Inpatient. Hospital 2. Urgent Care ER. Spec. N/A $5, % 80% $3,500 $12,000 $30 $45 $75 $150 $500 Admit $250 $250 $30 $75 $75 Embedded

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1 Health Plan Product Offering Please be advised that this guide is for informational purposes only. Premium rates and/or product forms included herein have been filed and are subject to approval by regulators. We reserve the right to modify this quote and benefits described if needed, once final approval is received, and to correct any typographical errors. For a complete listing of Massachusetts large group (51-100) products, please contact your sales representative Connecticut 3 Type 4 AA-HH $5,000 80% $3,500 $12,000 $30 $45 $75 $150 $500 AA-HI $5,000 80% $3,500 $12,000 $30 $45 $75 $150 $500 day, $2,000 max. AA-HJ $1,500 $5,000 70% $3,000 $12,000 $30 $45 $75 $150 AA-HK $3,000 $5,000 70% $5,500 $16,000 $30 $45 $75 $150 AA-HN $3,500 $10,000 70% $6,250 $24,000 $30 $45 $75 $150 AA-HO $500 $5,000 70% $2,500 $12,000 $40 $75 $150 $100 $100 $75 $75 AA-HP $1,000 $5,000 70% $3,500 $12,000 $40 $75 $150 $500 $75 $75 AA-HQ $6,000 $10,000 70% $6,600 $20,000 $30*, $30*, $30*, then then then WK SN-Y $1,000 $2,000 80% $1,500 $6,000 $20 $20 $50 $125 No charge SN-Z $1,500 $3,000 80% $2,000 $7,000 $20 $20 $75 $125 No charge SO-Y $2,000 $4,000 80% $2,500 $9,000 $75 $125 No charge 1

2 2016 Connecticut 3 Type 4 - continued SN-X SO-Z SO-1 SO-2 SO-3 AA-HR AA-HT (FWK) AA-HU (FWI) AA-HV (FWJ) AA-HW (FWK) AA-HX (FWL) $2,000 $4,000 80% 60% $4,500 $9,000 $45 $75 $150 $5,000 $7,500 80% $5,500 $15,000 $30 $45 $75 $150 $500 80% $1,000 $3,500 $15 $30 $75 $125 No charge No charge No charge $2,500 80% $3,000 $6,000 $20 $20 $50 $100 No charge No charge No charge No charge No charge No charge $2,500 $7,500 80% $5,500 $15,000 $30 $45 $75 $150 $3,000 $6,000 70% $5,500 $10,000 $50 $75 $150 $500 $1,000 80% $1,000 $4,000 $15 $30 $75 $150 $1,000 $2,000 80% $2,000 $8,000 $20 $30 $75 $150 $1,500 $3,000 80% $3,000 $12,000 $40 $75 $150 $2,000 $4,000 90% 70% $4,000 $16,000 $45 $75 $150 $3,000 $6,000 80% 60% $6,250 $24,000 $45 $75 $150 $500 day, $2,000 max. - ; - ; - ; Day $500 $75 $150 $150 $15 $20 $40 2

3 2016 Connecticut 3 Type 4 - continued AA-HY $3,500 $7,500 60% $6,000 $13,500 $50 $75 $200 - ; $500 AA-HZ $2,750 $6,000 60% $6,500 $12,500 $50 $75 $200 - ; $500 AA-H1 $1,000 $5,000 70% $3,500 $12,500 $50 $75 $200 - ; AJ-GF (SO-4) $4,000 $4,000 90% 70% $6,250 $9,000 90% 90% AJ-GG (UP-4) $2,000 $4,000 50% $4000/ $8,000 $150 AJ-GH (UP-5) $3,000 $5,000 50% $5,500 $10,000 $150 $500 AJ-GI (AA-HL) $3,000 $6,000 70% $6,250 $16,000 AJ-GJ (AA-HM) $4,000 $6,000 70% $6,250 $18,000 3

4 2016 Connecticut 3 Type 4 - continued AJ-GK (AA-HS) $2,500 $5,000 70% $5000/ $12,500 $150 $500 $150 AJ-GL (AA-H2) $2,000 $5,000 70% 00/ $12,500 $20 - ; $150 AJ-GD (AB-GR) (minimum value) $5,500 $11,000 70% 50% $6,350 $12,700 70% 70% 70% 70% 70% 70% 70% 70% 70% 70% 200, WK AJ-GE (AB-GS) (minimum value) $6,000 $10,000 70% $6,450 $20, , WK * PCP/SPC/UC co-payments apply for a maximum of 3 combined visits, then deductible applies. 4

5 2016 Connecticut Connecticut Large Group (51-99) Options 2015 Member Mail Order Plan Code Per Member Tier 2 Tier 3 (90 Day Supply) Separate Plans (s) 200 No deductible $5 $ x 201 $100 $5 $ x 202 $200 $5 $ x WK No deductible $5 $30 $ x 203 $100 $5 $30 $ x 204 $200 $5 $30 $ x 205 No deductible $5 50% to max. 2.5 x 206 $100 $5 50% to max. 2.5 x 207 $200 $5 50% to max. 2.5 x Combined Plans (for s) 200 Same as Medical $5 $ x WK Same as Medical $5 $30 $ x 205 Same as Medical $5 50% to max. 2.5 x 1 Primary Physicians include Family Practice, Internal Medicine, Obstetrics-Gynecology, and Pediatrics. 2 Facility and hospital co-payments are in addition any plan deductible and co-insurance. Facility and hospital co-payments do not apply to the deductible and continue to be required the deductible is satisfied. These co-payments may also be referred to in plan documents as per-occurrence co-payments or per-occurrence deductibles. 3 facilities are any of the following: outpatient facility, diagnostic or ambulatory center or independent laboratory. At a freestanding facility, deductible and co-insurance still apply. See plan benefit information for further details. 4 Plans with non-embedded reflect family deductible and maximum out-of-pocket meaning no individual in the family has satisfied the deductible or maximum out-of-pocket until the entire family amount has been met. deductibles mean all individual deductible amounts will count toward the family deductible, but an individual will not have to pay more than the individual deductible amount. Insurance coverage provided by or through Insurance Company or its affiliates. Administrative services provided by United Health Services, Inc. or their affiliates. MT / United Health Services, Inc rev. 1 (10/26/15) 5