Benefit Summary ASO Choice Plus VMware Medical Plan Name: HSA Plan

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1 Search for Providers and learn more about UnitedHealthcare at wwwwelcometouhccom/vmware Call our Customer Care team for VMware at , Monday Friday 8am 8pm in your time zone Benefit Summary ASO Choice Plus VMware Medical Plan Name: HSA Plan This document is a Summary of Benefits A Summary Plan Description (SPD) will be available in 2019 United HealthCare Services, Inc and VMware want to help you take control and make the most of your health care benefits That s why we provide convenient services to get your health care questions answered quickly and accurately: myuhccom - Take advantage of easy, time-saving online tools You can check your eligibility, benefits, claims, claim payments, search for a doctor and hospital and more 24-hour nurse support A nurse is a phone call away and you have other health resources available 24-hours a day, 7 days a week to provide you with information that can help you make informed decisions Just call the number on the back of your ID card Customer Care telephone support Need more help? Call a customer care professional using the toll-free number on the back of your ID card Get answers to your benefit questions or receive help looking for a doctor or hospital Unless otherwise specified maximums for services are combined innetwork and out of network per calendar year In addition to your premium (monthly) payments paid by you or your employer, you are responsible for Out-of- Annual Deductible What is an annual deductible? The annual deductible is the amount you pay for per year before you are eligible to receive Benefits It does not include any amount that exceeds Allowed Amounts The deductible may not apply to all You may have more than one type of deductible No one in the family is eligible for benefits until the family coverage deductible is met Medical Deductible Individual $1,500 per calendar year $1,500 per calendar year Medical Deductible - Family $3,000 per calendar year $3,000 per calendar year Out-of-Pocket Limit What is an out-of-pocket limit? The Out-of-Pocket Limit is the maximum you pay per year Once you reach the Out-of-Pocket Limit, Benefits are payable at 100% of Allowed Amounts during the rest of that year If more than one person in a family is covered under the Policy, the individual out-of-pocket limit does not apply Your, co-insurance and deductibles (including pharmacy) count towards meeting the out-of-pocket limit Out-of-Pocket Limit Individual $2,500 per calendar year $6,000 per calendar year Out-of-Pocket Limit Family $5,000 per calendar year $12,000 per calendar year Additional Information What is a co-insurance? Co-insurance is the amount you pay each time you receive certain calculated as a percentage of the Allowed Amount (for example, 10%) You pay co-insurance plus any deductibles you owe Co-insurance is not the same as a co-payment (or co-pay) What is a co-payment? A Co-payment is the amount you pay each time you receive certain calculated as a set dollar amount (for example, $50) You are responsible for paying the lesser of the applicable Co-payment or the Allowed Amount Please see the specific Covered Health Care Service to see if a co-payment applies and how much you have to pay What is Prior Authorization? Prior Authorization is getting approval before you receive certain Physicians and other health care professionals who participate in a Network are responsible for obtaining prior authorization However there are some Benefits that you are responsible for obtaining authorization before you receive the services Please see the specific Covered Health Care Service to find services that require you to obtain prior authorization Want more information? Find additional definitions in the glossary at justplainclearcom Page 1 of 7

2 Out-of- Ambulance Services Emergency Ambulance: 10% co-insurance Same as Network Non-Emergency Ambulance: 10% co-insurance 10% co-insurance Clinical Trials Prior Authorization is required for Non- Emergency Ambulance Prior Authorization is required for Non- Emergency Ambulance Congenital Heart Disease (CHD) Surgeries Benefits will be the same as stated under Hospital - Inpatient Stay Dental Services Accident Only Diabetes Services Diabetes Self-Management and Training/Diabetic Eye Exams/Foot Care: Out-of- are not available Deductible will be the same as stated under Hospital - Inpatient Stay 10% co-insurance Same as Network Diabetes Self-Management Items: The amount you pay is based on care service is provided under Durable Medical Equipment (DME), Orthotics and Supplies or in the Outpatient Prescription Drug Rider Prior Authorization is required for DME that costs more than $1,000 Durable Medical Equipment (DME), Orthotics and Supplies Limited to a single purchase of a type of DME or orthotic every three years Repair and/or replacement of DME or orthotics would apply to this limit in the same manner as a purchase This limit does not apply to wound vacuums Emergency Health Services - Outpatient 10% co-insurance 30% co-insurance Prior Authorization is required for DME or orthotics that costs more than $1,000 10% co-insurance Same as Network Gender Dysphoria Habilitative Services Inpatient: Inpatient services limited per year as follows: Limit will be the same as, and combined with, those stated under Skilled Nursing Facility/Inpatient Rehabilitation Services Notification is required if confined in an Outof-Network Hospital services services Outpatient: Outpatient therapies: Physical therapy Occupational therapy Manipulative Treatment 10% co-insurance 30% co-insurance Page 2 of 7

3 Speech therapy Post-cochlear implant aural therapy Cognitive therapy For the above outpatient therapies: Limits will be the same as, and combined with, those stated under Rehabilitation Services Outpatient Therapy and Manipulative Treatment Out-of- Hearing Aids Limited to $5,000 every year Benefits are further limited to a single purchase per hearing impaired ear every three years Repair and/or replacement of a hearing aid would apply to this limit in the same manner as a purchase Home Health Care Limited to 100 visits per calendar year One visit equals up to four hours of skilled care services This visit limit does not include any service which is billed only for the administration of intravenous infusion To receive for the administration of intravenous infusion, you must receive services from a provider the Claims Administrator identifies Hospice Care Hospital Inpatient Stay 10% co-insurance 30% co-insurance 0% co-insurance 30% co-insurance 10% co-insurance 30% co-insurance Prior Authorization is required for Inpatient Stay 10% co-insurance 30% co-insurance Lab, X-Ray and Diagnostics - Outpatient Lab Testing - Outpatient 10% co-insurance 30% co-insurance X-Ray and Other Diagnostic Testing - Outpatient 10% co-insurance 30% co-insurance Major Diagnostic and Imaging - Outpatient 10% co-insurance 30% co-insurance Mental Health Care and Substance Related and Addictive Disorders Services Inpatient: 10% co-insurance 30% co-insurance Outpatient: 10% co-insurance 30% co-insurance Partial Hospitalization/Intensive Outpatient Treatment: Ostomy Supplies 10% co-insurance 30% co-insurance services Page 3 of 7

4 Pharmaceutical Products - Outpatient This includes medications administered in an outpatient setting, in the Physician s Office or in a Covered Person s home Infusion Therapy covered 100% both innetwork and out of network Out-of- 10% co-insurance 30% co-insurance 10% co-insurance 30% co-insurance Physician Fees for Surgical and Medical Services 10% co-insurance 30% co-insurance Physician s Office Services Sickness and Injury Primary Care Physician Office Visit: 10% co-insurance 30% co-insurance Specialist Office Visit: 10% co-insurance 30% co-insurance Prior Authorization is required for Genetic Testing Additional co-pays, deductible, or co-insurance may apply when you receive other services at your physician s office Pregnancy Maternity Services The amount you pay is based on care service is provided except that an Annual Deductible will not apply for a newborn child whose length of stay in the Hospital is the same as the mother s length of stay Preventive Care Services Physician Office Services, Lab, X-Ray or other preventive tests Prior Authorization is required if the stay in the hospital is longer than 48 hours following a normal vaginal delivery or 96 hours following a cesarean section delivery You pay nothing 30% co-insurance Network: No Certain preventive care services are provided as specified by the Patient Protection and Affordable Care Act (ACA), with no cost-sharing to you These services are based on your age, gender and other health factors UnitedHealthcare also covers other routine services that may require a co-pay, co-insurance or deductible Prosthetic Devices Limited to a single purchase of each type of prosthetic device every three years Repair and/or replacement of a prosthetic device would apply to this limit in the same manner as a purchase Reconstructive Procedures 10% co-insurance 30% co-insurance Prior Authorization is required for Prosthetic Devices that costs more than $1,000 Rehabilitation Services Outpatient Therapy and Manipulative Treatment Benefits are limited as follows: Unlimited visits of physical therapy Unlimited visits of occupational therapy 20 visits of Manipulative Treatment per calendar year Unlimited visits of speech therapy Unlimited visits of pulmonary rehabilitation therapy Unlimited visits of cardiac rehabilitation therapy Unlimited visits of post-cochlear implant aural therapy Unlimited visits of cognitive rehabilitation therapy 10% co-insurance 30% co-insurance Scopic Procedures Outpatient Diagnostic and Therapeutic Diagnostic/therapeutic scopic procedures include, but are not limited to colonoscopy, sigmoidoscopy and endoscopy 10% co-insurance 30% co-insurance Skilled Nursing Facility / Inpatient Rehabilitation Facility Services Limited to 120 days per calendar year 10% co-insurance 30% co-insurance Page 4 of 7

5 Surgery Outpatient Out-of- 10% co-insurance 30% co-insurance Therapeutic Treatments Outpatient Therapeutic treatments include, but are not limited to dialysis, intravenous chemotherapy, medical education services and radiation oncology Transplantation Services must be received from a Designated Provider Urgent Care Center Services services 10% co-insurance 30% co-insurance The amount you pay is based on where the covered health services The amount you pay is based on where the covered health 10% co-insurance 30% co-insurance Additional co-pays, deductible, or co-insurance may apply when you receive other services at the urgent care facility Virtual Visits are available only when services are delivered through a Designated Virtual Visit Network Provider You can find a Designated Virtual Visit Network Provider by 10% co-insurance Out-of- are not available Out-of-Network: N/A contacting us at myuhccom or the telephone number on your ID card Access to Virtual Visits and prescription services may not be available in all states or for all groups Out-of- Acupuncture Services Limited to 20 visits per calendar year 10% co-insurance 30% co-insurance Infertility Services Limited to services provided by Progyny Call for care 10% co-insurance Out-of- are not available Out-of-Network: N/A Obesity Weight Loss Surgery Obesity surgery is covered when received at a designated facility and performed by a designated physician Designated services are provided by Bariatric Resource Services, a program for surgical weight loss solutions Temporomandibular Joint Services Limited to surgical treatment Non-surgical treatment is not covered The amount you pay is based on where the covered health Out-of- are not available Wigs Limited to $1,000 per calendar year Coverage is provided for hair loss as result of radiation therapy or chemotherapy or alopecia areata Massage Therapy Limited to 20 visits per calendar year Coverage must be provided by a Licensed Massage Therapist (LMT) for diagnosis of musculoskeletal or neuromuscular conditions or stress or tension 10% co-insurance 10% co-insurance Prior Authorization is required for Inpatient Stay 10% co-insurance 10% co-insurance Page 5 of 7

6 This is a list of the services your plan generally does NOT cover Review your Summary Plan Description (SPD), Schedule of Benefits (SBN) and Riders for an exact description of the services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage Cosmetic Surgery Dental Care Glasses Long-Term Care Non-emergency care when traveling outside the US Routine Vision Exams Routine Foot Care Temporomandibular Joint Services Non-Surgical Weight Loss Programs For Internal Use Only: SFXAB XXHSA Plan18 Page 6 of 7

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