ESBD_File_346205_Attachment D - Summary of Benefits and Coverage, 3 healthcare plans.pdf

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services

Choice Plus Plan 1

Coverage Period: 01/01/2024 – 12/31/2024

Coverage for: Family | Plan Type: PS1

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.

This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-866-633-2446.or visit welcometouhc.com. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-866-487-2365 to request a copy.

Important Questions Answers Why This Matters:

What is the overall deductible? Network: $500 Individual / $1,000 Family

Out-of-Network: $5,000 Individual / $10,000 Family Per calendar year.

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

Are there services covered before you meet your deductible? Yes. Preventive care and categories with a copay are covered before you meet your deductible.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/.

Are there other deductibles for specific services?

Yes. $5,000 deductible for all morbid obesity services.

This plan has a separate deductible for covered member that must be met before this plan will pay for qualifying service.

What is the out-of-pocket limit for this plan?

Network Ded/Coins OOP limit: $3,500 Individual / $7,000 Family Out-of-Network Medical OOP limit: Unlimited Network Plan Maximum OOP limit: $6,350 Individual / $12,700 Family Out-of-Network Plan Maximum OOP limit:

Unlimited

The Medical out-of-pocket limit is the most you could pay in a year for covered medical services (includes 20% coinsurance, up to $3,000 plus $500 deductible).

The Plan Maximum OOP limit includes Medical OOP, Deductible and copays. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

What is not included in the out-of-pocket limit?

Premiums, balance-billing charges, health care this plan doesn’t cover and penalties for failure to obtain preauthorization for services.

Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

http://www.welcometouhc.com/ https://www.healthcare.gov/sbc-glossary/ https://www.healthcare.gov/coverage/preventive-care-benefits/

* For more information about limitations and exceptions, see the plan or policy document at welcometouhc.com. Page 2 of 7

Will you pay less if you use a network provider?

Yes. See myuhc.com or call 1-866-633-2446 for a list of network providers.

You pay the least if you use a provider in the Designated Network. You pay more if you use a provider in the Network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

Do you need a referral to see a specialist?

No. You can see the specialist you choose without a referral.

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

i

Common Medical Event

Services You May Need

What You Will Pay

Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least)

Out-of-Network Provider (You will pay the most)

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness

$25 copay per visit, deductible does not apply.

40% coinsurance

Virtual visits - $15 copay per visit by a Designated Virtual Network Provider, deductible does not apply. No virtual coverage out-of-network.

If you receive services in addition to office visit, additional copays, deductibles or coinsurance may apply e.g.

surgery.

Specialist visit Designated Network:

$25 copay per visit, deductible does not apply.

Network:

$30 copay per visit, deductible does not apply.

40% coinsurance If you receive services in addition to office visit, additional copays, deductibles or coinsurance may apply e.g.

surgery.

Preventive care/screening/ immunization

No Charge 40% coinsurance You may have to pay for services that aren’t preventive.

Ask your provider if the services needed are preventive.

Then check what your plan will pay for.

If you have a test Diagnostic test (x-ray, blood work)

Outpatient Hospital /Free Standing/Office: No

Charge Inpatient Hospital:

20% coinsurance

40% coinsurance Preauthorization is required out-of-network for certain services

Imaging (CT/PET scans, MRIs)

Free Standing/Office:

$150 copay per service, deductible does not apply.

40% coinsurance Preauthorization is required out-of-network http://www.welcometouhc.com/ http://www.myuhc.com/

* For more information about limitations and exceptions, see the plan or policy document at welcometouhc.com. Page 3 of 7

Common Medical Event

Services You May Need

What You Will Pay

Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least)

Out-of-Network Provider (You will pay the most)

Hospital:

20% coinsurance

If you need drugs to treat your illness or condition

More information about prescription drug coverage is available at welcometouhc.com

Tier 1 – Your Lowest Cost Option

Retail:

$10 copay, deductible does not apply.

Mail-Order:

$20 copay, deductible does not apply.

Retail:

$10 copay, deductible does not apply.

Provider means pharmacy for purposes of this section.

Retail: Up to a 31 day supply.

Mail-Order: Up to a 90 day supply.

You may need to obtain certain drugs, including certain specialty drugs, from a pharmacy designated by us.

Certain drugs may have a preauthorization requirement or may result in a higher cost.

If you use a out-of-network pharmacy (including a mail order pharmacy), you may be responsible for any amount over the allowed amount.

Certain preventive medications (including certain contraceptives) are covered at No Charge.

See the website listed for information on drugs covered by your plan. Not all drugs are covered.

You may be required to use a lower-cost drug(s) prior to benefits under your policy being available for certain prescribed drugs.

Tier 2 – Your Mid-Range Cost Option

Retail:

$20 copay, deductible does not apply.

Mail-Order:

$40 copay, deductible does not apply.

Retail:

$20 copay, deductible does not apply.

Tier 3 – Your Mid-Range Cost Option

Retail:

$45 copay, deductible does not apply.

Mail-Order:

$90 copay, deductible does not apply.

Retail:

$45 copay, deductible does not apply.

Tier 4 – Your Highest Cost Option

Not Applicable Not Applicable

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)

Office:

No Charge

Ambulatory Surgical Center/Hospital:

20% coinsurance after deductible

40% coinsurance Preauthorization is required out-of-network for certain services

Physician/surgeon fees 20% coinsurance 40% coinsurance None

* For more information about limitations and exceptions, see the plan or policy document at welcometouhc.com. Page 4 of 7

Services You May Need

What You Will Pay

Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least)

Out-of-Network Provider (You will pay the most)

If you need immediate medical attention

Emergency room care

$500 copay per visit, deductible does not apply.

$500 copay per visit, deductible does not apply.

None

Emergency medical transportation

$250 copay per transport, deductible does not apply.

$250 copay per transport, deductible does not apply.

None

Urgent care $30 copay per visit, deductible does not apply.

40% coinsurance

If you receive services in addition to Urgent care visit, additional copays, deductibles, or coinsurance may apply e.g. surgery.

If you have a hospital stay

Facility fee (e.g., hospital room) 20% coinsurance

$250 copay per admission, then 40% coinsurance Preauthorization is required out-of-network

Physician/surgeon fees 20% coinsurance 40% coinsurance None

If you need mental health, behavioral health, or substance abuse services

Outpatient services

$30 copay per visit, deductible does not apply.

40% coinsurance

Network Partial hospitalization/intensive outpatient treatment: 20% coinsurance after deductible.

Preauthorization is required out-of-network for certain services.

See your policy or plan document for additional information about EAP benefits.

Inpatient services 20% coinsurance

$250 copay per admission, then 40% coinsurance

Preauthorization is required out-of-network See your policy or plan document for additional information about EAP benefits.

If you are pregnant Office visits No Charge 40% coinsurance Cost sharing does not apply for preventive services.

Depending on the type of service a copayment, coinsurance or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.)

Childbirth/delivery professional services

20% coinsurance 40% coinsurance

Childbirth/delivery facility services 20% coinsurance

$250 copay per admission, then 40% coinsurance

Inpatient preauthorization applies out-of-network if stay exceeds 48 hours (C-Section: 96 hours)

Home health care 20% coinsurance 40% coinsurance Limited to 60 visits per calendar year.

* For more information about limitations and exceptions, see the plan or policy document at welcometouhc.com. Page 5 of 7

Services You May Need

What You Will Pay

Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least)

Out-of-Network Provider (You will pay the most)

If you need help recovering or have other special health needs

Preauthorization is required out-of-network

Rehabilitation services

$30 copay per visit, deductible does not apply.

40% coinsurance

Limits per calendar year: Physical/ Occupational /Speech, Manipulative, Cognitive and Pulmonary Therapy: combined limit of 60 visits.

Cardiac therapy limited to 40 visits.

Post -Cochlear implant aural therapy limited to 30 visits.

Preauthorization required out-of-network for certain services

Habilitative services $30 copay per visit, deductible does not apply.

40% coinsurance

Services are provided under and limits are combined with Rehabilitation Services above.

Preauthorization required out-of-network for certain services

Skilled nursing care 20% coinsurance 40% coinsurance

Limited to 60 days per calendar year (combined with inpatient rehabilitation).

Preauthorization is required out-of-network

Durable medical equipment 20% coinsurance 40% coinsurance

Covers 1 per type of DME (including repair/replacement) every 3 years. Preauthorization is required out-of-network for DME over $500 or no coverage.

Hospice services 20% coinsurance 40% coinsurance

Preauthorization is required out-of-network before admission for an Inpatient Stay in a hospice facility or benefit reduces to 50% of allowed amount.

If your child needs dental or eye care

Children’s eye exam Not Covered Not Covered No coverage for Children’s eye exams.

Children’s glasses Not Covered Not Covered No coverage for Children’s glasses.

Children’s dental check-up

Not Covered Not Covered No coverage for Children’s Dental check-up.

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

• Acupuncture

• Cosmetic surgery

• Dental care

• Glasses

• Hearing aids

• Infertility treatment

• Long-term care

• Non-emergency care when travelling outside -the U.S.

• Private duty nursing

• Routine eye care

• Routine foot care – Except as covered for Diabetes

• Weight loss programs

* For more information about limitations and exceptions, see the plan or policy document at welcometouhc.com. Page 6 of 7

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

• Bariatric surgery – 1 procedure per lifetime Network

• Chiropractic (Manipulative care) – 60 visits per calendar year

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is:

U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1- 877-267-2323 x61565 or www.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: the Member Service number listed on the back of your ID card or myuhc.com or the Employee Benefits Security Administration at 1-866-444-3272 or dol.gov/ebsa/healthreform. Additionally, a consumer assistance program may help you file your appeal. Contact dol.gov/ebsa/healthreform.

Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services:

Spanish (Español): Para obtener asistencia en Español, llame al 1-866-633-2446.

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-866-633-2446.

Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-866-633-2446.

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-866-633-2446.

To see examples of how this plan might cover costs for a sample medical situation, see the next section.

http://www.dol.gov/ebsa http://www.cciio.cms.gov/ http://www.healthcare.gov/ http://www.myuhc.com/ http://www.myuhc.com/ https://www.dol.gov/ebsa/healthreform

The plan would be responsible for the other costs of these EXAMPLE covered services. Page 7 of 7

About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery)

◼ The plan’s overall deductible $500 ◼ Specialist copay $25

◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20%

This EXAMPLE event includes services like:

Specialist office visits (pre-natal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

Total Example Cost $12,700

In this example, Peg would pay:

Cost Sharing

Deductibles $500

Copayments $10

Coinsurance $1,900

What isn’t covered

Limits or exclusions $60

The total Peg would pay is $2,470

Managing Joe’s type 2 Diabetes

(a year of routine in-network care of a well-controlled condition)

◼ The plan’s overall deductible $500 ◼ Specialist copay $25

Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)

Total Example Cost $5,600

In this example, Joe would pay:

Deductibles $150

Copayments $800

Coinsurance $0

What isn’t covered

Limits or exclusions $30

The total Joe would pay is $950

Mia’s Simple Fracture

(in-network emergency room visit and follow up care)

◼ The plan’s overall deductible $500 ◼ Specialist copay $25

Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)

Total Example Cost $2,800

In this example, Mia would pay:

Deductibles $200

Copayments $900

Coinsurance $0

What isn’t covered

Limits or exclusions $0

The total Mia would pay is $1,100

We do not treat members differently because of sex, age, race, color, disability or national origin.

If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to the Civil

Rights Coordinator.

Online: UHC_Civil_Rights@uhc.com Mail: Civil Rights Coordinator. UnitedHealthcare Civil Rights Grievance. P.O. Box 30608 Salt Lake City, UTAH 84130

You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again.

If you need help with your complaint, please call the toll-free number listed within this Summary of Benefits and Coverage (SBC), TTY 711, Monday through Friday, 8 a.m. to 8 p.m.

You can also file a complaint with the U.S. Dept. of Health and Human Services.

Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD) Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201

We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the number contained within this Summary of Benefits and Coverage (SBC) , TTY 711, Monday through Friday, 8 a.m. to

8 p.m.

mailto:UHC_Civil_Rights@uhc.com https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

Choice Plan

Coverage for: Family | Plan Type: EP1

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.

This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-866-633-2446.or visit welcometouhc.com. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-866-487-2365 to request a copy.

deductible?

Network: $1,000 Individual / $2,000 Family Per calendar year.

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

Are there services covered before you meet your deductible? Yes. Preventive care and categories with a copay are covered before you meet your deductible.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/.

Are there other deductibles for specific services?

No.

You don’t have to meet deductibles for specific services.

What is the out-of-pocket limit for this plan?

Network Ded/Coins OOP limit: $4,000 Individual / $8,000 Family Network Plan Maximum OOP limit: $6,350 Individual / $12,700 Family

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

What is not included in the out-of-pocket limit?

Premiums, balance-billing charges, and health care this plan doesn’t cover.

Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

Will you pay less if you use a network provider?

Yes. See myuhc.com or call 1-866-633-2446 for a list of network providers.

You pay the least if you use a provider in the Designated Network. You pay more if you use a provider in the Network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

Do you need a referral to see a specialist?

No. You can see the specialist you choose without a referral.

http://www.welcometouhc.com/ https://www.healthcare.gov/sbc-glossary/

* For more information about limitations and exceptions, see the plan or policy document at welcometouhc.com. Page 2 of 6

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common Medical Event

Services You May Need What You Will Pay

Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least)

Out-of-Network Provider (You will pay the most)

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness

$25 copay per visit, deductible does not apply.

Not Covered

Virtual visits - No Charge by a Designated Virtual Network Provider.

If you receive services in addition to office visit, additional copays, deductibles or coinsurance may apply e.g.

surgery.

Specialist visit Designated Network:

$25 copay per visit, deductible does not apply.

Network:

$40 copay per visit, deductible does not apply.

Not Covered If you receive services in addition to office visit, additional copays, deductibles or coinsurance may apply e.g.

surgery.

Preventive care/screening/ immunization

No Charge Not Covered You may have to pay for services that aren’t preventive.

Ask your provider if the services needed are preventive.

Then check what your plan will pay for.

If you have a test Diagnostic test (x-ray, blood work)

Free Standing/Office: No Charge

Hospital:

20% coinsurance

Not Covered None

Imaging (CT/PET scans, MRIs)

Free Standing/Office:

$150 copay per service, deductible does not apply.

Hospital:

20% coinsurance

Not Covered None

* For more information about limitations and exceptions, see the plan or policy document at welcometouhc.com. Page 3 of 6

Services You May Need

What You Will Pay

Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least)

Out-of-Network Provider (You will pay the most)

If you need drugs to treat your illness or condition

More information about prescription drug coverage is

Retail:

$10 copay, deductible does not apply.

Mail-Order:

$20 copay, deductible does not apply.

Not Covered

Provider means pharmacy for purposes of this section.

Retail: Up to a 31 day supply.

Mail-Order: Up to a 90 day supply.

You may need to obtain certain drugs, including certain specialty drugs, from a pharmacy designated by us.

Certain drugs may have a preauthorization requirement or may result in a higher cost.

If you use a non-network pharmacy (including a mail order pharmacy), you may be responsible for any amount over the allowed amount.

Certain preventive medications (including certain contraceptives) are covered at No Charge.

See the website listed for information on drugs covered by your plan. Not all drugs are covered.

You may be required to use a lower-cost drug(s) prior to benefits under your policy being available for certain prescribed drugs.

Tier 2 – Your Mid-Range Cost Option

Retail:

$20 copay, deductible does not apply.

Mail-Order:

$40 copay, deductible does not apply.

Not Covered

Tier 3 – Your Mid-Range Cost Option

Retail:

$45 copay, deductible does not apply.

Mail-Order:

$90 copay, deductible does not apply.

Not Covered

Tier 4 – Your Highest Cost Option

Not Applicable Not Applicable

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)

Ambulatory Surgical Center/Office:

No Charge Hospital:

20% coinsurance

Not Covered None

Physician/surgeon fees 20% coinsurance Not Covered None

If you need immediate medical attention

Emergency room care $500 copay per visit, deductible does not apply.

$500 copay per visit, deductible does not apply.

None

Emergency medical transportation

$250 copay per transport, deductible does not apply.

$250 copay per transport, deductible does not apply.

None

Urgent care $30 copay per visit, deductible does not apply.

Not Covered

If you receive services in addition to Urgent care visit, additional copays, deductibles, or coinsurance may apply e.g. surgery.

* For more information about limitations and exceptions, see the plan or policy document at welcometouhc.com. Page 4 of 6

Services You May Need

What You Will Pay

Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least)

Out-of-Network Provider (You will pay the most)

If you have a hospital stay

Facility fee (e.g., hospital room)

20% coinsurance Not Covered None

Physician/surgeon fees 20% coinsurance Not Covered None

If you need mental health, behavioral health, or substance abuse services

Outpatient services $40 copay per visit, deductible does not apply.

Not Covered

Network Partial hospitalization/intensive outpatient treatment: 20% coinsurance.

See your policy or plan document for additional information about EAP benefits.

Inpatient services 20% coinsurance Not Covered

See your policy or plan document for additional information about EAP benefits.

If you are pregnant Office visits No Charge Not Covered Cost sharing does not apply for preventive services.

Depending on the type of service a copayment, coinsurance or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.)

Childbirth/delivery professional services

20% coinsurance Not Covered

Childbirth/delivery facility services

20% coinsurance Not Covered None

If you need help recovering or have other special health needs

Home health care 20% coinsurance Not Covered Limited to 60 visits per calendar year.

Rehabilitation services $40 copay per visit, deductible does not apply.

Not Covered

Limits per calendar year: Physical/Occupational /Cardiac and Pulmonary: combined limit 60 visits; Speech:

Unlimited.

Habilitative services $40 copay per visit, deductible does not apply.

Not Covered Services are provided under and limits are combined with Rehabilitation Services above.

Skilled nursing care 20% coinsurance Not Covered

Limited to 60 days per calendar year (combined with inpatient rehabilitation).

Durable medical equipment

20% coinsurance Not Covered Covers 1 per type of DME (including repair/replacement) every 3 years.

Hospice services 20% coinsurance Not Covered None

If your child needs dental or eye care

Children’s eye exam Not Covered Not Covered No coverage for Children’s eye exams.

Children’s glasses Not Covered Not Covered No coverage for Children’s glasses.

Children’s dental check-

* For more information about limitations and exceptions, see the plan or policy document at welcometouhc.com. Page 5 of 6

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

• Acupuncture

• Bariatric surgery

• Cosmetic surgery

• Dental care

• Glasses

• Infertility treatment

• Long-term care

• Non-emergency care when travelling outside -the U.S.

• Private duty nursing

• Routine eye care

• Routine foot care – Except as covered for Diabetes

• Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

• Chiropractic (Manipulative care) – 60 visits per

• Hearing aids

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is:

U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1- 877-267-2323 x61565 or www.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: the Member Service number listed on the back of your ID card or myuhc.com or the Employee Benefits Security Administration at 1-866-444-3272 or dol.gov/ebsa/healthreform.Additionally, a consumer assistance program may help you file your appeal. Contact dol.gov/ebsa/healthreform.

Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services:

Spanish (Español): Para obtener asistencia en Español, llame al 1-866-633-2446.

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-866-633-2446.

To see examples of how this plan might cover costs for a sample medical situation, see the next section.

http://www.cciio.cms.gov/ http://www.healthcare.gov/ http://www.myuhc.com/ http://www.myuhc.com/

The plan would be responsible for the other costs of these EXAMPLE covered services. Page 6 of 6

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

hospital delivery)

◼ The plan’s overall deductible $1,000 ◼ Specialist copay $25

Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services

Deductibles $1,000

Copayments $10

Coinsurance $1,800

What isn’t covered

The total Peg would pay is $2,870 controlled condition)

◼ The plan’s overall deductible $1,000 ◼ Specialist copay $25 education) Diagnostic tests (blood work)

Deductibles $150

Copayments $800

Coinsurance $0

What isn’t covered

Limits or exclusions $30

The total Joe would pay is $950 follow up care)

◼ The plan’s overall deductible $1,000 ◼ Specialist copay $25

Diagnostic test (x-ray)

Deductibles $200

Copayments $900

Coinsurance $0

What isn’t covered

The total Mia would pay is $1,100

If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to the Civil

Mail: Civil Rights Coordinator. UnitedHealthcare Civil Rights Grievance. P.O. Box 30608 Salt Lake City, UTAH 84130

You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within 30 days. If you disagree with

If you need help with your complaint, please call the toll-free number listed within this Summary of Benefits and Coverage (SBC), TTY 711, Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD) Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201

We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the number contained within this Summary of Benefits and Coverage (SBC) , TTY 711, Monday through Friday, 8 a.m. to

HSA Choice Plus Plan

Coverage for: Family | Plan Type: PS1

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.

This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-866-314-0335.or visit welcometouhc.com. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-866-487-2365 to request a copy.

deductible? Network: $3,200 Individual / $6,000 Family

Out-of-Network: $9,000 Individual / $18,000 Family Per calendar year.

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

Are there services covered before you meet your deductible? Yes. Preventive care is covered before you meet your deductible.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/.

Are there other deductibles for specific services?

No. You don’t have to meet deductibles for specific services.

What is the out-of-pocket limit for this plan?

Network: $4,000 Individual / $8,000 Family Out-of-Network: $12,000 Individual / $24,000 Family Per calendar year.

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

What is not included in the out-of-pocket limit?

Premiums, balance-billing charges, health care this plan doesn’t cover and penalties for failure to obtain preauthorization for services.

Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

Will you pay less if you use a network provider?

Yes. See myuhc.com or call 1-866-633-2446 for a list of network providers.

This plan uses a provider network. You will pay less if you use a provider in the plan's network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

Do you need a referral to see a specialist?

No. You can see the specialist you choose without a referral.

https://www.healthcare.gov/sbc-glossary/

* For more information about limitations and exceptions, see the plan or policy document at welcometouhc.com. Page 2 of 6

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common Medical Event

Services You May Need

What You Will Pay

Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least)

Out-of-Network Provider (You will pay the most)

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness 0% coinsurance 30% coinsurance

Virtual visits - 0% coinsurance by a Designated Virtual Network Provider. No virtual coverage out-of-network

Specialist visit 0% coinsurance 30% coinsurance None

Preventive care/screening/ immunization

No Charge 30% coinsurance You may have to pay for services that aren’t preventive.

Ask your provider if the services needed are preventive.

Then check what your plan will pay for.

If you have a test Diagnostic test (x-ray, blood work)

0% coinsurance 30% coinsurance Preauthorization is required out-of-network for certain services or benefit reduces to 50% of allowed amount.

Imaging (CT/PET scans, MRIs)

0% coinsurance 30% coinsurance Preauthorization is required out-of-network or benefit reduces to 50% of allowed amount.

If you need drugs to treat your illness or condition

More information about prescription drug coverage is

Retail: s$10 copay Mail-Order: $20 copay

Retail:

$10 copay

Provider means pharmacy for purposes of this section.

Retail: Up to a 31 day supply.

Mail-Order: Up to a 90 day supply.

You may need to obtain certain drugs, including certain specialty drugs, from a pharmacy designated by us.

Certain drugs may have a preauthorization requirement or may result in a higher cost.

If you use a out-of-network pharmacy (including a mail order pharmacy), you may be responsible for any amount over the allowed amount.

Certain preventive medications (including certain contraceptives) are covered at No Charge.

See the website listed for information on drugs covered by your plan. Not all drugs are covered.

You may be required to use a lower-cost drug(s) prior to benefits under your policy being available for certain prescribed drugs.

Prescription drug costs are subject to the annual deductible.

Network deductible will be applied to the out-of-network provider and applies to the Network out-of-pocket limit

Tier 2 – Your Mid-Range Cost Option

Retail: $40 copay Mail-Order: $80 copay

Retail:

$40 copay

Tier 3 – Your Mid-Range Cost Option

Retail: $70 copay Mail-Order: $140 copay

Retail:

$70 copay

Tier 4 – Your Highest Cost Option

Not Applicable Not Applicable

* For more information about limitations and exceptions, see the plan or policy document at welcometouhc.com. Page 3 of 6

Services You May Need

What You Will Pay

Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least)

Out-of-Network Provider (You will pay the most)

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)

0% coinsurance 30% coinsurance Preauthorization is required out-of-network for certain services or benefit reduces to 50% of allowed amount.

Physician/surgeon fees 0% coinsurance 30% coinsurance None

If you need immediate medical attention

Emergency room care 0% coinsurance *0% coinsurance *Network deductible applies

Emergency medical transportation

0% coinsurance *0% coinsurance *Network deductible applies

Urgent care 0% coinsurance 30% coinsurance None

If you have a hospital stay

Facility fee (e.g., hospital room)

0% coinsurance 30% coinsurance Preauthorization is required out-of-network or benefit reduces to 50% of allowed amount.

Physician/surgeon fees 0% coinsurance 30% coinsurance None

If you need mental health, behavioral health, or substance abuse services

Outpatient services

0% coinsurance 30% coinsurance

Network Partial hospitalization/intensive outpatient treatment: 0% coinsurance.

Preauthorization is required out-of-network for certain services or benefit reduces to 50% of allowed amount.

See your policy or plan document for additional information about EAP benefits.

Inpatient services

0% coinsurance 30% coinsurance

Preauthorization is required out-of-network or benefit reduces to 50% of allowed amount.

See your policy or plan document for additional information about EAP benefits.

If you are pregnant Office visits No Charge 30% coinsurance Cost sharing does not apply for preventive services.

Depending on the type of service a copayment, coinsurance or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.)

Childbirth/delivery professional services

0% coinsurance 30% coinsurance

Childbirth/delivery facility services

0% coinsurance 30% coinsurance Inpatient preauthorization applies out-of-network if stay exceeds 48 hours (C-Section: 96 hours) or benefit reduces to 50% of allowed amount.

* For more information about limitations and exceptions, see the plan or policy document at welcometouhc.com. Page 4 of 6

Services You May Need

What You Will Pay

Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least)

Out-of-Network Provider (You will pay the most)

If you need help recovering or have other special health needs

Home health care 0% coinsurance 30% coinsurance

Limited to 60 visits per calendar year.

Preauthorization is required out-of-network or benefit reduces to 50% of allowed amount.

Rehabilitation services 0% coinsurance 30% coinsurance

Limits per calendar year: Physical/ Occupational /Cardiac and Pulmonary: combined limit 60 visits; Speech:

Unlimited.

Habilitative services 0% coinsurance 30% coinsurance

Services are provided under and limits are combined with Rehabilitation Services above.

Skilled nursing care

0% coinsurance 30% coinsurance

Limited to 60 days per calendar year (combined with inpatient rehabilitation).

Preauthorization is required out-of-network or benefit reduces to 50% of allowed amount.

Durable medical equipment

0% coinsurance 30% coinsurance

Covers 1 per type of DME (including repair/replacement) every 3 years.

Preauthorization is required out-of-network for DME over $1,000 or no coverage.

Hospice services

0% coinsurance 30% coinsurance Preauthorization is required out-of-network before admission for an Inpatient Stay in a hospice facility or benefit reduces to 50% of allowed amount.

If your child needs dental or eye care

Children’s eye exam Not Covered Not Covered No coverage for Children’s eye exams.

Children’s glasses Not Covered Not Covered No coverage for Children’s glasses.

Children’s dental check-

* For more information about limitations and exceptions, see the plan or policy document at welcometouhc.com. Page 5 of 6

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

• Acupuncture

• Cosmetic surgery

• Dental care

• Glasses

• Infertility treatment

• Long-term care

• Non-emergency care when travelling outside -the U.S.

• Private duty nursing

• Routine eye care

• Routine foot care – Except as covered for Diabetes

• Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

• Bariatric surgery – Network only

• Chiropractic (Manipulative care) – 60 visits per

• Hearing aids

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is:

U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1- 877-267-2323 x61565 or www.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: the Member Service number listed on the back of your ID card or myuhc.com or the Employee Benefits Security Administration at 1-866-444-3272 or dol.gov/ebsa/healthreform. Additionally, a consumer assistance program may help you file your appeal. Contact dol.gov/ebsa/healthreform.

Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services:

Spanish (Español): Para obtener asistencia en Español, llame al 1-866-633-2446.

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-866-633-2446.

To see examples of how this plan might cover costs for a sample medical situation, see the next section.

http://www.cciio.cms.gov/ http://www.healthcare.gov/ http://www.myuhc.com/ http://www.myuhc.com/

The plan would be responsible for the other costs of these EXAMPLE covered services. Page 6 of 6

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

hospital delivery)

◼ The plan’s overall deductible $3,200 ◼ Specialist coinsurance 0%

◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 0%

Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services

Deductibles $3,200

Copayments $10

Coinsurance $0

What isn’t covered

The total Peg would pay is $3,270 controlled condition)

◼ The plan’s overall deductible $3,200 ◼ Specialist coinsurance 0% education) Diagnostic tests (blood work)

Deductibles $3,200

Copayments $400

Coinsurance $0

What isn’t covered

Limits or exclusions $10

The total Joe would pay is $3,600 follow up care)

◼ The plan’s overall deductible $3,200 ◼ Specialist coinsurance 0%

Diagnostic test (x-ray)

Deductibles $2,800

Copayments $0

Coinsurance $0

What isn’t covered

The total Mia would pay is $2,800

If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to the Civil

Mail: Civil Rights Coordinator. UnitedHealthcare Civil Rights Grievance. P.O. Box 30608 Salt Lake City, UTAH 84130

You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within 30 days. If you disagree with

If you need help with your complaint, please call the toll-free number listed within this Summary of Benefits and Coverage (SBC), TTY 711, Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD) Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201

We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the number contained within this Summary of Benefits and Coverage (SBC) , TTY 711, Monday through Friday, 8 a.m. to