2018-2019 Large Group (51+) Plans Please be advised that this guide is for informational purposes only. Premium rates and/or product forms inclu herein have been filed and are subject to approval by regulators. We reserve the right to modify this quote and benefits described if nee, once final approval is received, and to correct any typographical errors. For a complete listing of large group (51+) products, please contact your sales representative. Pocket Copay ( or Day) Choice/ AP-CK AP-CK AN-LG AN-LG AN-L5 AY-T4 SJ-4 AN-MM AN-MM AN-L3 AN-L3 AN-L7 AN-L7 AN-L8 AN-L8 AY-UK AN-MN AO-T8 AO-T8 BA-8S AO-T9 AO-T9 $3,000 $10 $50 $100 $1,000 0 $3,000 $3,000 $10 $50 $100 0 $1000* $3,000 $5,000 $10 $20 $40 $75 $150 0 $5,000 $5,000 $10,000 $10 0 $750 $3,000 0 $1,000 60% $3,000 $5,000 $10 $15 $15 $50 $100 * $1,000* $1,000 $4,000 $10 $20 $40 $50 $150 $1,000 $2,000 $3,000 $5,000 $10 $20 $20 $50 $100 $1,000* $2,000* $3,000 $5,000 $10 $40 $75 $150 $1,000 $1,000 $3,000 $5,000 $10 $20 $50 $100 $1,000 $3,000 $10 $20 $20 $50 $100 $1,000 $4,000 $3,000 $7,500 $10 $40 $40 $200 $1,500 $3,000 $3,000 $4,500 $10 $20 $20 $50 $100 POD, then POD, then 0 0 POD, then POD, then 2 2 1 of 6
2018-2019 Large Group (51+) Plans Pocket Copay ( or Day) AN-L4 AN-L4 $1,500 $3,000* $3,000 $5,000 $10 $20 $40 $75 $150 AT-YL SJ-Y $1,500 $3,000* $3,000 $7,000 AY-UB $1,500 $5,000 $10 $50 $50 0 0 AY-UA $1,750 $6,000 $10 $20 $45 $45 $1,000 AY-TZ AN-MB $2,000 $4,000 $3,000 $5,000 $10 $45 $75 $150 0 0 AN-LZ AN-LZ $2,000 $4,000 $4,000 $6,000 $10 $45 $75 $150 AN-L6 AN-L6 $2,000 $4,000 90% $4,000 $6,000 $10 $45 $75 0 90% 90% 90% AN-MT AN-MT $2,000 $5,000 $10 $50 $75 $200 Freestanding; Freestanding; AO-ON AO-ON $2,000 $6,500 $0 $0 $75 $50 then after AO-OM AO-OM $2,000 $5,000 60% $6,500 $10,000 $0 $0 $75 $50 then after AY-TK AJ-IH Choice $2,000 $6,850 $0 1st 3 visits,** then $0 1st 3 visits,** then $0 1st 2 visits,** then then then then after BA-8T $2,000 $5,000 60% $7,350 $10,000 $0 POD then $40 AT-2M AT-2M $3,000 $5,000 $0 $50 $1000 after AT-2N AT-2N $3,000 $5,000 $5,000 $10,000 $10 $45 $45 0 AT-2L AT-2L $3,000 $6,000 $7,150 $12,000 $10 $50 $50 $50 0 2 of 6
2018-2019 Large Group (51+) Plans Pocket Copay ( or Day) BE-HD $3,000 $6,000 60% $7,350 $15,000 $0 POD then $40 AY-UM $3,500 $6,000 $6,000 $12,000 $10 $50 $50 then Freestanding; Freestanding; after Freestanding; AY-T9 $3,750 $6,500 $7,350 $13,000 $10 $50 $50 0 BG-IC $4,000 $7,000 $6,500 $15,000 $10 BG-IB $4,000 $7,000 60% $7,000 $15,000 $10 BG-ID $5,000 $8,000 $7,000 $15,000 $10 $70 $70 BE-HE $5,000 $8,000 60% $7,350 $15,000 $0 POD then $40 BE-NQ $3,000 60% $7,350 $10 $70 $70 then Freestanding; after Freestanding; BG-IE $6,000 $9,000 $7,350 $15,000 $10 $70 $70 AY-T6 $7,350 $10,000 $7,350 $20,000 $10 after AN-L9 AN-L9 $1,000* $2,000* $3,000 $5,000 $10 $40 $75 $150 No Charge AN-MA AN-MA $2,000 $4,000 $3,000 $5,000 $10 $45 $75 $150 No Charge AG-XK AG-XK $2,000 $5,000 60% $4,000 $10,000 after AY-T3 AG-XH $3,000 $5,000 $4,000 $10,000 $10 $20 $40 $75 $200 after 3 of 6
2018-2019 Large Group (51+) Plans Pocket Copay ( or Day) AN-L2 AY-TY AN-L1 AN-L1 AY-T1 AN-MC AN-K4 AN-K4 EPO AN-MO AN-MO AJ-GO AJ-GO AN-LS AN-LS AY-T7 AJ-GM AJ-GM EPO AJ-GP AJ-GP AT-KJ AT-KJ AE-1H AE-1H AY-T5 BJ-NR AY-UC AN-MH $1,500 $3,000 $3,000 $6,000 $2,000 $4,000 $3,000 $8,000 $2,000 $4,000 $4,000 $8,000 $2,500 $5,000 $2,500 $5,000 $6,000 $10,000 $3,000 $5,000 $5,000 $10,000 $3,000 $5,000 $5,000 $10,000 $3,000 $6,000 $5,000 $8,000 $6,250 $12,000 $5,000 $8,000 60% $6,250 $12,000 $5,500 $8,500 50% $6,350 $12,700 $6,000 $9,000 $6,450 $20,000 $6,350 $9,000 $6,350 $20,000 $10 $10 $10 $20 $60 $50 $20 $100 $75 0 $200 then $4,000 $10 $40 $40 $200 $1,000 $4,000 $10 $40 $75 $200 0 $1,000 Day 0 $150 Freestanding; 0 after after after after after after after after after after after after after $150 Freestanding; 0 after 2 2 2 2 2 2 2 2 2 2 2 2 MM 4 of 6
2018-2019 Large Group (51+) Plans Pocket Copay ( or Day) AY-UD AN-ME AY-UE AN-MF AY-UG AY-UF AN-MG BE-HF BJ-NS AN-MD AN-MD AV-3C AV-3C BE-HG $1,500 $4,000 $10 $40 $75 $200 $2,000 $5,000 $10 $60 $75 $200 $2,000 $5,500 $0 $0, then $2,000 $6,500 $10 $60 $75 0 $2,000 $7,350 $0 $2,000 $7,350 $10 $70 $70 $2,500 $6,000 POD, then $3,000 $5,000 $10 $50 $50 $3,000 $7,350 $0 *Family uctible is 3 times the single uctible 1 Primary Care Physicians (PCP) include Family Practice, Internal Medicine, Obstetrics-Gynecology and Pediatrics. 2 Plan MM not available with this plan design POD, then Note: Plans listed meet Minimum Creditable Coverage Standards. Note: Plans listed as Non-/ reflect non-embed uctibles and embed out of pocket maximums, meaning no individual in the family has satisfied the uctible until the entire family uctible amount has been met. An individual will not have to pay more than the individual OOP Max amount. uctibles mean all individual uctible amounts will count toward the family uctible. An individual will not have to pay more than the individual uctible amount and OOP Max., then 0 Note: For s, copayments will not apply until after the uctible has been satisfied. Note: In 2018, maximum contribution is $3,450 single/$6,900 family. These amounts are subject to change by IRS and do not include catch-up contributions for subscribers age 55 and over. The Health Savings Account () high-uctible 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, Member of FDIC. refers generally to the product, which includes an HDHP, although at times may refer only and specifically to the Health Savings Account, provi in conjunction with Optum Bank and not to the associated HDHP. $150 POD, then 0 $40 after $40 2 5 of 6
2018-2019 Large Group (51+) Plans 2018-2019 Combined Separate Individual Family Member Tier 1 Tier 2 Tier 3 Tier 4 ialty Tier 1 Tier 2 Tier 3 Mail Order (90-Day Supply) MM Same as Medical Same as Medical $0 $0 $0 2.5x WT Same as Medical Same as Medical $15 $50 15 25% to $125 25% to 0 2.5x 2V Same as Medical Same as Medical $10 $60 2.5x H9 Same as Medical Same as Medical $10 $50 2.5x FF Same as Medical Same as Medical $20 $40 $70 2.5x 2V $10 $60 2.5x WY $100** ** $10 $50 $10 25% to $125 25% to 0 2.5x WZ $150** $450** $10 $60 $10 25% to $125 25% to 0 2.5x 01 $10 $70 2.5x EM $15 $60 2.5x H9 $10 $50 2.5x WW $10 $70 $10 25% to $125 25% to 0 2.5x WU $100** ** $15 $60 $15 25% to $125 25% to 0 2.5x OL $100** ** $10 $50 2.5x ES $150** $450** $10 $60 2.5x OM $100** ** $15 $60 2.5x FF $20 $40 $70 2.5x WT $15 $50 $15 25% to $125 25% to 0 2.5x XA $20 $40 $70 $20 25% to $125 25% to 0 2.5x 535 0*** *** $5 $50 $100 0 2.5x 536 0** ** $5 $50 $100 $5 25% to $125 25% to 0 2.5x ** does not apply on Tier 1 medications *** does not apply on Tier 1 or Tier 2 medications Insurance coverage provi by or through Insurance Company or its affiliates. Administrative services provi by United HealthCare Services, Inc. or their affiliates. MT-1070212.2 6/18 2018 United HealthCare Services, Inc. 485-5246 Rev. 5 (7/11/2018) 6 of 6