OON Indiv OOPM. OON Fam OOPM. INN Fam OOPM. PCP Copay. Virtual Visits

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1 Split s - Heritage Plus Per Type Type Rx s QS-7 AM-JX Platinum 20/100% N/A N/A $2,000 $6, % 70% $2,000 $6,000 $10,000 $20,000 N/A $20 $40 $100 $ % $250 $650 N/A $800 N/A Emb Sep N 247A QS-8 AM-JW Platinum 15/500/80% $500 $1,500 $1,000 $3,000 80% 60% $2,000 $6,000 $10,000 $20,000 N/A $15 $30 $100 $ % 80% 80% N/A 80% N/A Emb Sep N 249A AC-YG AM-KB Gold 25/1000/100% $1,000 $3,000 $2,000 $6, % 70% $4,250 $8,500 $10,000 $20,000 N/A $25 $50 $100 $ % $ % N/A 100% N/A Emb Sep N 252A QT-J AM-KD Gold 35/1000/80% $1,000 $3,000 $2,000 $6,000 80% 60% $5,000 $10,000 $10,000 $20,000 N/A $35 $75 $100 $ % 80% 80% N/A 80% N/A Emb Sep N 247A AM-KG Gold $30/$1,000/70% $1,000 $2,000 $5,000 $10,000 70% 50% $7,150 $14,300 $15,000 $30,000 N/A $30 $60 $75 $ % 70% 70% N/A 70% N/A Emb Sep N 247A AC-YI AM-J3 Gold 35/1500/100% $1,500 $3,000 $5,000 $10, % 80% $3,400 $6,800 $15,000 $30,000 N/A $35 $75 $100 $ % 100% 100% N/A 100% N/A Emb Sep N 247A QT-K AM-JZ Gold 25/1500/80% $1,500 $3,000 $5,000 $10,000 80% 60% $4,500 $9,000 $15,000 $30,000 N/A $25 $50 $100 $ % 80% 80% N/A 80% N/A Emb Sep N 247A AM-KH Gold 30/$1,500/70% $1,500 $3,000 $5,000 $10,000 70% 50% $6,850 $13,700 $15,000 $30,000 N/A 30 $60 $75 $ % 70% 70% N/A 70% N/A Emb Sep N 247A QT-H AM-J1 Gold 25/2000/100% $2,000 $4,000 $5,000 $10, % 70% $4,000 $12,000 $15,000 $30,000 N/A $25 $50 $100 $ % 100% 100% N/A 100% N/A Emb Sep N 247A AM-KO Gold 20/2000/80% $2,000 $4,000 $5,000 $10,000 80% 60% $4,800 $9,600 $15,000 $30,000 N/A $20 $50 $100 $ % 80% 80% N/A 80% N/A Emb Sep N 247A 82-8 AM-JY Gold 20/2500/100% $2,500 $5,000 $7,500 $15, % 70% $2,800 $5,600 $15,000 $30,000 N/A $20 $40 $75 $ % 100% 100% N/A 100% N/A Emb Sep N 247A AC-X6 AM-J7 Silver 35/2750/70% $2,750 $5,500 $5,000 $10,000 70% 60% $7,150 $14,300 $15,000 $30,000 N/A $35 $100 $100 $ % 70% 70% N/A 70% N/A Emb Sep N 253A 83-A AM-J8 Silver 35/3750/80% $3,750 $7,500 $7,500 $15,000 80% 60% $7,150 $14,300 $15,000 $30,000 N/A $35 $75 $100 N/A 80% 80% 80% N/A 80% N/A Emb Sep N 252A AM-KI Silver 30/4500/90% $4,500 $9,000 $7,500 $15,000 90% 65% $7,150 $14,300 $15,000 $30,000 N/A 30 $60 $75 $ % 90% 90% N/A 90% N/A Emb Sep N 250A AM-KE Silver 25/4500/80% $4,500 $9,000 $7,500 $15,000 80% 50% $7,150 $14,300 $15,000 $30,000 N/A $25 $50 $100 N/A 80% 70% 80% N/A 80% N/A Emb Sep N 250A 83-C AM-J4 Silver 35/5000/100% $5,000 $10,000 $10,000 $20, % 70% $6,750 $13,500 $20,000 $40,000 N/A $35 $70 $70 $ % 100% 100% N/A 100% N/A Emb Sep N 247A 83-B AM-J2 Silver 30/5000/90% $5,000 $10,000 $10,000 $20,000 90% 60% $6,300 $12,600 $20,000 $40,000 N/A $30 $60 $75 N/A 90% 90% 90% N/A 90% N/A Emb Sep N 247A AM-KF Silver 30/5000/80% $5,000 $10,000 $10,000 $20,000 80% 50% $6,500 $13,000 $20,000 $40,000 N/A $30 $60 $100 N/A 80% 80% 80% N/A 80% N/A Emb Sep N 247A Primary Physicians include ily Practice, Internal Medicine, Obstetrics-Gynecology, and Pediatrics 1 GA Broker

2 uctible s - Heritage Plus Per Type Type Rx s AC-X5 AM-JR Silver 2000/80% $2,000 $4,000 $5,000 $10,000 80% 60% $6,600 $13,200 $15,000 $30,000 N/A 80% 80% 80% N/A 80% 80% 80% N/A 80% N/A Emb AC-GC AM-J6 Silver 3250/100% $3,250 $6,500 $7,500 $15, % 70% $7,150 $14,300 $15,000 $30,000 N/A 100% 100% 100% N/A 100% 100% 100% N/A 100% N/A Emb AC-X7 AM-J9 Bronze 5500/90% $5,500 $11,000 $10,000 $20,000 90% 70% $7,150 $14,300 $20,000 $40,000 N/A 90% 90% 90% N/A 90% 90% 90% N/A 90% N/A Emb Comb N 253A AM-KJ Bronze 4500/70% $4,500 $9,000 $7,500 $15,000 70% 50% $7,150 $14,300 $15,000 $30,000 N/A 70% 70% 70% N/A 70% 70% 70% N/A 70% N/A Emb Comb N 239A AM-KK Bronze 7000/100% $7,000 $14,000 $10,000 $20, % 70% $7,000 $14,000 $20,000 $40,000 N/A 100% 100% 100% N/A 100% 100% 100% N/A 100% N/A Emb Comb N 270A Primary Physicians include ily Practice, Internal Medicine, Obstetrics-Gynecology, and Pediatrics Primary Advantage s Per Type Type Rx s AC-ZB AM-KQ Gold 25/500/100% $500 $1,000 $5,000 $10, % 70% $3,500 $7,000 $15,000 $30,000 N/A $25 $50 $100 $ % $300 $300 N/A $750 N/A Emb Sep N 247A AC-ZD AM-KS Silver 35/1750/100% $1,750 $3,500 $5,000 $10, % 70% $7,150 $14,300 $15,000 $30,000 N/A $35 $70 $100 $ % $500 $500 N/A $1,000 N/A Emb Sep N 250A AC-ZC AM-KR Silver 20/2500/100% $2,500 $5,000 $5,000 $10, % 70% $7,150 $14,300 $15,000 $30,000 N/A $20 $50 $100 $ % $300 $300 N/A $750 N/A Emb Sep N 247A AM-KU Silver 30/3000/100% $3,000 $6,000 $10,000 $20, % 70% $6,500 $13,000 $15,000 $30,000 N/A $30 $60 $125 $ % $500 $500 N/A $750 N/A Emb Sep N 250A AC-ZF AM-KP Bronze 50/5500/100% $5,500 $11,000 $10,000 $20, % 80% $6,800 $13,600 $20,000 $40,000 N/A $50 $135 $150 $ % $500 $500 N/A $1,500 N/A Emb Sep N 252A AC-ZE AM-KT Bronze 35/5750/100% $5,750 $11,500 $10,000 $20, % 70% $7,150 $14,300 $20,000 $40,000 N/A $35 $75 $125 $ % $500 $500 N/A $1,500 N/A Emb Sep N 253A Primary Physicians include ily Practice, Internal Medicine, Obstetrics-Gynecology, and Pediatrics 1 Services provided by a (physician office visits, preventive care, lab work and X-rays, office-based outpatient surgery, allergy testing) are not subject to the annual plan deductible. Services provided by a Specialist, including OB-GYN for prenatal visits, are first subject to the annual plan deductible; once the deductible is satisfied, then the member copay applies. 2 The following services will be subject to In-Network urance less than 100%: Ambulance, Skilled Nursing Facility, Allergy & Other Injections, Out-patient Chemotherapy, Hospice. 2 GA Broker

3 Health Savings Account (HSA) s - Heritage Plus Employer Funding Amount Min Max AC-YJ AM-KA Gold $0 $0 25/1500/100% $1,500 $4,500 $5,000 $10, % 70% $3,000 $6,000 $15,000 $30,000 N/A $25 $75 $100 $ % $350 $300 N/A $500 N/A AM-KM Gold $0 $0 2000/100% $2,000 $4,000 $10,000 $20, % 50% $2,000 $4,000 $20,000 $40,000 N/A 100% 100% 100% N/A 100% 100% 100% N/A 100% N/A AC-YD AM-JU Gold $650 $1, /80% $2,100 $6,300 $5,000 $10,000 80% 60% $6,550 $13,100 $15,000 $30,000 N/A 80% 80% 80% N/A 80% 80% 80% N/A 80% N/A AC-YB AM-JS Silver $50 $ /70% $2,250 $6,750 $5,000 $10,000 70% 60% $6,500 $13,000 $15,000 $30,000 N/A 70% 70% 70% N/A 70% 70% 70% N/A 70% N/A AC-YK AM-KC Silver $0 $0 40/2500/100% $2,500 $7,150 $5,000 $10, % 70% $6,500 $13,000 $15,000 $30,000 N/A $40 $ % $ % 100% 100% N/A $1,000 N/A AC-YE AM-JV Gold $900 $1, /80% $2,600 $7,150 $7,500 $15,000 80% 60% $6,550 $13,100 $15,000 $30,000 N/A 80% 80% 80% N/A 80% 80% 80% N/A 80% N/A Visit Per Type NonEmb / Emb NonEmb / Emb NonEmb / Emb NonEmb / Emb NonEmb / Emb NonEmb / Emb Type Rx s Comb N 270A Comb N 251A AM-KN Silver $0 $0 3000/70% $3,000 $6,000 $10,000 $20,000 70% 50% $4,750 $9,500 $20,000 $40,000 N/A 70% 70% 70% N/A 70% 70% 70% N/A 70% N/A Emb AC-YC AM-JT Gold $1,600 $2,050 15/5250/100% $5,250 $10,500 $10,000 $20, % 70% $6,550 $13,100 $20,000 $40,000 N/A $15 $30 $75 N/A 100% 100% 100% N/A 100% N/A Emb AC-YA AM-J5 Bronze $0 $0 5500/70% $5,500 $11,000 $10,000 $20,000 70% 60% $6,550 $13,100 $20,000 $40,000 N/A 70% 70% 70% N/A 70% 70% 70% N/A 70% N/A Emb Comb N 251A AM-KL Bronze $0 $0 6500/100% $6,500 $13,000 $10,000 $20, % 50% $6,500 $13,000 $20,000 $40,000 N/A 100% 100% 100% N/A 100% 100% 100% N/A 100% N/A Emb Comb N 270A Primary Physicians include ily Practice, Internal Medicine, Obstetrics-Gynecology, and Pediatrics In, maximum HSA contribution is $3,400 single/$6,750 family. These amounts are subject to change by the IRS and do not include catch-up contributions for subscribers age 55 and over. The UnitedHealthcare 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 Optum Bank SM, Member FDIC. UnitedHealthcare HSA refers generally to the UnitedHealthcare HSA product, which includes a HDHP, although at times UnitedHealthcare HSA may refer only and specifically to the UnitedHealthcare Health Savings Account, provided in conjunction with Optum Bank and not to the associated HDHP. 3 GA Broker

4 Pharmacy s Member / urance uctible Mail Service Prescription Rx Ratio Drug List Tier 1 Tier 2 Tier 3 Tier 4 Single ily (x Retail) (PDL) 249A $7 $15 $50 N/A N/A N/A 2.5 Advantage 247A $10 $35 $60 $100 N/A N/A 2.5 Advantage 250A $15 $45 $65 $100 N/A N/A 3 Advantage 252A $15 $45 $85 $200 N/A N/A 3 Advantage 253A $20 $65 $100 $200 N/A N/A 3 Advantage Combined /Rx uctible s 247A $10 $35 $60 $100 Same as medical Same as medical 2.5 Advantage 251A $15 $45 $85 $125 Same as medical Same as medical 2.5 Advantage 253A $20 $65 $100 $200 Same as medical Same as medical 3 Advantage 270A 0% 0% 0% 0% Same as medical Same as medical Advantage 239A 30% 30% 30% 30% Same as medical Same as medical Advantage 4 GA Broker

5 For all medical plans listed: uctible applies toward out-of-pocket maximum. All plans have an unlimited lifetime maximum. All plans cover in-network preventive care at 100%. 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 please refer to the Certificate of Coverage or talk to your UnitedHealthcare representative for additional details that could impact the benefits. Different UnitedHealthcare plans may have varying approaches to whether pharmacy costs are included or excluded from the medical deductible. Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by United Health Services, Inc. or their affiliates. Premium rates and/or product forms included herein are subject to approval by regulators. If rates or product forms offered herein are subsequently modified by regulators we will immediately advise you of the change in plan design and retroactively adjust premium in subsequent billings. 5 GA Broker