survival guide - the insurance exchange

SURVIVAL GUIDE2019 4th QTR

Table of Contents

1. UHC Fully Insured Plans 1-100

1.1 TX Comparison 1-100……………………………………………………………………………………………………………………………

1.2 2019 Dallas Multi-Choice Portfolio for 1-50…………………………………………………………………….…………………...

1.3 2019 Amarillo Core Essential Portfolio for 1-50…………………………………………………………………………………….

1.4 2020 Texas Charter Multi-Choice Portfolio for 1-50………………..…………………………………………………….………

1.5 2020 Texas Non-Charter Multi-Choice Portfolio for 1-50…………………………………….…………………………………

1.6 2020 Amarillo Core Essential Portfolio for 1-50…………………………………………………………………………………….

1.7 2019 Dallas Multi-Choice Portfolio for 51-100…………….…………………………………………………………….………….

1.8 2019 Amarillo Core & Core Essential Portfolio for 51-100……………………………………………………………………..

1.9 UnitedHealthcare Motion Overview……………………………………………………….………………………………………….

1.10 Virtual Visits Flier…………………………………………………………………………………………………….…………………………

1.11 $0 Kid Copay Flier………………………………………………………………………………………………………………………………

1.12 Charter Plan Highlights…………………………………………………………………………………..…………………………………...

1.13 El Paso Charter Flier……………………………………………………………………………………………………………………………..

1.14 Choice EPO Flier……………………………………………………………………………………………………………………………………

1.15 Fully Insured Broker Contact Numbers………………………………………………………………………………………………….

1.16 TX 1-50 Checklist………………………………………………………..………………………………………………………………….……

1.17 TX 51-100 Checklist........………………………………………...………………………………………………………..…………………

2. AllSavers Alternate Funding Plans 5-100

2.1 All Savers Overview……………………………………………………………………………………………………………………..…….

2.2 AllSavers 2019 Portfolio…………………………………………...………………………………………………………………………….

2.3 All Savers – UHC Comparison………………………………………………………………………………………………………………..

2.4 AllSavers Wellness Flier………………….…………………………………………………………………………………………………….

2.5 HealthiestYou Flier……………………………………………………………………………………………………………………………….

2.6 HealthiestYou Adding Dependent…………………………………………………………………………………………………………

2.7 AllSavers Motion Flier…………………………………………………………………………………………………………………………..

2.9 15 Month Rate Guarantee Flier…………………………………………………………………………………………………………….

2.10 AllSavers HB2015 with GRX guidelines………………………………………………………………………………………………….

2.11 AllSavers Final Checklist………………………………………………………………………………………………………………….…..

2.12 AllSavers Broker Contacts……………………………………………………………………………………………………….…………..

2.8 All Savers Real Appeal Flier…………………………………………………………………………………………………………………..

3. UHC Specialty Products

3.1 Specialty Benefits Smart Card………………………………………………………………………………………………................

3.2 3rd Quarter Vision Rate Card ……………………………………………………………………………………………….….….……….

3.3 4th Quarter Vision Rate Card………………………………………………………………………………………………………..……..

3.4 uBundle National 51-100 Employer Flier…………………………………………………………………………………….……….

3.5 Packaged Savings 2-99 Employer Flier………………………………………………………………….………………….………….

3.6 Warby Parker Benefits Member Flier……………………………………………………………………………………………………

3.7 How to get my UHC Vision ID Card…………………………………………………………………………………….………..………

3.8 2019 Dental Top Selling Plans Cheat Sheet…………………………………………………………………………………..………

Texas1-50 ATNE & 51-100 Eligible Employees

UnitedHealthcare ProductComparison Chart

PCP Specialist Virtual VisitsConvenience

CareUrgent Care ER Lab-Xray MRI

Inpatient Hospital

Outpatient Surgery

Premier$20-$35

$0 for child

$40-$70Premium

Designationspec at PCP

copay

$0 PCP copay $50-$75$300 or

$250 + coins$0

$400 orded + coins

ded + coins ded + coins

Premier Value$30-$45

$0 for child

$60-$90Premium

Designationat PCPcopay

$0 PCP copay $50-$100$300-$500 or$400 + coins

ded + coins $400$250+

ded + coins$250+

ded + coins

Premier PROformance$10-$15

$0 for child

$80-$100Premium Designation

at $40-$50

$0 PCP copay $25$300+

ded + coins$40 or

ded + coins$500 or

ded + coinsded + coins ded + coins

Primary Advantage® $0 $100 $0 $0 $50$250+

ded + coinsded + coins ded + coins ded + coins ded + coins

UnitedHealthcare FlexFree$0 1st 3 visits,

then ded + coins$0 $0

$0 1st 2 visits,then ded + coins

$250+ ded + coins

ded + coins$250+

ded + coins$250+

ded + coins$250+

ded + coins

HSA ded + coins ded + coins ded + coins ded + coins ded + coins ded + coins ded + coins ded + coins ded + coins ded + coins

UnitedHealthcare Navigate®$10-$25

$0 for childReferral required;

$30-$75$0 PCP copay $25-$100

$500-$650 or$500+ded+coins

Two options

offered1 $500Two options

offered2

Two options

offered2

UnitedHealthcare Charter®$10-$35

$0 for childReferral required;

$30-$105$0 PCP copay $25-$100

$500-$650 or$500+ded+coins

Two options

offered1 $500Two options

offered 3Two options

offered 3

1-Either $0-$40 or Deductible + Coinsurance

2-Either $250+Deductible+Coinsurance or Deductible + Coinsurance

3-Either $250/$400+Deductible+Coinsurance or Deductible + Coinsurance

Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by United HealthCare Services, Inc. or their affiliates.Health Plan coverage provided by or through UnitedHealthcare of Texas, Inc.

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1.1

Dallas-Multi-Choice Package 1-50 ATNE Employees

January 1, 2019

2019 Health Plan Product OfferingUnitedHealthcare Multi-Choice® allows you to purchase one health plan package with multiple benefit designoptions to meet a variety of health care and financial needs. Your employees can choose the option thatmeets their individual needs, whether it’s saving money on essential coverage or paying additional dollars formore comprehensive coverage. And you can keep or change your benefit design package year after year,ensuring that your health plan will evolve with the changing needs of your business and your employees.

UnitedHealthcare Premier PROformance Plans

Package

28 29 3018

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Plan Code

Choice+ EPO11

Coinsurance

NetworkOut of

Network

Deductible

Network

Single Family

Out of Network

Single Family

Out-Of-Pocket Maximum

Network

Single Family

Out of Network

Single Family

Copay/Per Occurrence

Virtual Visits

PCPAges

19+1

PCPAges

<191

SpecPrem

Des2

Spec3 UrgentCare

ER Lab/Xray MRI, CT.I/P & O/PSurgery

Rx Plan

• • G BI-ZG BG-HJ 80% 50% $1,500 $3,000 $5,000 $15,000 $6,500 $13,000 $10,000 $30,000 $0 $15 $0 $50 $100 $25$300+

Ded+20%Ded+20% Ded+20% Ded+20%

627-5/50/100/250

• • • G BI-ZH BG-HN 80% 50% $2,500 $5,000 $5,000 $15,000 $6,300 $12,600 $10,000 $30,000 $0 $15 $0 $50 $100 $25$300+


627-5/50/100/250

• • S BI-ZF BG-HG 80% 50% $6,000 $12,000 $10,000 $30,000 $7,350 $14,700 $20,000 $60,000 $0 $15 $0 $50 $100 $25$300+


627-5/50/100/250

UnitedHealthcare Primary Advantage Plans

Package

28 29 3018

Me

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c

Plan Code

Choice+ EPO11

Coinsurance

NetworkOut of

Network

Deductible

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family


Virtual Visits

PCP1 SpecUrgentCare


Rx Plan

• G BI-XS AS-54 80% 50% $1,000 $2,000 $5,000 $10,000 $5,000 $13,000 $10,000 $20,000 $0 $0 $100 $50$250+

Ded+20%Ded+20% Ded+20% Ded+20% 548 - 5/50/100/250

16

• G BI-XT AV-VQ 80% 50% $2,500 $5,000 $7,500 $15,000 $5,500 $13,500 $15,000 $30,000 $0 $0 $100 $50$250+

Ded+20%Ded+20% Ded+20% Ded+20% 548 - 5/50/100/250

16

• • S BI-XW AV-VS 70% 50% $5,000 $10,000 $10,000 $20,000 $7,350 $14,700 $10,000 $20,000 $0 $0 $100 $50$250+

Ded+30%Ded+30% Ded+30% Ded+30% 548 - 5/50/100/250

16

• S BI-XX BI-X8 70% 50% $7,000 $14,000 $10,000 $20,000 $7,900 $15,800 $10,000 $20,000 $0 $0 $100 $50$250+

Ded+30%Ded+30% Ded+30% Ded+30% 548 - 5/50/100/25016

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1.2


January 1, 2019

2019 Health Plan Product Offering

UnitedHealthcare Premier Value Plans

Package

28 29 3018

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Plan Code

Choice+ EPO11

Coinsurance

NetworkPhysician

Out ofNetwork

Deductible

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family


Virtual Visits

PCPAges

19+1

PCPAges

<191

SpecPrem

Des2

Spec3 UrgentCare


Rx Plan

• • G BI-Y6 AV-XD 100% 70% $1,000 $3,000 $5,000 $15,000 $6,350 $12,700 $10,000 $30,000 $0 $40 $0 $40 $80 $50 $400 Ded $400 $250+Ded NS-10/35/60

• • G BI-Y7 AV-XE 100% 70% $3,000 $9,000 $5,000 $15,000 $4,000 $12,000 $10,000 $30,000 $0 $35 $0 $35 $70 $50 $300 Ded $400 $250+Ded DV-20/45/80

• • • S BI-Y8 BI-ZC 100% 70% $6,000 $12,000 $10,000 $30,000 $7,350 $14,700 $20,000 $60,000 $0 $45 $0 $45 $90 $50 $500 Ded $400 $250+Ded DV-20/45/80

• • G BI-Y9 BI-ZD 80% 50% $2,000 $6,000 $5,000 $15,000 $7,000 $14,000 $10,000 $30,000 $0 $30 $0 $30 $60 $50 $400+20% Ded+20% $400$250+

Ded+20%DT-15/40/70

• S BI-ZA BI-ZE 80% 50% $4,500 $13,500 $10,000 $30,000 $7,350 $14,700 $20,000 $60,000 $0 $45 $0 $45 $90 $50 $400+20% Ded+20% $400$250+

Ded+20%DT-15/40/70

• G BI-ZI BI-ZJ 50% 50% $1,000 $3,000 $5,000 $15,000 $5,000 $10,000 $10,000 $30,000 $0 $35 $0 $35 $70 $50 $400+50% Ded+50% $400$250+

Ded+50%DV-20/45/80

• G BI-ZK BI-ZL 50% 50% $2,000 $6,000 $5,000 $15,000 $4,800 $9,600 $10,000 $30,000 $0 $35 $0 $35 $70 $50 $400+50% Ded+50% $400$250+

Ded+50%DV-20/45/80

• S BI-ZM BI-ZN 50% 50% $5,000 $10,000 $10,000 $30,000 $7,300 $14,600 $20,000 $60,000 $0 $35 $0 $35 $70 $50 $400+50% Ded+50% $400$250+

Ded+50%DV-20/45/80

UnitedHealthcare Health Savings Account (HSA) Motion Plans

Package

28 29 3018

Me

talli

c

Plan Code

Choice+ EPO11

Contrib Range

Coinsurance

NetworkOut of

Network

Deductible

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family


Virtual Visits

PCP1 SpecUrgentCare


Rx Plan9 Ded

Type5

• S BI-XU AV-VZ $0-$0 100% 70% $4,000 $8,000 $5,000 $15,000 $6,650 $13,300 $10,000 $30,000 100% 100% 100% 100% 100% 100% 100% 100% 871-0/25/50/100 Emb

• • • S BI-XM AE-O5 $0-$400 100% 70% $5,000 $10,000 $10,000 $30,000 $6,000 $12,000 $20,000 $60,000 100% 100% 100% 100% 100% 100% 100% 100% 871-0/25/50/100 Emb

• B BI-XV AV-VX $0-$0 100% 70% $6,650 $13,300 $10,000 $30,000 $6,650 $13,300 $20,000 $60,000 100% 100% 100% 100% 100% 100% 100% 100% 273-100% Emb

• S BI-XZ BI-X2 $0-$0 80% 50% $2,250 $4,500 $5,000 $15,000 $6,500 $7,150 $10,000 $30,000 100% 100% $1009 $509 $250+20%9 80% 80% 80% 871-0/25/50/100 Non-Emb

• S BI-XN AE-O6 $0-$0 80% 50% $2,700 $5,400 $5,000 $15,000 $6,350 $12,700 $10,000 $30,000 80% 80% 80% 80% 80% 80% 80% 80% 871-0/25/50/100 Emb

• • • S BI-XO AE-O7 $0-$350 80% 50% $3,750 $7,500 $5,000 $15,000 $6,350 $12,700 $10,000 $30,000 80% 80% 80% 80% 80% 80% 80% 80% 871-0/25/50/100 Emb

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January 1, 2019


UnitedHealthcare Navigate Plans8, 11

Package

28 29 3018

Me

talli

c NavigatePlan Code

Plan TypeContrib Range

Coins

Network

Deductible

Network

Single Family


Network

Single Family


Virtual Visits

PCPAges

19+1

PCPAges

<191

Specw/PCP

Referral

UrgentCare


Rx PlanDed

Type5

• G BI-Z2 PROformance N/A 80% $1,500 $3,000 $6,500 $13,000 $0 $15 $0 $50-Prem Des/$100 $25$300+

Ded+20% Ded+20% Ded+20% Ded+20% 099-15/50/100/125 Emb

• • G BI-Z3 PROformance N/A 80% $2,500 $5,000 $6,300 $12,600 $0 $15 $0 $50-Prem Des/$100 $25$300+

Ded+20%Ded+20% Ded+20% Ded+20% 099-15/50/100/125 Emb

• • S BI-Z4 PROformance N/A 80% $6,000 $12,000 $7,350 $14,700 $0 $15 $0 $50-Prem Des/$100 $25$300+


• G BI-YO Primary Advantage N/A 80% $1,000 $2,000 $5,000 $10,000 $0 $0 $0 $100 $50$250+


• G BI-YQ Primary Advantage N/A 80% $2,500 $5,000 $5,500 $13,500 $0 $0 $0 $100 $50$250+


• S BI-YT Primary Advantage N/A 70% $5,000 $10,000 $7,350 $14,700 $0 $0 $0 $100 $50$250+

Ded+30% Ded+30% Ded+30% Ded+30% 098-10/50/100/125 Emb

• S BI-YU Primary Advantage N/A 70% $7,000 $14,000 $7,900 $15,800 $0 $0 $0 $100 $50$250+


• P AV-V2 Copay N/A 100% N/A N/A $2,000 $6,000 $0 $10 $0 $30 $50 $650 Ded $500 $250 098-10/50/100/125 Emb

• G BI-YC Copay N/A 100% $1,000 $3,000 $6,600 $13,200 $0 $15 $0 $45 $50 $650 Ded $500 $250+Ded 098-10/50/100/125 Emb

• G AV-V4 Copay N/A 100% $3,000 $9,000 $5,000 $10,000 $0 $15 $0 $45 $50 $650 Ded $500 $250+Ded 099-15/50/100/125 Emb

• S BI-YD Copay N/A 80% $5,000 $10,000 $7,350 $14,700 $0 $35 $0 $105 $50 $650 Ded+20% $500 $250+Ded+20% 099-15/50/100/125 Emb

• S BI-YE HSA W/Motion $0-$0 100% $4,000 $8,000 $6,650 $13,300 100% 100% 100% 100% 100% 100% 100% 100% 100% 871-0/25/50/100 Emb

• S AE-PE HSA W/Motion $0-$400 100% $5,000 $10,000 $6,000 $12,000 100% 100% 100% 100% 100% 100% 100% 100% 100% 871-0/25/50/100 Emb

• B BI-YX HSA W/Motion $0-$0 100% $6,650 $13,300 $6,650 $13,300 100% 100% 100% 100% 100% 100% 100% 100% 100% 273-100% Emb

• S BI-Y2 HSA W/Motion $0-$0 80% $2,250 $4,500 $6,500 $7,150 100% 100% 100% 100% $509 $250+20%9 80% 80% 80% 871-0/25/50/100 Non-Emb

• S BI-YF HSA W/Motion $0-$0 80% $2,700 $5,400 $6,350 $12,700 80% 80% 80% 80% 80% 80% 80% 80% 80% 871-0/25/50/100 Emb

• S BI-YG HSA W/Motion $0-$350 80% $3,750 $7,500 $6,350 $12,700 80% 80% 80% 80% 80% 80% 80% 80% 80% 871-0/25/50/100 Emb

UnitedHealthcare FlexFree Plans17

Package

28 29 3018

Me

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Plan Code

Choice+ EPO11

Coinsurance

NetworkOut of

Network

Deductible

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family


Virtual Visits

PCP1 SpecUrgentCare


Rx Plan

• G BI-XP AV-VM 80% 50% $1,000 $3,000 $5,000 $15,000 $5,000 $14,000 $10,000 $30,000 $0 $0/3 visits combined $0/2 visits$250+

Ded+20%Ded+20%

$250+Ded+20%

$250+Ded+20%

099 -15/50/100/125

• S BI-XQ BI-XR 80% 50% $4,000 $12,000 $5,000 $15,000 $7,500 $15,000 $10,000 $30,000 $0 $0/3 visits combined $0/2 visits$250+

Ded+20%Ded+20%

$250+Ded+20%

$250+Ded+20%

099 -15/50/100/125

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January 1, 2019


UnitedHealthcare Dallas Charter HMO Plans8, 11

(These plans are only available in the following counties: Collin, Dallas, Denton, Ellis, Fannin, Hunt, Johnson, Parker, Rockwall and Tarrant)

Package

28 29 3018

Me

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Plan Type

Coins

Network

Deductible

Network

Single Family


Network

Single Family


Virtual Visits

PCPAges

19+1

PCPAges

<191

Specw/PCPReferral

UrgentCare


Ded Type5

Rx Plan

• P AV-WE Copay 100% $500 $1,500 $2,000 $6,000 $0 $20 $0 $60 $50 $500 100% $500 Ded Emb DV-20/45/80

• G AV-WL Copay 100% $2,000 $6,000 $7,350 $14,700 $0 $20 $0 $60 $50 $650 Ded $500 $250+Ded Emb NS-10/35/60

• G BI-YH Copay 80% $1,000 $3,000 $7,350 $14,700 $0 $20 $0 $60 $50 $500 Ded+20% $500 Ded+20% Emb DT-15/40/70

• G BI-YJ Copay 80% $2,000 $6,000 $7,350 $14,700 $0 $20 $0 $60 $50 $500 Ded $500 Ded+20% Emb NS-10/35/60

• S BI-YM Copay 80% $4,500 $13,500 $7,500 $15,000 $0 $35 $0 $105 $50 $650 Ded+20% $500 $400+Ded+20% Emb DV-20/45/80

• S BI-YN Copay 70% $4,000 $12,000 $7,500 $15,000 $0 $35 $0 $105 $50 $650 Ded+30% $500 $400+Ded+30% Emb DV-20/45/80

• S BI-YI Copay 70% $6,500 $13,000 $7,500 $15,000 $0 $35 $0 $105 $50 $500 Ded+30% $500 Ded+30% Emb DV-20/45/80

• S BI-YK HSA w/Motion 100% $4,000 $8,000 $6,650 $13,300 100% 100% 100% 100% 100% 100% 100% 100% 100% Emb 871-0/25/50/100

• S BI-YW HSA w/Motion 100% $5,000 $10,000 $6,000 $12,000 100% 100% 100% 100% 100% 100% 100% 100% 100% Emb 871-0/25/50/100

• B BI-YY HSA w/Motion 100% $6,650 $13,300 $6,650 $13,300 100% 100% 100% 100% 100% 100% 100% 100% 100% Emb 273-100%

• S BI-Y3 HSA w/Motion 80% $2,250 $4,500 $6,500 $7,150 100% 100% 100% $1009

$509

$250+20%9

80% 80% 80% Non-Emb 871-0/25/50/100

• S BI-YZ HSA w/Motion 80% $2,700 $5,400 $6,350 $12,700 80% 80% 80% 80% 80% 80% 80% 80% 80% Emb 871-0/25/50/100

• S BI-YL HSA w/Motion 80% $3,750 $7,500 $6,350 $12,700 80% 80% 80% 80% 80% 80% 80% 80% 80% Emb 871-0/25/50/100

• B BI-6N Value HSA 75% $6,250 $12,500 $6,650 $13,300 75% 75% 75% 75% 75% 75% 75% 75% 75% Emb 871-0/25/50/100

• G BI-YP Primary Advantage 80% $1,000 $2,000 $5,000 $10,000 $0 $0 $0 $100 $50$250+

Ded+20%Ded+20% Ded+20% Ded+20% Emb 098-10/50/100/125

• G BI-YR Primary Advantage 80% $2,500 $5,000 $5,500 $13,500 $0 $0 $0 $100 $50$250+


• S BI-YS Primary Advantage 70% $5,000 $10,000 $7,350 $14,700 $0 $0 $0 $100 $50$250+


• S BI-YV Primary Advantage 70% $7,000 $14,000 $7,900 $15,800 $0 $0 $0 $100 $50$250+


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January 1, 2019


UnitedHealthcare Premier Plans

Package

28 29 3018

Me

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Plan Code

Choice+ EPO11

Coinsurance

NetworkPhysician

Out ofNetwork

Deductible

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family


Virtual Visits

PCPAges

19+1

PCPAges

<191

SpecPrem

Des2

Spec3 UrgentCare


Rx Plan

• • • G BI-Y4 100% 70% $3,500 $10,500 $5,000 $15,000 $7,350 $14,700 $10,000 $30,000 $0 $35 $0 $35 $70 $50 $300 100% $400 Ded DV-20/45/80

• • G BI-ZB 100% 70% $3,500 $10,500 $5,000 $15,000 $7,350 $14,700 $10,000 $30,000 $0 $35 $0 $35 $70 $50 $300 100% $400 Ded DV-20/45/80

• • G BI-Y5 100% 70% $5,000 $10,000 $10,000 $30,000 $7,000 $14,000 $20,000 $60,000 $0 $30 $0 $30 $60 $50 $300 100% $400 Ded DV-20/45/80

• G AV-W7 100% 70% $5,000 $10,000 $10,000 $30,000 $7,000 $14,000 $20,000 $60,000 $0 $30 $0 $30 $60 $50 $300 100% $400 Ded DV-20/45/80

UnitedHealthcare Health Reimbursement Account (HRA) Plans

Package

28 29 3018

Me

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Plan Code

Choice+

Coinsurance

NetworkOut of

Network

Deductible

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family


Virtual Visits

PCPAges

19+1

PCPAges

<191

SpecPrem

Des2

Spec3 UrgentCare


Rx Plan

• S BI-XY 80% 50% $5,000 $10,000 $10,000 $30,000 $6,350 $12,700 $20,000 $60,000 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% DT-15/40/70

Pharmacy Plans

Rx PlanCode

Copays

Tier 1Tier 1

Specialtycopay

Tier 2Tier 2

Specialtycopay

Tier 3Tier 3

Specialtycopay

Tier 4 Tier 4

Specialtycopay

Deductible

Single Family

MailOrderRatio

NS $10 $10 $35 $100 $60 $300 N/A N/A N/A N/A 2.5

871* $0 N/A $25 N/A $50 N/A $100 N/A Same as medical Same as medical 2.5

DT $15 $15 $40 $100 $70 $300 N/A N/A N/A N/A 2.5

DV $20 $20 $45 $100 $80 $300 N/A N/A N/A N/A 2.5

098 $10 $10 $50 $100 $100 $300 $125 $500 N/A N/A 2.5

099 $15 $15 $50 $100 $100 $300 $125 $500 N/A N/A 2.5

627 $5 N/A $50 N/A $100 N/A $250 N/A N/A N/A 2.5

548 $5 N/A $50 N/A $100 N/A $250 N/A $250 $500 2.5

273* No Copay N/A No Copay N/A No Copay N/A N/A N/A Same as Medical Same as Medical No Copay

* Combined Rx plan. HSA plans can only be paired with Combined Pharmacy plans.

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January 1, 2019


January 1, 2019

2019 Health Plan Product Offering 1 Primary Care Physicians include Family Practice, Internal Medicine, Obstetrics-Gynecology, and Pediatrics

2 This tier of benefits applies to UnitedHealth Premium Tier 1 Designated Providers. Please visit myuhc.com for details

3 This tier of benefit applies to Physicians that are not UnitedHealth Premium Tier 1 Designated

5 "Embedded" deductible means once an individual meets their portion of the deductible, services are paid for that person without the entire family deductible being met. "Non-Embedded" deductible means no covered family member will satisfy an individual deductible until the entire family deductible is met.

8 “Navigate” plans require referrals for certain services. Failure to obtain a referral may result in either non-payment of claims or in a reduction of benefits.

9 Copayment and/or copayment+coinsurance on HSA plans will be required after the deductible has been met and will continue to be required until the annual out-of-pocket maximumis met.

11 EPO and Navigate plans exclude coverage for services provided by Out-of-Network Providers with the exception of (1) Services performed in a Network Facility by hospital-basedproviders; and (2) Services performed under the Emergency Care benefit

16 $250 individual and $500 family Rx deductible applies to Tier 3 and 4 only

17 “FlexFree” plans feature $0 copay for the first 3 PCP and/or Specialist office visits during the Calendar or Plan Year. Office visits 4+ will be subject to plan deductible/coinsurance. Plans also feature $0 copay for the first 2 Urgent Care visits during the Plan Year. Urgent Care visits 3+ will be subject to plan deductible/coinsurance. Preventive Care visits do notcount against the office visit copay limit.

18 Multi Choice package 30 is only available in the following 10 counties: Collin, Dallas, Denton, Ellis, Fannin, Hunt, Johnson, Parker, Rockwall and Tarrant

Please note: The information in this grid is provided for informational purposes only and is not intended for use as a contract. For a complete listing of coverage and exclusions, pleaserefer to the Certificate of Coverage or talk to your UnitedHealthcare representative for additional details that could impact the benefits. Different UnitedHealthcare plans may have varyingapproaches to whether pharmacy costs are included or excluded from the medical deductible. Insurance coverage provided by or through by United HealthCare Services, Inc. or theiraffiliates. UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by United HealthCare Services, Inc. or their affiliates. Version 9/20/18

6 of 6

Dallas-

January 1, 2019

Amarillo Core Essential-Multi-ChoicePackage

1-50 ATNE EmployeesJanuary 1, 2019


UnitedHealthcare Multi-Choice® allows you to purchase one health plan package with multiple benefit designoptions to meet a variety of health care and financial needs. Your employees can choose the option thatmeets their individual needs, whether it’s saving money on essential coverage or paying additional dollars formore comprehensive coverage. And you can keep or change your benefit design package year after year,ensuring that your health plan will evolve with the changing needs of your business and your employees.


Package

31

Me

talli

c

Plan Code

Choice+ Core Essential12

Coinsurance

NetworkOut of

Network

Deductible

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family


Virtual Visits

PCPAges

19+1

PCPAges

<191

SpecPrem

Des2

Spec3 UrgentCare


Rx Plan

• G BI-ZO 80% 50% $750 $1,500 N/A N/A $6,500 $13,000 N/A N/A $0 $15 $0 $50 $100 $25 $300+Ded+20%

Ded+20% Ded+20% Ded+20%627-5/50/100/250

• G BI-ZG BI-ZQ 80% 50% $1,500 $3,000 $5,000 $15,000 $6,500 $13,000 $10,000 $30,000 $0 $15 $0 $50 $100 $25$300+


627-5/50/100/250

• G BI-ZH BI-ZR 80% 50% $2,500 $5,000 $5,000 $15,000 $6,300 $12,600 $10,000 $30,000 $0 $15 $0 $50 $100 $25$300+


627-5/50/100/250

• S BI-ZF BI-ZP 80% 50% $6,000 $12,000 $10,000 $30,000 $7,350 $14,700 $20,000 $60,000 $0 $15 $0 $50 $100 $25$300+


627-5/50/100/250


Package

31

Me

talli

c

Plan Code


Coinsurance

NetworkOut of

Network

Deductible

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family


Virtual Visits

PCP1 SpecUrgent

CareER Lab/Xray MRI, CT.

I/P & O/PSurgery

Rx Plan

• G BI-XS BI-X3 80% 50% $1,000 $2,000 $5,000 $10,000 $5,000 $13,000 $10,000 $20,000 $0 $0 $100 $50$250+


548 - 5/50/100/25016

• G BI-XT BI-X4 80% 50% $2,500 $5,000 $7,500 $15,000 $5,500 $13,500 $15,000 $30,000 $0 $0 $100 $50$250+

Ded+20%Ded+20% Ded+20% Ded+20% 548 - 5/50/100/250

16

• S BI-XW BI-YA 70% 50% $5,000 $10,000 $10,000 $20,000 $7,350 $14,700 $10,000 $20,000 $0 $0 $100 $50$250+

Ded+30%Ded+30% Ded+30% Ded+30% 548 - 5/50/100/250

16

• S BI-XX BI-YB 70% 50% $7,000 $14,000 $10,000 $20,000 $7,900 $15,800 $10,000 $20,000 $0 $0 $100 $50$250+


548 - 5/50/100/25016

1 of 4

Amarillo Core Essential-

January 1, 2019

1.3





Package

31

Me

talli

c

Plan Code


Coinsurance

NetworkPhysician

Out ofNetwork

Deductible

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family


Virtual Visits

PCPAges

19+1

PCPAges

<191

SpecPrem

Des2

Spec3 UrgentCare


Rx Plan

• G BI-ZS 100% N/A $500 $1,500 N/A N/A $7,000 $14,000 N/A N/A $0 $35 $0 $35 $70 $50 $400 Ded $400 $250+Ded DV-20/45/80

• G BI-ZT 100% N/A $1,000 $3,000 N/A N/A $6,350 $12,700 N/A N/A $0 $40 $0 $40 $80 $50 $400 Ded $400 $250+Ded NS-10/35/60

• G BI-Y7 BI-ZV 100% 70% $3,000 $9,000 $5,000 $15,000 $4,000 $12,000 $10,000 $30,000 $0 $35 $0 $35 $70 $50 $300 Ded $400 $250+Ded DV-20/45/80

• S BI-Y8 BI-ZU 100% 70% $6,000 $12,000 $10,000 $30,000 $7,350 $14,700 $20,000 $60,000 $0 $45 $0 $45 $90 $50 $500 Ded $400 $250+Ded DV-20/45/80

• G BI-ZK 50% 50% $2,000 $6,000 $5,000 $15,000 $4,800 $9,600 $10,000 $30,000 $0 $35 $0 $35 $70 $50 $400+50% Ded+50% $400$250+

Ded+50%DV-20/45/80

• S BI-ZM 50% 50% $5,000 $10,000 $10,000 $30,000 $7,300 $14,600 $20,000 $60,000 $0 $35 $0 $35 $70 $50 $400+50% Ded+50% $400$250+

Ded+50%DV-20/45/80


Package

31

Me

talli

c

Plan Code


Contrib Range

Coinsurance

NetworkOut of

Network

Deductible

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family


Virtual Visits

PCP1 SpecUrgentCare


Rx Plan9 Ded

Type5

• S BI-XU BI-X9 $0-$0 100% 70% $4,000 $8,000 $5,000 $15,000 $6,650 $13,300 $10,000 $30,000 100% 100% 100% 100% 100% 100% 100% 100% 871-0/25/50/100 Emb

• S BI-XM BI-X5 $0-$400 100% 70% $5,000 $10,000 $10,000 $30,000 $6,000 $12,000 $20,000 $60,000 100% 100% 100% 100% 100% 100% 100% 100% 871-0/25/50/100 Emb

• B BI-XV BI-X6 $0-$0 100% 70% $6,650 $13,300 $10,000 $30,000 $6,650 $13,300 $20,000 $60,000 100% 100% 100% 100% 100% 100% 100% 100% 273-100% Emb

• S BI-XZ BI-X7 $0-$0 80% 50% $2,250 $4,500 $5,000 $15,000 $6,500 $7,150 $10,000 $30,000 100% 100% $1009 $509 $250+20%9 80% 80% 80% 871-0/25/50/100 Non-Emb


Package

31

Me

talli

c NavigatePlan Code

Plan TypeContrib Range

Coins

Network

Deductible

Network

Single Family


Network

Single Family


Virtual Visits

PCPAges

19+1

PCPAges

<191

Specw/PCPReferral

UrgentCare


Rx PlanDed

Type5

• G BI-YO Primary Advantage N/A 80% $1,000 $2,000 $5,000 $10,000 $0 $0 $0 $100 $50$250+


• G BI-YQ Primary Advantage N/A 80% $2,500 $5,000 $5,500 $13,500 $0 $0 $0 $100 $50$250+



2 of 4


January 1, 2019





Package

31

Me

talli

c Plan Code

Choice+

Coinsurance

NetworkOut of

Network

Deductible

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family


Virtual Visits

PCP1

SpecUrgentCare


Rx Plan

• G BI-XP 80% 50% $1,000 $3,000 $5,000 $15,000 $5,000 $14,000 $10,000 $30,000 $0 $0/3 visits combined $0/2 visits$250+

Ded+20%Ded+20%

$250+Ded+20%

$250+Ded+20%

099 -15/50/100/125

• S BI-XQ 80% 50% $4,000 $12,000 $5,000 $15,000 $7,500 $15,000 $10,000 $30,000 $0 $0/3 visits combined $0/2 visits$250+

Ded+20%Ded+20%

$250+Ded+20%

$250+Ded+20%

099 -15/50/100/125


Package

31

Me

talli

c Plan Code

Core Essential12

Coinsurance

NetworkPhysician

Out ofNetwork

Deductible

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family


Virtual Visits

PCPAges

19+1

PCPAges

<191

SpecPrem

Des2

Spec3 UrgentCare


Rx Plan

• P BI-ZW 100% N/A $750 $2,250 N/A N/A $3,000 $9,000 N/A N/A $0 $20 $0 $20 $40 $50 $300 100% $400 Ded DT-15/40/70

• G BI-ZZ 100% N/A $3,500 $10,500 N/A N/A $7,350 $14,700 N/A N/A $0 $35 $0 $35 $70 $50 $300 100% $400 Ded DV-20/45/80

• G BI-ZX 100% N/A $5,000 $10,000 N/A N/A $7,000 $14,000 N/A N/A $0 $30 $0 $30 $60 $50 $300 100% $400 Ded DV-20/45/80

• G BI-ZY 80% N/A $3,500 $10,500 N/A N/A $6,350 $12,700 N/A N/A $0 $25 $0 $25 $50 $50 $250+20% 100% $400 Ded+20% DV-20/45/80

Pharmacy Plans

Rx PlanCode

Copays

Tier 1Tier 1

Specialtycopay

Tier 2Tier 2

Specialtycopay

Tier 3Tier 3

Specialtycopay

Tier 4 Tier 4

Specialtycopay

Deductible

Single Family

MailOrderRatio

NS $10 $10 $35 $100 $60 $300 N/A N/A N/A N/A 2.5


DT $15 $15 $40 $100 $70 $300 N/A N/A N/A N/A 2.5

DV $20 $20 $45 $100 $80 $300 N/A N/A N/A N/A 2.5

098 $10 $10 $50 $100 $100 $300 $125 $500 N/A N/A 2.5

099 $15 $15 $50 $100 $100 $300 $125 $500 N/A N/A 2.5

627 $5 N/A $50 N/A $100 N/A $250 N/A N/A N/A 2.5

548 $5 N/A $50 N/A $100 N/A $250 N/A $250 $500 2.5



3 of 4


January 1, 2019




1 Primary Care Physicians include Family Practice, Internal Medicine, Obstetrics-Gynecology, and Pediatrics






11 Navigate plans exclude coverage for services provided by Out-of-Network Providers with the exception of (1) Services performed in a Network Facility by hospital-based providers;and (2) Services performed under the Emergency Care benefit

12 Core Essential plans exclude coverage for services provided by Out-of-Network Providers with the exception of (1) Services performed in a Network Facility by hospital-basedproviders; and (2) Services performed under the Emergency Care benefit




4 of 4


January 1, 2019

Texas Charter Packages1-50 ATNE Employees

January 1, 2020

2020 Health Plan Product Offering UnitedHealthcare Multi-Choice® allows you to purchase one health plan package with multiple benefit designoptions to meet a variety of health care and financial needs. Your employees can choose the option thatmeets their individual needs, whether it’s saving money on essential coverage or paying additional dollars formore comprehensive coverage. And you can keep or change your benefit design package year after year,ensuring that your health plan will evolve with the changing needs of your business and your employees.


Package

32 33

Met

allic

Plan Code

Choice+ EPO11

Coinsurance

NetworkOut of

Network

Deductible

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family


Virtual Visits

PCPAges19+1

PCPAges<191

SpecPremDes2

Spec3 UrgentCare ER Lab/Xray MRI, CT.

I/P & O/PSurgery

Rx Plan

• • G BR-QU BR-QX 80% 50% $1,500 $3,000 $5,000 $15,000 $6,500 $13,000 $10,000 $30,000 $0 $15 $0 $50 $100 $25 $300+Ded+20%

Ded+20% Ded+20% Ded+20%627-5/50/100/250

• • G BR-QV BR-QY 80% 50% $2,500 $5,000 $5,000 $15,000 $6,300 $12,600 $10,000 $30,000 $0 $15 $0 $50 $100 $25 $300+Ded+20%

Ded+20% Ded+20% Ded+20%627-5/50/100/250

• G BR-RD BR-RE 80% 50% $3,500 $7,000 $10,000 $30,000 $6,300 $12,600 $20,000 $60,000 $0 $15 $0 $50 $100 $25$300+

Ded+20% Ded+20% Ded+20% Ded+20%627-5/50/100/250

• • S BR-QT BR-QW 80% 50% $6,500 $13,000 $10,000 $30,000 $7,900 $15,800 $20,000 $60,000 $0 $15 $0 $50 $100 $25 $300+Ded+20%

Ded+20% Ded+20% Ded+20%627-5/50/100/250

• G BR-RG BR-RH 80% 50% $1,200 $2,400 $5,000 $15,000 $6,900 $13,800 $10,000 $30,000 $0 $10 $0 $40 $80 $25 $300+Ded+20%

$40 $500 Ded+20%627-5/50/100/250

• • G BR-RJ BR-RK 80% 50% $2,000 $4,000 $10,000 $30,000 $6,900 $13,800 $20,000 $60,000 $0 $10 $0 $40 $80 $25$300+

Ded+20% $40 $500 Ded+20%627-5/50/100/250

• G BR-RM BR-RN 80% 50% $3,000 $6,000 $10,000 $30,000 $6,900 $13,800 $20,000 $60,000 $0 $10 $0 $40 $80 $25 $300+Ded+20%

$40 $500 Ded+20%627-5/50/100/250

• G BR-RP BR-RQ 80% 50% $4,000 $8,000 $10,000 $30,000 $6,900 $13,800 $20,000 $60,000 $0 $10 $0 $40 $80 $25 $300+Ded+20%

$40 $500 Ded+20%627-5/50/100/250

1 of 5

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January 1, 2020

2020 Health Plan Product Offering UnitedHealthcare Primary Advantage Plans

Package

32 33

Met

allic

Plan Code

Choice+ EPO11

Coinsurance

Network Out ofNetwork

Deductible

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family


Virtual Visits

PCP1 Spec UrgentCare

ER Lab/Xray MRI, CT. I/P & O/PSurgery

Rx Plan

• G BR-PR BR-PS 80% 50% $1,200 $2,400 $5,000 $10,000 $5,000 $13,000 $10,000 $20,000 $0 $0 $100 $50$250+

Ded+20% Ded+20% Ded+20% Ded+20% 548 - 5/50/100/25016

• G BI-XT AV-VQ 80% 50% $2,500 $5,000 $7,500 $15,000 $5,500 $13,500 $15,000 $30,000 $0 $0 $100 $50 $250+Ded+20%

Ded+20% Ded+20% Ded+20% 548 - 5/50/100/25016

• S BR-PU BR-PT 70% 50% $5,500 $11,000 $10,000 $20,000 $7,350 $14,700 $10,000 $20,000 $0 $0 $100 $50 $250+Ded+30%

Ded+30% Ded+30% Ded+30% 548 - 5/50/100/25016

• S BR-PV BR-P3 70% 50% $7,000 $14,000 $10,000 $20,000 $7,900 $15,800 $10,000 $20,000 $0 $0 $100 $50$250+

Ded+30% Ded+30% Ded+30% Ded+30% 548 - 5/50/100/25016


Package

32 33

Met

allic

Plan Code

Choice+ EPO11

Coinsurance

NetworkPhysician

Out ofNetwork

Deductible

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family


Virtual Visits

PCPAges19+1

PCPAges<191

SpecPremDes2

Spec3 UrgentCare


Rx Plan

• G BI-Y6 AV-XD 100% 70% $1,000 $3,000 $5,000 $15,000 $6,350 $12,700 $10,000 $30,000 $0 $40 $0 $40 $80 $50 $400 Ded $400 $250+Ded NS-10/35/60

• G BI-Y7 AV-XE 100% 70% $3,000 $9,000 $5,000 $15,000 $4,000 $12,000 $10,000 $30,000 $0 $35 $0 $35 $70 $50 $300 Ded $400 $250+Ded DV-20/45/80

• S BR-QP BR-QS 100% 70% $7,000 $14,000 $10,000 $30,000 $7,900 $15,800 $20,000 $60,000 $0 $45 $0 $45 $90 $50 $500 Ded $400 $250+Ded DV-20/45/80

• G BI-ZI BI-ZJ 50% 50% $1,000 $3,000 $5,000 $15,000 $5,000 $10,000 $10,000 $30,000 $0 $35 $0 $35 $70 $50 $400+50% Ded+50% $400 $250+Ded+50%

DV-20/45/80


Package

32 33

Met

allic

Plan Code

Choice+ EPO11

Contrib Range

Coinsurance


Deductible

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family


Virtual Visits



Rx Plan9 DedType5

• • S BI-XM AE-O5 $0-$200 100% 70% $5,000 $10,000 $10,000 $30,000 $6,000 $12,000 $20,000 $60,000 100% 100% 100% 100% 100% 100% 100% 100% 871-0/25/50/100 Emb

• • B BI-XV AV-VX $0-$0 100% 70% $6,650 $13,300 $10,000 $30,000 $6,650 $13,300 $20,000 $60,000 100% 100% 100% 100% 100% 100% 100% 100% 273-100% Emb

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January 1, 2020

2020 Health Plan Product Offering UnitedHealthcare Navigate Plans8, 11

Package

32 33

Met

allic Navigate

Plan Code Plan Type Contrib Range

Coins

Network

Deductible

Network

Single Family


Network

Single Family


Virtual Visits

PCPAges19+1

PCPAges<191

Specw/PCP

Referral

UrgentCare


Rx Plan DedType5

• G BR-RS PROformance N/A 80% $3,500 $7,000 $6,300 $12,600 $0 $15 $0 $50-Prem Des/$100 $25$300+

Ded+20% Ded+20% Ded+20% Ded+20%627-5/50/100/250

Emb

• S BR-YV PROformance N/A 80% $6,500 $13,000 $7,900 $15,800 $0 $15 $0 $50-Prem Des/$100 $25 $300+Ded+20%

Ded+20% Ded+20% Ded+20%627-5/50/100/250

Emb

• S BR-RV PROformance N/A 80% $2,000 $4,000 $6,900 $13,800 $0 $10 $0 $40-Prem Des/$80 $25$300+

Ded+20% $40 $500 Ded+20%627-5/50/100/250

Emb

• S BR-RT PROformance N/A 80% $3,000 $6,000 $6,900 $13,800 $0 $10 $0 $40-Prem Des/$80 $25 $300+Ded+20%

$40 $500 Ded+20%627-5/50/100/250

Emb

• S BR-RW PROformance N/A 80% $4,000 $8,000 $6,900 $13,800 $0 $10 $0 $40-Prem Des/$80 $25 $300+Ded+20%

$40 $500 Ded+20%627-5/50/100/250

Emb

• S BR-QH Primary Advantage N/A 70% $7,000 $14,000 $7,900 $15,800 $0 $0 $0 $100 $50$250+

Ded+30% Ded+30% Ded+30% Ded+30% 548 - 5/50/100/25016

Emb

• P AV-V2 Copay N/A 100% N/A N/A $2,000 $6,000 $0 $10 $0 $30 $50 $650 Ded $500 $250 098-10/50/100/125 Emb

• S BI-YE HSA W/Motion $0-$0 100% $4,000 $8,000 $6,650 $13,300 100% 100% 100% 100% 100% 100% 100% 100% 100% 871-0/25/50/100 Emb

• S AE-PE HSA W/Motion $0-$200 100% $5,000 $10,000 $6,000 $12,000 100% 100% 100% 100% 100% 100% 100% 100% 100% 871-0/25/50/100 Emb


• S BI-YG HSA W/Motion $0-$150 80% $3,750 $7,500 $6,350 $12,700 80% 80% 80% 80% 80% 80% 80% 80% 80% 871-0/25/50/100 Emb

UnitedHealthcare Charter HMO Plans8, 11

Package

32 33

Met

allic Charter

Plan Code Plan Type

Coins

Network

Deductible

Network

Single Family


Network

Single Family


Virtual Visits

PCPAges19+1

PCPAges<191

Specw/PCPReferral

UrgentCare


Ded Type5 Rx Plan

• G AV-WL Copay 100% $2,000 $6,000 $7,350 $14,700 $0 $20 $0 $60 $50 $650 Ded $500 $250+Ded Emb NS-10/35/60

• G BR-P8 Copay 80% $1,000 $3,000 $7,350 $14,700 $0 $20 $0 $60 $50 $500 Ded+20% $500 Ded+20% Emb DT-15/40/70

• G BR-P9 Copay 80% $2,000 $6,000 $7,350 $14,700 $0 $20 $0 $60 $50 $500 Ded $500 Ded+20% Emb NS-10/35/60

• • S BR-QA Copay 80% $5,500 $11,000 $7,900 $15,800 $0 $35 $0 $105 $50 $650 Ded+20% $500 $400+Ded+20% Emb DV-20/45/80

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January 1, 2020

2020 Health Plan Product Offering UnitedHealthcare Charter HMO Plans8, 11

Package

32 33

Met

allic Charter

Plan Code Plan Type

Coins

Network

Deductible

Network

Single Family


Network

Single Family


Virtual Visits

PCPAges19+1

PCPAges<191

Specw/PCPReferral

UrgentCare


Ded Type5 Rx Plan

• G BR-QE Primary Advantage 80% $2,500 $5,000 $5,500 $13,500 $0 $0 $0 $100 $50$250+

Ded+20% Ded+20% Ded+20% Ded+20% Emb 548 - 5/50/100/25016

• S BR-QF Primary Advantage 70% $5,500 $11,000 $7,350 $14,700 $0 $0 $0 $100 $50 $250+Ded+30%

Ded+30% Ded+30% Ded+30% Emb 548 - 5/50/100/25016

• S BR-QI Primary Advantage 70% $7,000 $14,000 $7,900 $15,800 $0 $0 $0 $100 $50 $250+Ded+30%

Ded+30% Ded+30% Ded+30% Emb 548 - 5/50/100/25016

• S BI-YW HSA w/Motion 100% $5,000 $10,000 $6,000 $12,000 100% 100% 100% 100% 100% 100% 100% 100% 100% Emb 871-0/25/50/100

• • B BI-YY HSA w/Motion 100% $6,650 $13,300 $6,650 $13,300 100% 100% 100% 100% 100% 100% 100% 100% 100% Emb 273-100%

• • S BR-QJ HSA w/Motion 80% $2,800 $5,600 $6,350 $12,700 80% 80% 80% 80% 80% 80% 80% 80% 80% Emb 871-0/25/50/100

• S BI-YL HSA w/Motion 80% $3,750 $7,500 $6,350 $12,700 80% 80% 80% 80% 80% 80% 80% 80% 80% Emb 871-0/25/50/100

• S BR-QM Consumer 100% $7,900 $11,000 $7,900 $15,800 100% 100% 100% 100% 100% 100% 100% 100% 100% Emb B63-0/50/100/250

Charter is available in the following counties in North Texas: Collin, Dallas, Denton,Ellis, Fannin, Hunt, Johnson, Parker, Rockwall and Tarrant

Charter is available in the following counties in Houston: Brazoria, Chambers, FortBend, Galveston, Harris, Liberty and Montgomery

Charter is available in the following counties in El Paso: El Paso and Hudspeth


Package

32 33

Met

allic

Plan Code

Choice+ EPO11

Coinsurance

NetworkPhysician

Out ofNetwork

Deductible

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family


Virtual Visits

PCPAges19+1

PCPAges<191

SpecPremDes2

Spec3 UrgentCare ER Lab/Xray MRI, CT. I/P & O/P

Surgery

Rx Plan

• P BR-RA BR-RB 100% 70% $1,500 $4,500 $5,000 $15,000 $6,000 $12,000 $10,000 $30,000 $0 $20 $0 $20 $40 $50 $350 100% $400 Ded NS-10/35/60

• G BR-QN BR-QQ 100% 70% $3,500 $10,500 $5,000 $15,000 $7,900 $15,800 $10,000 $30,000 $0 $35 $0 $35 $70 $50 $350 100% $400 Ded DV-20/45/80

• G BR-QO BR-QR 100% 70% $5,000 $10,000 $10,000 $30,000 $7,000 $14,000 $20,000 $60,000 $0 $30 $0 $30 $60 $50 $300 100% $400 Ded DV-20/45/80

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January 1, 2020

2020 Health Plan Product Offering Pharmacy Plans

Rx PlanCode

Copays

Tier 1Tier 1

Specialtycopay

Tier 2Tier 2

Specialtycopay

Tier 3Tier 3

Specialtycopay

Tier 4 Tier 4

Specialtycopay

Deductible

Single Family

MailOrderRatio

NS $10 $10 $35 $100 $60 $300 N/A N/A N/A N/A 2.5


DT $15 $15 $40 $100 $70 $300 N/A N/A N/A N/A 2.5

DV $20 $20 $45 $100 $80 $300 N/A N/A N/A N/A 2.5

098 $10 $10 $50 $100 $100 $300 $125 $500 N/A N/A 2.5

099 $15 $15 $50 $100 $100 $300 $125 $500 N/A N/A 2.5

627 $5 N/A $50 N/A $100 N/A $250 N/A N/A N/A 2.5

548 $5 N/A $50 N/A $100 N/A $250 N/A $250 $500 2.5

B63 $0 N/A $50 N/A $100 N/A $250 N/A N/A N/A 2.5



1 Primary Care Physicians include Family Practice, Internal Medicine, Obstetrics-Gynecology, and Pediatrics




8 Navigate and Charter plans require referrals for certain services. Failure to obtain a referral may result in either non-payment of claims or in a reduction of benefits.


11 EPO, Navigate and Charter plans exclude coverage for services provided by Out-of-Network Providers with the exception of (1) Services performed in a Network Facility byhospital-based providers; and (2) Services performed under the Emergency Care benefit




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Texas-Multi-Choice Non-Charter1-50 ATNE Employees

January 1, 2020

2020 Health Plan Product OfferingUnitedHealthcare Multi-Choice® allows you to purchase one health plan package with multiple benefit designoptions to meet a variety of health care and financial needs. Your employees can choose the option thatmeets their individual needs, whether it’s saving money on essential coverage or paying additional dollars formore comprehensive coverage. And you can keep or change your benefit design package year after year,ensuring that your health plan will evolve with the changing needs of your business and your employees.


Package

34 35

Met

allic

Plan Code

Choice+ EPO11

Coinsurance

NetworkOut of

Network

Deductible

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family


Virtual Visits

PCPAges19+1

PCPAges<191

SpecPremDes2


I/P & O/PSurgery

Rx Plan

• • G BR-QU BR-QX 80% 50% $1,500 $3,000 $5,000 $15,000 $6,500 $13,000 $10,000 $30,000 $0 $15 $0 $50 $100 $25 $300+Ded+20%

Ded+20% Ded+20% Ded+20%627-5/50/100/250

• • G BR-QV BR-QY 80% 50% $2,500 $5,000 $5,000 $15,000 $6,300 $12,600 $10,000 $30,000 $0 $15 $0 $50 $100 $25 $300+Ded+20%

Ded+20% Ded+20% Ded+20%627-5/50/100/250

• • G BR-RD BR-RE 80% 50% $3,500 $7,000 $10,000 $30,000 $6,300 $12,600 $20,000 $60,000 $0 $15 $0 $50 $100 $25$300+

Ded+20% Ded+20% Ded+20% Ded+20%627-5/50/100/250

• • S BR-QT BR-QW 80% 50% $6,500 $13,000 $10,000 $30,000 $7,900 $15,800 $20,000 $60,000 $0 $15 $0 $50 $100 $25 $300+Ded+20%

Ded+20% Ded+20% Ded+20%627-5/50/100/250

• G BR-RG BR-RH 80% 50% $1,200 $2,400 $5,000 $15,000 $6,900 $13,800 $10,000 $30,000 $0 $10 $0 $40 $80 $25 $300+Ded+20%

$40 $500 Ded+20%627-5/50/100/250

• G BR-RJ BR-RK 80% 50% $2,000 $4,000 $10,000 $30,000 $6,900 $13,800 $20,000 $60,000 $0 $10 $0 $40 $80 $25$300+

Ded+20% $40 $500 Ded+20%627-5/50/100/250

• G BR-RM BR-RN 80% 50% $3,000 $6,000 $10,000 $30,000 $6,900 $13,800 $20,000 $60,000 $0 $10 $0 $40 $80 $25 $300+Ded+20%

$40 $500 Ded+20%627-5/50/100/250

• G BR-RP BR-RQ 80% 50% $4,000 $8,000 $10,000 $30,000 $6,900 $13,800 $20,000 $60,000 $0 $10 $0 $40 $80 $25 $300+Ded+20%

$40 $500 Ded+20%627-5/50/100/250

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January 1, 2020



Package

34 35

Met

allic

Plan Code

Choice+ EPO11

Coinsurance


Deductible

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family


Virtual Visits



Rx Plan

• S BR-PU BR-PT 70% 50% $5,500 $11,000 $10,000 $20,000 $7,350 $14,700 $10,000 $20,000 $0 $0 $100 $50$250+

Ded+30% Ded+30% Ded+30% Ded+30% 548 - 5/50/100/25016

• • S BR-PV BR-P3 70% 50% $7,000 $14,000 $10,000 $20,000 $7,900 $15,800 $10,000 $20,000 $0 $0 $100 $50 $250+Ded+30%

Ded+30% Ded+30% Ded+30% 548 - 5/50/100/25016


Package

34 35

Met

allic

Plan Code

Choice+ EPO11

Coinsurance

NetworkPhysician

Out ofNetwork

Deductible

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family


Virtual Visits

PCPAges19+1

PCPAges<191

SpecPremDes2


I/P & O/PSurgery

Rx Plan

• G BI-Y6 AV-XD 100% 70% $1,000 $3,000 $5,000 $15,000 $6,350 $12,700 $10,000 $30,000 $0 $40 $0 $40 $80 $50 $400 Ded $400 $250+Ded NS-10/35/60

• • G BI-Y7 AV-XE 100% 70% $3,000 $9,000 $5,000 $15,000 $4,000 $12,000 $10,000 $30,000 $0 $35 $0 $35 $70 $50 $300 Ded $400 $250+Ded DV-20/45/80

• • S BR-QP BR-QS 100% 70% $7,000 $14,000 $10,000 $30,000 $7,900 $15,800 $20,000 $60,000 $0 $45 $0 $45 $90 $50 $500 Ded $400 $250+Ded DV-20/45/80

• G BI-ZK BI-ZL 50% 50% $2,000 $6,000 $5,000 $15,000 $4,800 $9,600 $10,000 $30,000 $0 $35 $0 $35 $70 $50 $400+50% Ded+50% $400$250+

Ded+50% DV-20/45/80

• S BI-ZM BI-ZN 50% 50% $5,000 $10,000 $10,000 $30,000 $7,300 $14,600 $20,000 $60,000 $0 $35 $0 $35 $70 $50 $400+50% Ded+50% $400$250+

Ded+50% DV-20/45/80


Package

34 35

Met

allic

Plan Code

Choice+ EPO11

Contrib Range

Coinsurance


Deductible

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family


Virtual Visits PCP1 Spec Urgent

Care ER Lab/Xray MRI, CT. I/P & O/PSurgery

Rx Plan9 DedType5

• • S BI-XM AE-O5 $0-$200 100% 70% $5,000 $10,000 $10,000 $30,000 $6,000 $12,000 $20,000 $60,000 100% 100% 100% 100% 100% 100% 100% 100% 871-0/25/50/100 Emb

• • B BI-XV AV-VX $0-$0 100% 70% $6,650 $13,300 $10,000 $30,000 $6,650 $13,300 $20,000 $60,000 100% 100% 100% 100% 100% 100% 100% 100% 273-100% Emb

• S BR-PP BR-PQ $0-$0 80% 50% $2,800 $5,600 $5,000 $15,000 $6,350 $12,700 $10,000 $30,000 80% 80% 80% 80% 80% 80% 80% 80% 871-0/25/50/100 Emb

• S BI-XO AE-O7 $0-$150 80% 50% $3,750 $7,500 $5,000 $15,000 $6,350 $12,700 $10,000 $30,000 80% 80% 80% 80% 80% 80% 80% 80% 871-0/25/50/100 Emb

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January 1, 2020



Package

34 35

Met

allic Navigate

Plan Code Plan Type Contrib Range

Coins

Network

Deductible

Network

Single Family


Network

Single Family


Virtual Visits

PCPAges19+1

PCPAges<191

Specw/PCP

Referral

UrgentCare


Rx Plan DedType5

• G BI-Z3 PROformance N/A 80% $2,500 $5,000 $6,300 $12,600 $0 $15 $0 $50-Prem Des/$100 $25$300+

Ded+20% Ded+20% Ded+20% Ded+20%627-5/50/100/250

Emb

• G BR-RS PROformance N/A 80% $3,500 $7,000 $6,300 $12,600 $0 $15 $0 $50-Prem Des/$100 $25 $300+Ded+20%

Ded+20% Ded+20% Ded+20%627-5/50/100/250

Emb

• • S BR-YV PROformance N/A 80% $6,500 $13,000 $7,900 $15,800 $0 $15 $0 $50-Prem Des/$100 $25$300+

Ded+20% Ded+20% Ded+20% Ded+20%627-5/50/100/250

Emb

• S BR-QG Primary Advantage N/A 70% $5,500 $11,000 $7,350 $14,700 $0 $0 $0 $100 $50$250+

Ded+30%Ded+30% Ded+30% Ded+30% 548 - 5/50/100/25016

Emb

• S BR-QH Primary Advantage N/A 70% $7,000 $14,000 $7,900 $15,800 $0 $0 $0 $100 $50 $250+Ded+30%

Ded+30% Ded+30% Ded+30% 548 - 5/50/100/25016

Emb

• G AV-V4 Copay N/A 100% $3,000 $9,000 $5,000 $10,000 $0 $15 $0 $45 $50 $650 Ded $500 $250+Ded 099-15/50/100/125 Emb

• • S AE-PE HSA W/Motion $0-$200 100% $5,000 $10,000 $6,000 $12,000 100% 100% 100% 100% 100% 100% 100% 100% 100% 871-0/25/50/100 Emb

• • B BI-YX HSA W/Motion $0-$0 100% $6,650 $13,300 $6,650 $13,300 100% 100% 100% 100% 100% 100% 100% 100% 100% 273-100% Emb

• S BR-P7 HSA W/Motion $0-$0 80% $2,800 $5,600 $6,350 $12,700 80% 80% 80% 80% 80% 80% 80% 80% 80% 871-0/25/50/100 Emb


Package

34 35

Met

allic

Plan Code

Choice+ EPO11

Coinsurance


Deductible

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family


Virtual Visits



Rx Plan

• G BI-XP AV-VM 80% 50% $1,000 $3,000 $5,000 $15,000 $5,000 $14,000 $10,000 $30,000 $0 $0/3 visits combined $0/2 visits$250+

Ded+20% Ded+20%$250+

Ded+20%$250+

Ded+20% 099 -15/50/100/125

• S BI-XQ BI-XR 80% 50% $4,000 $12,000 $5,000 $15,000 $7,500 $15,000 $10,000 $30,000 $0 $0/3 visits combined $0/2 visits $250+Ded+20%

Ded+20% $250+Ded+20%

$250+Ded+20%

099 -15/50/100/125

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January 1, 2020



Package

34 35

Met

allic

Plan Code

Choice+ EPO11

Coinsurance

NetworkPhysician

Out ofNetwork

Deductible

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family


Virtual Visits

PCPAges19+1

PCPAges<191

SpecPremDes2


I/P & O/PSurgery

Rx Plan

• P BR-RA BR-RB 100% 70% $1,500 $4,500 $5,000 $15,000 $6,000 $12,000 $10,000 $30,000 $0 $20 $0 $20 $40 $50 $350 100% $400 Ded NS-10/35/60

• G BR-QN BR-QQ 100% 70% $3,500 $10,500 $5,000 $15,000 $7,900 $15,800 $10,000 $30,000 $0 $35 $0 $35 $70 $50 $350 100% $400 Ded DV-20/45/80

• • G BR-QO BR-QR 100% 70% $5,000 $10,000 $10,000 $30,000 $7,000 $14,000 $20,000 $60,000 $0 $30 $0 $30 $60 $50 $300 100% $400 Ded DV-20/45/80

Pharmacy Plans

Rx PlanCode

Copays

Tier 1Tier 1

Specialtycopay

Tier 2Tier 2

Specialtycopay

Tier 3Tier 3

Specialtycopay

Tier 4 Tier 4

Specialtycopay

Deductible

Single Family

MailOrderRatio

NS $10 $10 $35 $100 $60 $300 N/A N/A N/A N/A 2.5


DT $15 $15 $40 $100 $70 $300 N/A N/A N/A N/A 2.5

DV $20 $20 $45 $100 $80 $300 N/A N/A N/A N/A 2.5

098 $10 $10 $50 $100 $100 $300 $125 $500 N/A N/A 2.5

099 $15 $15 $50 $100 $100 $300 $125 $500 N/A N/A 2.5

627 $5 N/A $50 N/A $100 N/A $250 N/A N/A N/A 2.5

548 $5 N/A $50 N/A $100 N/A $250 N/A $250 $500 2.5

B63 $0 N/A $50 N/A $100 N/A $250 N/A N/A N/A 2.5



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January 1, 2020





8 Navigate plans require referrals for certain services. Failure to obtain a referral may result in either non-payment of claims or in a reduction of benefits.


11 EPO and Navigate plans exclude coverage for services provided by Out-of-Network Providers with the exception of (1) Services performed in a Network Facility by hospital-basedproviders; and (2) Services performed under the Emergency Care benefit




5 of 5

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UnitedHealthcare Multi-Choice® allows you to purchase one health plan package with multiple benefit designoptions to meet a variety of health care and financial needs. Your employees can choose the option thatmeets their individual needs, whether it’s saving money on essential coverage or paying additional dollars formore comprehensive coverage. And you can keep or change your benefit design package year after year,ensuring that your health plan will evolve with the changing needs of your business and your employees.


Package

36

Me

talli

c

Plan Code

Choice+ Choice EPO12 Navigate11 Core Essential12

Coinsurance

NetworkOut of

Network

Deductible

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family


Virtual

Visits

PCP

Ages

19+1

PCP

Ages

<191

Spec

Prem

Des2

Spec3 Urgent


I/P & O/P

Surgery

Rx Plan

• G BR-QZ 80% 50% $1,000 $2,000 N/A N/A $6,500 $13,000 N/A N/A $0 $15 $0 $50 $100 $25$300+


627-5/50/100/250

• G BI-Z2 BR-Q3 80% 50% $1,500 $3,000 N/A N/A $6,500 $13,000 N/A N/A $0 $15 $0 $50 $100 $25$300+


627-5/50/100/250

• G BR-Q4 80% 50% $2,500 $5,000 N/A N/A $6,300 $12,600 N/A N/A $0 $15 $0 $50 $100 $25$300+


627-5/50/100/250

• S BR-RF 80% 50% $3,500 $7,000 N/A N/A $6,300 $12,600 N/A N/A $0 $15 $0 $50 $100 $25$300+


627-5/50/100/250

• S BR-Q2 80% 50% $6,500 $13,000 N/A N/A $7,900 $15,800 N/A N/A $0 $15 $0 $50 $100 $25$300+


627-5/50/100/250

• S BR-RI 80% 50% $1,200 $2,400 N/A N/A $6,900 $13,800 N/A N/A $0 $10 $0 $40 $80 $25$300+

Ded+20%$40 $500 Ded+20%

627-5/50/100/250

• S BR-RL 80% 50% $2,000 $4,000 N/A N/A $6,900 $13,800 N/A N/A $0 $10 $0 $40 $80 $25$300+

Ded+20%$40 $500 Ded+20%

627-5/50/100/250

• S BR-RM BR-RN BR-RT BR-RO 80% 50% $3,000 $6,000 $10,000 $30,000 $6,900 $13,800 $20,000 $60,000 $0 $10 $0 $40 $80 $25 $300+

Ded+20%$40 $500 Ded+20%

627-5/50/100/250

• S BR-RR 80% 50% $4,000 $8,000 N/A N/A $6,900 $13,800 N/A N/A $0 $10 $0 $40 $80 $25 $300+

Ded+20%$40 $500 Ded+20%

627-5/50/100/250

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January 1, 2020

1.6





Package

36

Me

talli

c Plan Code

Core Essential12

Coinsurance

NetworkOut of

Network

Deductible

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family


Virtual Visits

PCP1

SpecUrgentCare


Rx Plan

• G BR-PZ 80% 50% $1,200 $2,400 $5,000 $10,000 $5,000 $13,000 $10,000 $20,000 $0 $0 $100 $50$250+

Ded+20%Ded+20% Ded+20% Ded+20% 548 - 5/50/100/250

16

• G BI-X4 80% 50% $2,500 $5,000 $7,500 $15,000 $5,500 $13,500 $15,000 $30,000 $0 $0 $100 $50$250+

Ded+20%Ded+20% Ded+20% Ded+20% 548 - 5/50/100/250

16

• S BR-P4 70% 50% $5,500 $11,000 $10,000 $20,000 $7,350 $14,700 $10,000 $20,000 $0 $0 $100 $50$250+


548 - 5/50/100/25016

• S BR-P5 70% 50% $7,000 $14,000 $10,000 $20,000 $7,900 $15,800 $10,000 $20,000 $0 $0 $100 $50$250+


548 - 5/50/100/25016


Package

36

Me

talli

c

Plan Code

Choice+ Choice EPO12 Core Essential12

Coinsurance

NetworkPhysician

Out ofNetwork

Deductible

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family


Virtual Visits

PCPAges

19+1

PCPAges

<191

SpecPrem

Des2

Spec3 UrgentCare


Rx Plan

• G BR-Q5 100% N/A $1,000 $2,000 N/A N/A $7,000 $14,000 N/A N/A $0 $35 $0 $35 $70 $50 $400 Ded $400 $250+Ded DV-20/45/80

• G BI-ZT 100% N/A $1,000 $3,000 N/A N/A $6,350 $12,700 N/A N/A $0 $40 $0 $40 $80 $50 $400 Ded $400 $250+Ded NS-10/35/60

• G BI-Y7 AV-XE BR-Q6 100% 70% $3,000 $9,000 $5,000 $15,000 $4,000 $12,000 $10,000 $30,000 $0 $35 $0 $35 $70 $50 $300 Ded $400 $250+Ded DV-20/45/80

• S BR-QP BR-QS BR-Q7 100% 70% $7,000 $14,000 $10,000 $30,000 $7,900 $15,800 $20,000 $60,000 $0 $45 $0 $45 $90 $50 $500 Ded $400 $250+Ded DV-20/45/80


Package

36

Me

talli

c

Plan Code

Choice+ Choice EPO12 Navigate11 Core Essential12

Contrib Range

Coinsurance

NetworkOut of

Network

Deductible

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family


Virtual Visits PCP1 Spec

UrgentCare ER Lab/Xray MRI, CT.

I/P & O/PSurgery

Rx Plan9 Ded

Type5

• S BI-X9 $0-$0 100% 70% $4,000 $8,000 $5,000 $15,000 $6,650 $13,300 $10,000 $30,000 100% 100% 100% 100% 100% 100% 100% 100% 871-0/25/50/100 Emb

• S BI-X5 $0-$200 100% 70% $5,000 $10,000 $10,000 $30,000 $6,000 $12,000 $20,000 $60,000 100% 100% 100% 100% 100% 100% 100% 100% 871-0/25/50/100 Emb

• B BI-XV AV-VX BI-YX BI-X6 $0-$0 100% 70% $6,650 $13,300 $10,000 $30,000 $6,650 $13,300 $20,000 $60,000 100% 100% 100% 100% 100% 100% 100% 100% 273-100% Emb

• S BR-P2 $0-$0 80% 50% $2,700 $5,400 $5,000 $15,000 $6,500 $7,150 $10,000 $30,000 100% 100% $1009 $509 $250+20%9 80% 80% 80% 871-0/25/50/100 Non-Emb

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January 1, 2020





Package

36

Me

talli

c Plan Code

Core Essential12

Coinsurance

NetworkPhysician

Out ofNetwork

Deductible

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family


Virtual Visits

PCPAges

19+1

PCPAges

<191

SpecPrem

Des2

Spec3 Urgent


I/P & O/PSurgery

Rx Plan

• P BI-ZW 100% N/A $750 $2,250 N/A N/A $3,000 $9,000 N/A N/A $0 $20 $0 $20 $40 $50 $300 100% $400 Ded DT-15/40/70

• P BR-RC 100% N/A $1,500 $4,500 N/A N/A $6,000 $12,000 N/A N/A $0 $20 $0 $20 $40 $50 $350 100% $400 Ded NS-10/35/60

• G BR-Q9 100% N/A $3,500 $10,500 N/A N/A $7,900 $15,800 N/A N/A $0 $35 $0 $35 $70 $50 $350 100% $400 Ded DV-20/45/80

• G BR-Q8 100% N/A $5,000 $10,000 N/A N/A $7,000 $14,000 N/A N/A $0 $30 $0 $30 $60 $50 $350 100% $400 Ded DV-20/45/80

• G BI-ZY 80% N/A $3,500 $10,500 N/A N/A $6,350 $12,700 N/A N/A $0 $25 $0 $25 $50 $50 $250+20% 100% $400 Ded+20% DV-20/45/80

Pharmacy Plans

Rx PlanCode

Copays

Tier 1Tier 1

Specialtycopay

Tier 2Tier 2

Specialtycopay

Tier 3Tier 3

Specialtycopay

Tier 4 Tier 4

Specialtycopay

Deductible

Single Family

MailOrderRatio

NS $10 $10 $35 $100 $60 $300 N/A N/A N/A N/A 2.5


DT $15 $15 $40 $100 $70 $300 N/A N/A N/A N/A 2.5

DV $20 $20 $45 $100 $80 $300 N/A N/A N/A N/A 2.5

098 $10 $10 $50 $100 $100 $300 $125 $500 N/A N/A 2.5

099 $15 $15 $50 $100 $100 $300 $125 $500 N/A N/A 2.5

627 $5 N/A $50 N/A $100 N/A $250 N/A N/A N/A 2.5

548 $5 N/A $50 N/A $100 N/A $250 N/A $250 $500 2.5



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January 1, 2020









11 Navigate plans exclude coverage for services provided by Out-of-Network Providers with the exception of (1) Services performed in a Network Facility by hospital-based providers;and (2) Services performed under the Emergency Care benefit

12 Core Essential and Choice EPO plans exclude coverage for services provided by Out-of-Network Providers with the exception of (1) Services performed in a Network Facility byhospital-based providers; and (2) Services performed under the Emergency Care benefit




4 of 4


January 1, 2020

Dallas51+ ATNE; 51-100 Eligible Employees

Effective July 1, 2019

Health Plan Product OfferingUnitedHealthcare Multi-Choice allows you to purchase one health plan package with multiple benefit designoptions (can choose up to 5 plans) to meet a variety of health care and financial needs. Your employees canchoose the option that meets their individual needs, whether it’s saving money on essential coverage orpaying additional dollars for more comprehensive coverage. And you can keep or change your benefitdesign package year after year, ensuring that your health plan will evolve with the changing needs of yourbusiness and your employees.

UnitedHealthcare Premium Designation & Standard Plans

Package

A B C

Plan Codes

Choice+ EPO11

Plan Type

Coinsurance

NetworkOut of

Network

Deductibles

Network

Single Family

Out of Network

Single Family

Out of Pocket Maximum

Network

Single Family

Out of Network

Single Family

Copays

PCP1

Dep <19 PCP

Spec

Tier 1

Spec2 Spec3

VirtualVisit

UrgentCare

ER4 Lab/XRay

MRI, CT,etc.

Inp / OutSurgery

• BC-X3 BC-ZM Premier 100% 70% $250 $500 $5,000 $10,000 $1,750 $3,500 $10,000 $20,000 $0 $20 $20 $40 $0 $75 $300 100% Ded Ded

• BC-X4 BC-ZN Premier 100% 70% $500 $1,000 $5,000 $10,000 $2,000 $4,000 $10,000 $20,000 $0 $25 $25 $50 $0 $75 $300 100% Ded Ded

• BM-DE BM-DF Premier 100% 70% $750 $1,500 $5,000 $10,000 $2,500 $5,000 $10,000 $20,000 $0 $25 $25 $50 $0 $75 $300 100% Ded Ded

• BC-X5 BC-ZO Premier 100% 70% $1,000 $2,000 $5,000 $10,000 $2,500 $5,000 $10,000 $20,000 $0 $25 $25 $50 $0 $75 $300 100% Ded Ded

• BC-X6 BC-ZP Premier 100% 70% $1,500 $3,000 $5,000 $10,000 $3,000 $6,000 $10,000 $20,000 $0 $25 $25 $50 $0 $75 $300 100% Ded Ded

• • BC-X7 BC-ZQ Premier 100% 70% $2,000 $4,000 $5,000 $10,000 $3,500 $7,000 $10,000 $20,000 $0 $30 $30 $60 $0 $75 $300 100% Ded Ded

• • BC-X8 BC-ZR Premier 100% 70% $2,500 $5,000 $5,000 $10,000 $4,000 $8,000 $10,000 $20,000 $0 $30 $30 $60 $0 $75 $300 100% Ded Ded

• • BC-X9 BC-ZS Premier 100% 70% $3,000 $6,000 $5,000 $10,000 $4,500 $9,000 $10,000 $20,000 $0 $30 $30 $60 $0 $75 $300 100% Ded Ded

• • • BC-YA BC-ZT Premier 100% 70% $5,000 $10,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 $0 $35 $35 $70 $0 $75 $300 100% Ded Ded

• BC-YB BC-ZU Premier 80% 50% $250 $500 $5,000 $10,000 $3,000 $6,000 $10,000 $20,000 $0 $20 $20 $40 $0 $75 $250+20% 100% Ded+20% Ded+20%

• BC-YC BC-ZV Premier 80% 50% $500 $1,000 $5,000 $10,000 $3,500 $7,000 $10,000 $20,000 $0 $25 $25 $50 $0 $75 $250+20% 100% Ded+20% Ded+20%

• BM-DG BM-DH Premier 80% 50% $750 $1,500 $5,000 $10,000 $4,000 $8,000 $10,000 $20,000 $0 $25 $25 $50 $0 $75 $250+20% 100% Ded+20% Ded+20%

• • BC-YD BC-ZW Premier 80% 50% $1,000 $2,000 $5,000 $10,000 $4,000 $8,000 $10,000 $20,000 $0 $25 $25 $50 $0 $75 $250+20% 100% Ded+20% Ded+20%

• • • BC-YE BC-ZX Premier 80% 50% $1,500 $3,000 $5,000 $10,000 $5,000 $10,000 $10,000 $20,000 $0 $25 $25 $50 $0 $75 $250+20% 100% Ded+20% Ded+20%

• • • BC-YF BC-ZY Premier 80% 50% $2,000 $4,000 $5,000 $10,000 $6,000 $12,000 $10,000 $20,000 $0 $30 $30 $60 $0 $75 $250+20% 100% Ded+20% Ded+20%

• • BC-YG BC-ZZ Premier 80% 50% $2,500 $5,000 $5,000 $10,000 $6,000 $12,000 $10,000 $20,000 $0 $30 $30 $60 $0 $75 $250+20% 100% Ded+20% Ded+20%

• • BC-YH BC-Z2 Premier 80% 50% $3,000 $6,000 $5,000 $10,000 $6,000 $12,000 $10,000 $20,000 $0 $30 $30 $60 $0 $75 $250+20% 100% Ded+20% Ded+20%

• BC-YI BC-Z3 Premier 80% 50% $5,000 $10,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 $0 $35 $35 $70 $0 $75 $250+20% 100% Ded+20% Ded+20%

• BC-YR BC-1C Premier 70% 50% $250 $500 $5,000 $10,000 $3,000 $6,000 $10,000 $20,000 $0 $20 $20 $40 $0 $75 $250+30% 100% Ded+30% Ded+30%

• BC-YS BC-1D Premier 70% 50% $500 $1,000 $5,000 $10,000 $3,500 $7,000 $10,000 $20,000 $0 $25 $25 $50 $0 $75 $250+30% 100% Ded+30% Ded+30%

• BM-DI BM-DJ Premier 70% 50% $750 $1,500 $5,000 $10,000 $4,000 $8,000 $10,000 $20,000 $0 $25 $25 $50 $0 $75 $250+30% 100% Ded+30% Ded+30%

• • BC-YT BC-1E Premier 70% 50% $1,000 $2,000 $5,000 $10,000 $4,000 $8,000 $10,000 $20,000 $0 $25 $25 $50 $0 $75 $250+30% 100% Ded+30% Ded+30%

• • • BC-YU BC-1F Premier 70% 50% $1,500 $3,000 $5,000 $10,000 $5,000 $10,000 $10,000 $20,000 $0 $25 $25 $50 $0 $75 $250+30% 100% Ded+30% Ded+30%

• • BC-YV BC-1G Premier 70% 50% $2,000 $4,000 $5,000 $10,000 $6,000 $12,000 $10,000 $20,000 $0 $30 $30 $60 $0 $75 $250+30% 100% Ded+30% Ded+30%

• • BC-YW BC-1H Premier 70% 50% $2,500 $5,000 $5,000 $10,000 $6,000 $12,000 $10,000 $20,000 $0 $30 $30 $60 $0 $75 $250+30% 100% Ded+30% Ded+30%

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1.7



Health Plan Product Offering

UnitedHealthcare Premium Designation & Standard Plans

Package

A B C

Plan Codes

Choice+ EPO11

Plan Type

Coinsurance

NetworkOut of

Network

Deductibles

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family

Copays

PCP1

Dep <19 PCP

Spec

Tier 1

Spec2 Spec3

VirtualVisit

UrgentCare

ER4 Lab/

XRayMRI, CT,

etc.Inp / OutSurgery

• • BC-YX BC-1I Premier 70% 50% $3,000 $6,000 $5,000 $10,000 $6,000 $12,000 $10,000 $20,000 $0 $30 $30 $60 $0 $75 $250+30% 100% Ded+30% Ded+30%

• BC-YY BC-1J Premier 70% 50% $5,000 $10,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 $0 $35 $35 $70 $0 $75 $250+30% 100% Ded+30% Ded+30%

• BC-YZ BC-1K Premier 50% 50% $250 $500 $5,000 $10,000 $3,000 $6,000 $10,000 $20,000 $0 $20 $20 $40 $0 $75 $250+50% 100% Ded+50% Ded+50%

• BC-Y2 BC-1L Premier 50% 50% $500 $1,000 $5,000 $10,000 $3,500 $7,000 $10,000 $20,000 $0 $25 $25 $50 $0 $75 $250+50% 100% Ded+50% Ded+50%

• BM-DK BM-DL Premier 50% 50% $750 $1,500 $5,000 $10,000 $4,000 $8,000 $10,000 $20,000 $0 $25 $25 $50 $0 $75 $250+50% 100% Ded+50% Ded+50%

• • • BC-Y3 BC-1M Premier 50% 50% $1,000 $2,000 $5,000 $10,000 $4,000 $8,000 $10,000 $20,000 $0 $25 $25 $50 $0 $75 $250+50% 100% Ded+50% Ded+50%

• • • BC-Y4 BC-1N Premier 50% 50% $1,500 $3,000 $5,000 $10,000 $5,000 $10,000 $10,000 $20,000 $0 $25 $25 $50 $0 $75 $250+50% 100% Ded+50% Ded+50%

• • BC-Y5 BC-1O Premier 50% 50% $2,000 $4,000 $5,000 $10,000 $6,000 $12,000 $10,000 $20,000 $0 $30 $30 $60 $0 $75 $250+50% 100% Ded+50% Ded+50%

• BC-Y6 BC-1P Premier 50% 50% $2,500 $5,000 $5,000 $10,000 $6,000 $12,000 $10,000 $20,000 $0 $30 $30 $60 $0 $75 $250+50% 100% Ded+50% Ded+50%

• BC-Y7 BC-1Q Premier 50% 50% $3,000 $6,000 $5,000 $10,000 $6,000 $12,000 $10,000 $20,000 $0 $30 $30 $60 $0 $75 $250+50% 100% Ded+50% Ded+50%

• BC-Y8 BC-1R Premier 50% 50% $5,000 $10,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 $0 $35 $35 $70 $0 $75 $250+50% 100% Ded+50% Ded+50%

• BC-WJ BC-WR 50/50 50% 50% $2,000 $4,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 N/A $50 $50 $50 $0 $100 Ded+50% Ded+50% Ded+50% Ded+50%

• BC-WK BC-WS 50/50 50% 50% $3,000 $6,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 N/A $50 $50 $50 $0 $100 Ded+50% Ded+50% Ded+50% Ded+50%

• BC-WL BC-WT 50/50 50% 50% $5,000 $10,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 N/A $50 $50 $50 $0 $100 Ded+50% Ded+50% Ded+50% Ded+50%

• AE-4E AG-X2 Consumer 80% 50% $2,000 $4,000 $5,000 $10,000 $6,000 $12,000 $10,000 $20,000 80% 80% 80% 80% 80% 80% 80% 80% 80% 80%

• AE-3R AG-X3 Consumer 80% 50% $5,000 $10,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 80% 80% 80% 80% 80% 80% 80% 80% 80% 80%

• BM-CU BM-CV Consumer 80% 50% $7,350 $14,700 $10,000 $20,000 $7,900 $15,800 $20,000 $40,000 80% 80% 80% 80% 80% 80% 80% 80% 80% 80%

• AE-3S AG-X4 Consumer 50% 50% $0 $0 $5,000 $10,000 $6,000 $12,000 $10,000 $30,000 50% 50% 50% 50% 50% 50% 50% 50% 50% 50%

AG-YF N/A Non-Diff 80% 80% $1,000 $2,000 N/A N/A $3,000 $6,000 N/A N/A 80% 80% 80% 80% 80% 80% 80% 80% 80% 80%

AG-YG N/A Non-Diff 80% 80% $2,000 $4,000 N/A N/A $4,000 $8,000 N/A N/A 80% 80% 80% 80% 80% 80% 80% 80% 80% 80%


Package

A B C

Plan Codes

Choice+ EPO11

Coinsurance

NetworkOut of

Network

Deductible

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family

Copays

PCP1

Dep <19 PCP

Spec

Tier 1

Spec2 Spec3

VirtualVisit

UrgentCare

ER4 Lab/XRay

MRI, CT,etc.

Inp / OutSurgery

Deductible

Type5

• • • AX-KJ AX-KR 80% 50% $1,000 $2,000 $5,000 $10,000 $7,150 $14,300 $10,000 $20,000 $0 $10 $40 $80 $0 $25 $300+Ded+20% 40 500 Ded+20% Emb

• • • AX-KK AX-KS 80% 50% $2,000 $4,000 $5,000 $10,000 $7,150 $14,300 $10,000 $20,000 $0 $10 $40 $80 $0 $25 $300+Ded+20% 40 500 Ded+20% Emb

• • AX-KL AX-KT 80% 50% $3,000 $6,000 $7,500 $15,000 $7,150 $14,300 $15,000 $30,000 $0 $10 $40 $80 $0 $25 $300+Ded+20% 40 500 Ded+20% Emb

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Package

A B C

Plan Codes

Choice+ EPO11

Coinsurance

NetworkOut of

Network

Deductible

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family

Copays

PCP1

Dep <19 PCP

Spec

Tier 1

Spec2 Spec3

VirtualVisit

UrgentCare

ER4 Lab/

XRayMRI, CT,


Deductible

Type5

• • AX-KM AX-KU 80% 50% $5,000 $10,000 $10,000 $20,000 $7,150 $14,300 $20,000 $40,000 $0 $10 $40 $80 $0 $25 $300+Ded+20% $40 $500 Ded+20% Emb

• BM-DM BM-DO 80% 50% $6,000 $12,000 $10,000 $20,000 $7,150 $14,300 $20,000 $40,000 $0 $10 $40 $80 $0 $25 $300+Ded+20% $40 $500 Ded+20% Emb

• • • AX-KN AX-KV 80% 50% $1,000 $2,000 $5,000 $10,000 $7,150 $14,300 $10,000 $20,000 $0 $15 $50 $100 $0 $25 $300+Ded+20% Ded+20% Ded+20% Ded+20% Emb

• • • AX-KO AX-KW 80% 50% $2,000 $4,000 $5,000 $10,000 $7,150 $14,300 $10,000 $20,000 $0 $15 $50 $100 $0 $25 $300+Ded+20% Ded+20% Ded+20% Ded+20% Emb

• • AX-KP AX-KX 80% 50% $3,000 $6,000 $7,500 $15,000 $7,150 $14,300 $15,000 $30,000 $0 $15 $50 $100 $0 $25 $300+Ded+20% Ded+20% Ded+20% Ded+20% Emb

• AX-KQ AX-KY 80% 50% $5,000 $10,000 $10,000 $20,000 $7,150 $14,300 $20,000 $40,000 $0 $15 $50 $100 $0 $25 $300+Ded+20% Ded+20% Ded+20% Ded+20% Emb

• BM-DN BM-DP 80% 50% $6,000 $12,000 $10,000 $20,000 $7,150 $14,300 $20,000 $40,000 $0 $15 $50 $100 $0 $25 $300+Ded+20% Ded+20% Ded+20% Ded+20% Emb

UnitedHealthcare Premier Value plans

Package

A B C

Plan Codes

Choice+ EPO11

Coinsurance

NetworkOut of

Network

Deductibles

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family

Copays

PCP1

Dep <19 PCP

Spec

Tier 1

Spec2 Spec3

VirtualVisit

UrgentCare

ER4 Lab/XRay

MRI, CT,etc.

Inp / OutSurgery

• BC-Y9 BC-1S 100% 70% $500 $1,500 $5,000 $15,000 $6,350 $12,700 $10,000 $30,000 $0 $35 $35 $70 $0 $100 $400 Ded $400 $250+Ded

• • BC-ZA BC-1T 100% 70% $1,000 $3,000 $5,000 $15,000 $6,350 $12,700 $10,000 $30,000 $0 $40 $40 $80 $0 $100 $400 Ded $400 $250+Ded

• • BC-ZB BC-1U 100% 70% $3,000 $9,000 $5,000 $15,000 $6,350 $12,700 $10,000 $30,000 $0 $45 $45 $90 $0 $100 $400 Ded $400 $250+Ded

• • BC-ZC BC-1V 100% 70% $5,000 $10,000 $10,000 $30,000 $6,350 $12,700 $20,000 $60,000 $0 $45 $45 $90 $0 $100 $400 Ded $400 $250+Ded

• BC-ZD BC-1W 80% 50% $0 $0 $5,000 $15,000 $6,350 $12,700 $10,000 $30,000 $0 $35 $35 $70 $0 $100 $400 + 20% Ded + 20% $400 $250+Ded+20%

• • • BC-ZE BC-1X 80% 50% $1,500 $4,500 $5,000 $15,000 $6,350 $12,700 $10,000 $30,000 $0 $40 $40 $80 $0 $100 $400 + 20% Ded + 20% $400 $250+Ded+20%

• • BC-17 BC-19 80% 50% $2,500 $7,500 $5,000 $15,000 $6,350 $12,700 $10,000 $30,000 $0 $40 $40 $80 $0 $100 $400 + 20% Ded + 20% $400 $250+Ded+20%

• • BC-18 BC-2A 80% 50% $5,000 $10,000 $10,000 $30,000 $6,350 $12,700 $20,000 $60,000 $0 $45 $45 $90 $0 $100 $400 + 20% Ded + 20% $400 $250+Ded+20%

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Package

A B C

Plan Codes

Choice+ EPO11 PLAN TYPE

Coinsurance

NetworkOut of

Network

Deductible

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family

Copays

PCP Spec3 VirtualVisit

UrgentCare

ER4 Lab/XRay

MRI, CT,etc.

Inp / OutSurgery

Deductible

Type5

• • • AN-DI AN-DO PrimAdv 80% 50% $1,000 $2,000 $5,000 $10,000 $6,500 $13,000 $10,000 $20,000 $0 $100 $0 $50 $250+Ded+20% Ded+20% Ded+20% Ded+20% Emb

• • • AN-DJ AN-DP PrimAdv 80% 50% $2,000 $4,000 $5,000 $10,000 $6,500 $13,000 $10,000 $20,000 $0 $100 $0 $50 $250+Ded+20% Ded+20% Ded+20% Ded+20% Emb

• AN-DK AN-DQ PrimAdv 80% 50% $3,000 $6,000 $10,000 $20,000 $6,500 $13,000 $20,000 $40,000 $0 $100 $0 $50 $250+Ded+20% Ded+20% Ded+20% Ded+20% Emb

• AN-DL AN-DR PrimAdv 80% 50% $5,000 $10,000 $10,000 $20,000 $6,500 $13,000 $20,000 $40,000 $0 $100 $0 $50 $250+Ded+20% Ded+20% Ded+20% Ded+20% Emb

• BM-CS BM-CT PrimAdv 80% 50% $6,000 $12,000 $10,000 $20,000 $7,000 $14,000 $20,000 $40,000 $0 $100 $0 $50 $250+Ded+20% Ded+20% Ded+20% Ded+20% Emb

• AN-DM AN-DS PrimAdv 50% 50% $1,000 $2,000 $5,000 $10,000 $6,500 $13,000 $10,000 $20,000 $0 $100 $0 $50 $250+Ded+50% Ded+50% Ded+50% Ded+50% Emb

• AN-DN AN-DT PrimAdv 50% 50% $2,000 $4,000 $5,000 $10,000 $6,500 $13,000 $10,000 $20,000 $0 $100 $0 $50 $250+Ded+50% Ded+50% Ded+50% Ded+50% Emb

• • AX-SO AX-SP PrimAdv HSA18

80% 50% $1,500 $3,000 $5,000 $10,000 $6,500 $7,150 $10,000 $20,000 $09

$1009

$09

$509

$250+Ded+20%9

Ded+20% Ded+20% Ded+20% Non-Emb

• • AX-SQ AX-SR PrimAdv HSA18 80% 50% $2,000 $4,000 $5,000 $10,000 $6,500 $7,150 $10,000 $20,000 $09 $1009 $09 $509 $250+Ded+20%9 Ded+20% Ded+20% Ded+20% Non-Emb

UnitedHealthcare Primary Advantage Rx

Rx PlanCopays

Tier 1 Tier 2 Tier 3 Tier 4

Mail Order Rx Ded Rx Deductible

454/454X $0 $50 $100 $250 2.5 $250/$500 Waived for tier 1 & 2

455/455X $5 $50 $100 $250 2.5 $250/$500 Waived for tier 1 & 2

751/751X $0 $50 $100 $250 2.5 Medical HSA Only

UnitedHealthcare Navigate8,11 Plans

Package

A B C

Plan Code

Coinsurance

NetworkOut of

Network

Deductibles

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family

Copays

PCP1

Dep <19 PCP

Spec withReferral

VirtualVisit

UrgentCare

ER4 Lab/

XRayMRI, CT,


Deductible

Type5

• BC-W7 100% NA $0 $0 NA NA $2,000 $6,000 NA NA $0 $10 $30 $0 $50 $650 Ded $500 $250 Emb

• BC-W8 100% NA $250 $750 NA NA $6,350 $12,700 NA NA $0 $15 $45 $0 $50 $650 Ded $500 $250 + Ded Emb

• BC-W9 100% NA $500 $1,500 NA NA $6,350 $12,700 NA NA $0 $15 $45 $0 $50 $650 Ded $500 $250 + Ded Emb

• • BC-XA 100% NA $1,000 $3,000 NA NA $6,350 $12,700 NA NA $0 $15 $45 $0 $50 $650 Ded $500 $250 + Ded Emb

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UnitedHealthcare Navigate8,11 Plans

Package

A B C

Plan Code

Coinsurance

NetworkOut of

Network

Deductibles

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family

Copays

PCP1

Dep <19 PCP

Spec withReferral

VirtualVisit

UrgentCare

ER4 Lab/XRay

MRI, CT,etc.

Inp / OutSurgery

Deductible

Type5

• • BC-XB 100% NA $3,000 $9,000 NA NA $6,350 $12,700 NA NA $0 $25 $75 $0 $50 $650 Ded $500 $250 + Ded Emb

• • BC-XC 100% NA $3,500 $10,500 NA NA $6,350 $12,700 NA NA $0 $25 $75 $0 $50 $650 Ded $500 $250 + Ded Emb

• • BC-XD 100% NA $4,000 $12,000 NA NA $6,350 $12,700 NA NA $0 $25 $75 $0 $50 $650 Ded $500 $250 + Ded Emb

• BC-XE 100% NA $5,000 $10,000 NA NA $6,350 $12,700 NA NA $0 $25 $75 $0 $50 $650 Ded $500 $250 + Ded Emb

• BC-XG 100% NA $0 $0 NA NA $2,500 $5,000 NA NA $0 $10 $30 $0 $50 $500 100% $500 100% Emb

• BC-XH 100% NA $500 $1,000 NA NA $3,000 $6,000 NA NA $0 $10 $30 $0 $50 $500 100% $500 Ded Emb

• • BC-XI 100% NA $1,000 $2,000 NA NA $3,500 $7,000 NA NA $0 $10 $30 $0 $50 $500 100% $500 Ded Emb

• BC-XJ 100% NA $2,000 $4,000 NA NA $4,500 $9,000 NA NA $0 $15 $45 $0 $75 $500 100% $500 Ded Emb

• • BC-XK 100% NA $2,500 $5,000 NA NA $5,000 $10,000 NA NA $0 $15 $45 $0 $75 $500 100% $500 Ded Emb

• • BC-XL 100% NA $3,000 $6,000 NA NA $5,500 $11,000 NA NA $0 $15 $45 $0 $75 $500 100% $500 Ded Emb

• • BC-XM 100% NA $5,000 $10,000 NA NA $6,500 $13,000 NA NA $0 $25 $75 $0 $100 $500 100% $500 Ded Emb

• • • AY-Y7 100% NA $1,000 $2,000 NA NA $4,000 $8,000 NA NA $0 $10 $60 $0 $25 $500+Ded $40 $500 Ded Emb

• • • AY-Y8 100% NA $2,000 $4,000 NA NA $5,000 $10,000 NA NA $0 $10 $60 $0 $25 $500+Ded $40 $500 Ded Emb

• • AY-Y9 100% NA $3,000 $6,000 NA NA $6,000 $12,000 NA NA $0 $10 $60 $0 $25 $500+Ded $40 $500 Ded Emb

• • AY-ZA 100% NA $4,000 $8,000 NA NA $7,000 $14,000 NA NA $0 $10 $60 $0 $25 $500+Ded $40 $500 Ded Emb

• AY-ZB 100% NA $5,000 $10,000 NA NA $7,350 $14,700 NA NA $0 $10 $60 $0 $25 $500+Ded $40 $500 Ded Emb

• BE-II 100% NA $6,000 $12,000 NA NA $7,350 $14,700 NA NA $0 $10 $60 $0 $25 $500+Ded $40 $500 Ded Emb

• BC-XN 80% NA $0 $0 NA NA $6,600 $13,200 NA NA $0 $25 $75 $0 $100 $500 Ded+20% $500 Ded + 20% Emb

• • • BC-XO 80% NA $1,000 $2,000 NA NA $6,600 $13,200 NA NA $0 $25 $75 $0 $100 $500 Ded+20% $500 Ded + 20% Emb

• • BC-XP 80% NA $2,500 $5,000 NA NA $6,600 $13,200 NA NA $0 $25 $75 $0 $100 $500 Ded+20% $500 Ded + 20% Emb

• • • AY-ZH 80% NA $1,000 $2,000 NA NA $4,000 $8,000 NA NA $0 $10 $60 $0 $25 $500+Ded+20% $40 $500 Ded+20% Emb

• • • AY-ZI 80% NA $2,000 $4,000 NA NA $5,000 $10,000 NA NA $0 $10 $60 $0 $25 $500+Ded+20% $40 $500 Ded+20% Emb

• • AY-ZJ 80% NA $3,000 $6,000 NA NA $6,000 $12,000 NA NA $0 $10 $60 $0 $25 $500+Ded+20% $40 $500 Ded+20% Emb

• • AY-ZK 80% NA $4,000 $8,000 NA NA $7,000 $14,000 NA NA $0 $10 $60 $0 $25 $500+Ded+20% $40 $500 Ded+20% Emb

• AY-ZL 80% NA $5,000 $10,000 NA NA $7,350 $14,700 NA NA $0 $10 $60 $0 $25 $500+Ded+20% $40 $500 Ded+20% Emb

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Dallas





UnitedHealthcare Dallas Charter8,11 Plans

These plans are available in the following counties: Collin, Dallas, Denton, Ellis, Fannin, Hunt, Johnson, Parker, Rockwall and Tarrant

Package

A B C

Plan Codes

CharterPLAN TYPE

Coinsurance

NetworkOut of

Network

Deductibles

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family

Copays

PCP

Dep <19 PCP

SCPVirtualVisit

UrgentCare

ER4 Lab/

XRayMRI, CT,


Deductible

Type5

• • • BM-C8 Charter PrimAdv 80% NA $1,000 $2,000 NA NA $6,500 $13,000 NA NA $0 $0 $100 $0 $50 $250+Ded+20% Ded+20% Ded+20% Ded+20% Emb

• • • BM-C9 Charter PrimAdv 80% NA $2,000 $4,000 NA NA $6,500 $13,000 NA NA $0 $0 $100 $0 $50 $250+Ded+20% Ded+20% Ded+20% Ded+20% Emb

• BM-DA Charter PrimAdv 80% NA $3,000 $6,000 NA NA $6,500 $13,000 NA NA $0 $0 $100 $0 $50 $250+Ded+20% Ded+20% Ded+20% Ded+20% Emb

• BM-DB Charter PrimAdv 80% NA $5,000 $10,000 NA NA $6,500 $13,000 NA NA $0 $0 $100 $0 $50 $250+Ded+20% Ded+20% Ded+20% Ded+20% Emb

• BM-DC Charter PrimAdv 50% NA $1,000 $2,000 NA NA $6,500 $13,000 NA NA $0 $0 $100 $0 $50 $250+Ded+20% Ded+20% Ded+20% Ded+20% Emb

• BM-DD Charter PrimAdv 50% NA $2,000 $4,000 NA NA $6,500 $13,000 NA NA $0 $0 $100 $0 $50 $250+Ded+20% Ded+20% Ded+20% Ded+20% Emb

• BC-XQ Charter 100% NA $0 $0 NA NA $2,500 $5,000 NA NA $0 $10 $30 $0 $50 $500 100% $500 100% Emb

• BC-XR Charter 100% NA $500 $1,500 NA NA $3,000 $6,000 NA NA $0 $10 $30 $0 $50 $500 100% $500 Ded Emb

• • BC-XS Charter 100% NA $1,000 $2,000 NA NA $3,500 $7,000 NA NA $0 $10 $30 $0 $50 $500 100% $500 Ded Emb

• BC-XT Charter 100% NA $2,000 $4,000 NA NA $4,500 $9,000 NA NA $0 $15 $45 $0 $75 $500 100% $500 Ded Emb

• • BC-XU Charter 100% NA $2,500 $5,000 NA NA $5,000 $10,000 NA NA $0 $15 $45 $0 $75 $500 100% $500 Ded Emb

• • BC-XV Charter 100% NA $3,000 $6,000 NA NA $5,500 $11,000 NA NA $0 $15 $45 $0 $75 $500 100% $500 Ded Emb

• • BC-XW Charter 100% NA $5,000 $10,000 NA NA $6,500 $13,000 NA NA $0 $25 $75 $0 $100 $500 100% $500 Ded Emb

• AY-ZC Charter 100% NA $1,000 $2,000 NA NA $4,000 $8,000 NA NA $0 $10 $60 $0 $25 $500+Ded $40 $500 Ded Emb

• • • AY-ZD Charter 100% NA $2,000 $4,000 NA NA $5,000 $10,000 NA NA $0 $10 $60 $0 $25 $500+Ded $40 $500 Ded Emb

• • AY-ZE Charter 100% NA $3,000 $6,000 NA NA $6,000 $12,000 NA NA $0 $10 $60 $0 $25 $500+Ded $40 $500 Ded Emb

• • AY-ZF Charter 100% NA $4,000 $8,000 NA NA $7,000 $14,000 NA NA $0 $10 $60 $0 $25 $500+Ded $40 $500 Ded Emb

• AY-ZG Charter 100% NA $5,000 $10,000 NA NA $7,350 $14,700 NA NA $0 $10 $60 $0 $25 $500+Ded $40 $500 Ded Emb

• BE-IJ Charter 100% NA $6,000 $12,000 NA NA $7,350 $14,700 NA NA $0 $10 $60 $0 $25 $500+Ded $40 $500 Ded Emb

• • • BC-XX Charter 80% NA $0 $0 NA NA $6,600 $13,200 NA NA $0 $25 $75 $0 $100 $500 Ded+20% $500 80% Emb

• • • BC-XY Charter 80% NA $1,000 $2,000 NA NA $6,600 $13,200 NA NA $0 $25 $75 $0 $100 $500 Ded+20% $500 80% Emb

• • BC-XZ Charter 80% NA $2,500 $5,000 NA NA $6,600 $13,200 NA NA $0 $25 $75 $0 $100 $500 Ded+20% $500 80% Emb

• • • AY-ZM Charter 80% NA $1,000 $2,000 NA NA $4,000 $8,000 NA NA $0 $10 $60 $0 $25 $500+Ded+20% $40 $500 80% Emb

• • • AY-ZN Charter 80% NA $2,000 $4,000 NA NA $5,000 $10,000 NA NA $0 $10 $60 $0 $25 $500+Ded+20% $40 $500 80% Emb

• • AY-ZO Charter 80% NA $3,000 $6,000 NA NA $6,000 $12,000 NA NA $0 $10 $60 $0 $25 $500+Ded+20% $40 $500 80% Emb

• • AY-ZP Charter 80% NA $4,000 $8,000 NA NA $7,000 $14,000 NA NA $0 $10 $60 $0 $25 $500+Ded+20% $40 $500 80% Emb

• AY-ZQ Charter 80% NA $5,000 $10,000 NA NA $7,350 $14,700 NA NA $0 $10 $60 $0 $25 $500+Ded+20% $40 $500 80% Emb

• • BC-X2 HSA Charter 100% NA $2,000 $4,000 NA NA $6,450 $6,850 NA NA $159 $459 $09 $759 $5009 100% $5009 100% Non-Emb

• • AG-ZL HSA Charter 100% NA $3,000 $6,000 NA NA $5,000 $10,000 NA NA 100% 100% 100% 100% 100% 100% 100% 100% Emb

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Dallas





UnitedHealthcare Dallas Charter8,11 Plans

These plans are available in the following counties: Collin, Dallas, Denton, Ellis, Fannin, Hunt, Johnson, Parker, Rockwall and Tarrant

Package

A B C

Plan Codes

CharterPLAN TYPE

Coinsurance

NetworkOut of

Network

Deductibles

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family

Copays

PCP

Dep <19 PCP

SCPVirtualVisit

UrgentCare

ER4 Lab/

XRayMRI, CT,


Deductible

Type5

• • BM-C6 HSA Charter 100% NA $4,000 $8,000 NA NA $5,450 $10,900 NA NA 100% 100% 100% 100% 100% 100% 100% 100% Emb

• • AG-ZM HSA Charter 100% NA $5,000 $10,000 NA NA $6,450 $12,900 NA NA 100% 100% 100% 100% 100% 100% 100% 100% Emb

• AG-ZN HSA Charter 100% NA $6,350 $12,700 NA NA $6,350 $12,700 NA NA 100% 100% 100% 100% 100% 100% 100% 100% Emb

• • AG-ZO HSA Charter 80% NA $3,000 $6,000 NA NA $6,450 $12,900 NA NA 80% 80% 80% 80% 80% 80% 80% 80% Emb

• • BM-C3 HSA Charter 70% NA $3,000 $6,000 NA NA $6,450 $12,900 NA NA 70% 70% 70% 70% 70% 70% 70% 70% Emb

UnitedHealthcare Health Savings Account (HSA) Plans

Package

A B C

Plan Codes

Choice+ EPO 11

Navigate8,

11

Coinsurance

NetworkOut of

Network

Deductibles

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family

Copays

PCP Spec3 Virtual

VisitUrgentCare

ER4 Lab/

XRayMRI, CT,


Deductible

Type5

• AE-3J AG-X6 AG-YQ 100% 70% $2,000 $4,000 $5,000 $10,000 $3,000 $6,000 $10,000 $20,000 100% 100% 100% 100% 100% 100% 100% 100% Non-Emb

• • • BC-WO BC-W6 BC-XF 100% 70% $2,000 $4,000 $5,000 $10,000 $4,500 $6,850 $10,000 $20,000 309

609

$09

$759

$5009

100% 100% 100% Non-Emb

• • AE-3K AG-X7 AG-YR 100% 70% $3,000 $6,000 $5,000 $10,000 $4,000 $8,000 $10,000 $20,000 100% 100% 100% 100% 100% 100% 100% 100% Emb

• • BM-CW BM-CX BM-C5 100% 70% $4,000 $8,000 $5,000 $10,000 $5,000 $10,000 $10,000 $20,000 100% 100% 100% 100% 100% 100% 100% 100% Emb

• • AE-3L AG-X8 AG-YS 100% 70% $5,000 $10,000 $5,000 $10,000 $6,000 $12,000 $10,000 $20,000 100% 100% 100% 100% 100% 100% 100% 100% Emb

• • AE-3M AG-X9 AG-YT 100% 70% $6,350 $12,700 $10,000 $20,000 $6,350 $12,700 $20,000 $40,000 100% 100% 100% 100% 100% 100% 100% 100% Emb

• • • AX-SM AX-SN AX-SS 80% 50% $2,700 $5,400 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 80% 80% 80% 80% 80% 80% 80% 80% Emb

• • AE-3N AG-YB AG-YV 80% 50% $3,000 $6,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 80% 80% 80% 80% 80% 80% 80% 80% Emb

• AE-3O AG-YC AG-YW 80% 50% $3,500 $7,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 80% 80% 80% 80% 80% 80% 80% 80% Emb

• BM-CY BM-CZ BM-C7 80% 50% $4,000 $8,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 80% 80% 80% 80% 80% 80% 80% 80% Emb

• AE-3P AG-YD AG-YX 80% 50% $5,000 $10,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 80% 80% 80% 80% 80% 80% 80% 80% Emb

• • BM-CO BM-CP BM-C2 70% 50% $3,000 $6,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 70% 70% 70% 70% 70% 70% 70% 70% Emb

• BM-CQ BM-CR BM-C4 70% 50% $5,000 $10,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 70% 70% 70% 70% 70% 70% 70% 70% Emb

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Dallas





UnitedHealthcare Flex Free17Plans

Package

A B C

Plan Codes

Choice+ EPO11

Coinsurance

NetworkOut of

Network

Deductibles

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family

Copays

PCP

Visits 1 -3, combined PCP, Spec

Spec VirtualVisit

UrgentCare

Visit 1-2

ER4 Lab/

XRayMRI, CT,


Deductible

Type5

• • BC-WY BC-W5 100% 50% $5,000 $10,000 $10,000 $20,000 $6,850 $13,700 $20,000 $40,000 $0 (Visit 1-3), then Ded & Coins $0 $0 $250+Ded Ded $250+Ded $250+Ded Emb

• BC-WU BC-WZ 80% 50% $1,000 $2,000 $5,000 $10,000 $6,850 $13,700 $10,000 $20,000 $0 (Visit 1-3), then Ded & Coins $0 $0 $250+Ded+20% Ded+20% $250+Ded+20% $250+Ded+20% Emb

• • • BC-WV BC-W2 80% 50% $2,000 $4,000 $5,000 $10,000 $6,850 $13,700 $10,000 $20,000 $0 (Visit 1-3), then Ded & Coins $0 $0 $250+Ded+20% Ded+20% $250+Ded+20% $250+Ded+20% Emb

• • • BC-WW BC-W3 80% 50% $3,000 $6,000 $5,000 $10,000 $6,850 $13,700 $10,000 $20,000 $0 (Visit 1-3), then Ded & Coins $0 $0 $250+Ded+20% Ded+20% $250+Ded+20% $250+Ded+20% Emb

• • BC-WX BC-W4 80% 50% $5,000 $10,000 $10,000 $20,000 $6,850 $13,700 $20,000 $40,000 $0 (Visit 1-3), then Ded & Coins $0 $0 $250+Ded+20% Ded+20% $250+Ded+20% $250+Ded+20% Emb

UnitedHealthcare Flex point6Plans

Package

A B C

Plan Codes

Choice+ EPO11

Coinsurance

NetworkOut of

Network

Deductibles

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family

Copays

PCP

PCP (Visits 1 -4, Includes Spec)

Spec

Tier 1

Spec2 Spec3

VirtualVisit

UrgentCare

Visit 1-4

ER4 Lab/XRay

MRI, CT,etc.

Inp / OutSurgery

Deductible

Type5

• • • BC-ZF BC-1Y 80% 50% $1,000 $2,000 $5,000 $10,000 $4,000 $8,000 $10,000 $20,000 $25 $25 $50 $0 $100 $250+20% Ded+20% Ded+20% Ded+20% Emb

• • BC-ZG BC-1Z 80% 50% $2,000 $4,000 $5,000 $10,000 $6,000 $12,000 $10,000 $20,000 $30 $30 $60 $0 $100 $250+20% Ded+20% Ded+20% Ded+20% Emb

• • BC-ZH BC-12 80% 50% $5,000 $10,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 $35 $35 $70 $0 $100 $250+20% Ded+20% Ded+20% Ded+20% Emb

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sDallas





Pharmacy Plans

Rx Plan Code

Copays


Mail Order Ration

K5 $10 $25 $50 2.5

H9/NN* $10 $30 $50 2.5

2V/NO* $10 $35 $60 2.5

5U $10 $35 $60 $100 2.5

OI $10 $35 $70 2.5

VQ $10 $40 $80 2.5

FZ $15 $30 $65 2.5

3B/032* $15 $35 $60 2.5

FE $15 $35 $70 2.5

IU/52* $15 $40 $75 2.5

V3 $15 $40 $75 $200 2.5

GB $15 $45 $80 2.5

QF/Z9* $15 $45 $85 2.5

EJ/53** $15 $45 $85 $200 2.5

LJ $20 $35 $70 2.5

KT $20 $40 $75 2.5

KU $20 $45 $80 2.5

V6 $20 $50 $85 2.5

V7 $20 $50 $85 $250 2.5

51/54* $20 $50 $100 2.5

*Rx plan features copays of $100/$300 for Specialty medications in Tiers 2/3. Available on the PRIME system only.

**Rx plan features copays of $100/$300/$500 for Specialty medications in Tiers 2/3/4. Available on the PRIME system only.

The 2V/NO are the only available Rx combinations for our HSA plans

Access PDL is available on the following RX plans: 2V,5U,H9,IU,V3,KT,455,454,NO,NN,032 and 52

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Dallas




Health Plan Product Offering 1 Primary Care Physicians include Family Practice, Internal medicine,and Pediatrics.

2 This tier of benefits applies to UnitedHealth Premium Tier 1 Designated Providers. Please visit myuhc.com for details.

3 This tier of benefits applies to physicians in specialties where there is no UnitedHealth Premium designation program and for physicians who are not UnitedHealth Premium Tier 1Designated.

4 Plan deductible is waived for Emergency Room visits on plans where copay or copay + coinsurance are listed.

5 “Embedded” deductible means once an individual meets their portion of the deductible, services are paid for that person without the entire family deductible being met.“Non-Embedded” deductible means no covered family member will satisfy an individual deductible until the entire family deductible is met.

6 “Flexpoint” plans feature a copay for office visits one through four during the calendar year or plan year, depending on plan type selected. Office visits five and over will be subject toplan deductible/coinsurance. This is a separate limit for both Physician Office visits and Urgent Care visits. Plans feature one Preventive Care visit per year, which does not count against the office visit copay limit.


9 Copayments on HSA plans will be required after the deductible has been met and will continue to be required until the annual out-of-pocket maximum is met.

11 EPO and Navigate plans exclude coverage for services provided by Out-of-Network Providers with the exceptions of 1) Services performed in a Network Facility by hospital-basedproviders; and 2) Services performed under the Emergency Care benefit.

17 “FlexFree” plans feature $0 copay for the first 3 PCP and/or Specialist office visits during the Plan Year. Office visits 4+ will be subject to plan deductible/coinsurance. Plans alsofeature $0 copay for the first 2 Urgent Care visits during the Plan Year. Urgent Care visits 3+ will be subject to plan deductible/coinsurance. Preventive Care visits do not count againstthe office visit copay limit.

18 Copayments on Primary Advantage HSA plans will be required only after the deductible has been met and will continue to be required until the annual out-of-pocket maximum ismet.

18 There is no separate additional Rx deductible required for Primary Advantage HSA plans.

Please Note: The information in this grid is provided for informational purposes only and is not intended for use as a contract. For a complete listing of coverage and exclusions, pleaserefer to the Benefit Summary or talk to your UnitedHealthcare representative for additional details that could impact the benefits. Insurance coverage provided by or throughUnitedHealthcare Insurance Company or its affiliates. Administrative services provided by United HealthCare Services, Inc. or their affiliates. Health Plan coverage provided by or throughUnitedHealthcare of Florida, Inc.

©2019 United HealthCare Services, Inc.

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Dallas


Texas51+

October 1, 2019

Health Plan Product Offering UnitedHealthcare offers a wide variety of plan options that allow you to tailor your benefit needs to yourbusiness needs, choosing what you value in a health plan.

UnitedHealthcare Copay Clear PlansPlan

Codes

Choice + EPO11

Coinsurance


Deductibles

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family

Copay / Per Occurrence

VirtualVisit

PCP1

Prem DesPCP1 Spec2

Prem DesSpec3 Urgent

CareER Lab/Xray MRI, CT,

etc.O/P

SurgeryI/P

Surgery

DeductibleType5

BT-C2 BT-C8 100% 50% $500 $1,000 $5,000 $10,000 $7,500 $15,000 $10,000 $20,000 $0 $0 $0* $75 $75* $50 $750* $0** $500* $750* $2,000* Emb

BT-C3 BT-C9 100% 50% $1,000 $2,000 $5,000 $10,000 $7,500 $15,000 $10,000 $20,000 $0 $0 $0* $75 $75* $50 $750* $0** $500* $750* $2,000* Emb

BT-C4 BT-DA 100% 50% $2,000 $4,000 $5,000 $10,000 $7,500 $15,000 $10,000 $20,000 $0 $0 $0* $75 $75* $50 $750* $0** $500* $750* $2,000* Emb

BT-C5 BT-DB 100% 50% $3,000 $6,000 $7,500 $15,000 $7,500 $15,000 $15,000 $30,000 $0 $0 $0* $75 $75* $50 $750* $0** $500* $750* $2,000* Emb

BT-C6 BT-DC 100% 50% $4,000 $8,000 $10,000 $20,000 $7,500 $15,000 $20,000 $40,000 $0 $0 $0* $75 $75* $50 $750* $0** $500* $750* $2,000* Emb

BT-C7 BT-DD 100% 50% $5,000 $10,000 $10,000 $20,000 $7,500 $15,000 $20,000 $40,000 $0 $0 $0* $75 $75* $50 $750* $0** $500* $750* $2,000* Emb

*After plan deductible

**Plan deductible waived at Preferred Lab Network (PLN) providers

1 of 2

trainwat

Highlight

Texas51+

October 1, 2019

Health Plan Product Offering Pharmacy PlansRx Plan Code

Copays

Tier 1 Tier 2 Tier 3 Tier 4Mail Order

Ration

K5 $10 $25 $50 2.5

H9 $10 $30 $50 2.5

2V $10 $35 $60 2.5

5U $10 $35 $60 $100 2.5

OI $10 $35 $70 2.5

VQ $10 $40 $80 2.5

FZ $15 $30 $65 2.5

FE $15 $35 $70 2.5

IU $15 $40 $75 2.5

V3 $15 $40 $75 $200 2.5

GB $15 $45 $80 2.5

LJ $20 $35 $70 2.5

KT $20 $40 $75 2.5

KU $20 $45 $80 2.5

V6 $20 $50 $85 2.5

V7 $20 $50 $85 $250 2.5

1 Primary Care Physicians include Family Practice, Internal medicine,and Pediatrics.




11 EPO plans exclude coverage for services provided by Out-of-Network Providers with the exceptions of 1) Services performed in a Network Facility by hospital-based providers; and2) Services performed under the Emergency Care benefit.

Please note: The information in this grid is provided for informational purposes only and is not intended for use as a contract. For a complete listing of coverage and exclusions, pleaserefer to the Certificate of Coverage or talk to your UnitedHealthcare representative for additional details that could impact the benefits. Different UnitedHealthcare plans may have varyingapproaches to whether pharmacy costs are included or excluded from the medical deductible. Insurance coverage provided by or through by United HealthCare Services, Inc. or theiraffiliates. UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by United HealthCare Services, Inc. or their affiliates.V10/16

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Highlight

UnitedHealthcare Amarillo Core & CoreEssential

51+ ATNE; 51-100 Eligible EmployeesEffective July 1, 2018


UnitedHealthcare Multi-Choice allows you to purchase one health plan package with multiple benefit designoptions (can choose up to 5 plans) to meet a variety of health care and financial needs. Your employees canchoose the option that meets their individual needs, whether it’s saving money on essential coverage orpaying additional dollars for more comprehensive coverage. And you can keep or change your benefitdesign package year after year, ensuring that your health plan will evolve with the changing needs of yourbusiness and your employees.


Package

A B C

Plan Codes

CoreCore

Essential11

Coinsurance

NetworkOut of

Network

Deductible

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family

Copays

PCP1

Dep <19 PCP

Spec

Tier 1

Spec2 Spec3

VirtualVisit

UrgentCare

ER4 Lab/XRay

MRI, CT,etc.

Inp / OutSurgery

Deductible

Type5

• • • BG-FZ BG-F9 80% 50% $1,000 $2,000 $5,000 $10,000 $7,150 $14,300 $10,000 $20,000 $0 $10 $40 $80 $0 $25 $300+Ded+20% $40 $500 Ded+20% Emb

• • • BG-F2 BG-GA 80% 50% $2,000 $4,000 $5,000 $10,000 $7,150 $14,300 $10,000 $20,000 $0 $10 $40 $80 $0 $25 $300+Ded+20% $40 $500 Ded+20% Emb

• • BG-F3 BG-GB 80% 50% $3,000 $6,000 $7,500 $15,000 $7,150 $14,300 $15,000 $30,000 $0 $10 $40 $80 $0 $25 $300+Ded+20% $40 $500 Ded+20% Emb

• • BG-F4 BG-GC 80% 50% $5,000 $10,000 $10,000 $20,000 $7,150 $14,300 $20,000 $40,000 $0 $10 $40 $80 $0 $25 $300+Ded+20% $40 $500 Ded+20% Emb

• BM-DM BM-DO 80% 50% $6,000 $12,000 $10,000 $20,000 $7,150 $14,300 $20,000 $40,000 $0 $10 $40 $80 $0 $25 $300+Ded+20% $40 $500 Ded+20% Emb

• • • BG-F5 BG-GD 80% 50% $1,000 $2,000 $5,000 $10,000 $7,150 $14,300 $10,000 $20,000 $0 $15 $50 $100 $0 $25 $300+Ded+20% Ded+20% Ded+20% Ded+20% Emb

• • • BG-F6 BG-GE 80% 50% $2,000 $4,000 $5,000 $10,000 $7,150 $14,300 $10,000 $20,000 $0 $15 $50 $100 $0 $25 $300+Ded+20% Ded+20% Ded+20% Ded+20% Emb

• • BG-F7 BG-GF 80% 50% $3,000 $6,000 $7,500 $15,000 $7,150 $14,300 $15,000 $30,000 $0 $15 $50 $100 $0 $25 $300+Ded+20% Ded+20% Ded+20% Ded+20% Emb

• BG-F8 BG-GG 80% 50% $5,000 $10,000 $10,000 $20,000 $7,150 $14,300 $20,000 $40,000 $0 $15 $50 $100 $0 $25 $300+Ded+20% Ded+20% Ded+20% Ded+20% Emb

• BM-DN BM-DP 80% 50% $6,000 $12,000 $10,000 $20,000 $7,150 $14,300 $20,000 $40,000 $0 $15 $50 $100 $0 $25 $300+Ded+20% Ded+20% Ded+20% Ded+20% Emb

UnitedHealthcare Premier Value plans

Package

A B C

Plan Codes

CoreCore

Essential11

Coinsurance

NetworkOut of

Network

Deductibles

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family

Copays

PCP1

Dep <19 PCP

Spec

Tier 1

Spec2 Spec3

VirtualVisit

UrgentCare

ER4 Lab/

XRayMRI, CT,


• BG-GH BG-GL 100% 70% $500 $1,500 $5,000 $15,000 $6,350 $12,700 $10,000 $30,000 $0 $35 $35 $70 $25 $100 $400 Ded $400 $250+Ded+20%

• • BG-GI BG-GM 100% 70% $1,000 $3,000 $5,000 $15,000 $6,350 $12,700 $10,000 $30,000 $0 $40 $40 $80 $25 $100 $400 Ded $400 $250+Ded+20%

• • BG-GJ BG-GN 100% 70% $3,000 $9,000 $5,000 $15,000 $6,350 $12,700 $10,000 $30,000 $0 $45 $45 $90 $25 $100 $400 Ded $400 $250+Ded+20%

• • BG-GK BG-GO 100% 70% $5,000 $10,000 $10,000 $30,000 $6,350 $12,700 $20,000 $60,000 $0 $45 $45 $90 $25 $100 $400 Ded $400 $250+Ded+20%

1 of 5

Amarillo


Core & CoreE i l

1.8





Package

A B C

Plan Codes

CoreCore

Essential11

PLAN TYPE

Coinsurance

NetworkOut of

Network

Deductible

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family

Copays

PCP Spec3 Virtual

VisitUrgentCare

ER4 Lab/

XRayMRI, CT,


Deductible

Type5

• • • BE-HK BE-HQ PrimAdv 80% 50% $1,000 $2,000 $5,000 $10,000 $6,500 $13,000 $10,000 $20,000 $0 $100 $0 $50 $250+Ded+20% Ded+20% Ded+20% Ded+20% Emb

• • • BE-HL BE-HR PrimAdv 80% 50% $2,000 $4,000 $5,000 $10,000 $6,500 $13,000 $10,000 $20,000 $0 $100 $0 $50 $250+Ded+20% Ded+20% Ded+20% Ded+20% Emb

• BE-HM BE-HS PrimAdv 80% 50% $3,000 $6,000 $10,000 $20,000 $6,500 $13,000 $20,000 $40,000 $0 $100 $0 $50 $250+Ded+20% Ded+20% Ded+20% Ded+20% Emb

• BE-HN BE-HT PrimAdv 80% 50% $5,000 $10,000 $10,000 $20,000 $6,500 $13,000 $20,000 $40,000 $0 $100 $0 $50 $250+Ded+20% Ded+20% Ded+20% Ded+20% Emb

• BM-CS BM-CT PrimAdv 80% 50% $6,000 $12,000 $10,000 $20,000 $7,000 $14,000 $20,000 $40,000 $0 $100 $0 $50 $250+Ded+20% Ded+20% Ded+20% Ded+20% Emb

• BE-HO BE-HU PrimAdv 50% 50% $1,000 $2,000 $5,000 $10,000 $6,500 $13,000 $10,000 $20,000 $0 $100 $0 $50 $250+Ded+50% Ded+50% Ded+50% Ded+50% Emb

• BE-HP BE-HV PrimAdv 50% 50% $2,000 $4,000 $5,000 $10,000 $6,500 $13,000 $10,000 $20,000 $0 $100 $0 $50 $250+Ded+50% Ded+50% Ded+50% Ded+50% Emb

• • BE-HW BE-HX PrimAdv HSA18 80% 50% $1,500 $3,000 $5,000 $10,000 $6,500 $7,150 $10,000 $20,000 $09 $1009 $09 $509 $250+Ded+20%9 Ded+20% Ded+20% Ded+20% Non-Emb

• • BE-HY BE-HZ PrimAdv HSA18 80% 50% $2,000 $4,000 $5,000 $10,000 $6,500 $7,150 $10,000 $20,000 $09 $1009 $09 $509 $250+Ded+20%9 Ded+20% Ded+20% Ded+20% Non-Emb

UnitedHealthcare Primary Advantage Rx

Rx PlanCopays


Mail Order Rx Ded Rx Deductible

454/454X $0 $50 $100 $250 2.5 $250/$500 Waived for tier 1 & 2

455/455X $5 $50 $100 $250 2.5 $250/$500 Waived for tier 1 & 2

751/751X $0 $50 $100 $250 2.5 Medical HSA Only


Package

A B C

Plan Codes

CoreCore

Essential11

Plan Type

Coinsurance

NetworkOut of

Network

Deductibles

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family

Copays

PCP1

Dep <19 PCP

Spec

Tier 1

Spec2 Spec3

VirtualVisit

UrgentCare

ER4 Lab/XRay

MRI, CT,etc.

Inp / OutSurgery

• BG-GP BG-GQ Premier 100% 70% $1,000 $2,000 $5,000 $10,000 $2,500 $5,000 $10,000 $20,000 $0 $25 $25 $50 $25 $75 $300 100% Ded Ded

• • BG-GR BG-GS Premier 80% 50% $1,000 $2,000 $5,000 $10,000 $4,000 $8,000 $10,000 $20,000 $0 $25 $25 $50 $25 $75 $250+20% 100% Ded+20% Ded+20%

2 of 5

Amarillo Core & CoreE i l





UnitedHealthcare Health Savings Account (HSA) Plans

Package

A B C

Plan Codes

CoreCore

Essential11

Coinsurance

NetworkOut of

Network

Deductibles

Network

Single Family

Out of Network

Single Family


Network

Single Family

Out of Network

Single Family

Copays

PCP Spec3 Virtual

VisitUrgentCare

ER4 Lab/

XRayMRI, CT,


Deductible

Type5

• • BE-H2 BE-H9 100% 70% $3,000 $6,000 $5,000 $10,000 $4,000 $8,000 $10,000 $20,000 100% 100% 100% 100% 100% 100% 100% 100% Emb

• • BE-H3 BE-IA 100% 70% $5,000 $10,000 $5,000 $10,000 $6,000 $12,000 $10,000 $20,000 100% 100% 100% 100% 100% 100% 100% 100% Emb

• • BE-H4 BE-IB 100% 70% $6,350 $12,700 $10,000 $20,000 $6,350 $12,700 $20,000 $40,000 100% 100% 100% 100% 100% 100% 100% 100% Emb

• • BS-DJ 100% 70% $6,750 $13,500 $10,000 $20,000 $6,750 $13,500 $20,000 $40,000 100% 100% 100% 100% 100% 100% 100% 100% Emb

• • • BE-IG BE-IH 80% 50% $2,700 $5,400 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 80% 80% 80% 80% 80% 80% 80% 80% Emb

• • BE-H5 BE-IC 80% 50% $3,000 $6,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 80% 80% 80% 80% 80% 80% 80% 80% Emb

• BE-H6 BE-ID 80% 50% $3,500 $7,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 80% 80% 80% 80% 80% 80% 80% 80% Emb

• BE-H7 BE-IE 80% 50% $5,000 $10,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 80% 80% 80% 80% 80% 80% 80% 80% Emb

• BE-H8 BE-IF 50% 50% $3,000 $6,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 50% 50% 50% 50% 50% 50% 50% 50% Emb

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Pharmacy Plans

Rx Plan Code

Copays


Mail Order Ration

K5 $10 $25 $50 2.5

H9/NN* $10 $30 $50 2.5

2V/NO* $10 $35 $60 2.5

5U $10 $35 $60 $100 2.5

OI $10 $35 $70 2.5

VQ $10 $40 $80 2.5

FZ $15 $30 $65 2.5

3B/032* $15 $35 $60 2.5

FE $15 $35 $70 2.5

IU/52* $15 $40 $75 2.5

V3 $15 $40 $75 $200 2.5

GB $15 $45 $80 2.5

QF/Z9* $15 $45 $85 2.5

EJ/53** $15 $45 $85 $200 2.5

LJ $20 $35 $70 2.5

KT $20 $40 $75 2.5

KU $20 $45 $80 2.5

V6 $20 $50 $85 2.5

V7 $20 $50 $85 $250 2.5

51/54* $20 $50 $100 2.5

*Rx plan features copays of $100/$300 for Specialty medications in Tiers 2/3. Available on the PRIME system only.

**Rx plan features copays of $100/$300/$500 for Specialty medications in Tiers 2/3/4. Available on the PRIME system only.

The 2V/NO are the only available Rx combinations for our HSA plans

Access PDL is available on the following RX plans: 2V,5U,H9,IU,V3,KT,455,454,NO,NN,032 and 52

4 of 5





Health Plan Product Offering 1 Primary Care Physicians include Family Practice, Internal medicine,and Pediatrics.



4 Plan deductible is waived for Emergency Room visits on plans where copay or copay + coinsurance are listed.


6 “Flexpoint” plans feature a copay for office visits one through four during the calendar year or plan year, depending on plan type selected. Office visits five and over will be subject toplan deductible/coinsurance. This is a separate limit for both Physician Office visits and Urgent Care visits. Plans feature one Preventive Care visit per year, which does not count against the office visit copay limit.

9 Copayments on HSA plans will be required after the deductible has been met and will continue to be required until the annual out-of-pocket maximum is met.

11 Core Essential plans exclude coverage for services provided by Out-of-Network Providers with the exceptions of 1) Services performed in a Network Facility by hospital-basedproviders; and 2) Services performed under the Emergency Care benefit.

17 “FlexFree” plans feature $0 copay for the first 3 PCP and/or Specialist office visits during the Plan Year. Office visits 4+ will be subject to plan deductible/coinsurance. Plans alsofeature $0 copay for the first 2 Urgent Care visits during the Plan Year. Urgent Care visits 3+ will be subject to plan deductible/coinsurance. Preventive Care visits do not count againstthe office visit copay limit.

18 Copayments on Primary Advantage HSA plans will be required only after the deductible has been met and will continue to be required until the annual out-of-pocket maximum ismet.

18 There is no separate additional Rx deductible required for Primary Advantage HSA plans.

Please note: The information in this grid is provided for informational purposes only and is not intended for use as a contract. For a complete listing of coverage and exclusions, pleaserefer to the Certificate of Coverage or talk to your UnitedHealthcare representative for additional details that could impact the benefits. Different UnitedHealthcare plans may have varyingapproaches to whether pharmacy costs are included or excluded from the medical deductible. Insurance coverage provided by or through by United HealthCare Services, Inc. or theiraffiliates. UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by United HealthCare Services, Inc. or their affiliates.

©2018 United HealthCare Services, Inc.

5 of 5



Help your employees get active. The UnitedHealthcare Motion® program helps motivate employees to do more of what they already do: walk. It promotes a healthier lifestyle through positive habits and rewards participants with deposits into their health savings account (HSA).

Employees may get healthier and wealthier.Members with an HSA may earn up to $3 per day if they meet all 3 FIT (Frequency, Intensity, Tenacity) goals for up to $1,095 per calendar year.

Three ways to earn1 HSA

Frequency. 500 steps in 7 minutes; 6 times a day, at least 1 hour apart. $1.00

Intensity. 3,000 steps in 30 minutes. $1.00

Tenacity. 10,000+ total daily steps. $1.00

$3/day$1,095/year

Motion really works.On average, participants take

12,000 steps daily.2

60 percent of participants sustain engagement over 6 months.3

45%—65% of those eligible to participate in Motion registered for the program.4

CONTINUED

Health and WellnessUnitedHealthcare Motion

1.9

MT-1146973.1 9/18 ©2018 United HealthCare Services, Inc. 18-9512-B

1 Rewards earned from eligible members in the Walk-It-Off payment option will be applied monthly to outstanding device balance.2 2018 internal analysis of 37,082 Motion participants who recorded at least one step in 2018.3 2018 internal analysis of 20,330 Motion participants in Key Accounts who recorded steps between 10/1/15 and 6/1/18.4 Internal analysis of registered Motion members in UnitedHealthcare book of business, 2018.5 Registered members can shop and pay for the device at point of sale. A Walk-It-Off payment option is available for Apple® devices.6 Applicable activation credit(s) available only in the first year.7 Centers for Disease Control and Prevention, https://www.cdc.gov/chronicdisease/about/costs/index.htm, accessed August 23, 2018.

UnitedHealthcare Motion is a voluntary program. The information provided under this program is for general informational purposes only and is not intended to be nor should be construed as medical advice. You should consult an appropriate health care professional before beginning any exercise program and/or to determine what may be right for you. Receiving an activity tracker and/or activation credit may have tax implications. You should consult an appropriate tax professional to determine if you have any tax obligations from receiving an activity tracker and/or activation credit under this program, as applicable. If any fraudulent activity is detected (e.g., misrepresented physical activity), you may be suspended and/or terminated from the program. If you are unable to meet a standard related to health factor to receive a reward under this program, you might qualify for an opportunity to receive the reward by different means. Contact us at 1-855-256-8669 and we will work with you (and, if necessary, your doctor) to find another way for you to earn the same reward.

Employers are responsible for ensuring that any wellness programs they offer to their employees comply with applicable state and/or federal law, including, but not limited to, GINA, ADA and HIPAA wellness regulations, which in many circumstances contain maximum incentive threshold limits for all wellness programs combined that are generally limited to 30 percent of the cost of self-only coverage of the lowest-cost plan and prohibitions on incentives to dependent children, as well as obligations for employers to provide certain notices to their employees. Employers should discuss these issues with their own legal counsel.

Administrative services provided by United HealthCare Services, Inc. or their affiliates. Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates.

Facebook.com/UnitedHealthcare Twitter.com/UHC Instagram.com/UnitedHealthcare YouTube.com/UnitedHealthcare

How it works:1 Members receive a welcome email from you and/or UnitedHealthcare.

2 Eligible employees and covered spouses create an account on unitedhealthcaremotion.com and shop⁵ for an activity device from the website or use a Motion-compatible activity device they already own.

3 An “activation credit” may be applied to purchased devices or taken as a reward if they use their own device. Purchased devices are delivered to the employee’s home.6

4 Participants set up their device, begin walking to meet daily FIT goals and sync their device daily.

5 Every day, participants can earn a $3 incentive, deposited quarterly into their HSA.1

Helping you manage health care costs.Employees may be your best strategy for improving quality and cost efficiency within your company. When they’re active, it’s possible for absenteeism to decline, productivity to increase and morale to improve—which may reduce medical claims.

Contact your UnitedHealthcare representative to learn more.

Why walking may matter.Those who have a sedentary lifestyle are at an increased risk for heart disease, stroke, type 2 diabetes, cancer and other serious health conditions.

85%of annual health care costs are for people with chronic conditions.7

$114 billionis spent annually on health care costs associated with physical inactivity.7

Motion may improve the well-being of your employees.The program is designed to make it easy for employees and covered spouses to participate with the goal of helping them:

• Lose weight.

• Improve cholesterol and blood sugar.

• Reduce the risk of diabetes andheart disease.

• Decrease symptoms of depressionand anxiety.

• Increase energy and productivity.

Health & Wellness | Motion | Groups 51–100 | Texas

Employees may be your best strategy for improving quality and cost efficiency within your company. When they’re healthier you may see reduced absenteeism and increased productivity and morale.

With Motion from UnitedHealthcare, you may help improve employee health while they earn over $1,000 in rewards, deposited directly into their health savings account (HSA).

Help your employees get healthier and wealthier. Motion encourages your employees to do more of what they already do every day: walk. Participants with an HSA can earn up to $3 per day if they meet all 3 Frequency, Intensity, Tenacity (FIT) goals. That’s up to $1,095 every year.**

Motion is now included in all new health plans with an HSA.*

New onboarding employer groups with 51–100 employees and a health savings account (HSA) will automatically have UnitedHealthcare Motion® through Jan. 1, 2020.

CONTINUED

FIT GoalsHSA

RewardFrequency 500 steps in 7 minutes; 6 times a day, at least 1 hour apart.

$1

Intensity 3,000 steps in 30 minutes. $1

Tenacity 10,000+ total daily steps. $1

*Applies to groups 51–100 only.

** Incentives may be limited due to applicable federal and/or state law incentive limits, generally equal to 30% of the cost of coverage for incentives available under all programs combined.

Do workplace wellness programs really work?The cost to employers for physically inactive employees may exceed

$3,100 per employee per year.1

U.S. employers who invest in workplace health and wellness programs may see a return of

$3–$6 for each dollar invested over a 2–5 year period.2

Get in on the Motion promotion. Contact your broker or UnitedHealthcare representative to learn more.

How Motion works.

1 Eligible employees and covered spouses create an account on unitedhealthcaremotion.com and select an activity tracker from the website, or use a Motion-compatible activity tracker they already own. A “registration credit” can be applied to purchased devices or taken as a reward if they use their own device.

2 Purchased devices are delivered to the employee’s home.

3 Participants set up their device, begin walking to meet daily FIT goals and sync their device weekly.

4 Every day, participants can earn a $3 incentive, deposited quarterly into their HSA. All they have to do is meet the walking goals to earn up to $1,095 per year.

Participating in Motion may help improve well-being by:• Aiding weight loss.

• Improving cholesterol and blood sugar.

• Reducing the risk of type 2 diabetes and heart disease.

• Decreasing symptoms of depression and anxiety.

• Increasing energy and productivity.

Participants average

8,000–10,000steps daily

80% participate for at least 18 months3

“ Our employees are going out walking at lunch. Our staff never used to walk at lunch. They’re being intentional about getting out and doing things, and the Motion program is what’s driving it.”

— Employer offering UnitedHealthcare Motion


1 Journal of Nutrition Education and Behavior: Volume 37, Supplement 2, Pages S115-S120.2 Wellness Council of America, www.welcoa.org.3 Savvy Sherpa, October 2018, Southwest Medical Associates Motion Challenge.

UnitedHealthcare Motion is a voluntary program. The information provided under this program is for general informational purposes only and is not intended to be nor should be construed as medical advice. You should consult an appropriate health care professional before beginning any exercise program and/or to determine what may be right for you. Receiving an activity tracker and/or activation credit may have tax implications. You should consult an appropriate tax professional to determine if you have any tax obligations from receiving an activity tracker and/or activation credit under this program, as applicable. If any fraudulent activity is detected (e.g., misrepresented physical activity), you may be suspended and/or terminated from the program. If you are unable to meet a standard related to health factor to receive a reward under this program, you might qualify for an opportunity to receive the reward by different means. Contact us at 1-855-256-8669 and we will work with you (and, if necessary, your doctor) to find another way for you to earn the same reward.

Administrative services provided by United HealthCare Services, Inc. or their affiliates. Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Health Plan coverage provided by or through UnitedHealthcare of Texas, Inc.

B2B 8354881.1 9/19 ©2019 United HealthCare Services, Inc. 19-13779

ToolsVirtual VisitsTools

Virtual Visits

When you’re sick and need care quick, a Virtual Visit is a convenient way to start feeling better faster.

With a Virtual Visit, you can see and talk to a doctor via mobile device or computer – 24/7, no appointment needed. The doctor can give you a diagnosis and prescription*, if needed. And with a UnitedHealthcare plan, your cost is $50 or less.

To get started with a Virtual Visit, go to uhc.com/virtualvisits.

Sick with the flu? See a doctor whenever, wherever.

• Bladder infection/Urinary tract infection

• Bronchitis

• Cold/flu

• Fever

• Pinkeye

• Rash

• Sinus problems

• Sore throat

• Stomachache

• Health plan ID card

• Credit card

• Pharmacy location

Get care in 20 minutes or less. Use a Virtual Visit for these minor medical needs:

Prepare for your Virtual Visit. Have these three items ready to register and complete your Virtual Visit:

* Prescription services may not be available in all states.

** Based on analysis of 2016 UnitedHealthcare ER claim volumes, where ER visits are low-acuity and could be treated in a Virtual Visit, PCP, or urgent/convenient care setting.

Virtual visits are not an insurance product, health care provider or a health plan. Unless otherwise required, benefits are available only when services are delivered through a Designated Virtual Network Provider. Virtual visits are not intended to address emergency or life-threatening medical conditions and should not be used in those circumstances. Services may not be available at all times or in all locations. The Designated Virtual Visit Provider’s reduced rate for a virtual visit is subject to change at any time.

Insurance coverage provided by or through UnitedHealthcare Insurance Company and its affiliates. Administrative services provided by United HealthCare Services, Inc. or their affiliates. Health Plan coverage provided by or through a UnitedHealthcare company.

MT-1167531.0 2/18 ©2018 United HealthCare Services, Inc. 18-7246 Facebook.com/UnitedHealthcare Twitter.com/UHC Instagram.com/UnitedHealthcare YouTube.com/UnitedHealthcare

Virtual Visits can savetime and money.An estimated 25 percent of ER visits could be treated with a Virtual Visit — which brings a potential $1,700 cost down to $50.**

1.10

Save your employees money with $0 primary care physician copays for kids.Family friendly. Family focused.

With the $0 primary care physician (PCP) Copays for Kids1 program, your employees will discover how UnitedHealthcare is working to help them improve health and lower their overall out-of-pocket medical costs. Designed for employees with unmarried dependents under the age of 19,* this benefit is available for enrollees in copay-based medical plan designs.

Making health care and cost decisions easier for families.Incentives to use PCPs should result in fewer emergency room visits, less need for specialty care and increased preventive health care. All of which helps lower overall health care costs for everyone.

MT 1160151.1 10/18 ©2018 United HealthCare Services, Inc. 18-10148

1 Does not apply to FlexPoint or non-copay plan designs.

* See the Certificate of Coverage for the full definition of a dependent child.


Contact your UnitedHealthcare representative for additional information.

Health Management PCP $0 kid copay

1.11

Working with The Hospitals of Providence Physician Performance Network (HPPPN), the UnitedHealthcare Charter® health plan focuses on delivering stronger physician-patient relationships, more coordinated care and less duplication of services — leading to better health for your employees and more savings for your business.

Working together for better health care.

Connecting employees to physicians.The Charter plan is designed to provide your employees with health care guidance during every step of their medical journey to help keep costs down.

An HPPPN primary care physician (PCP), selected by or for each enrolled employee, will work with them to ensure care is delivered seamlessly and without gaps. The PCP provides preventive care and treats illnesses and injuries. They also provide referrals to other network physicians or specialists.

A trusted network with deep El Paso roots.The Hospitals of Providence has cared for generations of El Paso families since 1902. As a premier local network with 206 primary care providers and over 500 unique specialty providers covering 55 specialties, the network includes:

• 34 facilities

• 316 practice locations

• 5 acute care hospitals

• 6 urgent care centers

Value-based care plans like Charter help deliver better health and lower costs.

87% of top quality comparisons vs. non-accountable care organizations.*1

14% fewer ER admissions. 2

CONTINUED

17% fewer hospital admissions. 3

12% better financial outcomes. 4

*Value-based health care plans such as Charter score higher on 87% of the top quality measures than non-accountable care organizations (ACOs).

El Paso

UnitedHealthcareCharter

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8851431.0 5/19 ©2019 United HealthCare Services, Inc. 19-11834-B

1,2,3,4 February 2018 UnitedHealthcare Value-Based Care Report. Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Health Plan coverage provided by or through UnitedHealthcare of Texas, Inc.


Quality health care. Close to home.For directions and location addresses, visit thehospitalsofprovidence.com/our-locations.

Other Care Sites

Acute Care Hospitals

For more information about The Hospitals of Providence Physician Performance Network, visit hpppn.com.

For more information about UnitedHealthcare Charter, visit uhc.com/charterelp, or contact your broker.

Health Plans | Choice EPO | Texas

Greater value starts with a larger network.Choice EPO members have access to the same national contracted network of 937,000+ providers and 5,800+ hospitals1 as Choice Plus PPO members.

Choice EPO does not require members to choose a primary care physician (PCP), and members can see network specialists without a referral. With Choice EPO, there is no coverage for services from out-of-network providers except in emergencies.

CONTINUED

Choice exclusive provider organization (EPO) plans from UnitedHealthcare are designed to deliver greater value and lower premiums. Benefits are generally provided only through EPO-contracted physicians and facilities, eliminating out-of-network expenses.

Find sizeable savings with a sizeable network.

Why Choice EPO?• Lower premiums thanks to a

defined network.• National network of 937,000+

providers and 5,800+ hospitals.1

• Tools to support better health,including myuhc.com ®, FindCare & Costs, Health4Me® mobileapp and 24/7 NurseLine.

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B2B 9144197.0 6/19 ©2019 United HealthCare Services, Inc. 19-12474


Contact your UnitedHealthcare representative for additional information.

Plan highlights. $0 Primary Care Copays for Kids. Available with most copayment-based EPO plan designs, this benefit covers dependent children (through age 18) at 100% for primary care visits. This early emphasis on primary care:

• Makes health care decisions easier for families.

• May result in fewer emergency room visits and less need for specialty care.

• Supports preventive health care, which helps lower overall health carecosts for everyone.

Emergency services. All emergency services, regardless of where they are obtained, are covered under Choice EPO and Choice Plus PPO plans.

Hospital-based provider services. Coverage for hospital-based providers — such as anesthesiologists, radiologists and pathologists — is the same under both Choice EPO and Choice Plus PPO plans; however, services under Choice EPO must be obtained at a network facility.

Additional plan design options. This suite of products also features EPO versions of some of our most popular plans, including PROformance and Primary Advantage® plans, which offer benefits such as:

• UnitedHealth Premium® designations for identifying doctors whomeet quality and cost-efficiency guidelines.

• Health savings accounts (HSAs), providing tax-advantaged savingsfor qualified medical expenses.

• $0–$15 copays for PCP office visits, plus $0 Virtual Visits to video chatwith a doctor anytime.

1 UnitedHealthcare internal analysis, April 12, 2019.

Please note: This select provider benefit plan does not provide out-of-network benefits and therefore does not generally cover services from out-of-network providers. This plan does provide coverage for services provided by certain out-of-network physicians when received in a network facility. It also provides coverage for emergency care services received from out-of-network providers. For a list of network providers, go to myuhc.com or call the telephone number on your health plan ID card.

EPO plans are not available in every state; ask your UnitedHealthcare representative for more information.

All UnitedHealthcare members can access a cost estimate online or on the mobile app. None of the cost estimates are intended to be a guarantee of your costs or benefits. Your actual costs may vary. When accessing a cost estimate, please refer to the Website or Mobile application terms of use under Find Care & Costs section.

NurseLine is for informational purposes only. Nurses cannot diagnose problems or recommend specific treatment and are not a substitute for your doctor’s care. NurseLine services are not an insurance program and may be discontinued at any time.

The UnitedHealth Premium® designation program is a resource for informational purposes only. Designations are displayed in UnitedHealthcare online physician directories at myuhc.com®. You should always visit myuhc.com for the most current information. Premium designations are a guide to choosing a physician and may be used as one of many factors you consider when choosing a physician. If you already have a physician, you may also wish to confer with him or her for advice on selecting other physicians. You should also discuss designations with a physician before choosing him or her. Physician evaluations have a risk of error and should not be the sole basis for selecting a physician. Please visit myuhc.com for detailed program information and methodologies.

The UnitedHealthcare plan with Health Savings Account (HSA) is a high deductible health plan (HDHP) that is designed to comply with IRS requirements so eligible enrollees may open a Health Savings Account (HSA) with a bank of their choice or through Optum Bank, Member of FDIC. The HSA refers only and specifically to the Health Savings Account that is provided in conjunction with a particular bank, such as Optum Bank, and not to the associated HDHP.

Virtual Visits are not an insurance product, health care provider or a health plan. Unless otherwise required, benefits are available only when services are delivered through a Designated Virtual Network Provider. Virtual Visits are not intended to address emergency or life-threatening medical conditions and should not be used in those circumstances. Services may not be available at all times or in all locations.

Health plan coverage provided by or through UnitedHealthcare Insurance Company of Texas, Inc.

Is an EPO similar to an HMO?EPO and HMO plans are similar in that coverage for out-of-network providers is limited. Generally, EPOs:

• Cover a larger geographicservice area and networkthan HMOs.

• Have a different cost andcontract structure.

• Do not require that memberscoordinate care and get referralsto specialists from their PCP.

New Business Quotes: [email protected] Business Installation Submissions: [email protected]

Broker Contact Numbers – Fully Insured Small Business (1-100)Customer Service………………………………1-888-842-4571 Customer Service Fax………………………...1-248-733-6062 Eligibility email: [email protected]

Broker assistance with:Billing payments or inquiries. Member eligibility additions, terminations, and other general changes.Claims assistance and review. Commissions

Vision Customer Service ............................... 1-800-638-3120Broker assistance with:Member eligibility and benefit questions. Providers-claims, Locate In-network vision providers

Dental Customer Service ................................. 1-877-816-3596Broker assistance with:Member eligibility and benefit questions. Locate In-network dental providers. ID card requests. Provider claims assistance.

Life Customer Service...................................... 1-866-293-1794

United Benefit Services…………………………..1-800-318-5311 COBRA email: [email protected]

Broker assistance with:Cobra, State Continuation, member eligibility additions or terminations. FSA or HRA assistance

Employer Optum Bank H.S.A………1-800-765-6766 (FAX) Optum Bank email: [email protected]

Billing AddressesUnitedHealthcare: Regular Mail

UHS Premium BillingPO BOX 94017 Palatine, IL 60094-4017

Employer eServices Customer Support .........1-800-651-5465 Broker Portal: www.employereservices.com

Assistance with online navigation, login ID, password and technical support.

Member Service .............................................. 1-800-357-0978For members questions about benefits, claims, ID cards, providers, Optum pharmacy, and notifications.

Myuhc.com Customer Support ..................... 1-877-844-4999 Myuhc web: www.myuhc.com

Website for member’s easy access to personal benefit information, claims, providers, Optum pharmacy, and wellness

United eServices............................................. 1-866-336-9369unitedeservices.com - Broker support

Sales Automation Management………….1-800-486-4585 SAM- Broker assistance with technical support.

Real Appeal Employer Support……1-844-944-REAL (7325) Real Appeal Employer web: Https://engage.realappeal.com

Real Appeal Member Support……1-844-344-REAL (7325) Real Appeal Member web: Https://newstart.realappeal.com

United Healthcare Motion Customer Support….1-855-256-8669

Overnight Mail: UHS Premium Billing Attn: Box 940175505 N. Cumberland Ave Suite 307Chicago, IL 60656-1471

Claims AddressesMedical Claims:

UnitedHealthcareAttn: Claims Department PO Box 740800Atlanta, GA 30374-0800

Optum RX Claims:OptumRxATTN: Claims DepartmentP.O. Box 29077Hot Springs, AR 71903

Dental Claims:UnitedHealthcare Dental Attn: Claims UnitPO Box 30567Salt Lake City, UT 84130

Vision Claims:UnitedHealthcare Vision Attn: Claims Department PO Box 30978Salt Lake City, UT 84130

Life Claims:UnitedHealthcare Life Attn: Claims Department PO Box 30759Salt Lake City, UT 84130

Claim Appeals: Medical and PharmacyUnitedHealthcareAttn: Appeals Department PO Box 30573Salt Lake City, UT 84130Appeals Fax- (801) 938-2109

1.15

Texas 1-50 ATNE Quoting & Installation Checklist Fully Insured (ACR-Adjusted Community Rating) Small Business Definition: Average Total Number of Employees (ATNE) is 50 and Under

To obtain a quote, submit the following documentation to Texas Quoting at [email protected] or click here to learn how puts you in charge Agency information should include:

Writing agent, agency name and full address

Where to email the quote

Your UnitedHealthcare Account Executive

Group information should include:

Group name, full address with ZIP code and type of industry or SIC code

Does the group currently have any coverage with UnitedHealthcare or has the group had any UnitedHealthcare coverage in the last 12 months? Yes No

Group size: Total number of Eligible Employees and Prior Calendar Year Average Total Number of Employees (ATNE)

Employee census in Microsoft Excel format should include each member’s name, relationship, gender, date of birth (including all dependents), state/ZIP code and product selection. Example shown below:

UnitedHealthcare QUOTE REQUEST CENSUS Include all full-time (30hr/wk) employees enrolling. Enter each member (EE, SP, or CH) on a separate line.

Relationship Last Name First Name Gender Date of Birth State ZIP MEDICAL DENTAL VISION LIFE STD LTD Annual Salary (MM/DD/YYYY)

EE EXAMPLE A EMPLOYEE M 01/01/1965 TN 37213 Y Y Y Y Y Y 45454

SP EXAMPLE A SPOUSE F 02/01/1967 Y Y Y N

CH EXAMPLE A CHILD M 01/01/1990 Y Y N N

CH EXAMPLE A CHILD F 02/01/1992 Y Y N N

EE EXAMPLE B EMPLOYEE M 01/01/1965 TN 37203 Y Y Y Y Y Y 54545

SP EXAMPLE B SPOUSE F 02/01/1967 N Y Y N

For installation of the group, submit the following documentation puts you in charge

to Texas Submissions at [email protected] or click here to learn how Completed UnitedHealthcare Employer Application for Small BusinessCompleted UnitedHealthcare enrollment spreadsheet(Click paper clip in left column) OR employee enrollment forms

If participation is below 50%, copies of ID cards are required for waivers

UnitedHealthcare proposal with correct census and sold ratesProduct and Benefit Selection formWage and tax documents*or Participation Certification form for Groups with 10+ Eligible EmployeesCopy of Binder Check* payable to UnitedHealthcare or UnitedHealthcare Direct Debit Form

Consumer Choice Plans Form (only for groups enrolling in an HMO)

* Please send only the original binder check to the below address for processing. Include the Tax ID number in the memo section of the check.UHS Premium Billing PO Box 94017Palatine, IL 60094-4017

If using overnight services: UHS Premium Billing Attn: Box 94017 5505 N. Cumberland Ave. Ste. 307 Chicago, IL 60656-1471

*Indicate the employment or eligibility status for each employee listed on any submitted QWR or payroll

records with these abbreviations: A=any employee submitting an application, W=Waiving, P/T=Part-Time, T=Terminated, S=Seasonal, WP=Waiting Period

1.16

Texas 1-50 ATNE Quoting & Installation Checklist Fully Insured (ACR-Adjusted Community Rating) continued

Participation Certification Form– Groups with 10 or more Eligible Employees may use the participation form in lieu of tax documents.

Quarterly Wage and Tax Report* (QWR) – Required for cases with 2-9 Eligible Employees. Most recent copy with all pages and all employees listed. New hires not listed on the QWR will require a two week payroll. Owners not listed require: Schedule C, K1 form or other acceptable tax document.

Proof of ownership – Proof of ownership is defined as having proof the owner works for the company. If the owner appears on the wage and tax statement, along with the other employees, additional documentation is not needed. If the owner does not appear on the wage and tax statement, additional tax forms are required proving that the owner owns and works for the company as a full-time employee.

Common ownership - occurs when an employer owns more than one company but wants to cover all of them under one new business submission. A Common Ownership Form must be completed and submitted.

Independent Contractor (1099 Employee) - Employers may elect to offer coverage to independent contractors if the business has a minimum of one regular, taxed employees or owner who is eligible. The employer must complete a 1099 Form.

One Life Groups - Allowed for all business types outside of sole proprietors. TX does not follow federal guidance on group eligibility that requires a common law employee to be enrolled on the plan.

Corporations: If an owner only and/or owner plus spouse are covered, they are eligible as a group health plan. Two owners who are not spouses qualify as a group health plan in all cases. An additional common law employee is not required to enroll as an owner may be considered a “common law employee” if working full time at the company – i.e. the group may consist of multiple owners only with nofull-time employees, where at least 1 owner is actively working and enrolled.In business < 1 year: Articles of incorporation, an IRS or Secretary of State letter indicating issued tax ID number, and a two-week payroll or quarterly wage and tax statement (if filed) for employees arerequired.In business > 1 year: A wage and tax statement or quarterly payroll (if prepared by a payroll company) is required. C-Corp: An 1120 Form is required for owners who are not listed on the wage and tax statement. Pages 1 and 2 of the 1120 Form, as well as the Schedule G, or the 1125-E Form (listing all the owners), must be provided. If the 1120 Form does not list all the owners, a letter from the owners’lawyer or certified public accountant (CPA) identifying all of the owners and their percentage of ownership is acceptable. S-Corp: A Schedule K-1 (Form 1120S) is required for all owners/partners if one(or more of the owners) is not indicated on the wage and tax statement.

LLC: If an owner only and/or owner plus spouse are covered, they are eligible as a group health plan. Two owners who are not spouses qualify as a group health plan in all cases. An additional common law employee is not required to enroll as an owner may be considered a “common law employee” if working full time at the company – i.e. the group may consist of multiple owners only with no full-time employees, where at least 1 owner is actively working and enrolled.In business < 1 year: LLC Agreement (signed by all parties), an IRS or Secretary of State letter indicating issued tax ID number, and a two-week payroll or quarterly wage and tax statement (if filed) for allemployees (other than those bound by the LLC Agreement) are required.In business > 1 year: A wage and tax statement or quarterly payroll (if prepared by a payroll company) is required. A Schedule K-1 or Schedule C is required for all owners/partners if one (or more) ofthe owners is not showing on the wage and tax statement.

Sole Proprietorship: When the owner is the only individual, it is not a group health plan

In business < 1 year: A business license, an IRS or Secretary of State letter indicating issued tax ID number (if available), and two-week payroll or quarterly wage and tax statement (if filed) for all employees not listed on the license are required. In business > 1 year: A wage and tax statement or quarterly payroll (if prepared by a payroll company) is required. A Schedule C is required for owners. A Schedule C is required if the SoleProprietorship is in the business of renting personal property. A Schedule E is required if the sole proprietorship is in the business of renting commercial property. If the spouse of a sole proprietor is an employee and not listed on the wage and tax statement, a current W2, two-week payroll, or Schedule SE (Self-Employment) is required. Partnership: If only partners and/or partners and their spouses are covered, they are eligible as a group health plan.In business < 1 year: A Partnership Agreement listing all partners, an IRS or Secretary of State letter indicating issued tax ID number (if available), and a two-week payroll or quarterly wage and taxstatement (if filed) for employees are required.In business > 1 year: A wage and tax statement or quarterly payroll (if prepared by a payroll company) is required for employees other than the partners in the group. Schedule K-1 (Form 1065)required for all partners if one or more of the owners are not indicated on the wage and tax statement. A Partnership Agreement is acceptable if the Schedule K-1 has not been filed. A copy of the filingextension is required at the time of submission.

Churches:Churches must provide a 941 or 940 Form and a two-week payroll or quarterly payroll or quarterly wage and tax statement (if filed) for all employees of the church. Religious orders (priests, nuns,monks, etc.) under a vow of poverty must provide a group letterhead signed by the director listing all eligible employees, their salaries and hours worked.

Farms:A farm must file a Schedule F and a two-week payroll or quarterly payroll or quarterly wage and tax statement (if filed) for all employees.

Nonprofit:A 941 or 940 Form and a two-week payroll or quarterly payroll or quarterly wage and tax statement (if filed) are required.

Municipality:A quarterly wage and tax statement is required for all employees.

Texas law allows married employees to choose whether they wish to enroll as the subscriber, or, if one wishes to enroll as the dependent of the other, if: 1) It is a reasonable interpretation of the TX law. 2) Any contradiction in TX statutes is being interpreted in favor of the member. 3) We can administer this type of choice consistently.

Post Install Prior Carrier Deductible Report for calendar year deductible credit. Note: Report would be

submitted to your Account Management team after the welcome letter is issued.

* Indicate the employment or eligibility status for each employee listed on any submitted QWR or payroll records with these abbreviations: A=any employee submitting an application, W=Waiving, P/T=Part-Time, T=Terminated, S=Seasonal, WP=Waiting Period

To get a quote submit the following documentation to Texas Quoting at [email protected] information should include:

Writing agent, agency name and full address Where to email the quoteYour UnitedHealthcare Account Executive

Group information should include: Group name, full address with ZIP code and type of industry or SIC codeEffective date

Does the group currently have any coverage with UnitedHealthcare or has the group had any UnitedHealthcare coverage in the last 12 months? Yes No

Employer contribution percentage toward employee and dependent premiumCurrent renewal date (If requesting quote over 90 days from renewal, include AOR letter.)Current carrier and number of years with this carrier

Current and renewal rates from current carrier

Texas 51-100 ATNE Quoting and Installation Checklist

Underwriting requirements

1.17

Texas 51-100 ATNE Quoting and Installation Checklist

continued

For installation of the group, submit the following documentation to Texas Submissions at [email protected]

Post install

Completed UnitedHealthcare EEmployer Application

Completed UnitedHealthcare nrollment spreadsheet (employee enrollment forms optional)

UnitedHealthcare proposal with correct census and sold rates

Product and Benefit Selection form

an ATNE of 51 or greater

2019 All Savers Traditional Portfolio Highlights

Contract for the All Savers Alternate Funding product Available to groups with 5-100 eligible employees ISL is $15K & ASL is 125%Fund Maximum Liability monthly 12/60 Contract PeriodOffering a 15/60 contract (3/60 followed by a 12/60) for effective dates 10/1/2019 through 4/1/20 – Specialty sold alongside medical will also receive an extended contract to follow the medical renewalReconciliation completed in 15th month with 50% surplus paid in the 16th month (group must renew)50% participation regardless of valid waivers and 50% contribution towards Employee Only

Network OptionsChoice Plus – PPO National NetworkChoice – EPO Network – same network as our Choice Plus. No out of network except for emergencies & hospital-based providers – such as anesthesiologists, radiologists, pathologists,and ER doctors. EPO and Choice Plus PPO plans true emergencyCharter DFW HMO TX – 10 counties – High Performance PCP’s/ Choice Plus Network for Specialists, Facilities, and Hospitals. No out of network but for true emergencyNavigate HMO TX – Choice Plus Network of PCP’s, Specialists, Facilities and Hospitals. No out of network but for true emergency

Plan Highlights PROFormance Plans – Effective 8/1/2019 – Low PCP copays at $10 or $15 and Low Urgent Care copays at $25Copay plans now offer Basic Lab & X-Ray – E plansDeductible, Medical copays and Rx copays apply toward the OOP MaxRx plans are tied to a medical plan – cannot pick and choose drug cardsMulti-Choice Product Offering –

Renewal Rate CapFirst Year and Second Year renewals only Eligible employees and covered spouses participate in the Motion program, meet daily “FIT”goals which convert to pointsMore points means a lower renewal price cap60% - 69% of total possible points: 9% renewal price cap70% or more: 7% renewal price capCensus and plan benefit design changes will affect final renewal pricing

Specialty Products Available to Package with All Savers Alternate FundingDental, Vision, and Life are available with your medical proposal Rate relief is available on all plans and productsPackaged Savings applies for all contributory lines and last the lifetime of the specialty product being offered alongside medical (Packaged Savings still applies if employer sponsored specialty is sold under UHC)Consolidated bill for all products if designated All Savers plans sell with the All Savers Alternate Funding Product

2.1

2019 All Savers Traditional Portfolio Highlights

F. UnitedHealthcare Motion Wellness a. Available on all plans within portfolio – HSA and Copay plansb. Enrolled Employees/Spouses EARN their “motion credit” by meeting daily activity goals:

i. Frequency – Six 7-minute walks/day = $1 ii. Intensity – 3,000 steps in 30 minutes = $1

iii. Total Steps – 10k+ steps in one day = $1c. Earn up to $3 a day with max credit of $1,095.00 d. Motion Credits earned apply to total OOP maximum spend e. Motion Reimbursements

i. HSA plans reimburse total earned amount on a quarterly basis into the employee’s HSA ii. Copay plans reimburse based upon the total amount of out of pocket paid out

quarterly. A physical check is sent back to the memberf. Log in to your account at myallsaversconnect.com and click the UnitedHealthcare Motion Link g. Call 1-855-256-8669 or email [email protected] with questions

G. Rally Wellness a. Rally is a digital health experience that helps members make simple changes in their everyday

routine, set goals, and track their results online i. Rally Age Health Survey (Health Assessment)

ii. Wellness Missionsiii. Wellness Challengesiv. Reward Opportunities – enter sweepstakes for rewards

b. All Savers Member Portal is the hub to access all wellness programs: myallsaversconnect.com c. Call 1-844-344-4944 (toll free) with questions

H. Real Appeal Wellness a. Free digital program for eligible members providing up to a full year of support for weight lossb. Personal transformation coach that provides step-by-step guidancec. Success kit full of resources to help you kick-start your weight loss d. Members can start today at: success.realappeal.com e. Call 1-844-344-REAL (7325) with questionsf. Success stories: realappeal.com/our-members

I. HealthiestYou & Best Doctorsa. $0 Employee cost share b. Group-Level Utilization Reportingc. Discount Rx and Pharmacy Locator d. Shop and price procedures using the app e. HealthiestYou website: member.healthiestyou.com f. Best Doctors website: members.bestdoctors.com g. Call 1-866-703-1259 (option 3) with questionsh. Call 1-866-703-1259 (option 1) to reach a doctor i. Available to all the subscriber’s dependents – even those not enrolled on the All Savers medical

plan

J. OptumBank a. Group can set up OptumBank with no additional feesb. Employees that set up their own account outside the employer group will be subject to the

normal HSA set up feesc. Requires All Savers Employer Notification form to set up with OptumBank

Additional downloadable forms and brochures can be found on myallsavers.com

of 10

All Savers® Alternate Funding Benefit Plan DesignsTexas

Plan Code Rx12 Network9

Deductible Coinsurance Out-of-Pocket Maximum CopaymentNetwork Non-Network

DedType1 In Out

Network Non-Network PCP

SPEC UC ERMinor Lab/

X-Ray10, 11

Major MRI/CT

IP/OP SurgerySingle Family Single Family Single Family Single Family

PCP DEP <19

PCP

Traditional: This category of plans, except for HSA, is also available in the non-LX version with the minor lab/X-ray benefit covered at 100 percent coinsurance.

PPO These plans are also available on the CORE network.

P50030ek0LX RX1 Choice Plus $500 $1,000 $1,000 $2,000 Emb 80% 50% $3,000 $6,000 $6,000 $12,000 $0 $30 $30 $100 $300 Ded + Coins

Ded + Coins

Ded + Coins

P5003060ek0LXi100 RX1 Choice Plus $500 $1,000 $1,000 $2,000 Emb 100% 50% $3,000 $6,000 $6,000 $12,000 $0 $30 $60 $100 $300 Ded + Coins

Ded + Coins

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P5003060ek0LX RX1 Choice Plus $500 $1,000 $1,000 $2,000 Emb 80% 50% $3,000 $6,000 $6,000 $12,000 $0 $30 $60 $100 $300 Ded + Coins

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P100030ek0LX RX2 Choice Plus $1,000 $2,000 $2,000 $4,000 Emb 80% 50% $3,500 $7,000 $7,000 $14,000 $0 $30 $30 $100 $300 Ded + Coins

Ded + Coins

Ded + Coins

P10003060ek0LXi100 RX2 Choice Plus $1,000 $2,000 $2,000 $4,000 Emb 100% 50% $3,500 $7,000 $7,000 $14,000 $0 $30 $60 $100 $300 Ded + Coins

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P20004080ek0i80MaxLX RX2 Choice Plus $2,000 $4,000 $4,000 $8,000 Emb 80% 50% $7,350 $14,700 $14,700 $29,400 $0 $40 $80 $100 $300 Ded + Coins

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2.2

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DedType1 In Out



X-Ray10, 11

Major MRI/CT


PCP DEP <19

PCP



Ded + Coins

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HSA PPO These plans are also available on the CORE network.

HP1500 Medical Co-insurance Choice Plus $1,500 $3,000 $3,000 $6,000 NonEmb 80% 50% $3,000 $6,000 $6,000 $12,000 N/A Ded +

CoinsDed + Coins

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Ded then 100%

Ded + Coins

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HP20003060 RX1 L4A Choice Plus $2,000 $4,000 $4,000 $8,000 NonEmb 100% 50% $6,550 $13,100 $8,000 $16,000 N/A $30 $60 $100 $300 Ded + Coins

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HP2000Rx10i80 RX1 L4A Choice Plus $2,000 $4,000 $4,000 $8,000 NonEmb 80% 50% $6,550 $13,100 $8,000 $16,000 N/A Ded + Coins

Ded + Coins

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HP2000X Medical Co-insurance Choice Plus $2,000 $4,000 $4,000 $8,000 NonEmb 80% 50% $4,000 $8,000 $8,000 $16,000 N/A Ded +

CoinsDed + Coins

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Ded then 100%

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HP28503060 RX1 L4A Choice Plus $2,850 $5,700 $5,700 $11,400 Emb 100% 50% $6,550 $13,100 $11,400 $22,800 N/A $30 $60 $100 $300 Ded + Coins

Ded + Coins

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HP2850Rx10i80 RX1 L4A Choice Plus $2,850 $5,700 $5,700 $11,400 Emb 80% 50% $6,550 $13,100 $11,400 $22,800 N/A Ded + Coins

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HP6650 Medical Co-insurance Choice Plus $6,650 $13,300 $13,300 $26,600 Emb 100% 50% $6,650 $13,300 $26,600 $53,200 N/A Ded +

CoinsDed + Coins

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EPO These plans are also available on the CORE network.

E50030ek0LX RX1 Choice $500 $1,000 N/A N/A Emb 80% N/A $3,000 $6,000 N/A N/A $0 $30 $30 $100 $300 Ded + Coins

Ded + Coins

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E5003060ek0LXi100 RX1 Choice $500 $1,000 N/A N/A Emb 100% N/A $3,000 $6,000 N/A N/A $0 $30 $60 $100 $300 Ded + Coins

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E5003060ek0LX RX1 Choice $500 $1,000 N/A N/A Emb 80% N/A $3,000 $6,000 N/A N/A $0 $30 $60 $100 $300 Ded + Coins

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E100030ek0LX RX2 Choice $1,000 $2,000 N/A N/A Emb 80% N/A $3,500 $7,000 N/A N/A $0 $30 $30 $100 $300 Ded + Coins

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E10003060ek0LXi100 RX2 Choice $1,000 $2,000 N/A N/A Emb 100% N/A $3,500 $7,000 N/A N/A $0 $30 $60 $100 $300 Ded + Coins

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DedType1 In Out



X-Ray10, 11

Major MRI/CT


PCP DEP <19

PCP



Ded + Coins

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E20004080ek0i80MaxLX RX2 Choice $2,000 $4,000 N/A N/A Emb 80% N/A $7,350 $14,700 N/A N/A $0 $40 $80 $100 $300 Ded + Coins

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DedType1 In Out



X-Ray10, 11

Major MRI/CT


PCP DEP <19

PCP


HSA2,4,5 EPO These plans are also available on the CORE network.

HE1500 Medical Co-insurance Choice $1,500 $3,000 N/A N/A NonEmb 80% N/A $3,000 $6,000 N/A N/A N/A Ded +

CoinsDed + Coins

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Ded then 100%

Ded + Coins

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HE20003060 RX1 L4A Choice $2,000 $4,000 N/A N/A NonEmb 100% N/A $6,550 $13,100 N/A N/A N/A $30 $60 $100 $300 Ded + Coins

Ded + Coins

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HE2000Rx10i80 RX1 L4A Choice $2,000 $4,000 N/A N/A NonEmb 80% N/A $6,550 $13,100 N/A N/A N/A Ded + Coins

Ded + Coins

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HE2000X Medical Co-insurance Choice $2,000 $4,000 N/A N/A NonEmb 80% N/A $4,000 $8,000 N/A N/A N/A Ded +

CoinsDed + Coins

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Ded then 100%

Ded + Coins

Ded + Coins

HE28503060 RX1 L4A Choice $2,850 $5,700 N/A N/A Emb 100% N/A $6,550 $13,100 N/A N/A N/A $30 $60 $100 $300 Ded + Coins

Ded + Coins

Ded + Coins

HE2850Rx10i80 RX1 L4A Choice $2,850 $5,700 N/A N/A Emb 80% N/A $6,550 $13,100 N/A N/A N/A Ded + Coins

Ded + Coins

Ded + Coins

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HE6650 Medical Co-insurance Choice $6,650 $13,300 N/A N/A Emb 100% N/A $6,650 $13,300 N/A N/A N/A Ded +

CoinsDed + Coins

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Deductible Coinsurance Out-of-Pocket Maximum Copayment

Network Non-Network Ded Type1 In Out Network Non-Network PCP SPEC UC ER

Minor Lab/

X- Ray10,11

Major MRI/ CT

IP/OP Surgery

Navigate: This category of plans, except for HSA, is also available in the non LX version with the minor lab/X-ray benefit covered at 100% coinsurance.

NavE5003060eLXk0 RX1 Navigate $500 $1,000 N/A N/A Emb 80% N/A $3,000 $6,000 N/A N/A $0 $30 $60 $100 $300 + Ded + Coins

Ded + Coins

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NavE50030eLXk0 RX1 Navigate $500 $1,000 N/A N/A Emb 80% N/A $3,000 $6,000 N/A N/A $0 $30 $30 $100 $300 + Ded + Coins

Ded + Coins

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NavE100030eLXk0 RX2 Navigate $1,000 $2,000 N/A N/A Emb 80% N/A $3,500 $7,000 N/A N/A $0 $30 $30 $100 $300 + Ded + Coins

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NavE20004080ei80MaxLXk0 RX2 Navigate $2,000 $4,000 N/A N/A Emb 80% N/A $7,350 $14,700 N/A N/A $0 $40 $80 $100 $300 + Ded + Coins

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Minor Lab/

X- Ray10,11

Major MRI/ CT

IP/OP Surgery

Navigate: This category of plans, except for HSA, is also available in the non LX version with the minor lab/X-ray benefit covered at 100% coinsurance.


Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

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Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

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Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins

HSA2,4,5,6

NavHE1500 Medical Coinsurance Navigate $1,500 $3,000 N/A N/A NonEmb 80% N/A $3,000 $6,000 N/A N/A N/A Ded +

CoinsDed + Coins

Ded + Coins Ded + Coins Ded then

100%Ded + Coins

Ded + Coins

NavHE20003060 RX1 L4A Navigate $2,000 $4,000 N/A N/A NonEmb 100% N/A $6,550 $13,100 N/A N/A N/A $30 $60 $100 $300 Ded + Coins

Ded + Coins

Ded + Coins

NavHE2000Rx10i80 RX1 L4A Navigate $2,000 $4,000 N/A N/A NonEmb 80% N/A $6,550 $13,100 N/A N/A N/A Ded + Coins

Ded + Coins

Ded + Coins Ded + Coins Ded +

CoinsDed + Coins

Ded + Coins

NavHE2000X Medical Coinsurance Navigate $2,000 $4,000 N/A N/A NonEmb 80% N/A $4,000 $8,000 N/A N/A N/A Ded +

CoinsDed + Coins


100%Ded + Coins

Ded + Coins

NavHE28503060 RX1 L4A Navigate $2,850 $5,700 N/A N/A Emb 100% N/A $6,550 $13,100 N/A N/A N/A $30 $60 $100 $300 Ded + Coins

Ded + Coins

Ded + Coins

NavHE2850Rx10i80 RX1 L4A Navigate $2,850 $5,700 N/A N/A Emb 80% N/A $6,550 $13,100 N/A N/A N/A Ded + Coins

Ded + Coins


CoinsDed + Coins

Ded + Coins


Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

NavHE6650 Medical Coinsurance Navigate $6,650 $13,300 N/A N/A Emb 100% N/A $6,650 $13,300 N/A N/A N/A Ded +

CoinsDed + Coins


CoinsDed + Coins

Ded + Coins

of 10




Minor Lab/

X- Ray10,11

Major MRI/ CT

IP/OP Surgery

Charter: This category of plans, except for HSA, is also available in the non-LX version with the minor lab/X-ray benefit covered at 100 percent coinsurance.

CharE5003060eLXk0 RX1 Charter $500 $1,000 N/A N/A Emb 80% N/A $3,000 $6,000 N/A N/A $0 $30 $60 $100 $300 + Ded + Coins

Ded + Coins

Ded + Coins

Ded + Coins

CharE10003060eLXk0 RX2 Charter $1,000 $2,000 N/A N/A Emb 80% N/A $3,500 $7,000 N/A N/A $0 $30 $60 $100 $300 + Ded + Coins

Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins

CharE20004080ei50MaxLXk0 RX2 Charter $2,000 $4,000 N/A N/A Emb 50% N/A $7,350 $14,700 N/A N/A $0 $40 $80 $100 $300 + Ded + Coins

Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins

of 10




Minor Lab/

X- Ray10,11

Major MRI/ CT

IP/OP Surgery

Charter: This category of plans, except for HSA, is also available in the non-LX version with the minor lab/X-ray benefit covered at 100 percent coinsurance.

HSA2,4,5,6

CharHE1500 Medical Coinsurance Charter $1,500 $3,000 N/A N/A NonEmb 80% N/A $3,000 $6,000 N/A N/A N/A Ded +

CoinsDed + Coins


100%Ded + Coins

Ded + Coins

CharHE20003060 RX1 L4A Charter $2,000 $4,000 N/A N/A NonEmb 100% N/A $6,550 $13,100 N/A N/A N/A $30 $60 $100 $300 Ded + Coins

Ded + Coins

Ded + Coins

CharHE2000Rx10i80 RX1 L4A Charter $2,000 $4,000 N/A N/A NonEmb 80% N/A $6,550 $13,100 N/A N/A N/A Ded + Coins

Ded + Coins


CoinsDed + Coins

Ded + Coins

CharHE2000X Medical Coinsurance Charter $2,000 $4,000 N/A N/A NonEmb 80% N/A $4,000 $8,000 N/A N/A N/A Ded +

CoinsDed + Coins


100%Ded + Coins

Ded + Coins

CharHE28503060 RX1 L4A Charter $2,850 $5,700 N/A N/A Emb 100% N/A $6,550 $13,100 N/A N/A N/A $30 $60 $100 $300 Ded + Coins

Ded + Coins

Ded + Coins

CharHE2850Rx10i80 RX1 L4A Charter $2,850 $5,700 N/A N/A Emb 80% N/A $6,550 $13,100 N/A N/A N/A Ded + Coins

Ded + Coins


CoinsDed + Coins

Ded + Coins


Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

CharHE6650 Medical Coinsurance Charter $6,650 $13,300 N/A N/A Emb 100% N/A $6,650 $13,300 N/A N/A N/A Ded +

CoinsDed + Coins


CoinsDed + Coins

Ded + Coins

Plan Code Rx Network9

Deductible Coinsurance Out-of-Pocket Maximum CopaymentNetwork

Ded Type1 In Out

Network Non-Network PCP SPECUC Visits

1-23 ER Minor Lab/ X- Ray

Major MRI/ CT

IP/OP SurgerySingle Family Family Single Family Single Family PCP

DEP<19Visits 1-3 Comb

PCP/Spec3

Flex Focus


Flex Focus P1000 RX FF Choice Plus $1,000 $3,000 $15,000 Emb 80% 50% $4,500 $13,500 $10,000 $30,000 N/A $0 $0 $0 $250 + Ded + Coins Ded + Coins Ded + Coins $250

Ded + Coins


Ded + Coins


Ded + CoinsEPO2 These plans are also available on the CORE network.

Flex Focus E1000 RX FF Choice $1,000 $3,000 N/A Emb 80% N/A $4,500 $13,500 N/A N/A N/A $0 $0 $0 $250 + Ded + Coins Ded + Coins Ded + Coins $250

Ded + Coins


Ded + Coins


Ded + Coins

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Deductible Coinsurance Out-of-Pocket Maximum CopaymentNetwork

Ded Type1 In Out

Network Non-Network PCPSPEC UC ER Minor Lab/

X- RayMajor MRI/

CTIP/OP

SurgerySingle Family Family Single Family Single Family PCP DEP<19 PCP


Focus P1000i80 RX PA Choice Plus $1,000 $2,000 $10,000 Emb 80% 50% $6,500 $13,000 $10,000 $20,000 N/A $0 $100 $50 $250 + Ded + Coins

Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins

EPO2 These plans are also available on the CORE network.

Focus E1000i80 RX PA Choice $1,000 $2,000 N/A Emb 80% N/A $6,500 $13,000 N/A N/A N/A $0 $100 $50 $250 + Ded + Coins

Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins


Ded + Coins

Ded + Coins

Ded + Coins



Ded Type1 In Out

Network Non-Network PCP SPEC

UC ER Minor Lab/ X-Ray13

Major MRI/CT13

IP/OP Surgery13Single Family Single Family Single Family Single Family

PCP DEP <19

PCP Tier 1 Spec7 Spec8

Advanced


AdvP1000 RX2 Choice Plus $1,000 $2,000 $2,000 $4,000 Emb 50% 50% $3,500 $7,000 $7,000 $14,000 N/A $30 $30 $60 $100 $300 + Ded

+ Coins$250 Ded +

Coins$500 Ded +

Coins$500 + Ded

+ Coins


+ Coins$250 Ded +

Coins$500 Ded +

Coins$500 + Ded

+ Coins


+ Coins$250 Ded +

Coins$500 Ded +

Coins$500 + Ded

+ Coins


+ Coins$250 Ded +

Coins$500 Ded +

Coins$500 + Ded

+ Coins


+ Coins$250 Ded +

Coins$500 Ded +

Coins$500 + Ded

+ CoinsEPO2 These plans are also available on the CORE network.

AdvE1000 RX2 Choice $1,000 $2,000 N/A N/A Emb 50% N/A $3,500 $7,000 N/A N/A N/A $30 $30 $60 $100 $300 + Ded + Coins

$250 Ded + Coins

$500 Ded + Coins

$500 + Ded + Coins


$250 Ded + Coins

$500 Ded + Coins

$500 + Ded + Coins


$250 Ded + Coins

$500 Ded + Coins

$500 + Ded + Coins


$250 Ded + Coins

$500 Ded + Coins

$500 + Ded + Coins


$250 Ded + Coins

$500 Ded + Coins

$500 + Ded + Coins

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Ded Type1 In Out

Network Non-Network PCP SPEC

UC ER Minor Lab/ X-Ray13

Major MRI/CT13

IP/OP Surgery13Single Family Single Family Single Family Single Family

PCP DEP <19

PCP Tier 1 Spec7 Spec8

PROformance


PROP100010 RX1 Choice Plus $1,000 $2,000 $5,000 $10,000 Emb 80% 50% $7,150 $14,300 $10,000 $20,000 $0 $10 $40 $80 $25 $300 + Ded

+ Coins$40 Copay

Only$500 Copay

Only Ded + Coins


+ Coins$40 Copay

Only$500 Copay

Only Ded + Coins


+ Coins$40 Copay

Only$500 Copay

Only Ded + Coins


+ Coins$40 Copay

Only$500 Copay

Only Ded + Coins


+ Coins Ded + Coins Ded + Coins Ded + Coins







EPO2 These plans are also available on the CORE network.

PROE100010 RX1 Choice $1,000 $2,000 N/A N/A Emb 80% N/A $7,150 $14,300 N/A N/A $0 $10 $40 $80 $25 $300 + Ded + Coins

$40 Copay Only

$500 Copay Only Ded + Coins


$40 Copay Only



$40 Copay Only



$40 Copay Only


PROE100015 RX2 Choice $1,000 $2,000 N/A N/A Emb 80% N/A $7,150 $14,300 N/A N/A $0 $15 $50 $100 $25 $300 + Ded + Coins Ded + Coins Ded + Coins Ded + Coins




of 10

All Savers plan options keye ER Copay, Deductible, Coinsurance.

LX Minor Lab/X-Ray Deductible, Coinsurance

i100 100 Percent Coinsurance



Max Maximum Allowable Out of Pocket

Rx10 Rx Copay after Deductible

X Out of Pocket for 1 Person Max $6,550

k0 $0 PCP Copay for Kids 19 and Under

Example Plan E35003060ek0i50MaxLX

ER Copay, Deductible then Coinsurance, Minor Lab/X-Ray Deductible, Coinsurance, 50 Percent Coinsurance after the Deductible to the Maximum Allowable Out of Pocket, $0 Copay for Kids

PharmacyRx Plan Code12 Deductible

Tier 1 Tier 2 Tier 3 Tier 4 Mail Service Ratio (90-Day Supply)Single Family

Advantage PDL

RX1 N/A N/A $10 $35 $60 $200 2.5

RX1 L4A N/A N/A $10 $35 $60 $100 2.5

RX2 N/A N/A $15 $35 $75 $250 2.5

RX FF N/A N/A $15 $50 $100 $125 2.5

RX PA $250 $500 $0 $50 $100 $250 2.5

Medical Coinsurance N/A N/A Med Coin Med Coin Med Coin Med Coin 2.5

1 “Embedded” deductible means once an individual meets his or her portion of the deductible, services are paid for that person without the entire family deductible being met. “Non-Embedded” deductible means no covered family member will satisfy an individual deductible until the entire family deductible is met.

2 EPO plans exclude coverage for services provided by Out-of-Network Providers with the exception of (1) Services performed in a Network Facility by an out-of-network pathologist, emergency room physician, anesthesiologist, radiologist or assistant surgeons; and (2) Services performed under the Emergency Care benefit.

3 Plans feature $0 copay for the first 3 Primary Care Physician (PCP) and/or Specialist office visits for a maximum of 3 combined during the Plan Year. Office visits 4+ will be subject to plan deductible/coinsurance. Plans also feature $0 copay for the first 2 Urgent Care visits during the Plan Year. Urgent Care visits 3+ will be subject to plan deductible/coinsurance. Preventive Care visits do not count against the office visit copayment limit.

4 With the HP2000X/HE2000X/NavHE2000X/CharHE2000X family plans, the Out-of-Pocket for 1 person is capped at $6,550 and $8,000 for family. With the HP1500/HE1500/NavHE1500/CharHE1500 and HP2500/HE2500/NavHE2500/CharHE2500 family plans, the Out-of-Pocket for 1 person is capped at $6,550 (where applicable).

5 If there are copayments on HSA plans, they will be required after the deductible has been met and will continue to be required until the annual out-of-pocket maximum is met.6 “Navigate” and “Charter” plans require referrals for certain services. Failure to obtain a referral may result in either non-payment of claims or a reduction of benefits.7 This tier of benefits applies to UnitedHealth Premium Tier 1 Designated Providers. Please visit myallsavers.com for details.8 This tier of benefits applies to physicians in specialties where there is no UnitedHealth Premium Program and for physicians who are not UnitedHealth Premium Tier 1 Designated. Primary Care Physicians include Family Practice, Internal medicine and Pediatrics.9 CORE only available in some areas.10 When selecting multiple Traditional and or Navigate/Charter category plans, the LX PPO and EPO plans cannot be offered in combination with non-LX PPO and EPO Plans.11 The Traditional and Navigate/Charter category of plans are available in the non-LX version with the benefit covered at 100 percent coinsurance.12 The Traditional and Navigate/Charter category of plans are available with the Essential PDL and cannot be offered in combination with the Advantage PDL.13 For the Advanced and Direct plan category, Minor Lab/X-Ray, Major MRI/CT and IP/OP Surgery are covered at deductible and coinsurance when services are done at a freestanding facility; copayment does not apply in a hospital setting. All plans may not be available in all markets. Plan availability is subject to change and is controlled via the quoting process on myallsavers.com.Administrative services provided by United HealthCare Services, Inc. or their affiliates. Stop-loss insurance is underwritten by All Savers Insurance Company (except MA, MN and NJ), UnitedHealthcare Insurance Company in MA and MN, and UnitedHealthcare Life Insurance Company in NJ. 3100 AMS Blvd., Green Bay, WI 54313, 1-800-291-2634.9560731.0 8/19 BROKER ©2019 United HealthCare Services, Inc. 19-13327-B

Benefit Coverage Differences. Key product attributes and coverage differences

Comparison of National Benefit Standards

All Savers® Alternate Funding vs. UnitedHealthcare 2018-19

UnitedHealthcare Fully Insured COC All Savers Alternate FundingMotion Credit Available on limited plans starting 1/1/18 Available on all plans; not applicable for PA, DE, WI, MO, NJNetwork Choice and Choice Plus Choice and Choice PlusPediatric Dental Covered Not covered

Plan Year Policy Year or Calendar Year Policy Year or Calendar Year (TX only offers Calendar Year plans)

Reimbursement – Non-Network Maximum Non-Network Reimbursement Program (MNRP) – most services reimbursed to 110 percent CMS Same

Underwriting Subject to Adjusted Community Rating Medical Underwriting applies

Vision Exam Pediatric Covered (Adult exams standardly not covered – may vary by state) Not Covered

Breast Cancer Drug and Tobacco Cessation Drugs

Prior Authorization Required for non-grandfathered plans Same

Podiatry Includes coverage for Bunionectomy or Hammer Toe Same

Maternity

If the mother and baby are inpatient together and both are on the medical plan, the annual deductible will be waived for all the baby’s eligible inpatient claims, including, but not limited to, physician and facility fees. However, if the baby stays longer than the mother, the baby’s annual deductible will apply upon mother’s discharge from the hospital. In all cases, any applicable copays and coinsurance will apply to the baby and mother separately.

Same

Transplant Travel Benefit $10,000 travel benefit $5,000 travel benefit

Non-Network Professional Charges when Facility is In-Network

RAPLS benefit paid at network benefit when facility is in-network. Biggest difference is the surgeon – paid in-network by UnitedHealthcare but not All Savers.

PEAR benefit paid at network benefit when facility is in-network (pathologists, ER physician, anesthesiologist, radiologist, hospitalist, assistant surgeon); surgeons are not paid in-network.

Inpatient and Outpatient Physician Fees

Covered under Hospital Inpatient or Outpatient stay facility benefit.

Covered under the Physician’s Visit — Sickness and Injury section in the SPD. Note: The professional fees are processed separately from the hospital benefit subject to an additional copay for each daily visit.

Benefit Limit Differences Categories that are covered by both Products, however, the dollar/visit limits may differ.

Dental Services – Accident Only $900/tooth limited to $3,000 per year* Unlimited – Includes impacted wisdom teeth

Durable Medical Equipment (DME)* Covered with no dollar maximum. Benefits are limited to a single purchase (including repair/replacement) every 3 years.

Unlimited – DME over $1,000 is subject to prior authorization requirements

Essential Health Benefits

May have to cover additional EHB and remove dollar limits as applicable. Visit and day limits may change depending on the state’s benchmark plan.

Require plans to cover at least 1 drug in each USP therapeutic category and class, e.g., Smoking Cessation

The All Savers Alternate Funding Plans are self-funded and not required to provide benefits for EHBs.

Hearing Aids – Adults over Age 18 $2,500 per year limited to single purchase per hearing impaired ear (including repair/replacement) every 3 years*

$5,000 every 36 months that includes a single purchase and repair/replacement

Home Health Care Limited to 60 visits per year* Limited to 30 visits per year

Health PlansAll Savers Alternate Funding

2.3

8253980.0 12/18 ©2018 United Healthcare Services, Inc. 18-10630

Administrative services provided by United HealthCare Services, Inc. or their affiliates. Stop-loss insurance is underwritten by All Savers Insurance Company (except MA, MN and NJ), UnitedHealthcare Insurance Company in MA and MN, and UnitedHealthcare Life Insurance Company in NJ. 3100 AMS Blvd., Green Bay, WI 54313, 1-800-291-2634.

State mandates and variations from the National Standards can and will take precedent over this summary.

Additional Differences.Issuance of ID Cards: Temporary ID cards issued within 48 hours for UnitedHealthcare and 24 business hours for All Savers. Permanent ID cards are sent within 2 business days for All Savers and 3 business days for UnitedHealthcare.

Open Enrollment: UnitedHealthcare offers open enrollment for eligible members for 31 days after new business enrollment, and this open enrollment is offered annually. All Savers does not offer open enrollment at new business but it is offered at renewal for 60 days prior to the effective date and 31 days after the effective date.

Newborn Coverage: UnitedHealthcare enrolls the newborn for the first 31 days of life and then requires an enrollment form for continued coverage. All Savers requires an enrollment form from birth for the baby to be added to the policy. If no enrollment form received within the first 31 days, the baby is not added.

Member Portal: myuhc.com vs. www.myallsaversconnect.com

Plan Credit: UnitedHealthcare credits deductible and out of pocket. All Savers credits deductible only on calendar year plans. No out-of-pocket credit for All Savers.

Comprehensive Wellness Platform includes Rally Wellness, HealthiestYou and UnitedHealthcare Motion® on all plans. HealthiestYou provides Telemedicine, Best Doctors and dependent visits for those not enrolled on the plan at no charge. PA, DE, MO and NJ not participating in any wellness. WI is participating in HealthiestYou and Rally effective 11/1/18 (but not UnitedHealthcare Motion).

UnitedHealthcare Fully Insured COC All Savers Alternate Funding

Manipulative Therapy (formerly Chiropractic)

Limited to 20 visits per year*Physical, Speech, Occupational, Manipulative, Cardiac, Post Cochlear and Cognitive therapy covered at a combined 30 visits per year

Ostomy Supplies Subject to $2,500 annual maximum* Unlimited

Prosthetic Devices Covered with no dollar maximum. Benefits are limited to a single purchase (including repair/replacement) every 3 years*

Unlimited

Rehabilitation Services, Outpatient Therapy

Visit Limits:*• Physical, Speech, Occupational, Pulmonary – 20 visits per

year each• Cardiac – 36 visits per year• Post Cochlear – 30 visits per year• Cognitive – 20 visits per year

Physical, Speech, Occupational, Manipulative, Cardiac, Post Cochlear and Cognitive therapy covered at a combined 30 visits per year

State-Mandated Benefits Covered Not applicable, ERISA appliesTransplant Services – Non-Network Not covered Same

* Essential Health Benefits may vary as defined by State’s Benchmark Plan

MT-1175983.0 7/18 ©2018 United HealthCare Services, Inc. 18-8918-E

UnitedHealthcare Motion is a voluntary program. The information provided under this program is for general informational purposes only and is not intended to be nor should be construed as medical advice. You should consult an appropriate health care professional to determine what may be right for you. Receiving an activity tracker may have tax implications. You should consult an appropriate tax professional to determine if you have any tax obligations from receiving a device under this program. If you are unable to meet a standard related to health factor to receive a reward under this program, you might qualify for an opportunity to receive the reward by different means. Contact us at 1-855-256-8669 or [email protected] and we will work with you (and, if necessary, your doctor) to find another way for you to earn the same reward.

Rally Health provides health and well-being information and support as part of your health plan. It does not provide medical advice or other health services, and is not a substitute for your doctor’s care. If you have specific health care needs, consult an appropriate health care professional. Participation in the Health Survey is voluntary. Your responses will be kept confidential in accordance with the law and will only be used to provide health and wellness recommendations or conduct other plan activities.

Administrative services provided by United HealthCare Services, Inc. or their affiliates. Stop-loss insurance is underwritten by All Savers Insurance Company in all states (except MA, MN and NJ), UnitedHealthcare Insurance Company in MA and MN, and UnitedHealthcare Life Insurance Company in NJ. 3100 AMS Blvd., Green Bay, WI 54313, 1-800-291-2634.

All trademarks are the property of their respective owners.

The plan built to help you stay healthy and save money.

Welcome to wellness!Your benefit plan provides you with easy, interactive programs and tools to help manage your care and get healthier. We want to make it easier for you to stay engaged in your health.

Sign up to get:

UnitedHealthcare Motion®UnitedHealthcare Motion®A wearable activity tracker that rewards you for meeting walking goals.Each enrolled employee and covered spouse can earn up to $1,095 peryear to help pay for qualified out-of-pocket medical expenses.

TMhy healthiestyou

HealthiestYou.Complete virtual care from your mobile device. Skip trips to the clinicwith 24/7 access to doctors who can diagnose, treat and prescribe withno copays. Potentially save money by comparing pricing for proceduresand prescriptions. Use the app to view your deductible in real time.

Rally®.A fun, personalized digital experience designed to make getting healthyeasier. Learn your Rally AgeSM and get custom recommendations to helpyou meet your health goals.

Check out the enclosed pages for more information. Go to myallsaversconnect.com.

Health & WellnessAll Savers® Alternate Funding

2.4

What is HealthiestYou™?HealthiestYou is an app that allows you to talk to a doctor from anywhere, anytime — with no copay or cost to you. Manage many of the situations that would normally involve a visit to the doctor’s office without leaving home. HealthiestYou also offers a price-comparison tool that may save you up to 85 percent on prescriptions, often beating your copay. The app allows you to compare prices for procedures and research doctors. It’s also a one-stop shop to view your medical plan deductibles in real time.

How does HealthiestYou work?If you’re sick, you can talk to a doctor in HealthiestYou’s physician network through the app or from your phone. (If you don’t have internet access, you can just make a phone call.) These doctors may diagnose, treat and prescribe, and you’ll have no copay. HealthiestYou is designed to complement the care you receive from your primary care doctor. If you need a prescription or procedure, you can use HealthiestYou’s geo-based search engine to find prices to help you make a more informed decision. Don’t stress; help save time and money!

How to sign up for HealthiestYou:• Go to member.healthiestyou.com.

• Register for your HealthiestYou account and downloadthe app.

• Sync your medical benefits to shop and book providersor view your deductibles.

• Call 1-866-703-1259 (option 3) with questions.

• Call 1-866-703-1259 (option 1) to reach a doctor.

Continued on reverse.

What is Best Doctors®?Best Doctors provides you and your eligible dependents the guidance and reassurance needed when facing any medical situation. If you have received a serious diagnosis, are considering multiple treatment options, need help deciding if surgery is right for you or have medical questions, Best Doctors can have a carefully selected expert physician conduct an in-depth review of your medical case and/or questions and provide a personalized response and recommendation.

How does Best Doctors work?As members of Best Doctors and HealthiestYou, you and your eligible dependents have access to a number of free and confidential services designed to put you at the center of your care and help ensure you get the right diagnosis, the most effective treatment and the answers you deserve.

Medical uncertainty is a problem. Combined, Best Doctors and HealthiestYou is a valuable solution.

How to sign up for Best Doctors:• Access Best Doctors through your HealthiestYou app

at the click of a button.

• Call 1-866-904-0910.

• Visit members.bestdoctors.com.

TMhy healthiestyou

Health & WellnessAll Savers®Alternate Funding

Virtual care is available from your phone or tablet.

2.5

MT-1171000.2 9/18 ©2018 United HealthCare Services, Inc. 18-9703A

This program is not insurance.



TMhy healthiestyouHealthiestYou and HSA-High Deductible Health PlansWho: All Savers members enrolled in HSA-High Deductible

Health Plans.

What: Eligible for HealthiestYou benefits and services.

Where: Virtual care —allowing members to talk to a doctor anywhere and at any time without an office visit.

When: Available from the effective date of the All Savers plan.

Why: Per IRS guidelines, HealthiestYou is compliant with All Savers HSA products. Therefore, services offered through HealthiestYou are available to All Savers HSA-High Deductible Health Plan members.

How: HealthiestYou services are not considered significant medical benefits and may include the following:

• Treatment for minor injuries, illness or first aid.

• Preventive care services, disease managementprograms, wellness programs, EAP programs.

• Services treated as outside ERISA and not subjectto COBRA.

For more information regarding the HealthiestYou benefit and services, log on to myallsavers.com and download the HealthiestYou brochure.

Note: The above services list is not all-inclusive. This information is solely provided for general informational purposes only and is not intended to take the place of legal or tax advice regarding HSA eligibility. Please consult your own legal or tax professional.

MT-1178910.0 7/18 ©2018 United HealthCare Services, Inc. 18-8941

This program is not insurance.



Health & WellnessAll Savers®Alternate Funding

1 Open the HealthiestYou app on your smartphone or tablet and select “Visit Doctor.”

2 Select the “Add new +” button to add a dependent. The app will already show your name and thenames of dependents who carry your medical coverage.

3 Complete the required fields. The dependent will now be listed in the “Family members” sectionof the app.

You will now be able to schedule a consultation for your minor dependents. Dependents over the age of 18 should call 1-866-703-1259 to schedule a consultation.

Note: You need to add adult dependents to your HealthiestYou account through the app to allow them to schedule a consultation.

12 3

HealthiestYou is now available to all your dependents — even those not currently carrying your medical coverage.

TMhy healthiestyou

2.6

All Savers® Alternate Funding UnitedHealthcare Motion® Walk to earn over $1,000 a year.

This program is not insurance.UnitedHealthcare Motion is a voluntary program. The information provided under this program is for general informational purposes only and is not intended to be nor should be construed as medical advice. You should consult an appropriate health care professional before beginning any exercise program and/or to determine what may be right for you. Receiving an activity tracker and/or certain credits may have tax implications. You should consult an appropriate tax professional to determine if you have any tax obligations from receiving an activity tracker and/or certain credits under this program, as applicable. If any fraudulent activity is detected (e.g., misrepresented physical activity), you may be suspended and/or terminated from the program. If you are unable to meet a standard related to health factor to receive a reward under this program, you might qualify for an opportunity to receive the reward by different means. Contact us at 1-855-256-8669 or [email protected] and we will work with you (and, if necessary, your doctor) to find another way for you to earn the same reward. Rewards may be limited due to incentive limits under applicable law.Administrative services provided by United HealthCare Services, Inc. or their affiliates. Stop-loss insurance is underwritten by All Savers Insurance Company in all states (except MA, MN and NJ), UnitedHealthcare Insurance Company in MA and MN, and UnitedHealthcare Life Insurance Company in NJ. 3100 AMS Blvd., Green Bay, WI 54313, 1-800-291-2634.MT-1165791.0 8/18 ©2018 United HealthCare Services, Inc. 18-8918-B

What is it?An innovative, web-based activity program that works with your activity tracker and an app. All Savers Alternate Funding recognizes the value of your steps; you can wear your tracker to earn rewards that reimburse qualified out-of-pocket medical expenses. Walking is not only good for your physical health, it may be one of the best medicines for mental health, too.

How does it work?After you set up the tracker and sync it with your computer or smartphone, wear it daily — and walk — paying attention to its helpful reminders. Log in to a personal dashboard for near-real-time feedback on your progress and rewards earned. You can earn over $1,000 to help reduce your annual health care costs. Your tracker measures how often you walk, how fast you walk and the number of steps you take. The research used to develop this program proved it’s significantly more beneficial to your health to 1) get up and move multiple times a day, 2) include one moderately intense walk and 3) reach a step-count goal. It’s called FIT because Frequency, Intensity and Tenacity matter.

How to sign up:1 Log in to your account at myallsaversconnect.com and click the

UnitedHealthcare Motion® link.

2 Create your UnitedHealthcare Motion account, and receive a $55 credit just for registering.

3 Select an activity tracker of your choice using the $55 registration credit to be shipped to your home. If you already have a FIT-compatible activity, you can save the registration credit for reimbursement of qualified out-of-pocket medical expenses.

4 Follow the instructions to set up your activity tracker and sync it with your computer or smartphone.

For the maximum benefit, meet these daily goals:• Take six brief walks, at least 1 hour

apart (each 500 steps taking lessthan 7 minutes).

• Take 1 brisk walk (3,000 stepswithin 30 minutes).

• Walk at least 10,000 steps total.

Questions? Call 1-855-256-8669 or [email protected].

Health & WellnessMotion

2.7

Health & WellnessReal Appeal

Tashawna O. Age 37

“This is no diet — this is not a gimmick.

I feel great!”

Dave L. Age 47

“I’m stronger. I have a lot more energy.

Thank you, Real Appeal.”

LOST

50 LBS

Real People. Real Appeal®.

LOST

37 LBS

All Savers® Alternate Funding members* can lose the weight FREE and keep it off!

2.8

*The Real Appeal program is provided to eligible members at no additional cost to you as part of your benefit plan.Real Appeal is a voluntary weight loss program that is offered to eligible participants over age 18 as part of their benefit plan. The information provided under this program is for general informational purposes only and is not intended to be nor should be construed as medical and/or nutritional advice. Participants should consult an appropriate health care professional to determine what may be right for them. Any items/tools that are provided may be taxable and participants should consult an appropriate tax professional to determine any tax obligations they may have from receiving items/tools under the program.Administrative services provided by United HealthCare Services, Inc. or their affiliates. Stop-loss insurance is underwritten by All Savers Insurance Company in all states (except MA, MN and NJ), UnitedHealthcare Insurance Company in MA and MN, and UnitedHealthcare Life Insurance Company in NJ. 3100 AMS Blvd., Green Bay, WI 54313, 1-800-291-2634.MT-1175001.1 7/18 ©2018 United HealthCare Services, Inc. 18-8702-A

Personal transformation coach.• Step-by-step guidance and customization for a program that fits

your needs, preferences and goals.

• Support and motivation for a full year to help you lose weight ormaintain results.

• A personalized dashboard to keep track of your calories, fitnessand goals.

24/7 convenience.Staying accountable to your goals may be easier than ever with:

• Food, activity, weight and goal trackers.

• Unlimited access to digital content.

• Your online group class, which is designed to help you buildcamaraderie and accountability with others in the program.

• Weekly health tips from celebrities, athletes and health experts.

Success kit.Resources to help you kick-start your weight loss and keep yourself on the road to results. Your kit will be delivered after your first class. It includes:

• Step-by-step Success Guides.

• Workout DVDs.

• Quick and simple recipes.

• Nutrition guide.

• And much more.

We are excited to offer Real Appeal, a free digital program that provides you with up to a full year of support for lasting weight loss.* On average, participants lose 10 pounds after attending just 4 online classes. Your program includes:

Join the thousands of members that have lost nearly 1 million pounds. Start today at success.realappeal.com. Spark your transformation with Real Appeal.

Not for Consumer Use Administrative services provided by United HealthCare Services, Inc. or their affiliates. Stop-loss insurance is underwritten by All Savers Insurance Company (except MA, MN and NJ), UnitedHealthcare Insurance Company in MA and MN, and UnitedHealthcare Life Insurance Company in NJ. 3100 AMS Blvd., Green Bay, WI 54313, 1-800-291-2634.

9287738.0 7/19 ©2019 United HealthCare Services, Inc. 19-12731

With the 15-month rate guarantee, effective dates move: • From October to January.• From November to February.• From December to March.• From January to April.• From February to May.• From March to June.• From April to July.

All Savers® Alternate Funding is offering a 15-month rate guarantee from October through April in Texas.

The rates stay the same as 12-month business, so why not elect 15?

The 15-month rate guarantee not only applies to medical but also to ancillary lines of coverage that include Dental, Vision and Life.

Health PlansAll Savers Alternate FundingTexas

2.9



I acknowledge that I understand and agree with the following arrangements related to our 15-month rate guarantee and the impact to the excess loss policy period we are entering into with All Savers Insurance Company or affiliated stop loss carriers (“ASIC”) and United HealthCare Services, Inc. (“United”).

The initial term of the excess loss policy will be a period of 3 months and therefore will fall under the early termination clause of the Administrative Services Agreement Section 6.5, which reads:

If this Agreement or the Stop Loss Policy terminates during the Term of the Agreement or before the end of the third calendar month following the close of the Term of the Agreement, United shall conduct a reconciliation after the 24th calendar month following the close of that Term of the Agreement (the “Reconciliation Date”) and also calculate a reserve (the “Customer IBNR Reserve”) for claims incurred during the Term of the Agreement but not paid prior to the Reconciliation Date. United will reconcile the amount of the cumulative Maximum Monthly Claim Liability payments paid to United for the Term of the Agreement over (i) the amount of claims incurred during the Term of the Agreement and paid before the Reconciliation Date, less any specific stop loss insurance reimbursements, and (ii) the Customer IBNR Reserve. The Customer IBNR Reserve shall be equal to 100 percent of claim payments made during the 3 months prior to the Reconciliation Date, and in no event shall the Customer IBNR Reserve be less than $0. Any amount in excess of the Customer IBNR shall be payable to United as a Deferred Service Fee in accordance with the applicable provision in Section 5.4.

The Individual Stop Loss and Aggregate Stop Loss coverage with ASIC or affiliated stop loss carriers will be in effect for an initial 3-month term, and will renew for a 12-month term immediately following the initial shortened term. The stop loss limits will reset on the first day of the 12-month term.

By signing below, I confirm and acknowledge full understanding of the above changes to our stop loss policy period resulting from our 15-month rate guarantee.

Legal Business Name: _____________________________________________________________________________________

By Authorized Signature: ___________________________________________________________________________________

Print Name and Title: _______________________________________________________________________________________

Date: ____________________________________________________________________________________________________

By Broker Signature: _______________________________________________________________________________________

Print Name: ______________________________________________________________________________________________

Date: ____________________________________________________________________________________________________

Acknowledgment for 15-month rate guarantee.

Health PlansAll Savers®Alternate Funding

UnitedHealthcare –All Savers 10-100 HB2015 Underwriting Guidelines

Guidelines 10-19 – GRx with HB Reports Combo Available for groups with 10-19 enrolled employees Premium versus claims data must be provided for the last 12 months Reports cannot be more than 120 days prior to the effective date $15k Large Claim Report must be provided for last 12 months - dates must be specified on the report If no large claims are present we must receive documentation from the carrier indicating no large claims Must provide a member level census Must provide group’s Tax ID# Must provide ATNE for prior calendar year Guidelines 20+ HB Reports: Available for groups with 20+ enrolled employees Premium versus claims data must be provided for the last 12 months Reports cannot be more than 120 days prior to the effective date $15k Large Claim Report must be provided for last 12 months - dates must be specified on the report If no large claims are present we must receive documentation from the carrier indicating no large claims Must provide group’s Tax ID# Must provide ATNE for prior calendar year Employee Count Thresholds (20+): If applying count is within +/- 10% of the most recent sub count from the claim report, no additional apps or member level census is required. If there is more than 10% greater applying than on the HB2015 report, individual medical applications must be submitted for the additional employees. If there are more than 10% less applying than on the HB2015 report, then a member level census for GRx must be submitted for the whole group, assuming at least 20 subs or more are enrolling. Example 1: 30 employees on the HB2015 report, 28 employeesapplying for coverage. GRx is not required.Example 2: 30 employees on the HB2015 report, 25 applying forcoverage. Member level census for GRx is required.Example 3: 20 employees on the HB2015 report, 17 applying forcoverage. Individual applications required.Guidelines 51-100+ HB Reports: Underwriting must approve and release a Fully Insured proposal with an All Savers Request Available for groups ATNE 51+ (average total number of employee’s prior year) Premium versus claims data must be provided for the last 12 months Reports cannot be more than 120 days prior to the effective date $15k Large Claim Report must be provided for last 12 months - dates must be specified on the report If no large claims are present we must receive documentation from the carrier indicating no large claims Must provide group’s Tax ID# Must provide ATNE for prior calendar year

2.10

CONTINUED

PDF versions of the documents below can be uploaded to myallsavers.com.

The following items are required for final quoting. All items are essential for successful and timely turnaround on your final rates request. Incomplete items may cause delays.

Submission Checklist for Final Quote — Member Level Census Underwriting for Groups with 20+ Enrolled Final Quote.

All Savers® Alternate Funding Case Submission Checklist for Final Quote — Member Level Census

Employer (additional required information after street quote/preliminary quote is completed) — this information can be provided in the notes section of myallsavers.com.

Employer Application.PDF versions of the employer application should be uploaded to the group record in myallsavers.com.All questions answered completely.Signed and dated by both employer and broker on all indicated pages.Payment Authorization Form (needed regardless of type of payment).Signed and dated by both employer and broker on all indicated pages.Note: The employer must sign and completely fill out the Authorization portion if selecting EFT.

First Month’s Premium.A copy can be uploaded to myallsavers.com.Send the original binder check to:

United HealthCare Services, Inc. P.O. Box 19032 Green Bay, WI 54307-9032 (If overnighting the check, please use United HealthCare Services, Inc., 3100 AMS Blvd., Green Bay, WI 54313.)

Electronic Fund Transfer (EFT).

Excess Loss Insurance Application.Filled out completely.Signed and dated by both the agent and the employer.

Billing & Collections Agreement (not required in all states).PEPM Value entered.Signed and dated by employer and broker.Note: Employer signs twice (once on page 3 and once on page 4).

2.11


New York Surcharge Forms.If the paperwork is received after the first of the month, the election will not be effective until the following month.

Demographic Spreadsheet OR Employee Applications (for employees electing health coverage) — Excel template OR PDF versions of the applications should be uploaded to the group record in myallsavers.com. The following information is needed for all electing employees and their dependents to provide an underwritten quote:

Name (first and last).Gender.Date of Birth.Home ZIP Code.Indication of Dependents (spouse, children).

Social Security Numbers.Home Address of Employee.Email Address of Employee.

Current Carrier Information

page 4 of 5

DisclosuresIf you are applying for medical coverage, please answer the following questions to the best of your knowledge by referencing available employee records and otherpersonnel documents for all eligible employees and dependents (proprietors, partners, corporate officers, employees, spouses, and dependent children) to the extentpermitted by applicable law. UnitedHealthcare is only seeking to collect information about the current health status of those employees and their dependents who areapplying for coverage. In answering these questions, do not include any genetic information about your employees or their dependents, including requests for geneticservices, genetic diseases for which they may be at risk or family medical history information.Please provide details to "Yes" answers in the space provided.IMPORTANT: Your answers to these questions must include all COBRA and State Continued individuals covered by your present plan.

If you have answered “Yes” to any of the questions above, please provide the requested information on the next page for each individual. If necessary, use additionalsheets of paper.

■■ Yes ■■ No 1. Within the past 3 years, has any employee or dependent filed a claim for short-term disability, long term disability, social securitydisability income, workers’ compensation, Medicare, or Medicaid benefits or any other type of disability benefits on any policy?

■■ Yes ■■ No 2. During the past 3 years, has any employee or dependent had life, disability or health insurance declined, postponed, changed,cancelled or withdrawn?

■■ Yes ■■ No 3. Except for a maternity or paternity leave, within the past 3 years, has any employee applied for a family or medical leave of more than2 weeks due to injury, disability or illness of the employee or dependent?

■■ Yes ■■ No 4. Within the past 3 years, has any employee been absent from work for more than 2 consecutive weeks due to injury, disability or illness?■■ Yes ■■ No 5. Except for a mental health admission, during the past 3 years, has any employee or dependent had a hospital stay lasting more than

5 days or is any employee or dependent contemplating treatment that would require hospitalization for more than 5 days?■■ Yes ■■ No 6. Is any employee or dependent currently hospitalized?■■ Yes ■■ No 7. Within the past 3 years has any employee or dependent been diagnosed, treated for, or received prescription medication for one of the

following conditions?■■ Cancer (any type) ■■ Hepatitis■■ Lung disease or respiratory problem (any type) ■■ Morbid obesity■■ Heart disease or disorder (any type) ■■ Congenital abnormality■■ Organ, tissue or cell transplant ■■ Vascular disease (any type)■■ Liver disease (any type) ■■ Neurological disorder (any type)■■ Kidney disease (any type) ■■ Immunological disorder (reportable types)■■ Pancreatic disorder (any type) ■■ Alcohol or drug addiction or abuse■■ Diabetes ■■ Hemophilia or Blood disorder (any type)

Does the group currently have any coverage with UnitedHealthcare or has the group had any UnitedHealthcare coverage in the last 12 months?■■ Yes ■■ No If Yes, please provide policy number ______________________ and Coverage Begin Date___/___ /___ End Date___/___ /___Has this group been covered for major dental services for the previous 12 consecutive months? ■■ Yes ■■ No

Name of Carrier Initial Coverage Begin Date Coverage End Date

Current Medical Carrier ■■ None

Current Dental Carrier ■■ None

Current Life Carrier ■■ None

Current Disability Carrier ■■ None

Current Vision Carrier ■■ None

Disclosures (continued)Question Check One Date of Date of Treatment/ Nature of Name of $ Amount CurrentNumber Employee Dependent Age Recovery Condition Medication Condition of Claims Treatment

Group Name ________________________________________________________________________________________________________

Texas Mandatory Disclosure Statement:

Dental indemnity benefits are provided through UnitedHealthcare Insurance Company and Dental HMO (DHMO) benefits are offered through National PacificDental, Inc. In order to receive benefits from the DHMO plan, an enrollee must utilize only network providers, except for emergency dental care, and pay thecopayments specified in the evidence of coverage. To receive benefits under the dental indemnity plan, the enrollee may utilize any provider but prior toreceiving reimbursement, the enrollee must meet the required deductible and is responsible for the coinsurance amount specified in the policy or certificate.

Important Information

The Group/Company certifies that the information provided above is complete and accurate. The Group/Company shall notify UnitedHealthcare and Affiliatespromptly of any changes in this information that may affect the eligibility of employees or their dependents, including the addition of any newly eligibleemployees or dependents. Prior to receiving notification of approval, the Group/Company shall notify UnitedHealthcare and Affiliates promptly of any significantchanges in the health status of an eligible employee or dependent including any inpatient hospital admissions. UnitedHealthcare and Affiliates shall be entitledto rely on the most current information in its possession regarding the eligibility and health status of employees and their dependents in providing coverageunder the policy/policies for which application is being made.I represent to the best of my knowledge the information I have furnished is accurate, and includes any employees and dependents who have electedcontinuation of insurance benefits. I understand that intentional misstatement or misrepresentations of a material fact, or omissions that constitute fraud, in theinformation requested on this form can result in the adjustment of rating or voiding of insurance.I understand that the Certificate of Coverage or Summary Plan Description and other documents, notices and communications regarding the benefit plan(s)indicated herein on this Application may be transmitted electronically to me and to the Group’s/Company’s employees. This consent remains in effect until it iswithdrawn. The Group may withdraw their consent at any time or request a document in a paper or non-electronic form.Knowingly or willfully presenting a false or fraudulent claim for payment of a loss or benefit or knowingly or willfully presenting false information, or concealinginformation for the purpose of misleading, in an application for insurance, is a crime punishable by fines and confinement in prison.Upon receipt by UnitedHealthcare and Affiliates of this signed employer application and payment of the required policy charges, the group policy is deemedexecuted. The deposit check in the estimated amount of the first month’s premium is not considered payment of the required policy charges.UnitedHealthcare disclosure regarding producer compensation:In some instances, we pay brokers and agents (referred to collectively as "producers") compensation for their services in connection with the sale of ourproducts, in compliance with applicable law. In certain states, we may pay "base commissions" based on factors such as product type, amount of premium,group/company size and number of employees. These commissions, if applicable, are reflected in the premium rate. In addition, we may pay bonuses pursuantto programs established to encourage the introduction of new products and provide incentives to achieve production targets, persistency levels, growth goalsor other objectives. Bonus expenses are not directly reflected in the premium rate but are included as part of the general administrative expenses. Pleasenote we also make payments from time to time to producers for services other than those relating to the sale of policies (for example, compensation forservices as a general agent or as a consultant). Producer compensation may be subject to disclosure on Schedule A of the ERISA Form 5500 for customers governed by ERISA. We provide Schedule Areports to our customers as required by applicable federal law. For specific information about the compensation payable with respect to your particularpolicy, please contact your producer.

Signature (Form must be signed)

Group/Company Signature ___________________________________________ Date __________________ Title___________________________________

DO NOT CANCEL YOUR EXISTING COVERAGE UNTIL YOU RECEIVE WRITTEN NOTIFICATION OF APPROVAL.

Producer Information (if applicable)Producer Name Agency Agent Code/Tax ID Number

Email Address Social Security # Phone Number

All Payments to:Producer Commission Schedule (if applicable) ___________ Std Scale of ____________%

Street Address City State Zip Code

Producer Signature Date

Rep Name Rep #

page 5 of 5

Group Name ________________________________________________________________________________________________________

General Agent Phone # Franchise Code

Street Address City State Zip Code

General Agent Information (if applicable)

Contact ListArea/Topic Responsible Party Email Phone

Prio

r to

Inst

alla

tion Broker contracting/appointments/commissions Licensing and Commissions [email protected] 1-866-405-7174

Quoting and enrollment Broker Services [email protected] 1-866-405-7174

Online employee enrollment Broker Services [email protected] 1-844-860-0401

Rates and underwriting Regional Underwriting Team Contact your Account Executive or Renewal Account Executive

Aft

er In

stal

latio

n

Medical and SpecialtyMembership changes, address changes, plan documents Policy Admin [email protected] 1-800-291-2634

Medical Employee enrollment, adding dependents Policy Admin [email protected] 1-800-291-2634

Medical and SpecialtyBilling questions, payment questions, reporting questions Member Services [email protected] 1-800-291-2634

MedicalSubmit prior carrier deductible credit report, claims appeals Claims [email protected]

MedicalProvider questions, verify eligibility or benefits, benefits or claims information, member ID cards

Member Services N/A 1-800-291-2634

WellnessUnitedHealthcare Motion®

UnitedHealthcare Motion Customer Support [email protected] 1-855-256-8669

HealthiestYou™ and Rally® General Questions [email protected] 1-866-405-7174

HealthiestYou Licensed Physician member.healthiestyou.com 1-866-703-1259

Spec

ialty

Dental claims, benefits, eligibility, provider information Dental Service Center www.myuhc.com 1-877-816-3596

Vision claims, benefits, eligibility, provider information Vision Service Center www.myuhcvision.com 1-800-638-3120

Proof of death form Life Service Center 1-888-299-2070

Web

site

s

Member Website - www.myallsaversconnect.com

Provider Website - www.myallsaversconnect.com

Employer Website - www.myallsaversconnect.com

Broker Website - www.myallsavers.com


Health PlansAll Savers®

2.12

Dental and Vision available as Standalone Plans

VALUE ADDED SERVICES - VISION

PLAN DESIGN ELEMENTS (NEW)INCLUDED VISION FEATURES

VISION 2-99 EMPLOYEESVOLUNTARY PLANS - Minimum 1 enrolled ; 2-99 market: 24 month rate guarantee

Available for groups down to 2 enrolled employees

Participation: 75% overallEmployer contributes 50% or more of single premium

ORTHO COVERAGE

Oral Cancer ScreeningPrenatal Dental Care Program

Last Updated: 05/29/19For reference purposes only. Not a legal document

DENTAL 2-99 Employees

Minimum 2 enrolled Employer contributes less than 50% of single premium

Consumer MaxMultiplier & Other Value Adds

NETWORK

EMPLOYER PAID

VOLUNTARY

NETWORK AND TECHNOLOGY

SPECIALTY BENEFITS

VALUE ADDED SERVICES - DENTAL

DHMO (TX, CA, FL, NY Markets Only)

DUAL OPTION STRATEGY

PLAN DESIGN ELEMENTSAdd Flex Enhancement package to selected plan (Req 10 Eligible): Flex Appeal Enhanced - Includes Implants, Full Mouth Composites, Periodontal Maintenance, and 2 additional cleanings per year. OR Preventive Max Multiplier (PMM) - Prev/Diag services not applied to deduc or annual maximum. Flexable Plan Designs , Annual Maximums, and OOP Reimbursments 12 Month rate guarantee Open enrollment allowed with each renewal date . NO late entrant provisions

PPO VOL plans - Minimum 5 eligible and 4 enrolled

$750 to $3,000 benefit available

Minimum 10 Enrolled for PPO plans Offer options of a low and high dental plan

Requires at least 20% differential between rates

National Networks include more than 105K unique providers and 240K Access Points Website: www.myuhc.com Network Name: National Options PPO Network:

National Options 20 = MAC OON PlansNational Options 30 = UCR OON Plans

Treatment Cost Calculator available online / Health4Me App

Online claim and benefit information

Dental Rollover Program allows you to rollover an awarded portion of your annual maximum into the following calendar year! Also, an Annual Network Bonus of $100 will be included for using in-network providers!

Able to takeover existing rollover programs

Embedded Benefit available for Women through out their whole pregnancy and three months after their baby is born. This is used because studies show that dental disease during pregnancy can affect your health and possibly even your baby's. This benefit covers Dental Cleanings, Non-surgical gum treatment, gum maintenance (care to keep gums healthy after treatment is complete). Has no limit on how often these services can be provided during this time. The Dentist will decide how often services are needed.

1. Covered at 100%2. Does not count towards your annual maximum or

deductible.

New test that detects oral cancer earlier and are covered by UHC for adult patients. Light Contrast screening "fluorescence visualization". The test uses light to help your dentist find healthy and unhealthy tissue.

Network Name: Spectera Eyecare Network Provider Lookup: www.myuhcvision.com

(Member can access ID Card from this website)

Network contains 50/50 split private practice & retail chains includinWal-Mart, Costco, and Sam's Club, Target, and Sears Optical. Also, have new partnership with Warby Parker!

Lasik Program (embedded) - You have access to discounts on laser vision correction from the Laser Vision Network of America (LVNA). Includes more than 550 laser vision correction locations: 1) 15% OFF Standard Prices; 2) Or 5% OFF Promotional Prices Hearing Aids Discount (embedded) - (hiHealthInnovations) Hearing aids can cost several thousands of dollars each, but with our program, high quality, custom-programmed hearing aids start at just $699.

Network has over 102,000 access points

Our Network composition gives members freedom to have the experience they want vs being confined to a private practice or retail chain model. Our approach is just one part of how we deliver the

Contains Inlays/Onlays, Teeth Whitening, and Enhanced Network.

Network Name: DHMO Select / VOL DHMO requires at least 5 Eligible and 3 enrolled employees when Dual Option with PPO plan

TX DHMO Plans are limited to our Dallas-Fort Worth and Houston Metro areas

Has $1,895 Ortho benefit for Adult and Child

DHMO - 2 Eligible and 2 enrolled employees

Children's Eyecare Program (embedded) - Starting Nov 2018, all vision plans will have a children's second coverage eyecare (0-12 age) as long as doctor prescription has changed by .5 or greater (replacement pair of frames) purchased by Materials Copay.

Polycarbonate Lenses for Children are covered at 100% Scratch Coating is covered at 100% in network on all plans!

Retinal Screening Imaging for Diabetics covered at 100% (New "S" plans)

"S" Plans - Members now get to select any Contact lens they wish. Member will have Contact & Fitting Allowances when utilizing this service.

"SF" Plans - Similar to our older design, Although there will be a fitting and contact allowance, Members will get to save money by selecting IN-NETWORK Contracts from our Contact lens formulary listing.

3.1

# of Employees Guarantee Issue Max Benefits Participation Requirements(10-19) $30,000 $100,000 25%(20-50) $30,000 $200,000 25%(51-99) $80,000 $300,000 25%

Medical + Vision Medical + Life Medical + Disability$2.00 $1.00 $1.00

All products available as Standalone (Some group sizes require coverage to be written with medical and/or basic life)

$100,000$175,000 $350,000

2-9 Employees

$250,000

SUPPLEMENTAL LIFE AND AD&D

PACKAGED SAVINGS!!! (2-99) (Refer to flyer for details)

Medical + Dental$3.00

CRITICAL ILLNESS / ACCIDENT PROTECTION PLAN / HOSPITAL INDEMNITY PROTECTION PLAN (available for 51+ groups)

2 yrs, 5 yrs, or to SSNRA

min of 0% cont / 25% part.min of 25% cont / 50% part.N/A; 100% ER Paid only

2 yrs, 5 yrs, or to SSNRA90 or 180 days

24 months/Extended**N/A; 100% ER Paid only

24 months

2 yrs, 5 yrs, or to SSNRA*

min of 25% cont / 50% part.

UBundle (51-100 Only) (Refer to flyer for details) Bridge 2 Health Program (included with DI and CIPP/APP/HIPP)

SPECIALTY BENEFITSBASIC LIFE AND AD&D SHORT TERM DISABILTY

(6-19)2-5 (with medical only)

# Of Employees

$175,000$50,000

Max Benefit

$50,000$25,000

Guarantee Issue

(51-99)(20-50)


Up to $1500$750$500 $750 $750

Up to $2000

51-99 Employees10-50 Employees

13, 26 or 52 wks

SUPPLEMENTAL DEPENDENT LIFE AND AD&D

VoluntaryBenefit Durations

Max. Flat Benefit

min of 0% cont / 25% part.N/A; 100% ER Paid only 13 or 26 wks 13, 26 or *52 wks

Residual

Max. % Benefit

min of 25% cont / 50% part.Residual or PartialResidual

$10,000$10,000


LONG TERM DISABILITY

N/A; 100% ER Paid only

Maximum Benefit

Def. of DisabilityContributory

Last Updated: 05/29/19

51-99 Employees10-50 Employees2-9 Employees

ContributoryVoluntary

Own Occ DurationElimination PeriodBenefit Durations

min of 0% cont / 25% part.24 months/Extended**

90 or 180 days90 or 180 days

For reference purposes only. Not a legal document

$5,000

Credits are applied based on medical enrollment and provided on per employee per month basis for packaging UnitedHealthcare Medical and Specialty Products. Credit is not available on voluntary dental or voluntary vision. Savings for packaging ALL specialty lines with medical insurance is a total of $7.00 per employee per month.

2-99 Employees: 24 month rate guaranteeWill and Trust Preparation and Travel Assistance Program and Beneficiary Services included at no charge.

Standard reduction Schedule: 65% at age 65; 50% at age 70

Must be sold with Basic Life and available to groups with 10-99 eligible employees ; 24 month rate guarantee AD&D Automatically Packaged

Available at flat $10,000 increments OR 1X or 2X Salary

Requires at least $25,000 Basic Life Benefit for Packaged Savings, but can quote down to $15,000

Must be sold with Supplemental Life and available to groups with 10-99 eligible employee 10-50 employees-- Minimum 25% participation; 51-99-- Minimum 25% participation

100% Guarantee Issue for timely entrants and NO Age Reduction AD&D Automatically Packaged

Benefit Amounts Spouse: $20,000 Child: $10,000 Spouse: $10,000 Child: $5,000

100% Guarantee Issue on all groups sizes / 24 month rate guarantee Groups with 2-50 lives require Medical OR another employer sponsered specialty product (Dental, Vision , or Basic Life)

No pre-ex on 100% ER paid plans for groups with 10 + employees Reduce the duration of a disability claim by 13% with Bridge 2 Health program

Reduce the duration of a disability claim by 13% with Bridge 2 Health program

* 52 WEEK BENEFIT DURATION IS ONLY AVAILABLE FOR 20 + LIFE GROUPS

100% Guarantee Issue on all group sizes / 24 month rate guarantee For groups with 2-50 lives, LTD must be sold with at least one Contrib or Non-Contrib product (Medical, Dental, Vision or Basic Life). If sold with Medical, must also have another ancillary benefit (Dental, Vision, Basic Life or STD).

* groups 2-9 EE's; SSNRA -$3K max benefit ** For groups 10-99, Extended Own Occ (to age 65) available on select employees

Pre-Existing Limitation Options: 3/12, 12/6/24 or 12/24

Fully Insured Customers can save up to 4% on medical premium when they bundle their UHC Medical plan with UHC Specialty Plans. The Cost Reductions will apply for the first 12 months that medical and specialty plans remain active.

Why B2H: Employers are looking for a more effective way to manage benefit costs and increase employee engagement. This is an innovat ive lever to control medical costs and improve productivity while delivering compassionate and consumer-centered care. How does it work: As soon as the employee contacts our disability team, our Care Advocacy Program reaches out to the employee and they are as signed One Clinical Case Manager that serves as the single point of contact guiding them through the health care system giving the employee access to Wellness Tools/Resources, Disease and Condition Management, and Treatment and Decision Support.

The Findings: Ability to see (1) Over 90% of disability claimants actively engaged in clinical case management, and (2) A 13% reduction in disability claim

Works best with High Deductible medical plans, HSA's, and HRA's Guaranteed Issue to member

Coordination outreach and support through Bridge 2 Health Program Wellness Rider Available!

3.2

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3.3

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Bundle more, save more.Offer one or more of the following plans for more savings. The savings will apply for the first 12 months that eligible plans remain in force.

Vision

.5%

Dental

2%*

DisabilityShort-term disability and long-term disability.

.25%to.5%

LifeBasic life and supplemental life.

.5%

Supplemental healthAccident, critical illness and/or hospital indemnity.

.5%

Save a bundle on medical premiums when you add specialty plans.

Introducing uBundle®, a simpler way to help lower your medical plan costs.

As a fully insured customer you can save up to 4 percent on first-year medical premiums by bundling your UnitedHealthcare medical plan with UnitedHealthcare dental, vision and financial protection plans. Plus, eligible customers may save long-term with Packaged Savings®.

The power of a united strategy.By bundling UnitedHealthcare plans, you also get a simpler, service-focused experience, with:• One dedicated account team.

• One integrated implementation process (eligibility, claims, billing).

• One self-service website.

CONTINUED

Plus, bringing our plans together brings Bridge2Health® integration, which gathers actionable data to help close gaps in care, reduce costs and improve productivity.

Employee

Medical

Critical Illness

Disability

Hosp

ital In

demnity

Acciden

t

*For new business effective Jan. 1, 2019, or later. See back for rules and requirements.

savings on our medical plan premiums

4%Up to

Groups 51–100

Specialty BenefitsuBundle

3.4

Medical: Must be a UnitedHealthcare fully insured medical plan; requires a minimum participation of 70 percent of eligible employees.Dental: Must be new business effective Jan. 1, 2019 or later with a fully insured dental plan (contributory or voluntary); requires 50 percent minimum participation of UnitedHealthcare medical enrollment to receive medical cost savings of 2 percent. Vision: Must be a fully insured vision plan (contributory or voluntary); requires 50 percent minimum participation of UnitedHealthcare medical enrollment to receive medical cost savings of 0.5 percent.Basic life and supplemental life: The following must apply to receive medical cost savings of 0.5 percent.• Basic life must be employer paid.• Basic life must have a minimum benefit of $25,000.• Supplemental life requires 20 percent minimum participation of UnitedHealthcare

medical enrollment.

Short-term disability and long-term disability: There are three ways to qualify for medical costs savings.• Option 1: Both plans must be employer paid and fully insured to receive medical

cost savings of 0.5 percent.• Option 2: Both plans must be fully insured; one plan must be voluntary and

one plan must be employer paid. Requires 25 percent minimum participation ofUnitedHealthcare medical enrollment to receive medical cost savings of 0.5 percent.

• Option 3: Both plans must be fully insured and voluntary. Requires 25 percentminimum participation of UnitedHealthcare medical enrollment to receive medicalcost savings of 0.25 percent.

Accident, critical illness and/or hospital indemnity: There are two ways to qualify for medical costs savings of 0.5 percent.• Option 1: One or more plans must be employer paid.• Option 2: Two or more plans must be voluntary. Requires a minimum combined 20

percent minimum participation of UnitedHealthcare medical enrollment.

uBundle rules and participation requirements.


Benefits and programs may not be available in all states or for all group sizes. Components subject to change. These policies have exclusions, limitations and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, contact your UnitedHealthcare sales representative.Health insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. UnitedHealthcare dental coverage underwritten by UnitedHealthcare Insurance Company, located in Hartford, Connecticut or their affiliates. Administrative services provided by Dental Benefit Providers, Inc., United HealthCare Services, Inc. or their affiliates. UnitedHealthcare vision coverage provided by or through UnitedHealthcare Insurance Company, located in Hartford, Connecticut or their affiliates. Administrative services provided by Spectera, Inc., United HealthCare Services, Inc. or their affiliates. UnitedHealthcare Life and Disability products are provided by UnitedHealthcare Insurance Company. Life and Disability products are provided on policy forms LASD-POL (05/03) et al. and UHCLD-POL 2/2008 et al. UnitedHealthcare Insurance Company is located in Hartford, CT.UnitedHealthcare Critical Illness product is provided by UnitedHealthcare Insurance Company on form UHICI-POL-1 et al. Critical Illness coverage is NOT considered “minimum essential coverage” under the Affordable Care Act and therefore does NOT satisfy the mandate to have health insurance coverage. Failure to have other health insurance coverage may be subject to a tax penalty. Please consult a tax advisor. UnitedHealthcare Insurance Company is located in Hartford, CT.UnitedHealthcare Accident Protection product is provided by UnitedHealthcare Insurance Company on form UHI-ACC-POL (2018) et al., in Texas on form UHI-ACC-POL-TX (2018) and in Virginia on form UHI-ACC-POL-VA (2018). UnitedHealthcare Insurance Company is located in Hartford, CT.UnitedHealthcare Hospital Indemnity product is provided by UnitedHealthcare Insurance Company. The product provides a limited benefit for certain hospital indemnity plan benefits. Please note: HOSPITAL INDEMNITY coverage is NOT considered “minimum essential coverage” under the Affordable Care Act and therefore does NOT satisfy the mandate to have health insurance coverage. Failure to have other health insurance coverage may be subject to a tax penalty. Please consult a tax advisor. UnitedHealthcare Insurance Company is located in Hartford, CT.Bridge2Health is included for employers who purchase a fully insured UnitedHealthcare health plan and one or more of the following UnitedHealthcare plans: Dental (groups 101+), Vision (groups 101+), Disability (groups 2+), Critical Illness Protection (groups 51+), Accident Protection (groups 51+), Hospital Indemnity Protection (groups 51+). Employers who purchase a UnitedHealthcare ASO health plan may be eligible for Bridge2Health, subject to review of medical care and behavioral management services. For additional details, contact your broker or UnitedHealthcare representative.Minimum participation requirements may apply for bundling programs. Bundling programs are not available for all group sizes. Please consult your broker or UnitedHealthcare representative for more details.

8519272.1 4/19 ©2019 United HealthCare Services, Inc. 19-12159-B

Contact your broker or UnitedHealthcare representative to learn more.

Annual medical savings by adding:

Dental (2 percent) $14,400

Vision (.5 percent) $3,600

Life and supplemental life (.5 percent) $3,600

Short-term and long-term disability (.5 percent) $3,600

Supplemental health plans (.5 percent) $3,600

Potential total annual medical premium savings: $28,800

See long-term savings with Packaged Savings. Customers with 2–99 total eligible employees may qualify for Packaged Savings administrative credits, which they can receive by bundling plans. Credits are earned based on the number of enrolled medical employees and the number of eligible specialty plans offered. Contact your broker or UnitedHealthcare representative for details.

For illustrative purposes. Your savings will differ depending on your group size, plans chosen and premiums.

An example of over $28,000 in uBundle savings:Group size: 75 employees Estimated medical premium (per employee per month): $800 per month ($720,000 total)

uBundle (for group size 51–100) is not available in the following states:AlaskaCaliforniaColoradoHawaiiMontana New MexicoNew YorkRhode Island Vermont

Ask for a quote today.

The more you bundle, the more you save.When fully insured customers bundle their medical, dental, vision, life and/or short-term disability plans with UnitedHealthcare, they can save money in administrative credits. Credits are earned based on the number of enrolled medical employees and the number of eligible specialty plans offered.

Purchase a fully insured medical plan and:Receive the following credits per enrolled medical employee per month:

Dental $3

Vision $2

Life1 $1

Short-term disability2 $1

Life1 and short-term disability2 $2

Life1 and long-term disability $2

Dental and vision $5

Dental and life1 $4

Vision and life1 $3

Dental, vision and life1 $6

Dental, vision, life1 and short-term disability2 $7

Contact your broker or UnitedHealthcare representative to learn more.

1 Requires a minimum of $25,000 benefit.2 Short-term disability must be fully insured.

See the back for complete program terms and conditions.

Specialty BenefitsPackaged Savings®

Fully InsuredGroups 2 – 99

More reasons to bundle. When our medical and specialty plans are purchased together, you get a simpler, service-focused experience with:

One dedicated account team.

One streamlined administration process and self-service website.

One integrated and simpler claims process.

3.5

1. The Packaged Savings program is available to customers with2–99 total eligible employees. New fully insured medical customers purchasing fully insured specialty products or existing medicalcustomers adding new fully insured specialty products may qualify.

2. The applied savings are available for as long as eligible medical andspecialty benefits remain in-force and meet eligibility requirements. Credits will be withdrawn when any medical or specialty coveragesterminate. Program is subject to change at any time.

3. Per-employee per-month (PEPM) savings is given as a monthlycredit based on the number of enrolled UnitedHealthcaremedical subscribers.

4. Employer-paid plans require an employer contribution level of 50% or greater of the employee premium. Voluntary plans and plans where employees contribute 51% or greater do not qualify for the program.

5. Employee enrollment in qualifying dental and vision plans must be75% or greater of total eligible medical employees for Packaged Savings to be activated.

6. Fully insured vision and dental plans qualify subject to theterms above.

7. Short-term disability plans must be fully insured.8. Life insurance plans qualifying for Packaged Savings must have a

minimum life benefit of $25,000. Life insurance plans qualifying forPackaged Savings must completely replace existing life plans or beadded to customers with no prior coverage; adding an additional lifepolicy to an existing life benefit does not qualify for Packaged Savings.

9. Customers who have existing basic and supplemental life planswith another carrier must place both the basic and supplemental lifeinsurance plans with UnitedHealthcare to qualify for Packaged Savings.

10. Any combination of life products counts as one product for thepurpose of the program. Any combination of disability productscounts as one product for the purpose of the program. Long-termdisability does not qualify alone; it must be packaged with life or short-term disability.

11. Customers who add UnitedHealthcare medical products to existingdental, vision, life and/or disability lines of coverage qualify forPackaged Savings (a.k.a. Reverse Packaged Savings).

12. Specialty benefits can be added off-cycle from the existing medical orspecialty benefits effective date and will be eligible for up to 12 monthsof Packaged Savings as long as medical coverage remains in forceand plans meet eligibility requirements.

13. UnitedHealthcare retains sole and complete discretion to revise orterminate the Packaged Savings program at any time.

14. Business underwritten or administered by Oxford Health Plans andSierra Health Services Inc. are currently excluded from the PackagedSavings program.

15. UnitedHealthcare Preventive Plans are not eligible for Packaged Savings administrative credits.

16. Specialty benefit plans and the Packaged Savings program may notbe available in all states or for all group sizes. Contact your broker orUnitedHealthcare sales representative for program availability.

Program terms and conditions.

Health insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates.Benefits and programs may not be available in all states or for all group sizes. Components subject to change. These policies have exclusions, limitations and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, contact your UnitedHealthcare sales representative.UnitedHealthcare dental coverage underwritten by UnitedHealthcare Insurance Company, located in Hartford, Connecticut or their affiliates. Administrative services provided by Dental Benefit Providers, Inc., United HealthCare Services, Inc. or their affiliates. UnitedHealthcare vision coverage provided by or through UnitedHealthcare Insurance Company, located in Hartford, Connecticut or their affiliates. Administrative services provided by Spectera, Inc., United HealthCare Services, Inc. or their affiliates. UnitedHealthcare Life and Disability products are provided by UnitedHealthcare Insurance Company. Life and Disability products are provided on policy forms LASD-POL (05/03) et al. and UHCLD-POL 2/2008 et al. UnitedHealthcare Insurance Company is located in Hartford, CT.UnitedHealthcare Critical Illness product is provided by UnitedHealthcare Insurance Company on form UHICI-POL-1 et al. Critical Illness coverage is NOT considered “minimum essential coverage” under the Affordable Care Act and therefore does NOT satisfy the mandate to have health insurance coverage. Failure to have other health insurance coverage may be subject to a tax penalty. Please consult a tax advisor. UnitedHealthcare Insurance Company is located in Hartford, CT.UnitedHealthcare Accident Protection product is provided by UnitedHealthcare Insurance Company on form UHCAC-POL-1 (01/12) et al. UnitedHealthcare Insurance Company is located in Hartford, CT.UnitedHealthcare Hospital Indemnity product is provided by UnitedHealthcare Insurance Company. The product provides a limited benefit for certain hospital indemnity plan benefits. Please note: HOSPITAL INDEMNITY coverage is NOT considered “minimum essential coverage” under the Affordable Care Act and therefore does NOT satisfy the mandate to have health insurance coverage. Failure to have other health insurance coverage may be subject to a tax penalty. Please consult a tax advisor. UnitedHealthcare Insurance Company is located in Hartford, CT.Minimum participation requirements may apply. Packaged Savings program is not available for all group sizes. Please consult your UnitedHealthcare representative for more details.


MT-1112469.2 7/18 ©2018 United HealthCare Services, Inc. 18-8780-C

Shop eyeglasses and sunglasses at warbyparker.com or find a location near you.You’ll need your Member ID.

Find it on your ID card or at myuhcvision.com. You’ll need it to check and apply benefits.

Can’t find it? Call Warby Parker at 855-550-0743 to have your benefits verified without it.

Check myuhcvision.com to:

• Confirm whether you havea benefit for eyeglasses.

• Learn what your copay is.

• Find out what your planmay cover after your copay.

Need to contact Warby Parker?

Call 855-550-0743 or email [email protected].

Questions about your benefits?

Call 1-800-638-3120.


Please note that Warby Parker does not sell contact lenses. Select Warby Parker locations offer eye exams. See warbyparker.com for details.

UnitedHealthcare vision coverage provided by or through UnitedHealthcare Insurance Company, located in Hartford, Connecticut, UnitedHealthcare Insurance Company of New York, located in Islandia, New York, or their affiliates. Administrative services provided by Spectera, Inc., United HealthCare Services, Inc. or their affiliates.


Head to Warby Parker for eyeglasses and sunglasses (both single-vision and

progressive) starting at just $95

That means that you’re eligible for a huge range of Warby Parker frames for just the cost of your copay. Lenses are included!

Warby Parker’s frames are designed in-house and crafted from top-tier materials. Their eyeglasses come with scratch-resistant,

smudge-resistant, and anti-reflective treatments at zero additional cost. And for every pair purchased, a pair is distributed to

someone in need.

warbyparker.com/united

Use your vision benefits at Warby Parker!You and anyone else covered on your plan can now shop for glasses at Warby Parker online and at their retail locations nationwide! It’s part of your UnitedHealthcare vision network.

3.6

How to print your vision ID card using myuhcvision.comThanks to our convenient paperless benefits and claims, you do not need a member ID card to use your benefits. However, if you’d like one, you can easily print one.

Steps to print your Vision ID cardYour ID card will be personalized with your name, member ID, as well as your exam and materials copay amounts.


UnitedHealthcare vision coverage provided by or through UnitedHealthcare Insurance Company, located in Hartford, Connecticut, UnitedHealthcare Insurance Company of New York, located in Islandia, New York, or their affiliates. Administrative services provided by Spectera, Inc., United HealthCare Services, Inc. or their affiliates. Plans sold in Texas use policy form number VPOL.06.TX and associated COC form number VCOC.INT.06.TX or VCOC.CER.13.TX. Plans sold in Virginia use policy form number VPOL.06. VA and associated COC form number VCOC.INT.06.VA or VCOC.CER.13.VA.


Sample Personalized ID Card

Member Web:Customer Service:

www.myuhcvision.com(800) 638-3120

Note to Providers:For more information about this UnitedHealthcare Vision plan, please visit usonline at www.Spectera.com or call 1-800-638-3120.

Member Name:Member ID:

Exam Copay:Material Copay:

Submit Out-of-Network Claims to:

Vision Identi cation Card

Vision Care B

UnitedHealthcare Vision Claims Department

[First, Last] [$XX.XX][$XX.XX]

[XXXXXXXXX-XX]

P.O. Box 30978Salt Lake City, UT 84130

fold here

1 Go to myuhcvision.com.

2 Log in or register. Do not register if you also have medical coverage with UnitedHealthcare. Use the single sign-on option through myuhc.com instead.

3 Click on “Print ID Card.” If you do not see this option, click on the blue “Select” button next to your plan name.

4 From the drop-down menu, select the person whose ID card you would like to print. Click on “View.”

5 This generates a document with your ID card called How to Use Your Vision Care Benefits. Scroll to the bottom of this document. A toolbar will appear; click on the printer icon to print.

2

3

4

5

Toolsmyuhcvision.com

3.7

UnitedHealthcare Dental Top Selling Plans (2-99)

Top Selling Voluntary Plans for Groups 2-9 LivesAVAILABLE Quoting Min. OON

Standard Gateway Enhanced Preventative UES/SAM? WP Of Elig Prev. & Diag Minor Rest. Endo/Perio Major Ortho Deductible Annual Max Life Ortho CMM? UCR/MAC

P1211 A1211 - - X 12 Month 2 100% 80% 50% 50% 0% 50/150 $1,000 - NO MAC

P3366 - - - X 12 Month 2 100% 80% 80% 50% 0% 50/150 $1,000 - YES MAC

- A8011 - - X 12 Month 2 100% 80% 50%/80% 50% 0% 50/150 $1,000 - NO 70%

P3365 - - - X 12 Month 2 100% 80% 50% 50% 0% 50/150 $1,000 - YES 90%

P7329 - - - X 12 Month 2 100% 80% 50% 50% 0% 50/150 $1,200 - YES MAC

- A8013 - - X 12 Month 2 100% 80% 50%/80% 50% 0% 50/150 $1,500 - NO 70%

P3322 - - - X 12 Month 2 100% 80% 50% 50% 0% 100/0 $1,500 - NO 85%

Top Selling Contributory Plans for Groups 2-9 LivesAVAILABLE Quoting Min. OON


- A8016 - - X NO 2 100% 80% 50%/80% 50% 0% 50/150 $1,000 - NO MAC

- A2543 - - X NO 2 100% 80% 50%/80% 50% 0% 50/150 $1,000 - NO 70%

P0012 - - - X 12 Month 2 100% 80% 80% 50% 0% 50/150 $1,000 - NO 85%

P3482 - - - X 12 Month 2 100% 80% 80% 50% 0% 50/150 $1,000 - YES 90%

P4877 - - H4877 X NO 2 100% 80% 50% 50% 0% 50/150 $1,000 - YES 90%

P0207 - - - X 12 Month 2 100% 80% 80% 50% 0% 50/150 $1,500 - NO MAC

- A7976 - - X NO 2 100% 80% 50% 50% 0% 50/150 $1,500 - NO MAC

- A7977 - - X NO 2 100% 80% 50% 50% 0% 50/150 $1,500 - NO 70%

P0019 - - - X 12 Month 2 100% 80% 80% 50% 0% 50/150 $1,500 - NO 85%

P4881 - - - X NO 2 100% 80% 50% 50% 0% 50/150 $1,500 - YES 90%

Top Selling Voluntary Plans for Groups 10-99 LivesAVAILABLE Quoting Min. OON


- - - H9890 X NO 2 100% 80% 50% 50% 0% 50/150 $500 - NO MAC

2017 Plan Codes IN NETWORK



3.8

AVAILABLE Quoting Min. OON


- - - H9891 X NO 2 100% 80% 50% 50% 0% 50/150 $500 - NO 90%

P1211 A1211 X1211 H1211 (STANDARD ONLY) 12 Month 2 100% 80% 50% 50% 0% 50/150 $1,000 - NO MAC

P7331 - X7331 H7331 NO 5 100% 80% 80% 50% 0% 50/150 $1,000 - YES 90%

P3383 - X3383 H3383 (ENHANCED ONLY) NO 5 100% 80% 50% 50% 50% 50/150 $1,000 $1,000 YES 90%

P3384 X3384 H3384 X NO 5 100% 80% 50% 50% 0% 50/150 $1,000 - YES 90%

P3305 - X3305 H3305 (STANDARD ONLY) NO 5 100% 80% 50% 50% 0% 50/150 $1,200 - NO MAC

P3381 - - - X NO 5 100% 80% 50% 50% 0% 50/150 $1,200 - YES 90%

P8012 A8012 - - 12 Month 2 100% 80% 50% 50% 0% 50/150 $1,500 - NO MAC

P5426 - - - X NO 5 100% 80% 50% 50% 0% 50/150 $1,500 - YES 90%

P7088 - X7088 H7088 NO 5 100% 80% 80% 50% 0% 50/150 $1,500 - YES 90%

P5437 - X5437 H5437 (STANDARD ONLY) 12 Month 5 100% 80% 50% 50% 50% 50/150 $1,500 $1,500 YES 90%

P5423 - X5423 H5423 12 Month 5 100% 80% 80% 50% 50% 50/150 $1,500 $1,500 YES 90%

P7089 - X7089 H7089 NO 5 100% 80% 80% 50% 50% 50/150 $1,500 $1,500 YES 90%

P8658 - - - NO 10 100% 80% 50% 50% 0% 50/150 $2,000 - YES 90%

P9683 - - - NO 10 100% 80% 80% 50% 50% 50/150 $2,000 $1,000 YES 90%

0P473 - - - NO 10 100% 80% 80% 50% 50% 50/150 $2,000 $2,000 YES MAC

1P750 - 1X750 - (STANDARD ONLY) NO 10 100% 80% 50%/80% 50% 0% 50/150 $5,000 - NO MAC

1P742 - 1X742 - (STANDARD ONLY) NO 10 100% 80% 50%/80% 50% 50% 50/150 $5,000 $1,000 NO MAC

1P748 - 1X748 - (STANDARD ONLY) NO 10 100% 80% 50%/80% 50% 0% 50/150 $5,000 - NO 90%

1P740 - 1X740 - (STANDARD ONLY) NO 10 100% 80% 50%/80% 50% 50% 50/150 $5,000 $1,000 NO 90%

Top Selling Contributory Plans for Groups 10-99 LivesAVAILABLE Quoting Min. OON


- - - H9892 X NO 2 100% 80% 50% 50% 0% 50/150 $500 - NO MAC

- - - H9893 X NO 2 100% 80% 50% 50% 0% 50/150 $500 - NO 90%

P8016 A8016 - - (ENHANCED ONLY) NO 2 100% 80% 50% 50% 0% 50/150 $1,000 - NO MAC

P0202 - X0202 H0202 (STANDARD ONLY) NO 5 100% 80% 80% 50% 0% 50/150 $1,000 - NO MAC

P3482 - - - X 12 Month 2 100% 80% 80% 50% 0% 50/150 $1,000 - YES 90%

P4877 - X4877 H4877 X NO 2 100% 80% 50% 50% 0% 50/150 $1,000 - YES 90%

P4878 - X4878 H4878 (STANDARD ONLY) NO 5 100% 80% 50% 50% 50% 50/150 $1,000 $1,000 YES 90%

P0207 - - - X 12 Month 2 100% 80% 80% 50% 0% 50/150 $1,500 - NO MAC

P7976 A7976 - - (ENHANCED ONLY) NO 2 100% 80% 50% 50% 0% 50/150 $1,500 - NO MAC



AVAILABLE Quoting Min. OON


P0019 - - - X 12 Month 2 100% 80% 80% 50% 0% 50/150 $1,500 - NO 85%



P5312 - - - 12 Month 5 100% 80% 80% 50% 50% 50/150 $1,500 $1,500 YES 90%

P7323 - - - NO 10 100% 80% 50% 50% 0% 50/150 $2,000 - YES 90%

P7322 - - - NO 10 100% 80% 50% 50% 50% 50/150 $2,000 $1,000 YES 90%

P9606 - - - NO 10 100% 80% 50% 50% 50% 50/150 $2,000 $2,000 YES 90%

1P754 - 1X754 - (STANDARD ONLY) NO 10 100% 80% 50%/80% 50% 0% 50/150 $5,000 - NO MAC

1P746 - 1X746 - (STANDARD ONLY) NO 10 100% 80% 50%/80% 50% 50% 50/150 $5,000 $1,000 NO MAC

1P752 - 1X752 - (STANDARD ONLY) NO 10 100% 80% 50%/80% 50% 0% 50/150 $5,000 - NO 90%

1P744 - 1X744 - (STANDARD ONLY) NO 10 100% 80% 50%/80% 50% 50% 50/150 $5,000 $1,000 NO 90%

All PlansAvailable Stand-Alone

Dual Option Available (need at least 20% rate differential in dual rates)

Orthodontia: Groups of 10+ Eligibles and 8 Enrollees ; If Ortho plan is available with 5+ Eligible, must have 4 enrollees.

Enhanced Options: (ONLY AVAILABLE FOR 10+ GROUPS)(ALL ENHANCED OPTIONS ARE NOT AVAILABLE IN SAM/UES)"A" Plans (Gateway) - has Endo/Perio/Oral Surgery in Major (Class III), UCR is 70% or MAC. 10-15% less expensive than Standard Plan

"X" Plan (FlexAppeal Enhanced) - Offers additional cleanings or gum (periodontal) treatments, Composite (white) fillings for back teeth, and dental implants.

"H" Plan (Preventive MaxMultiplier) - Pays for a members preventive and diagnostic care without deducting those claims from the plan's annual maximum.

CMM (Consumer Max-Multiplier) - Rollover Feature

Voluntary Plans Employer Sponsored PlansOnly 2 Enrollees Required for plans with NON-ORTHO 50% Employer Contribution Required for Employee Premium

No Participation Percentages Required 75% Participation of all Eligible Employees

Groups with 2-9 Eligibles Require a Waiting Period

Helpful Tips~ Moving from a UCR to MAC plan design, which encourages in-network services. This can result in approximately a 30% decrease in cost.

~ Lowering the annual maximum while adding the rollover benefit. Reducing the annual maximum from $1500 to $1000 and adding the rollover benefit can potentially save groups 7 to 8 percent

in Premium.

~ Moving from a $1500 PPO MAC plan of 100/80/50 to the same plan with an annual max of $1000 and adding the PMM enhancement can result in a reduction of premium of 7 to 10 percent.

~ Transitioning from a PPO to an (MAC) in-network only plan can result in savings up to 35%

UnitedHealthcare Dental (Updated as of 8/13/18)


survival guide - the insurance exchange

Documents