United Healthcare of Texas Copay Select Plan Information
Calendar-Year Deductible Choices You pay: $500, $1,000, $1,500, $2,500, $5,000, $7,500 or $10,000
Coinsurance Choices You pay: 0% 20% 30%
Coinsurance Out-of-Pocket Maximum 0% $3,000 $5,000
Lifetime Maximum Benefit $3 Million ($5Million plan enhancment available)
Initial Rate Gaurantee 12 Months (24 Months plan enhancment available)
Physicians (Illness & Injury)
Office Visit -History and Exam $35 copay-no deductible ($25 Copay plan enhancment available)
Primary Care Physician/Specialist Referrals Required No
Prescription Drugs
If you choose name -brand when generic is available, you pay your generic copay plus the additional cost above the generic price.
Tier 1 drugs-$15 copay, no deductible
Tier 2-4 drugs-Combined $200 deductible per person, per calendar year, then:
Tier 2 drugs- $35 copay
Tier 3 drugs- $65 copay
Tier 4 drugs- you pay 25% coinsurance
Annual Maximum $3,000
Wellness/Preventive Care Benefits (3 months waiting period, not subject to deductible unless otherwise indicated)
Doctor Office Visit (adult or child, in net-work only) $35 copay
X-ray and Lab You pay: Chosen coinsurance
Child Immunizations (0-18) You Pay: Chosen coinsurance
Preventive Mammogram, Pap Smear, PSA screening You pay: Chosen coinsurance
Outpatient Expense Benefits
X-ray and Lab You pay: Chosen coinsurance after deductible
Facility/Hospital for Outpatient Surgery You pay: Chosen coinsurance after deductible
Surgeon, Assistant Surgeon, and Facility Fees You pay: Chosen coinsurance after deductible
Hemodialysis, Radiation, Chemotherapy, Organ Transplant Drugs, and CAT Scans, MRIs You pay: Chosen coinsurance after deductible
Emergency Room Fees-Ilness You pay: Chosen copay if not afmitted 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 and Back Disorders(CAT scan and MRI tests are not subject to this limitation) You pay: Chosen coinsurance after deductible (limited benefit)
Mental and Nervous Disorders (including substance abuse) You pay: Chosen coinsurance after deductible (limited benefit)
Inpatient Expense Benefits
Room and Board, Intensive Care Unit, Operating Room, Recovery Room, Prescription Drugs, Physician Visit, and Professional Fees of Doctors, Surgeons, Nurses You pay: Chosen coinsurance after deductible
Other Covered Inpatient Services You pay: Chosen coinsurance after deductible
Calendar-Year Deductible Choices You pay: $500, $1,000, $1,500, $2,500, $5,000, $7,500 or $10,000
Coinsurance Choices You pay: 0% 20% 30%
Coinsurance Out-of-Pocket Maximum 0% $3,000 $5,000
Lifetime Maximum Benefit $3 Million ($5Million plan enhancment available)
Initial Rate Gaurantee 12 Months (24 Months plan enhancment available)
Physicians (Illness & Injury)
Office Visit -History and Exam $35 copay-no deductible ($25 Copay plan enhancment available)
Primary Care Physician/Specialist Referrals Required No
Prescription Drugs
If you choose name -brand when generic is available, you pay your generic copay plus the additional cost above the generic price.
Tier 1 drugs-$15 copay, no deductible
Tier 2-4 drugs-Combined $200 deductible per person, per calendar year, then:
Tier 2 drugs- $35 copay
Tier 3 drugs- $65 copay
Tier 4 drugs- you pay 25% coinsurance
Annual Maximum $3,000
Wellness/Preventive Care Benefits (3 months waiting period, not subject to deductible unless otherwise indicated)
Doctor Office Visit (adult or child, in net-work only) $35 copay
X-ray and Lab You pay: Chosen coinsurance
Child Immunizations (0-18) You Pay: Chosen coinsurance
Preventive Mammogram, Pap Smear, PSA screening You pay: Chosen coinsurance
Outpatient Expense Benefits
X-ray and Lab You pay: Chosen coinsurance after deductible
Facility/Hospital for Outpatient Surgery You pay: Chosen coinsurance after deductible
Surgeon, Assistant Surgeon, and Facility Fees You pay: Chosen coinsurance after deductible
Hemodialysis, Radiation, Chemotherapy, Organ Transplant Drugs, and CAT Scans, MRIs You pay: Chosen coinsurance after deductible
Emergency Room Fees-Ilness You pay: Chosen copay if not afmitted 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 and Back Disorders(CAT scan and MRI tests are not subject to this limitation) You pay: Chosen coinsurance after deductible (limited benefit)
Mental and Nervous Disorders (including substance abuse) You pay: Chosen coinsurance after deductible (limited benefit)
Inpatient Expense Benefits
Room and Board, Intensive Care Unit, Operating Room, Recovery Room, Prescription Drugs, Physician Visit, and Professional Fees of Doctors, Surgeons, Nurses You pay: Chosen coinsurance after deductible
Other Covered Inpatient Services You pay: Chosen coinsurance after deductible
Calendar-Year Deductible Choices You pay: $500, $1,000, $1,500, $2,500, $5,000, $7,500 or $10,000
Coinsurance Choices You pay: 0% 20% 30%
Coinsurance Out-of-Pocket Maximum 0% $3,000 $5,000
Lifetime Maximum Benefit $3 Million ($5Million plan enhancment available)
Initial Rate Gaurantee 12 Months (24 Months plan enhancment available)
Physicians (Illness & Injury)
Office Visit -History and Exam $35 copay-no deductible ($25 Copay plan enhancment available)
Primary Care Physician/Specialist Referrals Required No
Prescription Drugs
If you choose name -brand when generic is available, you pay your generic copay plus the additional cost above the generic price.
Tier 1 drugs-$15 copay, no deductible
Tier 2-4 drugs-Combined $200 deductible per person, per calendar year, then:
Tier 2 drugs- $35 copay
Tier 3 drugs- $65 copay
Tier 4 drugs- you pay 25% coinsurance
Annual Maximum $3,000
Wellness/Preventive Care Benefits (3 months waiting period, not subject to deductible unless otherwise indicated)
Doctor Office Visit (adult or child, in net-work only) $35 copay
X-ray and Lab You pay: Chosen coinsurance
Child Immunizations (0-18) You Pay: Chosen coinsurance
Preventive Mammogram, Pap Smear, PSA screening You pay: Chosen coinsurance
Outpatient Expense Benefits
X-ray and Lab You pay: Chosen coinsurance after deductible
Facility/Hospital for Outpatient Surgery You pay: Chosen coinsurance after deductible
Surgeon, Assistant Surgeon, and Facility Fees You pay: Chosen coinsurance after deductible
Hemodialysis, Radiation, Chemotherapy, Organ Transplant Drugs, and CAT Scans, MRIs You pay: Chosen coinsurance after deductible
Emergency Room Fees-Ilness You pay: Chosen copay if not afmitted 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 and Back Disorders(CAT scan and MRI tests are not subject to this limitation) You pay: Chosen coinsurance after deductible (limited benefit)
Mental and Nervous Disorders (including substance abuse) You pay: Chosen coinsurance after deductible (limited benefit)
Inpatient Expense Benefits
Room and Board, Intensive Care Unit, Operating Room, Recovery Room, Prescription Drugs, Physician Visit, and 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 Texas health insurance plans:
