Health Plan Product Offering UnitedHealthcare offers a wide variety of plan options that allow you to tailor your benefit needs to your business needs, choosing what you value in a health plan. / UnitedHealthcare ier Plans Choice+ Core Choice+ Core Coinsurance uctible Pocket Maximum Copay/Per Occurrence <19 Spec 2 4 AH-AT AH-BL AH-CN AH-DF 100% 80% $0 $0 $5,000 $10,000 $1,500 $3,000 $10,000 $20,000 $20 $20 $0 $20 $40 $75 $300 100% AH-AU AH-BM AH-CO AH-DG 100% 80% $250 $500 $5,000 $10,000 $1,750 $3,500 $10,000 $20,000 $20 $20 $0 $20 $40 $75 $300 100% AH-AV AH-BN AH-CP AH-DH 100% 80% $500 $1,000 $5,000 $10,000 $2,000 $4,000 $10,000 $20,000 $20 $20 $0 $20 $40 $75 $300 100% AH-AW AH-BO AH-CQ AH-DI 100% 80% $1,000 $2,000 $5,000 $10,000 $2,500 $5,000 $10,000 $20,000 $20 $20 $0 $20 $40 $75 $300 100% AH-AX AH-BP AH-CR AH-DJ 100% 80% $1,500 $3,000 $5,000 $10,000 $3,000 $6,000 $10,000 $20,000 $20 $20 $0 $20 $40 $75 $300 100% AH-AY AH-BQ AH-CS AH-DK 100% 80% $2,000 $4,000 $5,000 $10,000 $3,500 $7,000 $10,000 $20,000 $25 $30 $0 $30 $60 $75 $300 100% AH-AZ AH-BR AH-CT AH-DL 100% 80% $2,500 $5,000 $5,000 $10,000 $4,000 $8,000 $10,000 $20,000 $25 $30 $0 $30 $60 $75 $300 100% AH-A1 AH-BS AH-CU AH-DM 100% 80% $3,000 $6,000 $5,000 $10,000 $4,500 $9,000 $10,000 $20,000 $25 $30 $0 $30 $60 $75 $300 100% AH-A2 AH-BT AH-CV AH-DN 100% 80% $5,000 $10,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 $25 $30 $0 $30 $60 $75 $300 100% AH-A3 AH-BU AH-CW AH-DO 80% 60% $0 $0 $5,000 $10,000 $2,500 $5,000 $10,000 $20,000 $20 $20 $0 $20 $40 $75 $250 100% AH-A4 AH-BV AH-CX AH-DP 80% 60% $250 $500 $5,000 $10,000 $3,000 $6,000 $10,000 $20,000 $20 $20 $0 $20 $40 $75 $250 100% AH-A5 AH-BW AH-CY AH-DQ 80% 60% $500 $1,000 $5,000 $10,000 $3,500 $7,000 $10,000 $20,000 $20 $20 $0 $20 $40 $75 $250 100% AH-A6 AH-BX AH-CZ AH-DR 80% 60% $1,000 $2,000 $5,000 $10,000 $4,000 $8,000 $10,000 $20,000 $20 $20 $0 $20 $40 $75 $250 100% AH-A7 AH-BY AH-C1 AH-DS 80% 60% $1,500 $3,000 $5,000 $10,000 $5,000 $10,000 $10,000 $20,000 $20 $20 $0 $20 $40 $75 $250 100% AH-A8 AH-BZ AH-C2 AH-DT 80% 60% $2,000 $4,000 $5,000 $10,000 $6,000 $12,000 $10,000 $20,000 $25 $30 $0 $30 $60 $75 $250 100% AH-A9 AH-B1 AH-C3 AH-DU 80% 60% $2,500 $5,000 $5,000 $10,000 $6,000 $12,000 $10,000 $20,000 $25 $30 $0 $30 $60 $75 $250 100% AH-BA AH-B2 AH-C4 AH-DV 80% 60% $3,000 $6,000 $5,000 $10,000 $6,000 $12,000 $10,000 $20,000 $25 $30 $0 $30 $60 $75 $250 100% AH-BB AH-B3 AH-C5 AH-DW 80% 60% $5,000 $10,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 $25 $30 $0 $30 $60 $75 $250 100% AH-BC AH-B4 AH-C6 AH-DX 60% 50% $0 $0 $5,000 $10,000 $2,500 $5,000 $10,000 $20,000 $20 $20 $0 $20 $40 $75 40% 100% +40% AH-BD AH-B5 AH-C7 AH-DY 60% 50% $250 $500 $5,000 $10,000 $3,000 $6,000 $10,000 $20,000 $20 $20 $0 $20 $40 $75 40% 100% +40% AH-BE AH-B6 AH-C8 AH-DZ 60% 50% $500 $1,000 $5,000 $10,000 $3,500 $7,000 $10,000 $20,000 $20 $20 $0 $20 $40 $75 40% 100% +40% AH-BF AH-B7 AH-C9 AH-D1 60% 50% $1,000 $2,000 $5,000 $10,000 $4,000 $8,000 $10,000 $20,000 $20 $20 $0 $20 $40 $75 40% 100% +40% AH-BG AH-B8 AH-DA AH-D2 60% 50% $1,500 $3,000 $5,000 $10,000 $5,000 $10,000 $10,000 $20,000 $20 $20 $0 $20 $40 $75 40% 100% +40% AH-BH AH-B9 AH-DB AH-D3 60% 50% $2,000 $4,000 $5,000 $10,000 $6,000 $12,000 $10,000 $20,000 $25 $30 $0 $30 $60 $75 40% 100% +40% AH-BI AH-CA AH-DC AH-D4 60% 50% $2,500 $5,000 $5,000 $10,000 $6,000 $12,000 $10,000 $20,000 $25 $30 $0 $30 $60 $75 40% 100% +40% AH-BJ AH-CB AH-DD AH-D5 60% 50% $3,000 $6,000 $5,000 $10,000 $6,000 $12,000 $10,000 $20,000 $25 $30 $0 $30 $60 $75 40% 100% +40% AH-BK AH-CC AH-DE AH-D6 60% 50% $5,000 $10,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 $25 $30 $0 $30 $60 $75 40% 100% +40% Administrative services provided by United Health Services, Inc. or their affiliates. Health Plan coverage provided by or through UnitedHealthcare of, Inc. MT-1159710.0 11/17 BROK 2017 United Health Services, Inc. 17-6323 1
UnitedHealthcare PROformance Plans Choice+ Core Choice+ Core Coinsurance uctible Pocket Maximum Copay/Per Occurrence AX-LO AX-LS AX-OF AX-OJ 80% 50% $1,000 $2,000 $5,000 $10,000 $7,150 $14,300 $10,000 $20,000 $0 $10 $0 $40 $80 $25 AX-LP AX-LT AX-OG AX-OK 80% 50% $2,000 $4,000 $5,000 $10,000 $7,150 $14,300 $10,000 $20,000 $0 $10 $0 $40 $80 $25 AX-LQ AX-LU AX-OH AX-OL 80% 50% $3,000 $6,000 $7,500 $15,000 $7,150 $14,300 $15,000 $30,000 $0 $10 $0 $40 $80 $25 AX-LR AX-LV AX-OI AX-OM 80% 50% $5,000 $10,000 $10,000 $20,000 $7,150 $14,300 $20,000 $40,000 $0 $10 $0 $40 $80 $25 AX-LW AX-L1 AX-ON AX-OR 80% 50% $1,000 $2,000 $5,000 $10,000 $7,150 $14,300 $10,000 $20,000 $0 $15 $0 $50 $100 $25 AX-LX AX-L2 AX-OO AX-OS 80% 50% $2,000 $4,000 $5,000 $10,000 $7,150 $14,300 $10,000 $20,000 $0 $15 $0 $50 $100 $25 AX-LY AX-L3 AX-OP AX-OT 80% 50% $3,000 $6,000 $7,500 $15,000 $7,150 $14,300 $15,000 $30,000 $0 $15 $0 $50 $100 $25 AX-LZ AX-K4 AX-OQ AX-OU 80% 50% $5,000 $10,000 $10,000 $20,000 $7,150 $14,300 $20,000 $40,000 $0 $15 $0 $50 $100 $25 19+ <19 Spec 2 / $40 $500 $40 $500 $40 $500 $40 $500 UnitedHealthcare ier Value Plans Choice+ Core Choice+ Core Coinsurance uctible Pocket Maximum Copay/Per Occurrence 19+ <19 Spec 2 4 AK-UG AK-UP AK-VH AK-VQ 100% 70% $500 $1,500 $5,000 $15,000 $6,350 $12,700 $10,000 $30,000 $25 $35 $0 $35 $70 $100 $400 $400 AK-UH AK-UQ AK-VI AK-VR 100% 70% $1,000 $3,000 $5,000 $15,000 $6,350 $12,700 $10,000 $30,000 $25 $40 $0 $40 $80 $100 $400 $400 AK-UI AK-UR AK-VJ AK-VS 100% 70% $3,000 $9,000 $5,000 $15,000 $6,350 $12,700 $10,000 $30,000 $25 $45 $0 $45 $90 $100 $400 $400 AK-UJ AK-US AK-VK AK-VT 100% 70% $5,000 $10,000 $10,000 $30,000 $6,350 $12,700 $20,000 $60,000 $25 $45 $0 $45 $90 $100 $400 $400 AK-UK AK-UT AK-VL AK-VU 80% 50% $0 $0 $5,000 $15,000 $6,350 $12,700 $10,000 $30,000 $25 $35 $0 $35 $70 $100 $400 $400 AK-UL AK-UU AK-VM AK-VV 80% 50% $1,250 $3,750 $5,000 $15,000 $6,350 $12,700 $10,000 $30,000 $25 $40 $0 $40 $80 $100 $400 $400 AK-UM AK-UV AK-VN AK-VW 80% 50% $2,000 $6,000 $5,000 $15,000 $6,350 $12,700 $10,000 $30,000 $25 $40 $0 $40 $80 $100 $400 $400 AK-UN AK-UW AK-VO AK-VX 80% 50% $2,500 $7,500 $5,000 $15,000 $6,350 $12,700 $10,000 $30,000 $25 $40 $0 $40 $80 $100 $400 $400 AK-UO AK-UX AK-VP AK-VY 80% 50% $4,000 $12,000 $10,000 $30,000 $6,350 $12,700 $20,000 $60,000 $25 $45 $0 $45 $90 $100 $400 $400 Administrative services provided by United Health Services, Inc. or their affiliates. Health Plan coverage provided by or through UnitedHealthcare of, Inc. MT-1159710.0 11/17 BROK 2017 United Health Services, Inc. 17-6323 2
/ UnitedHealthcare PrimaryAdvantage Plans Choice+ Core Choice+ Core Coinsurance uctible Pocket Maximum Copay/Per Occurrence AN-CN AN-EZ AN-FO AN-F1 80% 50% $1,000 $2,000 $5,000 $10,000 $6,500 $13,000 $10,000 $20,000 $0 $0 $100 $50 AN-CO AN-E1 AN-FP AN-F2 80% 50% $2,000 $4,000 $5,000 $10,000 $6,500 $13,000 $10,000 $20,000 $0 $0 $100 $50 AN-CP AN-E2 AN-FQ AN-F3 80% 50% $3,000 $6,000 $10,000 $20,000 $6,500 $13,000 $20,000 $40,000 $0 $0 $100 $50 AN-CQ AN-E3 AN-FR AN-F4 80% 50% $5,000 $10,000 $10,000 $20,000 $6,500 $13,000 $20,000 $40,000 $0 $0 $100 $50 AN-CR AN-E4 AN-FS AN-F5 50% 50% $1,000 $2,000 $5,000 $10,000 $6,500 $13,000 $10,000 $20,000 $0 $0 $100 $50 AN-CS AN-E5 AN-FT AN-F6 50% 50% $2,000 $4,000 $5,000 $10,000 $6,500 $13,000 $10,000 $20,000 $0 $0 $100 $50 UnitedHealthcare PrimaryAdvantage HSA Plans Coinsurance uctible Pocket Maximum Choice+ Core Choice+ Core Spec AX-T7 AY-Y3 AX-U1 AY-Y5 80% 50% $1,000 $2,000 $5,000 $10,000 $6,500 $13,000 $10,000 $20,000 $0 $100 $50 AX-T8 AY-Y4 AX-U2 AY-Y6 80% 50% $2,000 $4,000 $5,000 $10,000 $6,500 $13,000 $10,000 $20,000 $0 $100 $50 Copayments on Primary Advantage HSA plans will be required only after the deductible has been met and will continue to be required until the annual out-of-pocket maximum is met. "Non-Embedded" deductible means no covered family member will satisfy an individual deductible until the entire family deductible is met. There is no separate additional Rx deductible required for Primary Advantage HSA plans. UnitedHealthcare Primary Advantage Rx Plans Rx Plan Code Copays Tier 1 Tier 2 Tier 3 Tier 4 Mail- Order Ratio Rx Ind/Fam Rx uctible Note 454/454x $0 $50 $100 $250 2.5x $250/$500 Tiers 3 & 4 only 455/455x $5 $50 $100 $250 2.5x $250/$500 Tiers 3 & 4 only 751/751x $0 $50 $100 $250 2.5x N/A For HSA use only Administrative services provided by United Health Services, Inc. or their affiliates. Health Plan coverage provided by or through UnitedHealthcare of, Inc. MT-1159710.0 11/17 BROK 2017 United Health Services, Inc. 17-6323 3
/ UnitedHealthcare FlexFree 17 Plans Choice+ Core Choice+ Core Coinsurance uctible Pocket Maximum Copay/Per Occurrence Spec AK-TB AK-TG AK-TV AK-T1 80% 50% $1,000 $2,000 $5,000 $10,000 $6,850 $13,700 $10,000 $20,000 $25 $0/3 visits combined $0/2 visits AK-TC AK-TH AK-TW AK-T2 80% 50% $2,000 $4,000 $5,000 $10,000 $6,850 $13,700 $10,000 $20,000 $25 $0/3 visits combined $0/2 visits AK-TD AK-TI AK-TX AK-T3 80% 50% $3,000 $6,000 $5,000 $10,000 $6,850 $13,700 $10,000 $20,000 $25 $0/3 visits combined $0/2 visits AK-TE AK-TJ AK-TY AK-T4 80% 50% $5,000 $10,000 $10,000 $20,000 $6,850 $13,700 $20,000 $40,000 $25 $0/3 visits combined $0/2 visits AK-TF AK-TK AK-TZ AK-T5 100% 50% $5,000 $10,000 $10,000 $20,000 $6,850 $13,700 $20,000 $40,000 $25 $0/3 visits combined $0/2 visits UnitedHealthcare Standard Plans Plan Type Choice+ Core Choice+ Core Coinsurance uctible Pocket Maximum Copay/Per Occurrence <19 AG-U4 AG-87 AG-U4 AG-87 50/50 50% 50% $2,000 $4,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 $50 $0 $50 $50 $100 AG-U5 AG-88 AG-U5 AG-88 50/50 50% 50% $3,000 $6,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 $50 $0 $50 $50 $100 AG-U6 AG-89 AG-U6 AG-89 50/50 50% 50% $5,000 $10,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 $50 $0 $50 $50 $100 AH-CD AH-CG AH-D7 AH-EA FlexPoint 6 80% 50% $1,000 $2,000 $5,000 $10,000 $4,000 $8,000 $10,000 $20,000 $25 N/A $25 $50 $100 AH-CE AH-CH AH-D8 AH-EB FlexPoint 6 80% 50% $2,000 $4,000 $5,000 $10,000 $6,000 $12,000 $10,000 $20,000 $30 N/A $30 $60 $100 AH-CF AH-CI AH-D9 AH-EC FlexPoint 6 80% 50% $5,000 $10,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 $35 N/A $35 $70 $100 AG-9A AG-9B AG-9A AG-9B Consumer 80% 60% $2,000 $4,000 $5,000 $10,000 $6,000 $12,000 $10,000 $20,000 AG-9C AG-9D AG-9C AG-9D Consumer 80% 60% $5,000 $10,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 AE-3S AG-9E AE-3S AG-9E Consumer 50% 50% $0 $0 $5,000 $10,000 $6,000 $12,000 $10,000 $20,000 50% 50% 50% 50% 50% 50% 50% 50% AG-YF N/A AG-YF N/A Non-Diff 80% 80% $1,000 $2,000 N/A N/A $3,000 $6,000 N/A N/A AG-YG N/A AG-YG N/A Non-Diff 80% 80% $2,000 $4,000 N/A N/A $4,000 $8,000 N/A N/A Spec 2 4 $250 $250 $250 Administrative services provided by United Health Services, Inc. or their affiliates. Health Plan coverage provided by or through UnitedHealthcare of, Inc. MT-1159710.0 11/17 BROK 2017 United Health Services, Inc. 17-6323 4
/ UnitedHealthcare Navigate 8,11 and Charter 8,11 Plans (Chicago market 471 only) Coinsurance Plan Type Navigate Charter uctible Pocket Maximum Single Family Single Family 19+ <19 Spec w/ PCP Referral Copay/Per Occurrence AG-9Y AM-24 Copay 100% $0 $0 $1,500 $3,000 $20 $20 $0 $40 $75 $300 100% AG-9Z AM-25 Copay 100% $250 $500 $1,750 $3,500 $20 $20 $0 $40 $75 $300 100% AG-91 AN-K3 Copay 100% $500 $1,000 $2,000 $4,000 $20 $20 $0 $40 $75 $300 100% AG-92 AM-2V Copay 100% $1,000 $2,000 $2,500 $5,000 $20 $20 $0 $40 $75 $300 100% AG-93 AM-2W Copay 100% $1,500 $3,000 $3,000 $6,000 $20 $20 $0 $40 $75 $300 100% AG-94 AM-2X Copay 100% $2,000 $4,000 $3,500 $7,000 $25 $30 $0 $60 $75 $300 100% AG-95 AM-2Y Copay 100% $2,500 $5,000 $4,000 $8,000 $25 $30 $0 $60 $75 $300 100% AG-96 AM-2Z Copay 100% $3,000 $6,000 $4,500 $9,000 $25 $30 $0 $60 $75 $300 100% AG-97 AM-21 Copay 100% $5,000 $10,000 $6,350 $12,700 $25 $30 $0 $60 $75 $300 100% AG-98 AM-22 Copay 80% $0 $0 $2,500 $5,000 $20 $20 $0 $40 $75 $250 100% AG-99 AM-23 Copay 80% $250 $500 $3,000 $6,000 $20 $20 $0 $40 $75 $250 100% AH-AA AM-26 Copay 80% $500 $1,000 $3,500 $7,000 $20 $20 $0 $40 $75 $250 100% AH-AB AM-27 Copay 80% $1,000 $2,000 $4,000 $8,000 $20 $20 $0 $40 $75 $250 100% AH-AC AM-28 Copay 80% $1,500 $3,000 $5,000 $10,000 $20 $20 $0 $40 $75 $250 100% AH-AD AM-29 Copay 80% $2,000 $4,000 $6,000 $12,000 $25 $30 $0 $60 $75 $250 100% AH-AE AM-3A Copay 80% $2,500 $5,000 $6,000 $12,000 $25 $30 $0 $60 $75 $250 100% AH-AF AM-3B Copay 80% $3,000 $6,000 $6,000 $12,000 $25 $30 $0 $60 $75 $250 100% AH-AG AM-3C Copay 80% $5,000 $10,000 $6,350 $12,700 $25 $30 $0 $60 $75 $250 100% AH-AH AM-3D Copay 60% $0 $0 $2,500 $5,000 $20 $20 $0 $40 $75 40% 100% +40% +40% AH-AI AM-3E Copay 60% $250 $500 $3,000 $6,000 $20 $20 $0 $40 $75 40% 100% +40% +40% AH-AJ AM-3F Copay 60% $500 $1,000 $3,500 $7,000 $20 $20 $0 $40 $75 40% 100% +40% +40% AH-AK AM-3G Copay 60% $1,000 $2,000 $4,000 $8,000 $20 $20 $0 $40 $75 40% 100% +40% +40% AH-AL AM-3H Copay 60% $1,500 $3,000 $5,000 $10,000 $20 $20 $0 $40 $75 40% 100% +40% +40% AH-AM AM-3I Copay 60% $2,000 $4,000 $6,000 $12,000 $25 $30 $0 $60 $75 40% 100% +40% +40% AH-AN AM-3J Copay 60% $2,500 $5,000 $6,000 $12,000 $25 $30 $0 $60 $75 40% 100% +40% +40% AH-AO AM-3K Copay 60% $3,000 $6,000 $6,000 $12,000 $25 $30 $0 $60 $75 40% 100% +40% +40% AH-AP AM-3L Copay 60% $5,000 $10,000 $6,350 $12,700 $25 $30 $0 $60 $75 40% 100% +40% +40% AX-T9 AX-UA HSA 80% $2,800 $5,600 $6,350 $12,700 80% 80% N/A 80% 80% 80% 80% 80% 80% AH-AR AM-3N HSA 80% $3,500 $7,000 $6,350 $12,700 80% 80% N/A 80% 80% 80% 80% 80% 80% AH-AS AM-3O HSA 80% $5,000 $10,000 $6,350 $12,700 80% 80% N/A 80% 80% 80% 80% 80% 80% Administrative services provided by United Health Services, Inc. or their affiliates. Health Plan coverage provided by or through UnitedHealthcare of, Inc. MT-1159710.0 11/17 BROK 2017 United Health Services, Inc. 17-6323 5
/ UnitedHealthcare Charter Primary Advantage 8,11 Plans (Chicago market 471 only) Charter Coinsurance uctible Pocket Maximum Copay/Per Occurrence Single Family Single Family Spec AX-ZC 80% 50% $1,000 $2,000 $6,500 $13,000 $0 $0 $50 $75 AX-ZD 80% 50% $2,000 $4,000 $6,500 $13,000 $0 $0 $50 $75 AX-ZE 80% 50% $3,000 $6,000 $6,500 $13,000 $0 $0 $50 $75 AX-ZF 80% 50% $5,000 $10,000 $6,500 $13,000 $0 $0 $50 $75 UnitedHealthcare Primary Advantage Rx Plans Rx Plan Code Copays Tier 1 Tier 2 Tier 3 Tier 4 Mail-Order Ratio Rx Ind/Fam Rx uctible Note 454/454x $0 $50 $100 $250 2.5x $250/$500 Tiers 3 & 4 only 455/455x $5 $50 $100 $250 2.5x $250/$500 Tiers 3 & 4 only UnitedHealthcare Advanced Tier Plans Choice+ Core Choice+ Core Physician Physician 2 2 Coinsurance uctible Pocket Maximum Copay/Per Occurrence Facility,2 Spec 2 4 AH-CJ N/A AH-ED N/A 80% 50% 80% 50% $1,500 $3,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 $25 $50 $50 $100 $100 $250 AH-CK N/A AH-EE N/A 80% 50% 80% 50% $2,000 $4,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 $25 $50 $50 $100 $100 $250 AH-CL N/A AH-EF N/A 80% 50% 80% 50% $1,500 $3,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 $35 $70 $70 $100 $100 $250 AH-CM N/A AH-EG N/A 80% 50% 80% 50% $2,000 $4,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 $35 $70 $70 $100 $100 $250 Administrative services provided by United Health Services, Inc. or their affiliates. Health Plan coverage provided by or through UnitedHealthcare of, Inc. MT-1159710.0 11/17 BROK 2017 United Health Services, Inc. 17-6323 6
/ UnitedHealthcare Health Savings Account (HSA) Plans Choice+ Core Navigate 8,11 Charter 8,11 Coinsurance uctible Pocket Maximum Copay/Per Occurrence 9 5 Spec Type Rx Plan 9 AG-9G AG-9F 100% 80% $2,000 $4,000 $5,000 $10,000 $3,000 $6,000 $10,000 $20,000 100% 100% 100% 100% Non-Emb 10/35/60 AG-9I AG-9H 100% 80% $2,500 $5,000 $5,000 $10,000 $2,500 $5,000 $10,000 $20,000 100% 100% 100% 100% Non-Emb 100% AX-T4 AX-TZ 100% 80% $2,800 $5,600 $5,000 $10,000 $2,800 $5,600 $10,000 $20,000 100% 100% 100% 100% Emb 100% AX-T5 AX-T1 100% 80% $2,800 $5,600 $5,000 $10,000 $3,500 $7,000 $10,000 $20,000 100% 100% 100% 100% Emb 10/35/60 AX-T6 AX-T2 100% 80% $2,800 $5,600 $5,000 $10,000 $5,000 $10,000 $10,000 $20,000 $30 9 $60 9 $75 9 $300 9 Emb 10/35/60 AG-9J AG-9K 100% 80% $3,000 $6,000 $5,000 $10,000 $4,000 $8,000 $10,000 $20,000 100% 100% 100% 100% Emb 10/35/60 AG-9L AG-9M 100% 80% $5,000 $10,000 $5,000 $10,000 $6,000 $12,000 $10,000 $20,000 100% 100% 100% 100% Emb 10/35/60 AG-9N AG-9O 100% 80% $5,000 $10,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 $30 9 $60 9 $75 9 $300 9 Emb 10/35/60 AG-9P AG-9Q 100% 80% $6,350 $12,700 $10,000 $20,000 $6,350 $12,700 $20,000 $40,000 100% 100% 100% 100% Emb 100% AX-TY AX-T3 AX-T9 AX-UA 80% 60% $2,800 $5,600 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 80% 80% 80% 80% Emb 10/35/60 AG-9S AG-9T 80% 60% $3,000 $6,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 80% 80% 80% 80% Emb 10/35/60 AG-9U AG-9V AH-AR AM-3N 80% 60% $3,500 $7,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 80% 80% 80% 80% Emb 10/35/60 AG-9W AG-9X AH-AS AM-3O 80% 60% $5,000 $10,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 80% 80% 80% 80% Emb 10/35/60 AE-3Q AG-9R 50% 50% $3,000 $6,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 50% 50% 50% 50% Emb 10/35/60 Administrative services provided by United Health Services, Inc. or their affiliates. Health Plan coverage provided by or through UnitedHealthcare of, Inc. MT-1159710.0 11/17 BROK 2017 United Health Services, Inc. 17-6323 7
UnitedHealthcare Health Savings Account (HSA) Plans Choice+ Core Coinsurance uctible Pocket Maximum Copay/Per Occurrence Spec / AG-9G AG-9F 100% 80% $2,000 $4,000 $5,000 $10,000 $3,000 $6,000 $10,000 $20,000 100% 100% 100% 100% Non-Emb 10/35/60 AG-9I AG-9H 100% 80% $2,500 $5,000 $5,000 $10,000 $2,500 $5,000 $10,000 $20,000 100% 100% 100% 100% Non-Emb 100% AX-UX AX-UT 100% 80% $2,800 $5,600 $5,000 $10,000 $2,800 $5,600 $10,000 $20,000 100% 100% 100% 100% Emb 100% AX-UV AX-UU 100% 80% $2,800 $5,600 $5,000 $10,000 $3,500 $7,000 $10,000 $20,000 100% 100% 100% 100% Emb 10/35/60 AX-UW AX-UY 100% 80% $2,800 $5,600 $5,000 $10,000 $5,000 $10,000 $10,000 $20,000 $30 9 $60 9 $75 9 $300 9 Emb 10/35/60 AG-9J AG-9K 100% 80% $3,000 $6,000 $5,000 $10,000 $4,000 $8,000 $10,000 $20,000 100% 100% 100% 100% Emb 10/35/60 AG-9L AG-9M 100% 80% $5,000 $10,000 $5,000 $10,000 $6,000 $12,000 $10,000 $20,000 100% 100% 100% 100% Emb 10/35/60 AG-9N AG-9O 100% 80% $5,000 $10,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 $30 9 $60 9 $75 9 $300 9 Emb 10/35/60 AG-9P AG-9Q 100% 80% $6,350 $12,700 $10,000 $20,000 $6,350 $12,700 $20,000 $40,000 100% 100% 100% 100% Emb 100% AX-US AX-UZ 80% 60% $2,800 $5,600 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 80% 80% 80% 80% Emb 10/35/60 AG-9S AG-9T 80% 60% $3,000 $6,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 80% 80% 80% 80% Emb 10/35/60 AG-9U AG-9V 80% 60% $3,500 $7,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 80% 80% 80% 80% Emb 10/35/60 AG-9W AG-9X 80% 60% $5,000 $10,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 80% 80% 80% 80% Emb 10/35/60 AE-3Q AG-9R 50% 50% $3,000 $6,000 $5,000 $10,000 $6,350 $12,700 $10,000 $20,000 50% 50% 50% 50% Emb 10/35/60 5 Type Rx Plan 9 Pharmacy Plans Rx Plan Code Copays Tier 1 Tier 2 Tier 3 Tier 4 Mail-Order Ratio H9* $10 $30 $50 2.5 2V* $10 $35 $60 2.5 EU* $10 $40 $75 $125 2.5 3B* $15 $35 $60 2.5 IU* $15 $40 $75 2.5 DS* $15 $45 $85 $200 3 51* $20 $50 $100 2.5 *Access PDL is available on these pharmacy plans starting Aug. 1, 2017. Click here for additional information on Access vs Advantage PDL. Administrative services provided by United Health Services, Inc. or their affiliates. Health Plan coverage provided by or through UnitedHealthcare of, Inc. MT-1159710.0 11/17 BROK 2017 United Health Services, Inc. 17-6323 8
/ Navigate plans available to employers sitused in the following counties only: Boone, Cook, Dekalb, Dupage, Grundy, Iroquis, Kane, Kankakee, Kendall, Lake, LaSalle, McHenry, Winnebago, Will. Charter plans available to employers sitused in the following counties only: Cook, Dupage, Kane, Kendall, Lake, McHenry, Will. 1 Primary Physicians include Family Practice, Internal Medicine, Obstetrics-Gynecology, and Pediatrics. 2 This tier of benefits applies to UnitedHealth ium Tier 1 ignated Providers. Please visit myuhc.com for details. 3 This tier of benefit applies to Physicians that are not UnitedHealth ium Tier 1 ignated. 4 Plan deductible is waived for Emergency Room visits on plans where copay or copay+coinsurance is listed. 5 Embedded deductible means once an individual meets their portion of the deductible, services are paid for that person without the entire family deductible being met. Non-Embedded deductible means no covered family member will satisfy an individual deductible until the entire family deductible is met. 6 Flexpoint plans feature a copay for office visits one through four during the calendar year or plan year, depending on plan type selected. Office visits five and over will be subject to plan deductible/coinsurance. This is a separate limit for both Physician Office and visits. Plans feature one Preventive visit per year, which does not count against the office visit copay limit. 8 Navigate and Charter plans require referrals for certain services. Failure to obtain a referral may result in either non-payment of claims or in a reduction of benefits. 9 Copayments on HSA plans will be required after the deductible has been met and will continue to be required until the annual out-of-pocket maximum is met. 11 Navigate, Charter, and HMO plans exclude coverage for services provided by Providers with the exception of (1) Services performed in a Facility by hospital-based providers; and (2) Services performed under the Emergency benefit. 17 FlexFree plans feature $0 copay for the first 3 PCP and/or Specialist office visits during the Calendar or Plan Year. Office visits 4+ will be subject to plan deductible/ coinsurance. Plans also feature $0 copay for the first 2 visits during the Plan Year. visits 3+ will be subject to plan deductible/coinsurance. Preventive visits do not count against the office visit copay limit. Administrative services provided by United Health Services, Inc. or their affiliates. Health Plan coverage provided by or through UnitedHealthcare of, Inc. MT-1159710.0 11/17 BROK 2017 United Health Services, Inc. 17-6323 9