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Arizona Medical Insurance > Golden Rule Insurance Company > Copay Plan Benefits

UnitedHealthCare underwritten by Golden Rule

Convenient Doctor Office Copay Benefits

Copay plans are more like traditional employer plans with a copayment for routine health care expenses. When you use a Preferred Network doctor for an office visit, we pay 100% of history and exam fees after a $35 copay with Copay SelectSM. Office visit expenses outside your network are not eligible for copay benefits.

Adult and Child Preventive Care Included

You pay $35 for the doctor office visit with Copay Select. X-ray and lab tests are covered at 80% — you pay 20%.

Prescription Drug Card Benefits

  • Tier 1 drugs: $15 Copay
  • Tiers 2-4 - combined $150 per person, per calendar year deductible , then:
    — Tier 2 drugs: $30 Copay
    — Tier 3 drugs: $60 Copay
    — Tier 4 drugs: you pay 25% coinsurance

Comprehensive Coverage for Inpatient and Outpatient Medical Expenses

  • You choose $3 million or $5 million lifetime maximum benefit per covered person
  • Covered inpatient and outpatient expenses are reimbursed at 80% once the deductible has been met

Copay SaverSM

The Copay SaverSM plan provides the convenience of copays for doctor office visits (limited to 2 visits per person, per calendar year) for a lower monthly premium.

 
Copay Select SM
Copay Saver SM
Design Basics
Calendar-Year Deductible Choices
(maximum 2 per family, per calendar year)
You pay: 500, $1,000, $1,500, $2,500, or $5,000
You pay: $1,500, $2,500 or $5,000
Coinsurance After Deductible
(per covered person, per calendar year)
You pay: 20% to $2,000
We pay: 80% to $8,000 then 100%
You pay: 20% to $3,000
We pay: 80% to $12,000 then 100%
Lifetime Maximum Benefit
(per covered person)
$3 million
($5 million available)
$3 million
($5 million available)
Initial Rate Guarantee
(subject to benefit and address changes)
12 months
12 months
We pay the percentages below AFTER you pay the deductible unless otherwise indicated.
Preventive Care Benefits
Doctor Office Visit
($300 annual max.)
(Not subject to deductible)
History and exam: $35 Copay
X-ray and Lab: 80%
Not Covered
Child Immunizations
($300 annual max., age 0-18)
Vaccine: 80%
(not subject to deductible)
Not Covered
Preventive Mammogram, Pap Smear, PSA Testing
Testing: 80%
(not subject to deductible)
Testing: 80%
Outpatient Expense Benefits
Doctor Office Visit Fees — Illness & Injury
(not subject to the deductible)
For history and exam: $35 Copay
For history and exam: $35 Copay, then 100% (maximum 2 visits per person, per year — with an option to buy 2 more, see Optional Benefits)
Outpatient X-ray and Lab
(performed in a doctor's office or a network facility)
80%
80% if performed within 14 days of a surgery or confinement
Outpatient Prescription Drugs*
(Maximum $3,000 per covered person, per calendar year for Copay Select SM.  Or choose the optional Prescription Drug Benefit Buy-up to eliminate this annual limit)
Tier 1 drugs: $15 Copay
Tiers 2-4 - combined $150 per person, per calendar year deductible, then:
Tier 2 drugs: $30 Copay
Tier 3 drugs: $60 Copay
Tier 4 drugs: you pay 25% coinsurance
Generic: $15 Copay
Name-brand: not covered
Surgeon, Assistant Surgeon, and Facility Fees
80%
80%
Hemodialysis, Radiation, Chemotherapy, and Organ Transplant Drugs
80%
80%
Cat Scans, MRIs
80%
80%
Emergency Room Fees
Illness: 80%, additional $100 Copay if not admitted
Injury: 80%
Illness & Injury: 80%, additional $500 Copay if not admitted
Other Covered Outpatient Expenses
80%
Inpatient Expense Benefits
Room and Board, Intensive Care Unit, Operating Room, Recovery Room, and Professional Fees of Doctors, Surgeons, Nurses
80%
80%
Other Covered Inpatient Services
80%
80%
Dental and Vision Discounts — Programs Are Not Insurance Discounts through FACT membership provided by Health Allies — save up to 50% on dental and vision.
Optional Benefits — For a complete list, see Optional Benefits.
  • $5 Million Lifetime Maximum Benefit
  • First-Dollar Accident Benefit
  • Term Life Benefit
  • Maternity Benefit
  • Enhanced Preventive Care Benefits Package
  • Two additional Doctor Office Visits (Copay SaverSM)
  • Prescription Drug Card Benefit Buy-up (Copay SelectSM)
This chart only summarizes standard covered expenses, exclusions, and limitations of each plan. To be considered for reimbursement, expenses must qualify as covered expenses. Expenses are also subject to reasonable and customary limits unless you use a network. We recommend review of the more detailed plan information under Covered Expenses, Provisions That Apply To All Plans.

*NOTE:  Tier status for a prescription drug may be determined by accessing your prescription drug benefits view the company web site or by calling the telephone number on you ridentification card.  The tier to which a prescription drug is assigned may change as detailed in your policy/certificate.

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