California Small Business 1 50 Employees Effective January 1, Product Catalog Plans designed with the needs of employers mind

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1 Caifornia Sma Business 1 50 Empoyees Effective January 1, 2014 Product Cataog Pans designed with the needs of empoyers mind

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3 Product Detais by Category The Power of the Network 4 UnitedHeathcare Product Continuum Chart 5 Choice Simpified* 6 Medica Pans Overview 9 Seect Pus, Consumer-Driven Heath and 13 Non-Differentia PPO Seect Pus 14 Consumer-Driven Heath 19 Non-Differentia PPO 22 Additiona Vaue-Added Programs for Seect Pus, Consumer-Driven 24 Heath and Non-Differentia PPO HMO 27 Signature +, Advantage +, and Aiance + 29 Additiona Vaue-Added Programs for Signature, Advantage, and Aiance 34 eservices 37 Manage Business Onine with eservices 38 Vaue-Added Programs Avaiabe with Every Pan and Additiona Services 41 Sma Business Weness Programs 42 Market-Specific Soutions and Resources 43 Speciaty Pans 44 Packaged Savings 46 Enhanced Member Service 47 Benefit Services 47 * Forma product name: UnitedHeathcare Muti-Choice + Forma HMO product names: Signature = UnitedHeathcare SignatureVaue Advantage = UnitedHeathcare SignatureVaue Advantage Aiance = UnitedHeathcare SignatureVaue Aiance

4 Better Information. Better Decisions. Better Heath. UnitedHeathcare is a division of UnitedHeath Group, a Fortune 50 company and one of the singe argest heath coverage carriers in the country. We offer a diverse range of heath coverage pans and a nationa network of more than 726,000 physicians and heath care professionas, 5,600 hospitas and 64,000 pharmacies. Serving neary 25 miion members nationwide, we re committed to enhancing the heath care experience through: Better information We aert individuas and their doctors to potentia heath risks or opportunities to take charge of their heath. We give empoyers access to information to pan and impement worksite weness programs to boost productivity and morae. Better decisions When we give empoyers, individuas and doctors access to reevant information, they can be empowered to make better-informed decisions. Better heath Our shared goa is to hep peope ive heathier ives, which contributes to a heathier and more productive, costefficient workpace. 2

5 We asked our customers what to improve and they tod us Do something about the costs Make it easy You be gad to know that we re doing just that. Affordabiity Good heath. We hear and read every day that the best way to get contro over heath care costs is to get heathy. It s been we-documented: Poor heath costs money. And unheathy empoyees cost their empoyers in ost productivity as we as heath care costs. UnitedHeathcare pans incude 100 percent coverage for preventive care and weness benefits, such as weness coaching, fitness memberships and biometric screenings, with buit-in incentives to encourage members to adopt heathy behaviors, and other vaue-added programs at no additiona premium cost. And we contact our members to get that preventive care or take action on persona heath risks when the need arises. Education. We re making it easier for our customers to understand and manage their heath care costs with toos such as our easy-to-use myheathcare Cost Estimator and easiy accessibe heath advisers, professionas who offer guidance as needed through the compex heath care system. Pan design. Pans such as Seect Pus and Aiance feature fexibiity in choice of benefits and financia responsibiity, as we as give the member more contro over managing heathreated expenses. And the increasing avaiabiity of ower-cost generic drugs is making a significant dent in the high cost of prescription medication. Simpicity Simper is better. We ve improved our services, simpified administration and renewas, and made it easier to offer more we-rounded heath care coverage options to empoyers and their empoyees. And our Choice Simpified option provides empoyers with the opportunity to mix and match any of our pans to meet their needs. Pus, speciaty pans, such as denta, vision or ife, can be added at considerabe savings, and administration services are part and parce of the program. 3

6 The Power of the Network Our commitment to providing you with heath coverage soutions incudes offering an expansive network, both nationay and ocay. Our Caifornia HMO network incudes over: 52,000 physicians and heath care professionas, and 220 hospitas Advantage pan: More than 30,000 physicians and speciaists, and 140 hospitas Aiance pan: More than 21,000 physicians and speciaists, and 120 hospitas Our Caifornia Seect Pus network incudes over: 100,000 physicians and heath care professionas, and 340 hospitas Our nationa network incudes over: 726,000 physicians and heath care professionas, and 5,600 hospitas Network coverage Empoyees have nationwide access to 83 percent of a avaiabe U.S. hospita beds and two out of three avaiabe doctors and heath care professionas. Seamess and easy to use Fuy integrated Stabe 4

7 UnitedHeathcare Product Continuum Chart Caifornia Sma Business (1-50 empoyees) UnitedHeathcare offers a broad range of heath pans that are designed to be affordabe and fexibe for empoyers of various sizes. To hep determine the pans that best suit their empoyees need for affordabiity, we ve created a product continuum chart. The pans are arranged from owest to highest premium and ist key features. LOW PREMIUM COST Aiance Cost-effective pans with a network of highy effective medica groups focused on providing patientcentered care PCP Referra Network ony Non-referra No copayment High deductibe HSA-quaified Network and non-network Patinum, god, siver, bronze pans avaiabe HSA Vaues federa income-tax-free savings for future heath care costs Advantage Strives for ow-cost network access PCP Referra Network ony PCP Referra Network ony Signature Wants a arge network access and fexibe benefits Seect Pus Seeks a nationa network with non-network fexibiity Non-referra Network and non-network coverage options Incentives to use preferred providers or pace of service Non-referra Network and non-network Non-Differentia PPO Seeks utimate provider fexibiity HIGH PREMIUM COST 5

8 Choice Simpified Choice Simpified offers more options to suit the diverse needs of sma businesses A we-designed, fexibe heath pan, supported by streamined administration and empoyee-focused weness programs, can hep sma businesses create a ong-term strategy to manage heath care costs now and in the future. Pans in the Choice Simpified portfoio aow sma group empoyers with one or more enroing empoyees to purchase one heath pan package that incudes mutipe benefit design options. They can offer their empoyees an array of heath care coverage options to meet a variety of heath care and financia needs. Our pans incude different product options, ranging from HMOs to consumer-driven heath pans eigibe for HSAs. Here s how it works: Step 1: Pick the pans that best fit the empoyees needs. Empoyer can choose as many pans as they need to fit their program. Step 2: Direct empoyees to choose the benefit design option that best meets their individua needs from the seected pans. Step 3: As the empoyer renews with UnitedHeathcare, they can keep or change their pan offerings within the package year after year, ensuring that the heath pan benefits wi evove with the changing needs of the empoyer and their empoyees. 6

9 Caifornia Sma Business (1-50) Choice Simpified UnitedHeathcare Pan Pan Description Pan Code Choice Simpified Muti-Choice State Seect Pus 15/10% GN-3 Seect Pus 15/250/10% GO-V Seect Pus 15/500/10% GO-W Seect Pus 15/1000/10% GO-X Seect Pus 25/2000/20% GO-Y Seect Pus 4500/20% GP-5 Seect Pus HSA 1500/20% GN-4 Seect Pus HSA 2000/20% GN-5 Seect Pus HSA 3500/20% GN-6 Seect Pus HSA 5000/20% GN-7 Signature 10-20/300a/250ded 3T-K Signature 20-40/1000d/500ded 3T-L Signature 20-40/1000d/1000ded 3T-M Signature 30-50/25%/2000ded 3T-N Signature 50-75/30%/4500ded 3T-P Advantage 10-20/300a/250ded 3T-Q Advantage 20-40/1000d/500ded 3T-R Advantage 20-40/1000d/1000ded 3T-S Advantage 30-50/25%/2000ded 3T-T Advantage 50-75/30%/4500ded 3T-V Aiance 10-20/300a/250ded 3T-W Aiance 20-40/1000d/500ded 3T-X Aiance 20-40/1000d/1000ded 3T-Y Aiance 30-50/25%/2000ded 3T-Z Aiance 50-75/30%/4500ded 3T-2 Aiance HSA 20%/2000ded 3T-4 Aiance HSA 20%/3500ded 3T-5 Aiance HSA 20%/5000ded 3T-6 Non-Differentia PPO 2000/20% GN-2 Seect 20/10% GN-8 Seect 30/20% GN-9 Seect 45/1500/20% GN-Z Seect HSA 4500/40% GO-1 Aiance 20-40/250d 3T-7 Aiance 30-50/600d 3T-8 Aiance HSA 20%/1500ded 3T-9 Aiance HSA 40%/4500ded 3U-U Choice Simpified Package Groups may offer a Choice Simpified package aongside a staff mode if 75% of the eigibe empoyees, excuding COBRA participants, enro with UnitedHeathcare. Groups may offer a Choice Simpified package aongside a staff mode if 75% of the eigibe empoyees, excuding COBRA participants, enro with UnitedHeathcare and the staff mode (75% combined) with a minimum of five active Caifornia empoyees (residing/working in Caifornia) as UnitedHeathcare enroees. Muti-Choice State Package Groups may offer a Choice Simpified package aongside a staff mode if 75% of the eigibe empoyees, excuding COBRA participants, enro with UnitedHeathcare. Guideines subject to change. 7

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11 Medica Pans Overview 9

12 Medica Pans Overview Seect Pus Pan Type Metaic Leve Deductibe Out-of-Pocket 1 Maximum Coinsurance 2 Network3 Deductibe IP Per- OP Per- Out of Type Network Network Network Out of Network Network Out of Network PCP Spec ER Inpatient Occurence Occurence Hospita Ded 4 Ded 4 Combined Med/RX Ded Pan Rx Pan Code Code Seect Pus Patinum N/A $1,000 $4,000 $8,000 10% 50% $15 $30 $100 10% N/A N/A Embedded No GN-3 HH Seect Pus God $250 $500 $4,000 $8,000 10% 50% $15 $30 $100 10% $250 $250 Embedded No GO-V HD Seect Pus God $500 $1,000 $4,000 $8,000 10% 50% $15 $30 $100 10% $250 $250 Embedded No GO-W HD Seect Pus God $1,000 $2,000 $4,000 $8,000 10% 50% $15 $30 $100 10% $250 $250 Embedded No GO-X HD Seect Pus Siver $2,000 $4,000 $6,000 $12,000 20% 50% $25 $50 $200 20% $250 $250 Embedded No GO-Y HL Seect Pus Bronze $4,500 $9,000 $6,250 $12,500 20% 50% 20% 20% 20% 20% $250 $250 Embedded No GP-5 HQ Seect Pus HSA Siver $1,500 $3,000 $5,000 $10,000 20% 50% 20% 20% 20% 20% N/A N/A Non-Embedded Yes GN-4 HJ Seect Pus HSA Siver $2,000 $4,000 $5,000 $10,000 20% 50% 20% 20% 20% 20% N/A N/A Non-Embedded Yes GN-5 HJ Seect Pus HSA Bronze $3,500 $7,000 $6,250 $12,500 20% 50% 20% 20% 20% 20% N/A N/A Non-Embedded Yes GN-6 HP Seect Pus HSA Bronze $5,000 $10,000 $6,250 $12,500 20% 50% 20% 20% 20% 20% N/A N/A Non-Embedded Yes GN-7 HP Signature, Advantage, and Aiance Pan Type Metaic Leve Deductibe 1 Out-Of- Pocket PCP Spec ER Inpatient Maximum Hospita 2 IP Copay Max IP Copay Type Outpatient Surgery Deductibe Type Combined Med/RX Ded HMO Pan Codes Rx Pan Signature Advantage Aiance Code HMO Patinum $250 $1,500 $10 $20 $100 $300 N/A Admit $150 Embedded No 3T-K 3T-Q 3T-W 2R HMO God $500 $4,000 $20 $40 $200 $1,000 $4,000 Day $500 Embedded No 3T-L 3T-R 3T-X 2T HMO God 1,000 $4,000 $20 $40 $200 $1,000 $4,000 Day $500 Embedded No 3T-M 3T-S 3T-Y 2T HMO Siver $2,000 $6,250 $30 $50 $300 25% N/A Admit 25% Embedded No 3T-N 3T-T 3T-Z 2U HMO Bronze $4,500 $6,250 $50 $75 $300 30% N/A Admit 30% Embedded No 3T-P 3T-V 3T-2 2Y HMO HSA Siver $2,000 $5,000 20% 20% 20% 20% N/A Admit 20% Non-Embedded Yes N/A N/A 3T-4 2X HMO HSA Bronze $3,500 $6,250 20% 20% 20% 20% N/A Admit 20% Non-Embedded Yes N/A N/A 3T-5 2Z HMO HSA Bronze $5,000 $6,250 20% 20% 20% 20% N/A Admit 20% Non-Embedded Yes N/A N/A 3T-6 2Z Seect State* Pan Type Metaic Leve Deductibe Out-of-Pocket 1 Maximum Coinsurance 2 Network3 Deductibe IP Per- OP Per- Out of Type Network Network Network Out of Network Network Out of Network PCP Spec ER Inpatient Occurence Occurence Hospita Ded 4 Ded 4 Combined Med/RX Ded Pan Rx Pan Code Code Seect Patinum N/A N/A $4,000 N/A 10% N/A $20 $40 $150 10% N/A N/A Embedded No GN-8 G2 Seect God N/A N/A $6,350 N/A 20% N/A $30 $50 $250 20% N/A N/A Embedded No GN-9 G3 Seect Siver $1,500 N/A $6,350 N/A 20% N/A $45 $65 $250 20% N/A N/A Embedded No GN-Z G9 Seect HSA Bronze $4,500 N/A $6,350 N/A 40% N/A 40% 40% 40% 40% N/A N/A Non-Embedded Yes GO-1 HB Aiance State* Pan Type Metaic Leve Deductibe 1 Out-Of- Pocket PCP Spec ER Maximum 2 Inpatient Hospita IP Copay Max IP Copay Type Outpatient Surgery Deductibe Type Combined Med/RX Ded HMO Pan Codes Rx Pan Signature Advantage Aiance Code HMO Patinum N/A $4,000 $20 $40 $150 $250 $1,250 Day $250 N/A N/A N/A N/A 3T-7 20 HMO God N/A $6,350 $30 $50 $250 $600 $3,000 Day $600 N/A N/A N/A N/A 3T-8 21 HMO HSA Siver $1,500 $6,350 20% 20% N/A 20% N/A Admit 20% Non-Embedded Yes N/A N/A 3T-9 24 HMO HSA Bronze $4,500 $6,350 40% 40% N/A 40% N/A Admit 40% Non-Embedded Yes N/A N/A 3U-U 25 10

13 Non-Differentia PPO Pan Type Non-Differentia PPO Metaic Leve Deductibe Out-of-Pocket 1 Maximum Coinsurance 2 Network3 Deductibe IP Per- OP Per- Out of Type Network Network Network Out of Network Network Out of Network PCP Spec ER Inpatient Occurence Occurence Hospita Ded 4 Ded 4 Combined Med/RX Ded Siver $2,000 $4,000 20% 20% 20% 20% 20% N/A N/A Embedded No GN-2 HC Pan Code Rx Pan Code Pharmacy for Seect, Seect Pus, and Non-Differentia PPO Deductibe 5 Member Copay Individua Famiy Tier 1 Tier 2 Tier 3 Tier 4 Mai Order (90-Day Suppy) Pan Code N/A N/A $10 $30 $60 25% 2.5x HH N/A N/A $15 $35 $60 25% 2.5x HD $250 $750 $15 $35 $70 25% 2.5x HL $250 $750 $20 $50 $100 25% 2.5x HQ Medica Deductibe $15 $35 $70 25% 2.5x HJ Medica Deductibe $20 $50 $100 25% 2.5x HP $150 $450 $20 $35 $60 25% 2.5x HC N/A N/A $5 $15 $25 10% 2.5x G2 N/A N/A $19 $50 $70 20% 2.5x G3 $500 $1,000 $19 $50 $70 20% 2.5x G9 Medica Deductibe 40% 40% 40% 40% 2.5x HB Pharmacy for Signature, Advantage, and Aiance Deductibe 6 Member Copay Mai Order Individua Famiy Generic Formuary Brand-Name (90-Day Suppy) Formuary Non-Formuary Speciaty Medications Pan Code N/A N/A $15 $35 $50 25% 2x 2R N/A N/A $15 $35 $60 25% 2x 2T $250 $750 $15 $35 $70 25% 2x 2U $250 $750 $20 $50 $100 25% 2x 2Y Medica Deductibe $15 $35 $70 25% 2x 2X Medica Deductibe $20 $50 $100 25% 2x 2Z N/A N/A $5 $15 $25 10% 2x 20 N/A N/A $20 $50 $70 20% 2x 21 Medica Deductibe 20% 20% 20% 20% 2x 24 Medica Deductibe 40% 40% 40% 40% 2x 25 1 Famiy Deductibe is 2x Individua, except for the Non-Differentia PPO pan, which is 3x Individua. For pans with a Non-Embedded deductibe, one or more eigibe members of a famiy unit may satisfy the entire Famiy Deductibe. No one in the famiy wi be eigibe for benefits unti the Famiy Deductibe has been met. 2 Famiy Out-of-Pocket Maximum is 2x Individua, except for the Non-Differentia PPO pan, which is 3x Individua. Member cost share, incuding Office Visits, deductibe, coinsurance and pharmacy, appy to the Out-of-Pocket Maximum. 3 Benefits with coinsurance (%) responsibiity are subject to the Deductibe. 4 The Per-Occurrence Deductibe is separate from the Annua Deductibe and accrues toward the Out-of-Pocket Maximum. The Outpatient Per-Occurrence Deductibe may be waived for outpatient services received at an in-network independent, non-hospita-affiiated provider. 5 Does not appy to Tier 1. Appies to a tiers for pharmacy pans subject to the Medica Deductibe. 6 Does not appy to Generic drugs. Appies to a drugs for pharmacy pans subject to the Medica Deductibe. *Pans match the CA Exchange pans and are avaiabe on a imited basis. In-network coverage ony. Pease contact your UnitedHeathcare representative for detais. 11

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15 Seect Pus, Consumer-Driven Heath and Non-Differentia PPO Seect Pus Consumer-Driven Heath Non-Differentia PPO Additiona Vaue-Added Programs for Seect Pus, Consumer- Driven Heath and Non-Differentia PPO 13

16 Seect Pus Fexibe Pans with Network Advantages UnitedHeathcare provides network and non-network benefits, pans for singe-site, muti-site and muti-state businesses and variabe options for deductibes, coinsurance and pharmacy pans that hep meet empoyers needs. Our new Seect Pus pan designs incude a peroccurrence deductibe, which is appied to inpatient hospita and certain outpatient services such as outpatient surgery, standard ab/x-ray, and compex imaging (e.g., MRI, CT, PET). Members with these pans have the option to avoid the per- when accessing these outpatient benefits by receiving services from an in-network independent, non-hospita-affiiated provider. These benefit pan designs offer empoyers: Affordabiity Low-cost aternatives for premiums Choice Popuar combinations of benefits and pricing Network Access to more than 726,000 physicians, 5,600 hospitas, and 64,000 pharmacies across the country Seect Pus Seect Pus pans give members the freedom to see any doctor in or outside the Seect Pus network without a referra. A imited number of Seect (in-network ony) pans, which are modeed after the Covered Caifornia State Exchange standard pans, are aso avaiabe. Benefits of the Seect Pus pan incude: Members visit any participating network physician or faciity (incuding speciaist) without a referra When members visit participating network physicians and hospitas, there aren t any caim forms or bis to worry about Range of pan designs with different deductibe eves, copayments, coinsurance and out-of-pocket amounts 14

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18 Seect Pus Metaic Leve Patinum God God Seect Pus Pan 15/10% 15/250/10% 15/500/10% Network 1 Network Non-Network Network Non-Network Network Non-Ne Annua Deductibe 2 (individua/famiy) None $1,000/$2,000 $250/$500 $500/$1,000 $500/$1,000 $1,000/ Annua Out-of-Pocket Maximum 3 (individua/famiy) $4,000/$8,000 $8,000/$16,000 $4,000/$8,000 $8,000/$16,000 $4,000/$8,000 $8,000/$ Professiona Services Office Visists PCP $15 50% after deductibe $15 50% after deductibe $15 50% after d Office Visits Speciaist $30 50% after deductibe $30 50% after deductibe $30 50% after d Laboratory 4 (Standard) 10% 50% after deductibe Radioogy 4 (Standard) 10% 50% after deductibe 10% after deductibe, 10% after deductibe, 50% after deductibe, 50% after deductibe, 10% after deductibe, 10% after deductibe, 50% after d pus $2 occurrence 50% after d pus $2 occurrence Maternity Care 5 $15 50% after deductibe $15 50% after deductibe $15 50% after d Preventive Care Services No copayment No benefit No copayment No benefit No copayment No be Hospitaization Services Inpatient Hospita Benefits 10% 50% after deductibe 10% after deductibe, 50% after deductibe, 10% after deductibe, 50% after d pus $2 occurrence Inpatient Physician Care 10% 50% after deductibe 10% after deductibe 50% after deductibe 10% after deductibe 50% after d Skied Nursing Faciity Care (100 days per benefit period) 10% 50% after deductibe 10% after deductibe 50% after deductibe 10% after deductibe 50% after d Emergency Heath Coverage Emergency Services $100 Same as Network Same as Network Same as $100 $100 benefit benefit ben Urgenty Needed Services $50 50% after deductibe $50 50% after deductibe $50 50% after d Ambuance Services 10% Same as Network Same as Network Same as 10% after deductibe 10% after deductibe benefit benefit ben Outpatient Services Outpatient Surgery 4 10% 50% after deductibe 10% after deductibe, 50% after deductibe, 10% after deductibe, 50% after d pus $2 occurrence Durabe Medica Equipment 10% 50% after deductibe 10% after deductibe 50% after deductibe 10% after deductibe 50% after d Home Heath Services (Up to 100 visits per caendar year) 10% 50% after deductibe 10% after deductibe 50% after deductibe 10% after deductibe 50% after d Infertiity Services (Benefits imited to $2,000 per ifetime) 10% 50% after deductibe 10% after deductibe 50% after deductibe 10% after deductibe 50% after d Injections Received in a Physician's Office $15 50% after deductibe $15 50% after deductibe $15 50% after d Menta Heath and Substance Use Disorder Services Inpatient 10% 50% after deductibe 10% after deductibe 50% after deductibe 10% after deductibe 50% after d Outpatient No copayment 50% after deductibe $15 50% after deductibe $15 50% after d Outpatient Prescription Drug Coverage Caendar Year Deductibe (individua/famiy) None None None Tier 1 $10 $15 $15 Tier 2 $30 $35 $35 Tier 3 $60 $60 $60 Tier 4 25% 25% 25% Pediatric Denta and Vision Coverage 6 Denta Exam (preventive/diagnostic) No copayment 20% No copayment 20% No copayment 20 Vision Exam (routine) No copayment 50% No copayment 50% No copayment 50 Gasses (frames and enses) 10% 50% 10% 50% 10% 50 1 Reimbursement for Non-Network services is based on a percentage of the pubished rates aowed by Medicare for the same or simiar services. 2 When a member of a famiy unit satisfies the individua Deductibe amount for the caendar year, no further deductibe wi be required for him or her for that caendar year. The per- does not appy to the Annua Deductibe. 3 Member cost share, incuding office visits, annua deductibe, per-, coinsurance and pharmacy, appy to the Out-of-Pocket Maximum. 4 The outpatient per- may be waived for outpatient services received at an in-network independent, non-hospita affiiated provider. 5 No copayment appies to physician office visits for prenata care after the first visit. 6 One routine vision exam and one pair of gasses per caendar year for chidren under age

19 God Siver Bronze 15/1000/10% 25/2000/20% 4500/20% twork Network Non-Network Network Non-Network Network Non-Network $2,000 $1,000/$2000 $2000/$4,000 $2,000/$4,000 $4,000/$8,000 $4,500/$9,000 $9,000/$18,000 16,000 $4,000/$8,000 $8,000/$16,000 $6,000/$12,000 $12,000/$24,000 $6,250/$12,500 $12,500/$25,000 eductibe $15 50% after deductibe $25 50% after deductibe 20% after deductibe 50% after deductibe eductibe $30 50% after deductibe $50 50% after deductibe 20% after deductibe 50% after deductibe eductibe, 50 per deductibe eductibe, 50 per deductibe 10% after deductibe, 10% after deductibe, 50% after deductibe, 50% after deductibe, 20% after deductibe, 20% after deductibe, 50% after deductibe, 50% after deductibe, 20% after deductibe, 20% after deductibe, 50% after deductibe, 50% after deductibe, eductibe $15 50% after deductibe $25 50% after deductibe 20% after deductibe 50% after deductibe nefit No copayment No benefit No copayment No benefit No copayment No benefit eductibe, 50 per deductibe 10% after deductibe, 50% after deductibe, 20% after deductibe, 50% after deductibe, 20% after deductibe, 50% after deductibe, eductibe 10% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe eductibe 10% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe Network efit $100 Same as Network benefit $200 Same as Network benefit 20% after deductibe Same as Network benefit eductibe $50 50% after deductibe $75 50% after deductibe 20% after deductibe 50% after deductibe Network efit 10% after deductibe Same as Network benefit 20% after deductibe Same as Network benefit 20% after deductibe Same as Network benefit eductibe, 50 per deductibe 10% after deductibe, 50% after deductibe, 20% after deductibe, 50% after deductibe, 20% after deductibe, 50% after deductibe, eductibe 10% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe eductibe 10% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe eductibe 10% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe eductibe $15 50% after deductibe $25 50% after deductibe 20% after deductibe 50% after deductibe eductibe 10% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe eductibe $15 50% after deductibe $25 50% after deductibe 20% after deductibe 50% after deductibe None $250/$750 does not appy to Tier 1 $250/$750 does not appy to Tier 1 $15 $15 $20 $35 $35 $50 $60 $70 $100 25% 25% 25% % No copayment 20% No copayment 20% No copayment 20% % No copayment 50% No copayment 50% No copayment 50% % 10% 50% 20% 50% 20% 50% 17

20 Seect State Metaic Leve Patinum God Siver Bronze Seect Pan 20/10% 30/20% 45/1500/20% HSA 4500/40% Network 1 Network Network Network Network Annua Deductibe (individua/famiy) None None $1,500/$3,000 2 $4,500/$9,000 3 Annua Out-of-Pocket Maximum 4 (individua/famiy) $4,000/$8,000 $6,350/$12,700 $6,350/$12,700 $6,350/$12,700 Professiona Services Office Visists PCP $20 $30 $45 40% after deductibe Office Visits Speciaist $30 $50 $65 40% after deductibe Laboratory (Standard) $20 $30 $45 40% after deductibe Radioogy (Standard) $40 $50 $65 40% after deductibe Maternity Care 5 $20 $30 $45 40% after deductibe Preventive Care Services No copayment No copayment No copayment No copayment Hospitaization Services Inpatient Hospita Benefits 10% 20% 20% after deductibe 40% after deductibe Inpatient Physician Care 10% 20% 20% after deductibe 40% after deductibe Skied Nursing Faciity Care (100 days per benefit period) 10% 20% 20% after deductibe 40% after deductibe Emergency Heath Coverage Emergency Services $150 $250 $250 after deductibe 40% after deductibe Urgenty Needed Services $40 $60 $90 40% after deductibe Ambuance Services $150 $250 $250 after deductibe 40% after deductibe Outpatient Services Outpatient Surgery 10% 20% 20% 40% after deductibe Durabe Medica Equipment 10% 20% 20% 40% after deductibe Home Heath Services (Up to 100 visits per caendar year) 10% 20% 20% 40% after deductibe Infertiity Services (Benefits imited to $2000 per ifetime) Not covered Not covered Not covered Not covered Injections Received in a Physician s Office $20 $30 $45 40% after deductibe Menta Heath and Substance Use Disorder Services Inpatient 10% 20% 20% after deductibe 40% after deductibe Outpatient $20 $30 $45 40% after deductibe Outpatient Prescription Drug Coverage Caendar Year Deductibe (individua/famiy) None None $500/$1000 does not appy to Tier 1 Annua Deductibe appies Tier 1 $5 $19 $19 40% Tier 2 $15 $50 $50 40% Tier 3 $25 $70 $70 40% Tier 4 10% 20% 20% 40% Pediatric Denta and Vision Coverage 6 Denta Exam (preventive/diagnostic) No copayment No copayment No copayment No copayment Vision Exam (routine) No copayment No copayment No copayment No copayment Gasses (frames and enses) No copayment No copayment No copayment No copayment after deductibe 1 No benefits for Non-Network services, except for emergency heath and urgent care services. 2 When a member of a famiy unit satisfies the individua Deductibe amount for the caendar year, no further deductibe wi be required for him or her for that caendar year. 3 The Annua Deductibe is combined for medica and pharmacy benefits. One or more eigibe members of a famiy unit may satisfy the entire famiy deductibe. No one in the famiy wi be eigibe for benefits unti the famiy deductibe has been met. 4 Member cost share, incuding office visits, annua deductibe, coinsurance and pharmacy, appy to the Out-of-Pocket Maximum No copayment appies to physician office visits for prenata care after the first visit. 6 One routine vision exam and one pair of gasses per caendar year for chidren under age 19.

21 Consumer-Driven Heath UnitedHeathcare Heath Savings Account (HSA) HSA Overview UnitedHeathcare s HSA pans are designed with the new heath care consumer in mind. Our HSA pans offer a medica pan, coverage for preventive care and a heath care account that members contro and access themseves to cover some of the costs of quaified medica expenses. Account-based consumer soutions initiate the transformation from passive heath pan members into vaue-conscious consumers. HSA features Members can manage their medica caims and HSA together onine or with a customer care professiona. Three account types offer baance of interest, account fees and spending. Non-proprietary mutua fund investing is avaiabe. For greater member convenience, HSAs incude a debit card and onine bi payment. Accounts are administered by Optum Bank ȘM Member FDIC. OptumHeath Financia Services SM provides educationa toos that hep both empoyers and individuas successfuy engage in their financia heath. UnitedHeathcare HSA pans hep members become more-informed and active heath care consumers. By taking ownership of their heath and heath care spending, empoyees can aso hep their empoyers have more contro of their heath care costs. Recent studies support the vaue of HSA-eigibe pans in reducing costs and promoting a heathier workpace. HSA-eigibe pans have shown 20 percent to 30 percent ower-cost-than-average premiums, heping U.S. businesses save money. 1 Premium savings for empoyees with an HSA-eigibe pan amount to an average of $ HSA pan members are two to three times more ikey to participate in weness programs than those in non-consumer-driven heath pans. 3 Our weness offerings incude worksite weness programs, a confidentia,* personaized heath assessment, onine and teephonic coaching and persona support. 1 HSA Insider, HSA Road Rues for Empoyers, Seventh Edition, May th Annua Nationa Business Group on Heath/Watson Wyatt Survey Report 2009, The Effect of the Economic Crisis on Heath Care Programs survey of 212,000 UnitedHeathcare members enroed in UnitedHeathcare Heath Savings Accounts for the fu year of * Confidentia to the fuest extent permitted by aw. 19

22 Seect Pus HSA Metaic Leve Siver Siver Seect Pus HSA Pan 1500/20% 2000/20% Network 1 Network Non-Network Network Annua Deductibe 2 (individua/famiy) $1,500/$3,000 $3,000/$9,000 $2,000/$4,000 Annua Out-of-Pocket Maximum 3 (individua/famiy) $5000/$10,000 $10,000/$20,000 $5000/$10,000 Professiona Services Office Visists PCP 20% after deductibe 50% after deductibe 20% after deductibe Office Visits Speciaist 20% after deductibe 50% after deductibe 20% after deductibe Laboratory (Standard) 20% after deductibe 50% after deductibe 20% after deductibe Radioogy (Standard) 20% after deductibe 50% after deductibe 20% after deductibe Maternity Care 20% after deductibe 50% after deductibe 20% after deductibe Preventive Care Services No copayment No benefit No copayment Hospitaization Services Inpatient Hospita Benefits 20% after deductibe 50% after deductibe 20% after deductibe Inpatient Physician Care 20% after deductibe 50% after deductibe 20% after deductibe Skied Nursing Faciity Care (100 days per benefit period) 20% after deductibe 50% after deductibe 20% after deductibe Emergency Heath Coverage Emergency Services 20% after deductibe Same as Network benefit 20% after deductibe Urgenty Needed Services 20% after deductibe 50% after deductibe 20% after deductibe Ambuance Services 20% after deductibe Same as Network benefit 20% after deductibe Outpatient Services Outpatient Surgery 20% after deductibe 50% after deductibe 20% after deductibe Durabe Medica Equipment 20% after deductibe 50% after deductibe 20% after deductibe Home Heath Services (Benefits imited to $2,000 per ifetime) 20% after deductibe 50% after deductibe 20% after deductibe Infertiity Services (Up to 100 visits per caendar year) 20% after deductibe 50% after deductibe 20% after deductibe Injections Received in a Physician s Office 20% after deductibe 50% after deductibe 20% after deductibe Menta Heath and Substance Use Disorder Services Inpatient 20% after deductibe 50% after deductibe 20% after deductibe Outpatient 20% after deductibe 50% after deductibe 20% after deductibe Outpatient Prescription Drug Coverage Caendar Year Deductibe (individua/famiy) Annua Deductibe appies Annua Deductibe a Tier 1 $15 $15 Tier 2 $35 $35 Tier 3 $70 $70 Tier 4 25% 25% Pediatric Denta and Vision Coverage 4 Denta Exam (preventive/diagnostic) No copayment 20% No copayment Vision Exam (routine) No copayment 50% after deductibe No copayment Gasses (frames and enses) 20% after deductibe 50% after deductibe 20% after deductibe 1 Reimbursement for Non-Network services is based on a percentage of the pubished rates aowed by Medicare for the same or simiar services. 2 The Annua Deductibe is combined for medica and pharmacy benefits. One or more eigibe members of a famiy unit may satisfy the entire famiy deductibe. No one in the famiy wi be eigibe for benefits unti the famiy deductibe has been met. 3 Member cost share, incuding office visits, annua deductibe, coinsurance and pharmacy, appy to the Out-of-Pocket Maximum. 4 One routine vision exam and one pair of gasses per caendar year for chidren under age

23 Bronze Bronze 3500/20% 5000/20% Non-Network Network Non-Network Network Non-Network $4,000/$8,000 $3,500/$7,000 $7,000/$14,000 $5,000/$10,000 $10,000/$20,000 $10,000/$20,000 $6,250/$12,500 $12,500/$25,000 $6,250/$12,500 $12,500/$25,000 50% after deductibe 20% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe No benefit No copayment No benefit No copayment No benefit 50% after deductibe 20% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe Same as Network benefit 20% after deductibe Same as Network benefit 20% after deductibe Same as Network benefit 50% after deductibe 20% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe Same as Network benefit 20% after deductibe Same as Network benefit 20% after deductibe Same as Network benefit 50% after deductibe 20% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe ppies Annua Deductibe appies Annua Deductibe appies $20 $20 $50 $50 $100 $100 25% 25% 20% No copayment 20% No copayment 20% 50% after deductibe No copayment 50% after deductibe No copayment 50% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe 20% after deductibe 50% after deductibe 21

24 Non-Differentia PPO The UnitedHeathcare Non-Differentia PPO product provides maximum freedom for deaing with any heath care situation. This fexibe product provides a broader-based coverage to incude more doctors and speciaists to visit without referras. With this version of heath insurance, benefits are provided for covered heath services received from any physician or other icensed heath care professiona. Metaic Leve Siver Non-Differentia PPO Pan /20% Network Network and Non-Network Annua Deductibe 2 (individua/famiy) $2,000/$6,000 Annua Out-of-Pocket Maximum 3 (individua/famiy) $4,000/$12,000 Professiona Services Office Visists PCP 20% after deductibe Office Visits Speciaist 20% after deductibe Laboratory (Standard) 20% after deductibe Radioogy (Standard) 20% after deductibe Maternity Care 20% after deductibe Preventive Care Services No copayment Hospitaization Services Inpatient Hospita Benefits 20% after deductibe Inpatient Physician Care 20% after deductibe Skied Nursing Faciity Care (100 days per benefit period) 20% after deductibe Emergency Heath Coverage Emergency Services 20% after deductibe Urgenty Needed Services 20% after deductibe Ambuance Services 20% after deductibe Outpatient Services Outpatient Surgery 20% after deductibe Durabe Medica Equipment 20% after deductibe Home Heath Services (Up to 100 visits per caendar year) 20% after deductibe Infertiity Services (Benefits imited to $2,000 per ifetime) 20% after deductibe Injections Received in a Physician's Office 20% after deductibe Menta Heath and Substance Use Disorder Services Inpatient 20% after deductibe Outpatient 20% after deductibe Outpatient Prescription Drug Coverage Caendar Year Deductibe (individua/famiy) $150/$450 does not appy to Tier 1 Tier 1 $20 Tier 2 $35 Tier 3 $60 Tier 4 25% Pediatric Denta and Vision Coverage 4 Denta Exam (preventive/diagnostic) No copayment Vision Exam (routine) No copayment Gasses (frames and enses) 20% 1 Out-of-area pan avaiabe outside of our contracted network service areas. Subject to underwriting guideines. 2 When a member of a famiy unit satisfies the individua Deductibe amount for the caendar year, no further deductibe wi be required for him or her for that caendar year. 3 Member cost share, incuding office visits, annua deductibe, coinsurance and pharmacy, appy to the Out-of-Pocket Maximum. 4 One routine vision exam and one pair of gasses per caendar year for chidren under age

25 Notes 23

26 Additiona Vaue-Added Programs for Seect Pus, Consumer-Driven Heath and Non-Differentia PPO Our goa is to hep empoyers and empoyees manage costs by heping peope improve their tota heath and productivity. That s why we offer these additiona heath and weness programs with a our Seect Pus, Consumer-Driven Heath and Non-Differentia PPO pans at no additiona charge. myheathcare Cost Estimator myheathcare Cost Estimator is a personaized onine too that wi empower empoyees to make moreinformed heath care decisions. myheathcare Cost Estimator is avaiabe to UnitedHeathcare members at no additiona cost. When members are abe to get information based on their pan, they have the knowedge to better understand their choices and be in greater contro of heath care. Care Coordination SM Coordinates and customizes services where gaps in care may exist. Education and prevention programs incude pre-admission counseing, inpatient care advocacy and readmission prevention. esync Patform Technoogy UnitedHeathcare s sophisticated esync patform takes a big-picture ook at a member s heath, and, using proprietary technoogy, aerts the member and his or her physician to a potentiay serious condition so that intervention can occur at the diagnostic stage. Disease Management Identifies high-risk individuas with chronic conditions, such as asthma, diabetes and coronary artery disease, who may benefit from a focused intervention program. Individuas are paced on one of three eves of intervention to improve quaity of ife and keep cost trends in check. Compex Medica Conditions The Compex Medica Conditions program provides access to Centers of Exceence networks comprising medica centers that are identified as speciaists in the treatment of specific conditions and that meet strict evauation requirements. The Compex Medica Conditions program aso provides cinica consuting services to manage treatment programs and costs to maximize empoyee benefits. Evidence-Based Medicine Improves consistent cinica outcomes and reduces inefficient deivery of care. We offer Cinica Evidence (a compiation of thousands of recent research studies); faciitate peer-to-peer data-sharing consutations; and provide physicians and hospitas with reevant data regarding their performance compared to nationay accepted, evidence-based practices. United Behaviora Heath Behaviora heath and substance disorder services, ranging from counseing to acute inpatient care are deivered by our affiiate, United Behaviora Heath (UBH). Features Support and treatment for menta heath and substance disorder issues Integration with medica benefits for streamined administration Indirect and direct cost-savings 24

27 Care24 Our Care24 resources assist empoyees with heath, persona or famiy-reated concerns via a to-free phone number 24 hours a day, seven days a week. One to-free number puts them in touch with nurses, counseors, financia consutants and attorneys. For situations where in-person resources are needed, Care24 contracts with more than 9,000 professionas nationwide who provide oca, in-person support. In addition, our database of more than 60,000 unique community resources, representing 400,000 points of expertise, adds to Care24 s depth of service. Care24 aso offers empoyers access to audio messages on more than 1,100 heath and we-being topics. Most audio tapes are avaiabe in Spanish, and we provide transation services for more than 140 anguages. myuhc.com Gives Seect Pus, Consumer-Driven Heath and Non- Differentia PPO members onine, sef-service access to benefit and network information. myuhc.com aso provides customized information and artices on hundreds of heath-reated topics. 25

28

29 HMO Signature Advantage Aiance Additiona Vaue-Added Programs for Signature, Advantage, and Aiance 27

30 28

31 Signature Advantage Aiance The Signature pan incudes our fu network of contracted providers. With this HMO pan, members simpy choose a Primary Care Physician (PCP) from our fu network of contracted providers to coordinate a their medica care. They can then visit their PCP for routine checkups, and when they need to see a speciaist, their PCP can provide a referra. Members are charged ony a copayment for each doctor s visit. Preventive care, incuding checkups, is covered. The Advantage pan offers the same eve of benefit coverage as a traditiona HMO pan at a ower premium. The difference is in the network. The Advantage pan offers a narrower network of contracted providers. Members must choose a PCP from the Advantage network to coordinate a their medica care. The Aiance pan requires members to choose a PCP from network medica groups that were seected based on their outstanding reputations and cinicay proven abiities to deiver the kind of care that keeps heath care costs down. The focus of these pans is on patient-centered care the PCP coordinates the member s care with other physicians and speciaists in their chosen medica group s network to ensure that the member wi receive outstanding care. As with our other pans, members get the toos they need to do their own evauations, so they can seect the right physician to meet their unique needs and preferences. 29

32 Signature, Advantage, and Aiance Metaic Leve Patinum God God HMO Pan 10-20/300a/250ded 20-40/1000d/500ded 20-40/1000d/1000ded Annua Deductibe 1 (individua/famiy) $250/500 $500/$1000 $1000/$2000 Annua Out-of-Pocket Maximum 2 (individua/famiy) $1500/$3000 $4000/$8000 $4000/$8000 Professiona Services Office Visists PCP $10 $20 $20 Office Visits Speciaist $20 $40 $40 Laboratory (Standard) Paid in fu $20 $20 Radioogy (Standard) Paid in fu $20 $20 Maternity Care Paid in fu Paid in fu Paid in fu Preventive Care Services Paid in fu Paid in fu Paid in fu Hospitaization Services Inpatient Hospita Benefits $300/admit after deductibe $1000/day, max 4 days per stay after $1000/day, max 4 days per stay after deductibe deductibe Inpatient Physician Care Paid in fu Paid in fu Paid in fu Skied Nursing Faciity Care (100 days per benefit period) $300/admit after deductibe $300/day after deductibe $300/day after deductibe Emergency Heath Coverage Emergency Services $100 $200 $200 Urgenty Needed Services $50 $75 $75 Ambuance Services $100 $100 $100 Outpatient Services Outpatient Surgery $150/admit after deductibe $500/admit after deductibe $500/admit after deductibe Durabe Medica Equipment $50 $50 $50 Home Heath Services (Up to 100 visits per caendar year) $10 $20 $20 Infertiity Services 50% Not covered Not covered Injectabe Drugs $150 $150 $150 Menta Heath and Substance Use Disorder Services Inpatient $300/admit after deductibe $500/day, max 4 days per stay after deductibe $500/day, max 4 days per stay after deductibe Outpatient $20 $40 $40 Outpatient Prescription Drug Coverage Caendar Year Deductibe (individua/famiy) None None None Generic Formuary $15 $15 $15 Brand-Name Formuary $35 $35 $35 Non-Formuary $50 $60 $60 Speciaty Medications 25% up to $300 25% up to $300 25% up to $300 Pediatric Denta and Vision Coverage 3 Denta Exam (preventive/diagnostic) Paid in fu Paid in fu Paid in fu Vision Exam (routine) Paid in fu Paid in fu Paid in fu Gasses (frames and enses) 10% 10% 10% Optiona Group Coverage Chiropractic Offered Through OptumHeath Care Soutions, Inc. (Maximum 30 visits per Caendar Year) $10 $10 $10 1 When a member of a famiy unit satisfies the individua Deductibe amount for the caendar year, no further deductibe wi be required for him or her for that caendar year. 2 Member cost share, incuding office visits, annua deductibe, coinsurance and pharmacy, appy to the Out-of-Pocket Maximum. 3 One routine vision exam and one pair of gasses per caendar year for chidren under age

33 Siver 30-50/25%/2000ded Bronze 50-75/30%/4500ded $2000/$4000 $4500/$9000 $6250/$12,500 $6250/$12,500 $30 $50 $50 $75 $25 $25 $25 $25 Paid in fu Paid in fu Paid in fu Paid in fu 25% after deductibe 30% after deductibe 25% 30% after deductibe 25% after deductibe 30% after deductibe $300 $300 $75 $100 $100 $100 25% after deductibe 30% after deductibe $50 $50 $30 $50 Not covered Not covered $150 $150 25% after deductibe 30% after deductibe $40 $40 $250/$750 brand-name deductibe $250/$750 brand-name deductibe $15 $20 $35 $50 $70 $100 25% up to $300 25% up to $300 Paid in fu Paid in fu Paid in fu Paid in fu 25% 30% $10 $10 31

34 Aiance HSA Metaic Leve Siver Bronze Bronze HMO Pan HSA 20%/2000ded HSA 20%/3500ded HSA 20%/5000ded Annua Deductibe 1 (individua/famiy) $2,000/$4,000 $3,500/$7,000 $5,000/$10,000 Annua Out-of-Pocket Maximum 2 (individua/famiy) $5,000/$10,000 $6,250/$12,500 $6,250/$12,500 Professiona Services Office Visists PCP 20% after deductibe 20% after deductibe 20% after deductibe Office Visits Speciaist 20% after deductibe 20% after deductibe 20% after deductibe Laboratory (Standard) 20% after deductibe 20% after deductibe 20% after deductibe Radioogy (Standard) 20% after deductibe 20% after deductibe 20% after deductibe Maternity Care 20% after deductibe 20% after deductibe 20% after deductibe Preventive Care Services Paid in fu Paid in fu Paid in fu Hospitaization Services Inpatient Hospita Benefits 20% after deductibe 20% after deductibe 20% after deductibe Inpatient Physician Care 20% after deductibe 20% after deductibe 20% after deductibe Skied Nursing Faciity Care (100 days per benefit period) 20% after deductibe 20% after deductibe 20% after deductibe Emergency Heath Coverage Emergency Services 20% after deductibe 20% after deductibe 20% after deductibe Urgenty Needed Services 20% after deductibe 20% after deductibe 20% after deductibe Ambuance Services 20% after deductibe 20% after deductibe 20% after deductibe Outpatient Services Outpatient Surgery 20% after deductibe 20% after deductibe 20% after deductibe Outpatient Surgery Physician Care 20% after deductibe 20% after deductibe 20% after deductibe Durabe Medica Equipment 20% after deductibe 20% after deductibe 20% after deductibe Home Heath Services (Up to 100 visits per caendar year) 20% after deductibe 20% after deductibe 20% after deductibe Infertiity Services Not covered Not covered Not covered Injectabe Drugs 20% after deductibe 20% after deductibe 20% after deductibe Menta Heath and Substance Use Disorder Services Inpatient 20% after deductibe 20% after deductibe 20% after deductibe Outpatient 20% after deductibe 20% after deductibe 20% after deductibe Outpatient Prescription Drug Coverage Caendar Year Deductibe (individua/famiy) Annua Deductibe appies Annua Deductibe appies Annua Deductibe appies Generic Formuary $15 $20 $20 Brand-Name Formuary $35 $50 $50 Non-Formuary $70 $100 $100 Speciaty Medications 25% up to $300 25% up to $300 25% up to $300 Pediatric Denta and Vision Coverage 3 Denta Exam (preventive/diagnostic) Paid in fu Paid in fu Paid in fu Vision Exam (routine) Paid in fu Paid in fu Paid in fu Gasses (frames and enses) 20% after deductibe 20% after deductibe 20% after deductibe Optiona Group Coverage - Chiropractic Offered Through OptumHeath Care Soutions, Inc. (Maximum 30 visits per Caendar Year) Not avaiabe Not avaiabe Not avaiabe 1 The Annua Deductibe is combined for medica and pharmacy benefits. One or more eigibe members of a famiy unit may satisfy the entire famiy deductibe. No one in the famiy wi be eigibe for benefits unti the famiy deductibe has been met. 2 Member cost share, incuding office visits, annua deductibe, coinsurance and pharmacy, appy to the Out-of-Pocket Maximum. 3 One routine vision exam and one pair of gasses per caendar year for chidren under age

35 Aiance State Metaic Leve Patinum God Siver Bronze HMO Pan 20-40/250d 30-50/600d HSA 20%/1500ded HSA 40%/4500ded Annua Deductibe 1 (individua/famiy) None None $1,500/$3,000 $4,500/$9,000 Annua Out-of-Pocket Maximum 2 (individua/famiy) $4,000/$8,000 $6,350/$12,700 $6,350/$12,700 $6,350/$12,700 Professiona Services Office Visists PCP $20 $30 20% after deductibe 40% after deductibe Office Visits Speciaist $40 $50 20% after deductibe 40% after deductibe Laboratory (Standard) $20 $30 20% after deductibe 40% after deductibe Radioogy (Standard) $40 $50 20% after deductibe 40% after deductibe Maternity Care Paid in fu Paid in fu 20% after deductibe 40% after deductibe Preventive Care Services Paid in fu Paid in fu Paid in fu Paid in fu Hospitaization Services Inpatient Hospita Benefits $250/day, max 5 days per stay $600/day, max 5 days per stay 20% after deductibe 40% after deductibe Inpatient Physician Care Paid in fu Paid in fu 20% after deductibe 40% after deductibe Skied Nursing Faciity Care (100 days per benefit period) $150/day, max 5 days per stay $300/day, max 5 days per stay 20% after deductibe 40% after deductibe Emergency Heath Coverage Emergency Services $150 $250 20% after deductibe 40% after deductibe Urgenty Needed Services $40 $60 20% after deductibe 40% after deductibe Ambuance Services $150 $250 20% after deductibe 40% after deductibe Outpatient Services Outpatient Surgery $250 $600 20% after deductibe 40% after deductibe Outpatient Surgery Physician Care Paid in fu Paid in fu 20% after deductibe 40% after deductibe Durabe Medica Equipment 10% 20% 20% after deductibe 40% after deductibe Home Heath Services (Up to 100 visits per caendar year) $20 $30 20% after deductibe 40% after deductibe Infertiity Services Not covered Not covered Not covered Not covered Injectabe Drugs $150 $150 20% after deductibe 40% after deductibe Menta Heath and Substance Use Disorder Services Inpatient $250/day, max 5 days per stay $600/day, max 5 days per stay 20% after deductibe 40% after deductibe Outpatient $20 $30 20% after deductibe 40% after deductibe Outpatient Prescription Drug Coverage Caendar Year Deductibe (individua/famiy) None None Annua Deductibe appies Annua Deductibe appies Generic Formuary $5 $19 20% 40% Brand-Name Formuary $15 $50 20% 40% Non-Formuary $25 $70 20% 40% Speciaty Medications 10% 20% 20% 40% Pediatric Denta and Vision Coverage 3 Denta Exam (preventive/diagnostic) Paid in fu Paid in fu Paid in fu Paid in fu Vision Exam (routine) Paid in fu Paid in fu Paid in fu Paid in fu Gasses (frames and enses) Paid in fu Paid in fu Paid in fu Paid in fu Optiona Group Coverage - Chiropractic Offered Through OptumHeath Care Soutions, Inc. (Maximum 30 visits per Caendar Year) $10 $10 Not avaiabe Not avaiabe 1 The Annua Deductibe is combined for medica and pharmacy benefits. One or more eigibe members of a famiy unit may satisfy the entire famiy deductibe. No one in the famiy wi be eigibe for benefits unti the famiy deductibe has been met. 2 Member cost share, incuding office visits, annua deductibe, coinsurance and pharmacy, appy to the Out-of-Pocket Maximum. 3 One routine vision exam and one pair of gasses per caendar year for chidren under age