UnitedHealthcare Plan Mapping Insurance Portfolio - From Small Business 1-50 to Small Business 1-100 Plan Mapping Select Plus Platinum - - 5/10% AE-JA Select Plus Platinum 15/10% GN-3 15/15% AE-JB Select Plus Gold 15/250/10% GO-V 20/250/20% AE-JW Select Plus Gold 15/500/10% GO-W 20/750/20% AE-JX Select Plus Gold 15/1000/10% GO-X 20/1000/20% AE-JY Select Plus Silver 25/1800/20% GO-Y 30/1800/30% AE-JZ Select Plus Silver 35/1800/30% 7V-M 40/1800/30% AE-J1 Select Plus Bronze 4500/20% GP-5 40/6600/0% AE-JC Select Plus HSA* Silver 2000/20% GN-5 2000/30% AE-JD Select Plus HSA Bronze 3500/20% GN-6 4500/40% AE-JE Core Platinum - - 5/10% AE-JF Core Platinum 15/10% AB-4Y 15/15% AE-JG Core Gold 15/250/10% AB-44 20/250/20% AE-J2 Core Gold 15/500/10% AB-45 20/750/20% AE-J3 Core Gold 15/1000/10% AB-46 20/1000/20% AE-J4 Core Silver 25/1800/20% AB-47 30/1800/30% AE-J5 Core Silver 35/1800/30% AB-5A 40/1800/30% AE-J6 Core Bronze 4500/20% AB-48 40/6600/0% AE-JH Core HSA* Silver 2000/20% AB-41 2000/30% AE-JI Core HSA Bronze 3500/20% AB-42 4500/40% AE-JJ Non-Differential PPO Silver 2000/20% GN-2 2000/20% AE-I9 Select Platinum 20/10% 77-C 20/10% AE-JK Select Gold 30/20% 77-D 35/20% AE-JL Select Silver 45/1500/20% 77-E 45/1500/20% AE-JM Select Bronze - - 70/6000/100% AE-JN Select HSA Bronze 4500/40% 77-F 4500/40% AE-JP Core Essential Platinum - - 20/10% AE-JQ Core Essential Gold - - 35/20% AE-JR Core Essential Silver - - 45/1500/20% AE-JS Core Essential Bronze - - 70/6000/100% AE-JT Core Essential Bronze - - 4500/40% AE-JV * This 2015 HSA plan will map to a 2016 non-hsa plan. 1 of 6
HMO Portfolio - From Small Business 1-50 to Small Business 1-100 Plan Mapping 2 of 6 Signature 1 Platinum - - KNL 15-30/250a AE-J7 J0I Signature Platinum 20-40/250d 6X-9 KNL 20-40/30% AE-J8 J3J Signature Gold 30-50/1000d 6Y-A KPE 30-50/30% AE-J9 J4J Signature Gold 30-50/900d/1000ded 6Y-B KQE 30-50/30%/1000ded AE-KA J5J Signature Silver 30-50/25%/1750ded 3T-N H79 45-65/40%/2000ded AE-KB J60 Signature Bronze 50-75/30%/4500ded 3T-P H57 55-85/0%/6600ded AE-KC J6L Advantage 1 Platinum 20-40/250d 6Y-C KRE 20-40/30% AE-KE J8I Advantage Gold 30-50/1000d 6Y-D KX1 30-50/30% AE-KF J8S Advantage Gold 30-50/900d/1000ded 6Y-E KXG 30-50/30%/1000ded AE-KG J91 Advantage Silver 30-50/25%/1750ded 3T-T H4T 45-65/40%/2000ded AE-KH JAO Advantage Bronze 50-75/30%/4500ded 3T-V H7Q 55-85/0%/6600ded AE-KI JCI Focus 1 Platinum - - KNL 15-30/250a AE-KJ F0I Focus Platinum 20-40/250d AB-YI FAI 20-40/30% AE-KK F91 Focus Gold 30-50/1000d AB-YJ FIO 30-50/30% AE-KL F9D Focus Gold 30-50/900d/1000ded AB-YK FA0 30-50/30%/1000ded AE-KM F0K Focus Silver 30-50/25%/1750ded AB-YL FJ0 45-65/40%/2000ded AE-KN FOR Focus Bronze 50-75/30%/4500ded AB-YM F00 55-85/0%/6600ded AE-KO F69 Alliance 1 Platinum 20-40/250d 6Y-F KXP 20-40/30% AE-KQ JSI Alliance Gold 30-50/1000d 6Y-G KY1 30-50/30% AE-KR JMI Alliance Gold 30-50/900d/1000ded 6Y-H KYG 30-50/30%/1000ded AE-KS JNO Alliance Silver 30-50/25%/1750ded 3T-Z H9F 45-65/40%/2000ded AE-KT JIE Alliance Bronze 50-75/30%/4500ded 3T-2 HTW 55-85/0%/6600ded AE-KU JIN Alliance HSA Silver 20%/2000ded 3T-4 HVY 25%/2000ded AE-KV JOB Alliance HSA Bronze 20%/3500ded 3T-5 HWY 40%/4500ded AE-KW JOK Signature Platinum - - - 20-40/10% AE-KX JO1 Signature Gold - - - 35-55/20% AE-KY J1O Signature Silver - - - 45-70/20%/1500ded AE-KZ J31 Focus Platinum - - - 20-40/10% AE-K1 F7H Focus Gold - - - 35-55/20% AE-K2 F8E Focus Silver - - - 45-70/20%/1500ded AE-K3 FE8 Alliance Platinum 20-40/250d AB-GV K90 20-40/10% AE-K4 J41 Alliance Gold 30-50/600d AB-GW K9B 35-55/20% AE-K5 JPT Alliance Silver - - - 45-70/20%/1500ded AE-K6 J70 Alliance HSA Silver 20%/1500ded AB-GX K9L 25%/2000ded AE-KV JOB Alliance HSA Bronze 40%/4500ded 77-B K81 40%/4500ded AE-K8 J5Y 1 Formal HMO product names: Signature = UnitedHealthcare SignatureValue Advantage = UnitedHealthcare SignatureValue Advantage Alliance = UnitedHealthcare SignatureValue Alliance Focus = UnitedHelathcare SignatureValue Focus
Insurance Portfolio - From Small Business 51-100 to Small Business 1-100 Plan Mapping Paired Rx Select Plus* 2000/90% LX-W 2000/30% Silver AE-JD 367 Select Plus* 2000/80% RY-M 2000/30% Silver AE-JD 367 Select Plus 3000/90% RY-N 4500/40% Silver AE-JE HP Select Plus 3000/80% RY-O 4500/40% Silver AE-JE HP Select Plus 4000/80% RY-P 4500/40% Bronze AE-JE HP Choice Plus* 2000/90% 3Y-H 2000/30% Silver AE-JD 367 Select Plus 10/250/90% AA-IP 15/15% Platinum AE-JB HH Select Plus 20/500/80% AA-IQ 20/1000/20% Platinum AE-JY HD Select Plus 20/750/80% AA-IR 20/1000/20% Platinum AE-JY HD Select Plus 30/1000/80% AA-IS 30/1800/30% Platinum AE-JZ HL Core* 2000/90% AC-BI 2000/30% Silver AE-JI 367 Core* 2000/80% AC-BJ 2000/30% Silver AE-JI 367 Core 3000/90% AC-BK 4500/40% Silver AE-JJ HP Core 3000/80% AC-BL 4500/40% Silver AE-JJ HP Core 4000/80% AC-BM 4500/40% Bronze AE-JJ HP Core 10/250/90% AC-BN 15/15% Platinum AE-JG HH Core 20/500/80% AC-BO 20/1000/20% Platinum AE-J4 HD Core 20/750/80% AC-BP 20/1000/20% Platinum AE-J4 HD Core 30/1000/80% AC-BQ 30/1800/30% Platinum AE-J5 HL Select Plus Direct 10/250/90% RZ-K 20/750/20% Gold AE-JX HD Select Plus Direct 15/250/90% RZ-L 20/750/20% Gold AE-JX HD Select Plus Direct 20/250/90% RZ-M 20/750/20% Gold AE-JX HD Select Plus Direct 15/250/80% RZ-N 20/750/20% Gold AE-JX HD Select Plus Direct 20/250/80% RZ-O 20/750/20% Gold AE-JX HD Select Plus Direct 15/500/90% RZ-P 20/1000/20% Gold AE-JY HD Select Plus Direct 20/500/90% RZ-Q 30/1800/30% Gold AE-JZ HL Select Plus Direct 15/500/80% RZ-R 30/1800/30% Gold AE-JZ HL Select Plus Direct 20/500/80% RZ-S 20/1000/20% Gold AE-JY HD Select Plus Direct 15/750/90% AA-IT 20/1000/20% Gold AE-JY HD Select Plus Direct 20/750/90% AA-IU 20/1000/20% Gold AE-JY HD Select Plus Direct 15/750/80% AA-IV 30/1800/30% Gold AE-JZ HL Select Plus Direct 20/750/80% AA-IW 30/1800/30% Gold AE-JZ HL Select Plus Direct 30/1000/80% RZ-T 30/1800/30% Gold AE-JZ HL Select Plus Direct 30/1000/70% RZ-U 30/1800/30% Gold AE-JZ HL Select Plus Direct 30/1500/70% RZ-V 30/1800/30% Silver AE-JZ HL Select Plus Direct 40/1500/70% RZ-W 30/1800/30% Silver AE-JZ HL Select Plus Direct 40/2000/70% RZ-X 2000/30% Silver AE-JD 367 Select Plus Direct 30/3000/80% RZ-Y 30/1800/30% Silver AE-JZ HL Select Plus Direct 40/4000/80% RZ-Z 40/1800/30% Silver AE-J1 298 Select Plus Direct 50/5000/80% RZ-1 40/1800/30% Silver AE-J1 298 Select Plus Direct HRA** 2000/70% RZ-2 4500/40% Silver AE-JE HP Select Plus Direct HRA** 3000/70% RZ-3 4500/40% Silver AE-JE HP Select Plus Direct HRA** 4000/70% RZ-4 4500/40% Bronze AE-JE HP Core Direct 10/250/90% AC-BR 20/250/20% Gold AE-J3 HD * This 2015 HSA plan will map to a 2016 non-hsa plan. **This 2015 HRA plan will map to a 2016 HSA plan. 3 of 6
Insurance Portfolio - From Small Business 51-100 to Small Business 1-100 Plan Mapping (continued) Paired Rx Core Direct 15/250/90% AC-BS 20/750/20% Gold AE-J3 HD Core Direct 20/250/90% AC-BT 20/750/20% Gold AE-J3 HD Core Direct 15/250/80% AC-BU 20/750/20% Gold AE-J3 HD Core Direct 20/250/80% AC-BV 20/250/20% Gold AE-J3 HD Core Direct 15/500/90% AC-BW 20/1000/20% Gold AE-J4 HD Core Direct 20/500/90% AC-BX 30/1800/30% Gold AE-J5 HL Core Direct 15/500/80% AC-BY 30/1800/30% Gold AE-J5 HL Core Direct 20/500/80% AC-BZ 20/1000/20% Gold AE-J4 HD Core Direct 15/750/90% AC-CC 20/1000/20% Gold AE-J4 HD Core Direct 20/750/90% AC-CD 20/1000/20% Gold AE-J4 HD Core Direct 15/750/80% AC-CE 30/1800/30% Gold AE-J5 HL Core Direct 20/750/80% AC-CF 30/1800/30% Gold AE-J5 HL Core Direct 30/1000/80% AC-B1 30/1800/30% Gold AE-J5 HL Core Direct 30/1000/70% AC-B2 30/1800/30% Gold AE-J5 HL Core Direct 30/1500/70% AC-B3 30/1800/30% Silver AE-J5 HL Core Direct 40/1500/70% AC-B4 30/1800/30% Silver AE-J5 HL Core Direct 40/2000/70% AC-B5 2000/30% Silver AE-JI 367 Core Direct 30/3000/80% AC-B6 30/1800/30% Silver AE-J5 HL Core Direct 40/4000/80% AC-B7 40/1800/30% Silver AE-J6 298 Core Direct 50/5000/80% AC-B8 40/1800/30% Silver AE-J6 298 Core Direct HRA** 2000/70% AC-B9 4500/40% Silver AE-JJ HP Core Direct HRA** 3000/70% AC-CA 4500/40% Silver AE-JJ HP Core Direct HRA** 4000/70% AC-CB 4500/40% Bronze AE-JJ HP Non-Differential PPO 500/80% LX-V 2000/20% Silver AE-I9 HC **This 2015 HRA plan will map to a 2016 HSA plan. HMO Portfolio - From Small Business 51-100 to Small Business 1-100 Plan Mapping Paired Rx Paired Rx Signature 10-20/100% L0A 15-30/250a Platinum AE-J7 2R J0I 4G5 Signature 15-30/100% LB1 15-30/250a Platinum AE-J7 2R J0I 4G5 Signature 20-40/100% LB8 15-30/250a Platinum AE-J7 2R J0I 4G5 Signature 10-20/250a LCA 15-30/250a Platinum AE-J7 2R J0I 4G5 Signature 15-30/250a LC2 15-30/250a Platinum AE-J7 2R J0I 4G5 Signature 20-40/250a LC6 20-40/30% Platinum AE-J8 2R J3J 4G6 Signature 10-20/500a LD8 20-40/30% Platinum AE-J8 2R J3J 4G6 Signature 15-30/500a LE1 20-40/30% Platinum AE-J8 2R J3J 4G6 Signature 20-40/500a L0D 20-40/30% Platinum AE-J8 2R J3J 4G6 Signature 15-30/80% LFE 20-40/30% Platinum AE-J8 2R J3J 4G6 Signature 20-40/80% LFR 20-40/30% Platinum AE-J8 2R J3J 4G6 Signature 30-50/80% LFV 30-50/30% Gold AE-J9 051 J4J 4G7 Signature 15-30/70% L1P 20-40/30% Platinum AE-J8 2R J3J 4G6 4 of 6
HMO Portfolio - From Small Business 51-100 to Small Business 1-100 Plan Mapping (continued) Paired Rx Paired Rx Signature 20-40/70% LF6 20-40/30% Platinum AE-J8 2R J3J 4G6 Signature 30-50/70% LC9 30-50/30% Gold AE-J9 051 J4J 4G7 Signature 15-30/60% LC0 30-50/30% Gold AE-J9 051 J4J 4G7 Signature* 20-40/60% LGR 30-50/30%/1000ded Gold AE-KA 051 J5J 4G8 Signature* 30-50/60% LGV 30-50/30%/1000ded Gold AE-KA 051 J5J 4G8 Signature* 40-60/70% LEY 30-50/30%/1000ded Gold AE-KA 051 J5J 4G8 Signature 40-60/70%/1000ded LG1 30-50/30%/1000ded Gold AE-KA 051 J5J 4G8 Signature 40-60/70%/2000ded LOS 45-65/40%/2000ded Silver AE-KB 2Z J60 4H6 Advantage 10-20/100% LHP 20-40/30% Platinum AE-KE 2R J8I 4G6 Advantage 15-30/100% LHS 20-40/30% Platinum AE-KE 2R J8I 4G6 Advantage 20-40/100% LHW 20-40/30% Platinum AE-KE 2R J8I 4G6 Advantage 10-20/250a L5H 20-40/30% Platinum AE-KE 2R J8I 4G6 Advantage 15-30/250a L0G 20-40/30% Platinum AE-KE 2R J8I 4G6 Advantage 20-40/250a LOV 20-40/30% Platinum AE-KE 2R J8I 4G6 Advantage 10-20/500a L5N 20-40/30% Platinum AE-KE 2R J8I 4G6 Advantage 15-30/500a LOM 20-40/30% Platinum AE-KE 2R J8I 4G6 Advantage 20-40/500a LI1 20-40/30% Platinum AE-KE 2R J8I 4G6 Advantage 15-30/80% LI6 20-40/30% Platinum AE-KE 2R J8I 4G6 Advantage 20-40/80% L2I 20-40/30% Platinum AE-KE 2R J8I 4G6 Advantage 30-50/80% L5I 30-50/30% Gold AE-KF 051 J8S 4G7 Advantage 15-30/70% L8I 20-40/30% Platinum AE-KE 2R J8I 4G6 Advantage 20-40/70% L80 20-40/30% Platinum AE-KE 2R J8I 4G6 Advantage 30-50/70% L83 30-50/30% Gold AE-KF 051 J8S 4G7 Advantage 15-30/60% L86 30-50/30% Gold AE-KF 051 J8S 4G7 Advantage* 20-40/60% LO9 30-50/30%/1000ded Gold AE-KG 051 J91 4G8 Advantage* 30-50/60% LJP 30-50/30%/1000ded Gold AE-KG 051 J91 4G8 Advantage* 40-60/70% LJS 30-50/30%/1000ded Gold AE-KG 051 J91 4G8 Advantage 40-60/70%/1000ded LJW 30-50/30%/1000ded Gold AE-KG 051 J91 4G8 Advantage 40-60/70%/2000ded LJ1 45-65/40%/2000ded Silver AE-KH 2Z JAO 4H6 Focus 10-20/100% FMP 15-30/250a Platinum AE-KJ 2R F0I 4G5 Focus 15-30/100% FNN 15-30/250a Platinum AE-KJ 2R F0I 4G5 Focus 20-40/100% FNT 15-30/250a Platinum AE-KJ 2R F0I 4G5 Focus 10-20/250a FNW 15-30/250a Platinum AE-KJ 2R F0I 4G5 Focus 15-30/250a FPI 15-30/250a Platinum AE-KJ 2R F0I 4G5 Focus 20-40/250a FQQ 20-40/30% Platinum AE-KK 2R F91 4G6 Focus 10-20/500a FQT 20-40/30% Platinum AE-KK 2R F91 4G6 Focus 15-30/500a FRG 20-40/30% Platinum AE-KK 2R F91 4G6 Focus 20-40/500a FRR 20-40/30% Platinum AE-KK 2R F91 4G6 Focus 15-30/80% FSI 20-40/30% Platinum AE-KK 2R F91 4G6 Focus 20-40/80% FSR 20-40/30% Platinum AE-KK 2R F91 4G6 Focus 30-50/80% FTI 30-50/30% Gold AE-KL 051 F9D 4G7 Focus 15-30/70% FTS 20-40/30% Platinum AE-KK 2R F91 4G6 Focus 20-40/70% FUI 20-40/30% Platinum AE-KK 2R F91 4G6 Focus 30-50/70% FVR 30-50/30% Gold AE-KL 051 F9D 4G7 *This 2015 HMO plan will map to a 2016 Deductible HMO plan. 5 of 6
HMO Portfolio - From Small Business 51-100 to Small Business 1-100 Plan Mapping (continued) Paired Rx Paired Rx Focus 15-30/60% FWB 30-50/30% Gold AE-KL 051 F9D 4G7 Focus* 20-40/60% FWS 30-50/30%/1000ded Gold AE-KM 051 F0K 4G8 Focus* 30-50/60% FXM 30-50/30%/1000ded Gold AE-KM 051 F0K 4G8 Focus* 40-60/70% FYH 30-50/30%/1000ded Gold AE-KM 051 F0K 4G8 Focus 40-60/70%/1000ded FZC 30-50/30%/1000ded Gold AE-KM 051 F0K 4G8 Focus 40-60/70%/2000ded FZT 45-65/40%/2000ded Silver AE-KN 2Z FOR 4H6 Alliance 10-20/100% LJ7 20-40/30% Platinum AE-KQ 2R JSI 4G6 Alliance 15-30/100% L5J 20-40/30% Platinum AE-KQ 2R JSI 4G6 Alliance 20-40/100% L90 20-40/30% Platinum AE-KQ 2R JSI 4G6 Alliance 10-20/250a L94 20-40/30% Platinum AE-KQ 2R JSI 4G6 Alliance 15-30/250a LKE 20-40/30% Platinum AE-KQ 2R JSI 4G6 Alliance 20-40/250a LKR 20-40/30% Platinum AE-KQ 2R JSI 4G6 Alliance 10-20/500a LKW 20-40/30% Platinum AE-KQ 2R JSI 4G6 Alliance 15-30/500a L5K 20-40/30% Platinum AE-KQ 2R JSI 4G6 Alliance 20-40/500a L8K 20-40/30% Platinum AE-KQ 2R JSI 4G6 Alliance 15-30/80% LLM 20-40/30% Platinum AE-KQ 2R JSI 4G6 Alliance 20-40/80% LLT 20-40/30% Platinum AE-KQ 2R JSI 4G6 Alliance 30-50/80% LL6 30-50/30% Gold AE-KR 051 JMI 4G7 Alliance 15-30/70% LLX 20-40/30% Platinum AE-KQ 2R JSI 4G6 Alliance 20-40/70% L5L 20-40/30% Platinum AE-KQ 2R JSI 4G6 Alliance 30-50/70% LMM 30-50/30% Gold AE-KR 051 JMI 4G7 Alliance 15-30/60% LMQ 30-50/30% Gold AE-KS 051 JNO 4G8 Alliance* 20-40/60% LMU 30-50/30%/1000ded Gold AE-KS 051 JNO 4G8 Alliance* 30-50/60% LM6 30-50/30%/1000ded Gold AE-KS 051 JNO 4G8 Alliance* 40-60/70% L1M 30-50/30%/1000ded Gold AE-KS 051 JNO 4G8 Alliance 40-60/70%/1000ded L7M 30-50/30%/1000ded Gold AE-KS 051 JNO 4G8 Alliance 40-60/70%/2000ded LM9 45-65/40%/2000ded Silver AE-KT 2Z JIE 4H6 Alliance HSA 90%/1500ded LNH 25%/2000ded Silver AE-KV 2Z JOB 4H2 Alliance HSA 80%/2000ded LNQ 25%/2000ded Silver AE-KV 2Z JOB 4H2 Alliance HSA 80%/3000ded LNT 25%/2000ded Silver AE-KV 2Z JOB 4H2 Alliance HRA** 30-45/90%/1500ded LN1 25%/2000ded Silver AE-KV 2Z JOB 4H2 Alliance HRA** 35-50/80%/2000ded LN7 25%/2000ded Silver AE-KV 2Z JOB 4H2 Alliance HRA** 40-55/70%/3000ded L1N 40%/4500ded Bronze AE-KW 2Z JOK 4H3 *This 2015 HMO plan will map to a 2016 Deductible HMO plan. **This 2015 HRA plan will map to a 2016 HSA plan. Formal HMO product names: Signature = UnitedHealthcare SignatureValue Advantage = UnitedHealthcare SignatureValue Advantage Alliance = UnitedHealthcare SignatureValue Alliance Focus = UnitedHelathcare SignatureValue Focus Core and Select Plus coverage are provided by or through UnitedHealthcare Insurance Company. These benefit grids are intended only to highlight plan benefits and should not be relied upon to fully determine coverage. These plans may not cover all health care expenses. This agreement has exclusions, limitations, and terms under which the agreement may be continued in force or discontinued. For costs and complete details of the coverage, contact your sales representative. Health plan coverage provided by or through UnitedHealthcare Insurance Company and UnitedHealthCare of California. Administrative services provided by United Healthcare Services, Inc., OptumRx or OptumHealth Care Solutions, Inc. Behavioral health products are provided by U.S. Behavioral Health Plan, California (USBHPC) or United Behavioral Health (UBH). MT-992963 12/15 2015 United HealthCare Services, Inc. 15-0916 UHCCA755091-000 6 of 6