per year
Plan Enhancements
Lifetime Maximum $3 Million-$5 Million
Initial Rate Guarantee 12 Month-24 Months
Prescription Drug $3,000 Annual Maximum -No Annual Maximum
Office Visit No charge after Ded
Physicians (Illness & Injury)
Office Visit History & Exam (Primary Care, Specialist) No charge after deductible
Primary Care Physician / Specialist Referrals Required No
Prescription Drug
Prescription Drugs Preferred price card - No charge after deductible
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: $0 (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: $0 (ages 0-18, 3 month waiting period, not subject to deductible)
Preventive Mammogram & PSA Testing You pay: $0 (no waiting period)
Outpatient Expense Benefits
X-ray & Lab No charge after deductible (performed in the doctor’s office or a network facility)
Facility/Hospital for Outpatient Surgery No charge after deductible
Surgeon, Assistant Surgeon, & Facility Fees No charge after deductible
Hemodialysis, Radiation, Chemotherapy, Organ Transplant Drugs, & CAT Scans, MRIs No charge after deductible
Emergency Room Fees - Illness No charge after deductible
Emergency Room Fees - Injury No charge after deductible
Other Covered Outpatient Expenses No charge after deductible
Spine & Back Disorders No charge after deductible (Limited benefit)
Mental & Nervous Disorders (including substance abuse) No charge after deductible (Limited benefit)
Inpatient Expense Benefits
Room & Board, Intensive Care Unit, Operating Room, Recovery Room, Physician Visit, & Professional Fees of Doctors, Surgeons, Nurses No charge after deductible
Other Covered Inpatient Services No charge after deductible
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