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- Benedict Brooks
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1 Insurance Choice Plus ICX X4-C 15/250/90% Trad. w/ded. $15 $15 $50 $100 90% 90% 90% 70% $250 $750 $500 $1,500 $2,250 $4,500 $4,500 $9,000 PVN Emb $5,000,000 USA X4-J 20/250/90% Trad. w/ded. $20 $20 $50 $100 90% 90% 90% 70% $250 $750 $500 $1,500 $1,500 $3,000 $3,000 $6,000 PVN Emb $5,000,000 LIK X4-Y 25/250/90% Trad. w/ded. $25 $50 $75 $200 90% 90% 90% 70% $250 $750 $500 $1,500 $2,500 $5,000 $5,000 $10,000 PVN Emb $5,000,000 USB X4-H 20/250/80% Trad. w/ded. $20 $20 $50 $100 80% 80% 80% 60% $250 $750 $500 $1,500 $1,500 $3,000 $3,000 $6,000 PVN Emb $5,000,000 USC X4-K 20/500/90% Trad. w/ded. $20 $20 $50 $100 90% 90% 90% 70% $500 $1,500 $1,000 $3,000 $2,000 $4,000 $4,000 $8,000 PVN Emb $5,000,000 LIJ X4-Z 25/500/90% Trad. w/ded. $25 $50 $75 $200 90% 90% 90% 70% $500 $1,500 $1,000 $3,000 $3,000 $6,000 $6,000 $12,000 PVN Emb $5,000,000 7A-A 25/500/80% Trad. w/ded. $25 $50 $75 $200 80% 80% 80% 60% $500 $1,500 $1,000 $3,000 $3,000 $6,000 $6,000 $12,000 PVN Emb $5,000,000 USD U5-P 20/500/80% Trad. w/ded. $20 $20 $50 $100 80% 80% 80% 60% $500 $1,500 $1,000 $3,000 $2,500 $5,500 $5,000 $11,000 PVN Emb $5,000,000 EAA X4-P 20/500/80% Trad. w/ded. $20 $35 $50 $100 80% 80% 80% 60% $500 $1,500 $1,000 $3,000 $2,000 $4,000 $4,000 $8,000 PVN Emb $5,000,000 ICL X4-Q 25/500/80% Trad. w/ded. $25 $25 80% $100 80% 80% 80% 60% $500 $1,500 $1,500 $4,500 $2,000 $6,000 $4,000 $12,000 PVN Emb $5,000,000 X4-F 20/500/70% Trad. w/ded. $20 $20 $50 $100 70% 70% 70% 50% $500 $1,500 $1,000 $3,000 $2,500 $5,500 $5,000 $11,000 PVN Emb $5,000,000 USE X4-I 20/1000/90% Balanced $20 $20 $50 $100 90% 90% 90% 70% $1,000 $3,000 $2,000 $6,000 $2,500 $5,000 $5,000 $10,000 PVN Emb $5,000,000 7A-B 25/1000/80% Balanced $25 $50 $75 $200 80% 80% 80% 60% $1,000 $3,000 $2,000 $6,000 $3,500 $7,000 $7,000 $14,000 PVN Emb $5,000,000 EAB X4-O 20/1000/80% Balanced $20 $35 $50 $100 80% 80% 80% 60% $1,000 $3,000 $2,000 $6,000 $2,500 $5,000 $5,000 $10,000 PVN Emb $5,000,000 USF X4-G 20/1000/80% Balanced $20 $20 $50 $100 80% 80% 80% 60% $1,000 $3,000 $2,000 $6,000 $2,500 $5,000 $5,000 $10,000 PVN Emb $5,000,000 X4-E 20/1000/70% Balanced $20 $20 $50 $100 70% 70% 70% 50% $1,000 $3,000 $2,000 $6,000 $3,500 $8,000 $7,000 $16,000 PVN Emb $5,000,000 USH X4-T 25/1500/90% Balanced $25 $25 $75 $125 90% 90% 90% 70% $1,500 $4,500 $3,000 $9,000 $3,500 $7,000 $7,000 $14,000 PVN Emb $5,000,000 7A-C 25/1500/80% Balanced $25 $50 $75 $200 80% 80% 80% 60% $1,500 $4,500 $3,000 $9,000 $4,500 $9,000 $9,000 $18,000 PVN Emb $5,000,000 EAC X4-X 25/1500/80% Balanced $25 $50 $75 $125 80% 80% 80% 60% $1,500 $4,500 $3,000 $9,000 $3,500 $7,000 $7,000 $14,000 PVN Emb $5,000,000 USJ X4-R 25/1500/80% Balanced $25 $25 $75 $125 80% 80% 80% 60% $1,500 $4,500 $3,000 $9,000 $3,500 $7,000 $7,000 $14,000 PVN Emb $5,000,000 ICE X4-B 10/100% Traditional $10 $10 100% $50 100% 100% 100% 80% N/A N/A $200 $600 N/A N/A $1,000 $3,000 PVN Emb $5,000,000 ICD X4-A 10/90% Traditional $10 $10 90% $50 90% 90% 90% 70% N/A N/A $200 $600 $500 $1,500 $1,000 $3,000 PVN Emb $5,000,000 ICH X4-D 20/90% Traditional $20 $20 90% $100 90% 90% 90% 60% N/A N/A $1,000 $3,000 $1,000 $3,000 $3,000 $9,000 PVN Emb $5,000,000 ICY X4-N 20/100% Traditional $20 $20 $50 $ % 100% 100% 50% N/A N/A $2,000 $6,000 N/A N/A $10,000 $20,000 PVN Emb $5,000,000 ICZ X4-L 20/90% Traditional $20 $20 $50 $100 90% 90% 90% 50% N/A N/A $2,000 $6,000 $2,000 $4,000 $10,000 $20,000 PVN Emb $5,000,000 1
2 Insurance Choice Plus (continued) 7A-E 25/1000/100% Balanced 100 $25 $50 $75 $ % 100% 100% 80% $1,000 $3,000 $2,000 $6,000 $1,000 $3,000 $5,000 $10,000 PVN Emb $5,000,000 ANA X4-M 20/1000/100% Balanced 100 $20 $20 $50 $ % 100% 100% 80% $1,000 $3,000 $2,000 $6,000 $1,000 $3,000 $5,000 $10,000 PVN Emb $5,000,000 7A-K 1000/100% Consumer 100% 100% 100% 100% 100% 100% 100% 80% $1,000 $3,000 $2,000 $6,000 $1,000 $3,000 $5,000 $10,000 PVY Emb $5,000,000 X5-E 1500/70% Consumer 70% 70% 70% 70% 70% 70% 70% 50% $1,500 $4,500 $3,000 $9,000 $5,000 $11,500 $10,000 $23,000 PVY Emb $5,000,000 USI X5-F 1500/80% Consumer 80% 80% 80% 80% 80% 80% 80% 60% $1,500 $4,500 $3,000 $9,000 $3,500 $7,000 $7,000 $14,000 PVY Emb $5,000,000 USG X5-K 1500/90% Consumer 90% 90% 90% 90% 90% 90% 90% 70% $1,500 $4,500 $3,000 $9,000 $3,500 $7,000 $7,000 $14,000 PVY Emb $5,000,000 7A-F 25/1500/100% Balanced 100 $25 $50 $75 $ % 100% 100% 80% $1,500 $4,500 $3,000 $9,000 $1,500 $4,500 $6,000 $12,000 PVN Emb $5,000,000 7A-L 1500/100% Consumer 100% 100% 100% 100% 100% 100% 100% 80% $1,500 $4,500 $3,000 $9,000 $1,500 $4,500 $6,000 $12,000 PVY Emb $5,000,000 7A-D 25/2000/80% Balanced $25 $50 $75 $200 80% 80% 80% 60% $2,000 $6,000 $4,000 $12,000 $4,000 $8,000 $8,000 $16,000 PVN Emb $5,000,000 USN X4-S 25/2000/80% Balanced $25 $25 $75 $125 80% 80% 80% 60% $2,000 $6,000 $4,000 $12,000 $4,000 $8,000 $8,000 $16,000 PVN Emb $5,000,000 USL X4-U 25/2000/90% Balanced $25 $25 $75 $125 90% 90% 90% 70% $2,000 $6,000 $4,000 $12,000 $4,000 $8,000 $8,000 $16,000 PVN Emb $5,000,000 7A-G 25/2000/100% Balanced 100 $25 $50 $75 $ % 100% 100% 80% $2,000 $6,000 $4,000 $12,000 $2,000 $6,000 $8,000 $16,000 PVN Emb $5,000,000 ANC X4-W 25/2000/100% Balanced 100 $25 $25 $75 $ % 100% 100% 80% $2,000 $6,000 $4,000 $12,000 $2,000 $6,000 $8,000 $16,000 PVN Emb $5,000,000 7A-M 2000/100% Consumer 100% 100% 100% 100% 100% 100% 100% 80% $2,000 $6,000 $4,000 $12,000 $2,000 $6,000 $8,000 $16,000 PVY Emb $5,000,000 RTB X5-P 2000/100% Consumer 100% 100% 100% 100% 100% 100% 100% 80% $2,000 $6,000 $4,000 $8,000 $2,000 $6,000 $8,000 $16,000 PVY Emb $5,000,000 USP X4-V 25/2500/90% Balanced $25 $25 $75 $125 90% 90% 90% 70% $2,500 $7,500 $5,000 $15,000 $4,500 $9,000 $9,000 $18,000 PVN Emb $5,000,000 7A-P 30/2500/100% Balanced 100 $30 $60 $100 $ % 100% 100% 80% $2,500 $7,500 $5,000 $15,000 $2,500 $7,500 $10,000 $20,000 PVN Emb $5,000,000 LIB X5-A 25/2500/100% Balanced 100 $25 $50 $75 $ % 100% 100% 80% $2,500 $7,500 $5,000 $15,000 $2,500 $7,500 $9,000 $18,000 PVN Emb $5,000,000 USV X5-C 30/3000/80% Balanced $30 $30 $100 $150 80% 80% 80% 60% $3,000 $9,000 $6,000 $18,000 $5,000 $10,000 $10,000 $20,000 PVN Emb $5,000,000 UST X5-D 30/3000/90% Balanced $30 $30 $100 $150 90% 90% 90% 70% $3,000 $9,000 $6,000 $18,000 $5,000 $10,000 $10,000 $20,000 PVN Emb $5,000,000 7A-Q 30/3000/100% Balanced 100 $30 $60 $100 $ % 100% 100% 80% $3,000 $9,000 $6,000 $18,000 $3,000 $9,000 $12,000 $24,000 PVN Emb $5,000,000 LIC X5-B 25/3000/100% Balanced 100 $25 $50 $75 $ % 100% 100% 80% $3,000 $9,000 $6,000 $18,000 $3,000 $9,000 $10,000 $20,000 PVN Emb $5,000,000 7A-R 30/5000/100% Balanced 100 $30 $60 $100 $ % 100% 100% 80% $5,000 $15,000 $8,000 $24,000 $5,000 $15,000 $14,000 $28,000 PVN Emb $5,000,000 LIE M1-Q 25/5000/100% Balanced 100 $25 $50 $75 $ % 100% 100% 80% $5,000 $15,000 $6,000 $18,000 $5,000 $15,000 $10,000 $20,000 PVN Emb $5,000,000 2
3 Insurance Choice Plus (continued) 7A-S 1250/100% Definity HSA 100% 100% 100% 100% 100% 100% 100% 80% $1,250 $2,500 $2,500 $5,000 $2,500 $5,000 $5,000 $10,000 PVY Non-Emb $5,000,000 HDP 7A-H 1250/100% Definity HSA 100% 100% 100% 100% 100% 100% 100% 80% $1,250 $2,500 $2,500 $5,000 $1,250 $2,500 $5,000 $10,000 PVY Non-Emb $5,000,000 HDQ 1A-S 1250/80% Definity HSA 80% 80% 80% 80% 80% 80% 80% 60% $1,250 $2,500 $2,500 $5,000 $2,500 $5,000 $5,000 $10,000 PVY Non-Emb $5,000,000 USK X5-L 2000/90% Consumer 90% 90% 90% 90% 90% 90% 90% 70% $2,000 $6,000 $4,000 $12,000 $4,000 $8,000 $8,000 $16,000 PVY Emb $5,000,000 USM X5-G 2000/80% Consumer 80% 80% 80% 80% 80% 80% 80% 60% $2,000 $6,000 $4,000 $12,000 $4,000 $8,000 $8,000 $16,000 PVY Emb $5,000,000 7A-T 2000/100% Definity HSA 100% 100% 100% 100% 100% 100% 100% 80% $2,000 $4,000 $4,000 $8,000 $4,000 $8,000 $8,000 $16,000 PVY Non-Emb $5,000,000 7A-V 2500/100% Consumer 100% 100% 100% 100% 100% 100% 100% 80% $2,500 $7,500 $5,000 $15,000 $2,500 $7,500 $10,000 $20,000 PVY Emb $5,000,000 USO X5-M 2500/90% Consumer 90% 90% 90% 90% 90% 90% 90% 70% $2,500 $7,500 $5,000 $15,000 $4,500 $9,000 $9,000 $18,000 PVY Emb $5,000,000 USQ X5-H 2500/80% Consumer 80% 80% 80% 80% 80% 80% 80% 60% $2,500 $7,500 $5,000 $15,000 $4,500 $9,000 $9,000 $18,000 PVY Emb $5,000,000 HYA X7-A 2500/100% Definity HSA 100% 100% 100% 100% 100% 100% 100% 80% $2,500 $5,000 $5,000 $10,000 $2,500 $5,000 $10,000 $20,000 PVY Emb $5,000,000 RTC X5-Q 2850/100% Consumer 100% 100% 100% 100% 100% 100% 100% 80% $2,850 $8,550 $5,000 $10,000 $2,850 $8,550 $10,000 $20,000 PVY Emb $5,000,000 7A-U 2850/100% Definity HSA 100% 100% 100% 100% 100% 100% 100% 80% $2,850 $5,700 $5,000 $10,000 $4,850 $9,700 $10,000 $20,000 PVY Non-Emb $5,000,000 HDF X7-B 2850/100% Definity HSA 100% 100% 100% 100% 100% 100% 100% 80% $2,850 $5,600 $5,000 $10,000 $2,850 $5,600 $10,000 $20,000 PVY Non-Emb $5,000,000 7A-W 3000/100% Consumer 100% 100% 100% 100% 100% 100% 100% 80% $3,000 $9,000 $6,000 $18,000 $3,000 $9,000 $12,000 $24,000 PVY Emb $5,000,000 USS X5-N 3000/90% Consumer 90% 90% 90% 90% 90% 90% 90% 70% $3,000 $9,000 $6,000 $18,000 $5,000 $10,000 $10,000 $20,000 PVY Emb $5,000,000 USU X5-I 3000/80% Consumer 80% 80% 80% 80% 80% 80% 80% 60% $3,000 $9,000 $6,000 $18,000 $5,000 $10,000 $10,000 $20,000 PVY Emb $5,000,000 HDI X7-C 3500/100% Definity HSA 100% 100% 100% 100% 100% 100% 100% 80% $3,500 $7,000 $7,500 $15,000 $3,500 $7,000 $10,000 $30,000 PVY Non-Emb $5,000,000 7A-X 5000/100% Consumer 100% 100% 100% 100% 100% 100% 100% 80% $5,000 $15,000 $8,000 $24,000 $5,000 $15,000 $14,000 $28,000 PVY Emb $5,000,000 USW X5-O 5000/90% Consumer 90% 90% 90% 90% 90% 90% 90% 70% $5,000 $15,000 $7,500 $22,500 $7,500 $15,000 $10,000 $20,000 PVY Emb $5,000,000 USY X5-J 5000/80% Consumer 80% 80% 80% 80% 80% 80% 80% 60% $5,000 $15,000 $7,500 $22,500 $7,500 $15,000 $10,000 $20,000 PVY Emb $5,000,000 HDL X7-D 5000/100% Definity HSA 100% 100% 100% 100% 100% 100% 100% 80% $5,000 $10,000 $7,500 $15,000 $5,000 $10,000 $10,000 $30,000 PVY Non-Emb $5,000,000 The Definity SM Health Savings Account (HSA) high deductible health plan (HDHP) is designed to comply with IRS requirements so eligible enrollees may open a Health Savings Account with a bank of their choice or through Exante Bank. Definity HSA refers generally to the Definity SM HSA product, which includes a HDHP, although at times Definity HSA may refer only and specifically to the Definity Health Savings Account, and not to the associated HDHP. Services supplied by Exante Bank, Inc. are not available in Hawaii, Alaska or the U.S. Virgin Islands. UnitedHealthcare s DefinitySM Health Reimbursement Account, or HRA, combines the flexibility of a medical benefit plan with an employer-funded reimbursement account. 3
4 Insurance Choice Plus Value Plans*** X5-W 20/1000/80% Balanced $20 $35 $50 $250 80% 80% 80% 60% $1,000 $2,000 $2,000 $4,000 $3,500 $7,000 $7,000 $14,000 PVN Non-Emb $5,000,000 X5-X 25/1500/80% Balanced $25 $25 $75 $250 80% 80% 80% 60% $1,500 $3,000 $3,000 $6,000 $5,000 $10,000 $10,000 $20,000 PVN Non-Emb $5,000,000 X5-T 1500/90% Consumer 90% 90% 90% 90% 90% 90% 90% 70% $1,500 $3,000 $3,000 $6,000 $5,000 $10,000 $10,000 $20,000 PVN Non-Emb $5,000,000 X5-R 1500/80% Consumer 80% 80% 80% 80% 80% 80% 80% 60% $1,500 $3,000 $3,000 $6,000 $5,000 $10,000 $10,000 $20,000 PVN Non-Emb $5,000,000 X5-Y 25/2000/90% Balanced $25 $25 $75 $250 90% 90% 90% 70% $2,000 $4,000 $4,000 $8,000 $6,000 $12,000 $12,000 $24,000 PVN Non-Emb $5,000,000 7V-A 25/2000/80% Balanced $25 $50 $75 $250 80% 80% 80% 60% $2,000 $4,000 $4,000 $8,000 $4,000 $8,000 $8,000 $16,000 PVN Non-Emb $5,000,000 7V-B 25/2000/100% Balanced 100 $25 $50 $75 $ % 100% 100% 80% $2,000 $4,000 $4,000 $8,000 $3,000 $6,000 $8,000 $16,000 PVN Non-Emb $5,000,000 X5-Z 25/2000/100% Balanced 100 $25 $50 $75 $ % 100% 100% 80% $2,000 $4,000 $4,000 $8,000 $5,000 $10,000 $12,000 $24,000 PVN Non-Emb $5,000,000 X5-V 2000/100% Consumer 100% 100% 100% 100% 100% 100% 100% 80% $2,000 $4,000 $4,000 $8,000 $5,000 $10,000 $12,000 $24,000 PVN Non-Emb $5,000,000 7V-C 30/2500/100% Balanced 100 $30 $60 $100 $ % 100% 100% 80% $2,500 $5,000 $5,000 $10,000 $3,500 $7,000 $10,000 $20,000 PVN Non-Emb $5,000,000 X6-A 25/2500/100% Balanced 100 $25 $50 $75 $ % 100% 100% 80% $2,500 $5,000 $5,000 $10,000 $6,000 $12,000 $14,000 $28,000 PVN Non-Emb $5,000,000 7V-D 2500/100% Consumer 100% 100% 100% 100% 100% 100% 100% 80% $2,500 $5,000 $5,000 $10,000 $3,500 $7,000 $10,000 $20,000 PVN Non-Emb $5,000,000 X5-U 2500/90% Consumer 90% 90% 90% 90% 90% 90% 90% 70% $2,500 $5,000 $5,000 $10,000 $7,000 $14,000 $14,000 $28,000 PVN Non-Emb $5,000,000 X5-S 2500/80% Consumer 80% 80% 80% 80% 80% 80% 80% 60% $2,500 $5,000 $5,000 $10,000 $7,000 $14,000 $14,000 $28,000 PVN Non-Emb $5,000,000 X6-B 30/3000/90% Balanced $30 $30 $100 $250 90% 90% 90% 70% $3,000 $6,000 $6,000 $12,000 $8,000 $16,000 $16,000 $32,000 PVN Non-Emb $5,000,000 7V-E 30/3000/100% Balanced 100 $30 $60 $100 $ % 100% 100% 80% $3,000 $6,000 $6,000 $12,000 $4,000 $8,000 $12,000 $24,000 PVN Non-Emb $5,000,000 7V-F 3000/100% Consumer 100% 100% 100% 100% 100% 100% 100% 80% $3,000 $6,000 $6,000 $12,000 $4,000 $8,000 $12,000 $24,000 PVN Non-Emb $5,000,000 7V-G 30/5000/100% Balanced 100 $30 $60 $100 $ % 100% 100% 80% $5,000 $10,000 $8,000 $16,000 $6,000 $12,000 $14,000 $28,000 PVN Non-Emb $5,000,000 7V-H 5000/100% Consumer 100% 100% 100% 100% 100% 100% 100% 80% $5,000 $10,000 $8,000 $16,000 $6,000 $12,000 $14,000 $28,000 PVN Non-Emb $5,000,000 *** Value plans feature non-embedded deductibles and additional per occurrence deductibles on inpatient hospitalization and outpatient surgery. 4
5 Non-Differential PPO Type 7C-A 1500/80% Non-Diff. PPO 80% 80% 80% 80% 80% 80% 80% 80% $1,500 $4,500 $1,500 $4,500 $4,000 $12,000 $4,000 $12,000 PVN Emb $ 5,000,000 7C-B 2000/80% Non-Diff. PPO 80% 80% 80% 80% 80% 80% 80% 80% $2,000 $6,000 $2,000 $6,000 $4,000 $12,000 $4,000 $12,000 PVN Emb $ 5,000,000 HMO Choice Type PVA X3-A 10/100% Traditional $10 $10 $50 $ % 100% 100% 0% N/A N/A N/A N/A N/A N/A N/A N/A PVN Emb Unlimited PVB X3-B 20/100% Traditional $20 $20 $50 $ % $ % 0% N/A N/A N/A N/A N/A N/A N/A N/A PVN Emb Unlimited PVF X3-C 25/90% Traditional $25 $25 $50 $100 90% $250 90% 0% N/A N/A N/A N/A $1,500 $4,500 N/A N/A PVN Emb Unlimited PVG X3-D 30/80% Traditional $30 $30 $50 $100 80% $250 80% 0% N/A N/A N/A N/A $1,500 $3,000 N/A N/A PVN Emb Unlimited PVH X3-E 35/70% Traditional $35 $35 $50 $100 70% $250 70% 0% N/A N/A N/A N/A $1,500 $3,000 N/A N/A PVN Emb Unlimited 5
6 Pharmacy Plans Plan Single Family. Single. Family Tier 1 Tier 2 Tier 3 Tier 4 Mail Service Ratio 4F $0 $0 $0 $0 $10 $30 $50 $ V $0 $0 $0 $0 $10 $35 $60 $ S $100 $300 $0 $0 $10 $30 $50 $ H $0 $0 $0 $0 $10 $30 $70 $ M $100 $300 $0 $0 $10 $35 $60 $ U $0 $0 $0 $0 $10 $35 $60 $ V $100 $300 $0 $0 $10 $35 $60 $ I $0 $0 $0 $0 $10 $35 $70 $0 2.5 AT $100 $300 $0 $0 $10 $35 $70 $0 2.5 H9 $0 $0 $0 $0 $10 $30 $50 $0 2.5 Combined medical/pharmacy plans 2V $0 $0 $0 $0 $10 $35 $60 $0 2.5 MM Same as Medical Same as Medical $0 $0 No No No $0 No H9* $0 $0 $0 $0 $10 $30 $50 $
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