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UnitedHealthcare Plans

Key Accounts 51+ Medical and Pharmacy Plans

Effective January 1, 2014

OREGON – Key Accounts

A variety of plan designs, ranging from network-based solutions that promote consumer engagement to traditional designs that focus on primary care.

Plan Categories DefinitionFlat Copay} Flat Copay plans for PCP and specialist o ce visits

Premier } Split Copay plans that incorporate the UnitedHealth Premium® designation program for specialists

Premier FlexPoint } Split Copay plans that incorporate the UnitedHealth Premium designation program for specialists.

Applicable specialist copayment for limited number of visits

HSA} High-deductible plans that are HSA-eligible and can integrate Optum HSA accounts

Consumer} Plan designs that engage members in their health care decisions

UnitedHealthcare Navigate®

} Network-only plans that utilize a PCP to manage and direct a member’s care

UnitedHealthcare Navigate Balanced®

} Network-only plans that utilize a PCP to manage and direct a member’s care while also oering lower coverage for visits to a network specialist without a referral

Navigate HSA} Navigate plans that are HSA-eligible and can integrate Optum HSA accounts

Navigate Balanced HSA } Navigate Balanced plans that are HSA-eligible and can integrate Optum HSA accounts

$0 Copay for Children} Family-friendly Flat Copay and Navigate plans with a $0 PCP network copayment for children under age 19

Non-Differential PPO } Coinsurance plans for employees outside the UnitedHealthcare network service area

Pharmacy } Pharmacy plans with 3 or 4 tiers can be paired with medical plans

1

• Member cost share including o ce visits, deductible, coinsurance and pharmacy apply to the out-of-pocket maximum• Lab and X-ray are covered at 100%, deductible is waived• Family deductible and out-of-pocket maximum amounts are embedded and 2x individual• Emergency room is $200, then 100% deductible waived• Urgent care is $50• Choice Plus non-network bene�ts are covered at 20% less than network coinsurance or 50%, whichever is greater, and are

subject to the separate non-network deductible and out-of-pocket maximums (2x network amounts)• Choice plans are network only and have no non-network bene�ts

Flat Copay

Plan Type Plan Code Description PCP Office Visit

Specialist Office Visit

NetworkIndividual Deductible Coinsurance Out-of-Pocket

MaximumChoice Plus Flat Copay

Choice Plus Flat Copay VN-D 20/250/90% $20 $20 $250 90% $3,000

Choice Plus Flat Copay VN-E 20/250/80% $20 $20 $250 80% $3,000

Choice Plus Flat Copay VN-F 25/250/80% $25 $25 $250 80% $3,000

Choice Plus Flat Copay VN-G 25/500/90% $25 $25 $500 90% $3,000

Choice Plus Flat Copay VN-H 20/500/80% $20 $20 $500 80% $3,500

Choice Plus Flat Copay VN-I 25/500/80% $25 $25 $500 80% $3,500

Choice Plus Flat Copay VN-J 25/500/80% $25 $25 $500 80% $4,000

Choice Plus Flat Copay VN-K 20/750/90% $20 $20 $750 90% $3,750

Choice Plus Flat Copay VN-L 25/750/80% $25 $25 $750 80% $4,500

Choice Plus Flat Copay VN-M 25/1000/90% $25 $25 $1,000 90% $4,500

Choice Plus Flat Copay VN-N 20/1000/80% $20 $20 $1,000 80% $4,500

Choice Plus Flat Copay VN-O 25/1000/80% $25 $25 $1,000 80% $5,000

Choice Plus Flat Copay VN-P 30/1000/80% $30 $30 $1,000 80% $5,000

Choice Plus Flat Copay VN-R 25/1500/80% $25 $25 $1,500 80% $5,500

Choice Plus Flat Copay VN-S 30/1500/80% $30 $30 $1,500 80% $5,500

Choice Plus Flat Copay VN-T 20/2000/80% $20 $20 $2,000 80% $5,000

Choice Plus Flat Copay VN-U 25/2000/80% $25 $25 $2,000 80% $5,000

Choice Plus Flat Copay VN-V 30/2000/80% $30 $30 $2,000 80% $6,000

Choice Plus Flat Copay VN-W 20/2000/70% $20 $20 $2,000 70% $4,500

Choice Plus Flat Copay VN-X 25/2000/70% $25 $25 $2,000 70% $5,500

Choice Plus Flat Copay VN-Y 30/2000/70% $30 $30 $2,000 70% $5,500

Choice Plus Flat Copay VN-Z 25/2500/80% $25 $25 $2,500 80% $6,000

Choice Plus Flat Copay VN-1 30/2500/80% $30 $30 $2,500 80% $6,250








Choice Plus Flat Copay VO-A 30/3000/50% $30 $30 $3,000 50% $6,250

Choice Plus Flat Copay VO-B 25/4000/80% $25 $25 $4,000 80% $6,250

Choice Plus Flat Copay VO-C 30/4000/80% $30 $30 $4,000 80% $6,250

Choice Plus Flat Copay VO-D 25/4000/70% $25 $25 $4,000 70% $6,250

Choice Plus Flat Copay VO-E 30/4000/70% $30 $30 $4,000 70% $6,250

Choice Plus Flat Copay VO-F 25/4000/50% $25 $25 $4,000 50% $6,250

Choice Plus Flat Copay VO-G 30/4000/50% $30 $30 $4,000 50% $6,250

Choice Plus Flat Copay VO-H 25/5000/80% $25 $25 $5,000 80% $6,250

Choice Plus Flat Copay VO-I 30/5000/80% $30 $30 $5,000 80% $6,250

Choice Plus Flat Copay VO-J 25/5000/70% $25 $25 $5,000 70% $6,250

Choice Plus Flat Copay VO-K 30/5000/70% $30 $30 $5,000 70% $6,250

Choice Plus Flat Copay VO-L 25/5000/50% $25 $25 $5,000 50% $6,250

Choice Plus Flat Copay VO-M 30/5000/50% $30 $30 $5,000 50% $6,250

Choice Flat CopayChoice Flat Copay VB-P 25/500/80% $25 $25 $500 80% $4,000

Choice Flat Copay VB-Q 25/1000/80% $25 $25 $1,000 80% $4,500

Choice Flat Copay VB-R 30/1000/80% $30 $30 $1,000 80% $5,000

Choice Flat Copay VB-S 30/1500/80% $30 $30 $1,500 80% $5,500

Choice Flat Copay VB-T 25/2000/80% $25 $25 $2,000 80% $5,500

Choice Flat Copay VB-U 30/2000/70% $30 $30 $2,000 70% $5,000

Choice Flat Copay VB-V 25/2500/70% $25 $25 $2,500 70% $5,500

Choice Flat Copay VB-X 30/5000/80% $30 $30 $5,000 80% $6,250

2


Premium Designated Specialist Office Visit

Non-Premium Designated Specialist Office Visit

Network

Individual Deductible Coinsurance

Out-of-Pocket

MaximumChoice Plus Premier

Choice Plus Premier VT-C 20/250/80% $20 $20 $40 $250 80% $3,000Choice Plus Premier VT-D 20/500/90% $20 $20 $40 $500 90% $3,000Choice Plus Premier VT-E 20/500/80% $20 $20 $40 $500 80% $3,500Choice Plus Premier VT-F 25/500/80% $25 $25 $50 $500 80% $3,500Choice Plus Premier VT-G 20/750/90% $20 $20 $40 $750 90% $4,000Choice Plus Premier VT-H 25/750/80% $25 $25 $50 $750 80% $4,250Choice Plus Premier VT-I 20/1000/80% $20 $20 $40 $1,000 80% $4,000Choice Plus Premier VT-J 25/1000/80% $25 $25 $50 $1,000 80% $4,000Choice Plus Premier VT-K 30/1000/80% $30 $30 $60 $1,000 80% $4,500Choice Plus Premier VT-L 25/1000/70% $25 $25 $50 $1,000 70% $5,000Choice Plus Premier VT-M 30/1000/70% $30 $30 $60 $1,000 70% $5,000Choice Plus Premier VT-N 20/1500/80% $20 $20 $40 $1,500 80% $5,000Choice Plus Premier VT-O 25/1500/80% $25 $25 $50 $1,500 80% $5,000Choice Plus Premier VT-P 30/1500/80% $30 $30 $60 $1,500 80% $6,000Choice Plus Premier VT-Q 20/2000/80% $20 $20 $40 $2,000 80% $5,000Choice Plus Premier VT-R 25/2000/80% $25 $25 $50 $2,000 80% $5,500Choice Plus Premier VT-S 30/2000/80% $30 $30 $60 $2,000 80% $6,000Choice Plus Premier VT-T 25/2000/70% $25 $25 $50 $2,000 70% $5,000Choice Plus Premier VT-U 30/2000/70% $30 $30 $60 $2,000 70% $6,000Choice Plus Premier VT-V 25/2500/80% $25 $25 $50 $2,500 80% $6,000Choice Plus Premier VT-W 30/2500/80% $30 $30 $60 $2,500 80% $6,250Choice Plus Premier VT-X 25/2500/70% $25 $25 $50 $2,500 70% $6,250Choice Plus Premier VT-Y 30/2500/70% $30 $30 $60 $2,500 70% $6,250Choice Plus Premier VT-Z 25/3000/80% $25 $25 $50 $3,000 80% $6,250Choice Plus Premier VT-1 30/3000/80% $30 $30 $60 $3,000 80% $6,250Choice Plus Premier VT-2 25/3000/70% $25 $25 $50 $3,000 70% $6,250Choice Plus Premier VT-3 30/3000/70% $30 $30 $60 $3,000 70% $6,250Choice Plus Premier VT-4 25/3000/50% $25 $25 $50 $3,000 50% $6,250Choice Plus Premier VT-5 35/3000/50% $35 $35 $70 $3,000 50% $6,250Choice Plus Premier VT-6 25/4000/80% $25 $25 $50 $4,000 80% $6,250Choice Plus Premier VT-7 30/4000/80% $30 $30 $60 $4,000 80% $6,250Choice Plus Premier VT-8 25/4000/70% $25 $25 $50 $4,000 70% $6,250Choice Plus Premier VT-9 30/4000/70% $30 $30 $60 $4,000 70% $6,250Choice Plus Premier VU-C 25/4000/50% $25 $25 $50 $4,000 50% $6,250Choice Plus Premier VU-D 35/4000/50% $35 $35 $70 $4,000 50% $6,250Choice Plus Premier VU-E 25/5000/80% $25 $25 $50 $5,000 80% $6,250Choice Plus Premier VU-F 30/5000/80% $30 $30 $60 $5,000 80% $6,250Choice Plus Premier VU-G 25/5000/70% $25 $25 $40 $5,000 70% $6,250Choice Plus Premier VU-H 30/5000/70% $30 $30 $60 $5,000 70% $6,250Choice Plus Premier VU-I 25/5000/50% $25 $25 $50 $5,000 50% $6,250Choice Plus Premier VU-J 30/6000/50% $30 $30 $60 $6,000 50% $6,250Choice Plus Premier VU-K 25/6000/80% $25 $25 $40 $6,000 80% $6,250

Choice PremierChoice Premier VU-N 25/500/80% $25 $25 $50 $500 80% $3,500Choice Premier VU-O 20/1000/80% $20 $20 $40 $1,000 80% $4,000Choice Premier VU-P 20/1500/80% $20 $20 $40 $1,500 80% $5,000Choice Premier VU-Q 20/2000/80% $20 $20 $40 $2,000 80% $5,500Choice Premier VU-R 25/2000/70% $25 $25 $50 $2,000 70% $5,500Choice Premier VU-S 25/3000/70% $25 $25 $50 $3,000 70% $6,250Choice Premier VU-T 30/3000/80% $30 $30 $60 $3,000 80% $6,250Choice Premier VU-U 25/5000/80% $25 $25 $50 $5,000 80% $6,250

Premier• Member cost share including o ce visits, deductible, coinsurance and pharmacy apply to the out-of-pocket maximum• Family deductible and out-of-pocket maximum amounts are embedded and 2x individual• Tiered bene�ts apply to all specialist physicians for whom there is a UnitedHealth Premium designation program. Specialists

in areas where there is no designation program follow the non-designated specialist cost share.• Lab and X-ray are covered at plan coinsurance, deductible is waived• Emergency room is $200 then 100%, deductible is waived• Urgent care is $50• Non-network bene�ts are covered at 30% less than network coinsurance or 50%, whichever is greater, and are subject to the

separate non-network deductible and out-of-pocket maximums (2x network amounts)• Choice plans are network only and have no non-network bene�ts

3

Plan Type Plan Code Description

PCP Office Visit

Premium Designated Specialist Office Visit

Non-Premium Designated Specialist Office Visit

Office Visit

Limits

Network


Out-of-Pocket

MaximumChoice Plus Premier FlexPoint

Choice Plus Premier FlexPoint VU-M 3000/70% 100% $40 $70 2 $3,000 70% $6,250

Choice Plus Premier FlexPoint VU-L 5000/70% 100% $40 $70 2 $5,000 70% $6,250

Choice Premier FlexPointChoice Premier FlexPoint VU-V 3000/80% 100% $40 $70 2 $3,000 80% $6,250

Choice Premier FlexPoint VU-W 5000/80% 100% $35 $65 2 $5,000 80% $6,250

Premier FlexPoint• Member cost share including o ce visits, deductible, coinsurance and pharmacy apply to the out-of-pocket maximum • Plan design applies a copay for a limited number of PCP and/or specialist sickness and injury o ce visits combined. After, the deductible

then coinsurance will apply.• Family deductible and out-of-pocket maximum amounts are embedded and 2x individual• Tiered bene�ts apply to all specialist physicians for whom there is a UnitedHealth Premium designation program. Specialists in

areas where there is no designation program follow the non-designated specialist cost share.• Lab and X-ray are covered at plan coinsurance, deductible is waived• Emergency room is covered at $300 then plan coinsurance, deductible is waived• Urgent care is $50• Non-network bene�ts are covered at 30% less than network coinsurance or 50%, whichever is greater, and are subject to the

separate non-network deductible and out-of-pocket maximums (2x network amounts)




MaximumChoice Plus HSA

Choice Plus HSA U4-N 1500/100% 100% 100% $1,500 100% $3,500

Choice Plus HSA U4-P 1500/90% 90% 90% $1,500 90% $3,500

Choice Plus HSA U4-S 1500/80% 80% 80% $1,500 80% $4,500

Choice Plus HSA U4-Q 2000/90% 90% 90% $2,000 90% $4,500

Choice Plus HSA U4-T 2000/80% 80% 80% $2,000 80% $5,000

Choice Plus HSA U4-V 2000/70% 70% 70% $2,000 70% $5,000

Choice Plus HSA U4-U 2500/80% 80% 80% $2,500 80% $5,500

Choice Plus HSA U4-6* 2500/80% 80% 80% $2,500* (emb) 80% $6,250* (emb)

Choice Plus HSA U4-Y 2500/70% 70% 70% $2,500 70% $6,250

Choice Plus HSA U4-3 2500/50% 50% 50% $2,500 50% $6,250

Choice Plus HSA U4-O 3000/100% 100% 100% $3,000 100% $4,500

Choice Plus HSA U4-R 3000/90% 90% 90% $3,000 90% $5,000

Choice Plus HSA U4-W 3000/80% 80% 80% $3,000 80% $6,250


Choice Plus HSA U4-Z 3000/70% 70% 70% $3,000 70% $6,250

Choice Plus HSA U4-4 3000/50% 50% 50% $3,000 50% $6,250


Choice Plus HSA U4-X 5000/80% 80% 80% $5,000 80% $6,250

Choice Plus HSA U4-2 5000/70% 70% 70% $5,000 70% $6,250

Choice Plus HSA U4-5 5000/50% 50% 50% $5,000 50% $6,250

Choice HSAChoice HSA U4-9 1500/80% 80% 80% $1,500 80% $5,000

Choice HSA U5-1 2000/80% 80% 80% $2,000 80% $5,500

Choice HSA U5-2 3000/70% 70% 70% $3,000 70% $6,250

* Plan has embedded medical deductible and out-of-pocket maximum.

HSA• Member cost share including o ce visits, deductible, coinsurance and pharmacy apply to the out-of-pocket maximum• Family deductible and out-of-pocket maximum amounts are 2x individual and non-embedded, except as noted• All services, except preventive services, are subject to the deductible and apply to the out-of-pocket maximum• Choice Plus non-network bene�ts are covered at 30% less than network coinsurance or 50%, which ever is greater, and are

subject to the separate non-network deductible and out-of-pocket maximums• Only HSA-eligible pharmacy plans can be selected with HSA-eligible medical plans• Choice HSA plans are network only and have no non-network bene�ts

4




MaximumChoice Plus Consumer VN-C 50% 50% 50% $0 50% $5,000

Choice Plus Consumer VN-Q 1000/50% 50% 50% $1,000 50% $5,500

Choice Plus Consumer VO-N 25/1500/80% $25 $25 $1,500 80% $5,000

Choice Plus Consumer VO-O 25/2000/80% $25 $25 $2,000 80% $5,500

Choice Plus Consumer VO-T 25/2000/70% $25 $25 $2,000 70% $6,250

Choice Plus Consumer VO-P 25/2500/80% $25 $25 $2,500 80% $6,000

Choice Plus Consumer VO-U 25/2500/70% $25 $25 $2,500 70% $6,250

Choice Plus Consumer VN-4 2500/50% 50% 50% $2,500 50% $6,250

Choice Plus Consumer VB-W 2500/50% 50% 50% $2,500 50% $6,000

Choice Plus Consumer VO-Q 25/3000/80% $25 $25 $3,000 80% $6,250

Choice Plus Consumer VO-R 30/3000/80% $30 $30 $3,000 80% $6,250

Choice Plus Consumer VO-V 30/3000/70% $30 $30 $3,000 70% $6,250

Choice Plus Consumer VO-S 30/5000/80% $30 $30 $5,000 80% $6,250

Choice Plus Consumer VO-W 30/5000/70% $30 $30 $5,000 70% $6,250

Consumer• Member cost share including o ce visits, deductible, coinsurance and pharmacy apply to the out-of-pocket maximum• Family deductible and out-of-pocket maximum amounts are embedded and 2x individual• Emergency room is covered at deductible, then coinsurance• Urgent care is $50 when a PCP o ce visit is a copayment; deductible and coinsurance for all other plans• Lab and X-ray are covered at 100%, deductible is waived for plans with o ce visit copays; deductible and coinsurance for

plans with deductible and coinsurance o ce visits• Bene�ts with plan coinsurance are subject to deductible, unless noted• Choice Plus non-network bene�ts are covered at 50%, and subject to the separate non-network deductible and

out-of-pocket maximums (2x network amount)

5


PCP Office Visit


with Referral


without Referral

Network


Coinsurance without Referral

Out-of-Pocket

MaximumNavigate VO-6 20/250/90% $20 $40 N/A $250 90% N/A $3,500Navigate VO-7 20/500/90% $20 $40 N/A $500 90% N/A $3,500Navigate VO-8 20/500/80% $20 $40 N/A $500 80% N/A $4,000Navigate VO-9 30/500/80% $30 $60 N/A $500 80% N/A $4,000Navigate VP-V 25/500/70% $25 $50 N/A $500 70% N/A $4,500Navigate VP-W 25/750/90% $25 $50 N/A $750 90% N/A $4,500Navigate VP-X 20/750/80% $20 $40 N/A $750 80% N/A $4,000Navigate VP-Z 35/750/80% $35 $70 N/A $750 80% N/A $4,000Navigate VP-Y 25/750/70% $25 $50 N/A $750 70% N/A $5,000Navigate VP-1 25/1000/90% $25 $50 N/A $1,000 90% N/A $4,000Navigate VP-2 20/1000/80% $20 $40 N/A $1,000 80% N/A $4,500Navigate VP-3 25/1000/80% $25 $50 N/A $1,000 80% N/A $4,500Navigate VP-4 30/1000/80% $30 $60 N/A $1,000 80% N/A $5,000Navigate VP-5 25/1000/70% $25 $50 N/A $1,000 70% N/A $5,000Navigate VP-6 25/1500/80% $25 $50 N/A $1,500 80% N/A $5,000Navigate VP-7 35/1500/80% $35 $70 N/A $1,500 80% N/A $5,500Navigate VP-8 25/1500/70% $25 $50 N/A $1,500 70% N/A $5,500Navigate VP-9 25/2000/80% $25 $50 N/A $2,000 80% N/A $5,500Navigate VS-T 35/2000/80% $35 $70 N/A $2,000 80% N/A $6,000Navigate VS-U 25/2000/70% $25 $50 N/A $2,000 70% N/A $6,250Navigate VS-V 25/3000/80% $25 $50 N/A $3,000 80% N/A $6,250 Navigate VS-W 35/3000/80% $35 $70 N/A $3,000 80% N/A $6,250 Navigate VS-X 25/3000/70% $25 $50 N/A $3,000 70% N/A $6,250 Navigate 31-D 30/5000/70% $30 $60 N/A $5,000 70% N/A $6,350

UnitedHealthcare Navigate• Network-only split copay plans that utilize PCP managed referrals• Member cost share including o ce visits, deductible, coinsurance and pharmacy apply to the out-of-pocket maximum• Family deductibles and out-of-pocket maximums are embedded and 2x individual • Routine lab and X-ray are covered at plan coinsurance, deductible is waived• Urgent care is $75• Emergency room is covered at $250 then network coinsurance, deductible is waived• A $250 per-occurrence deductible applies to inpatient services


PCP Office Visit


with Referral


without Referral

Network



Out-of-Pocket

MaximumNavigate Balanced VS-Y 20/500/90% $20 $40 $70 $500 90% 60% $3,000Navigate Balanced VS-Z 15/500/80% $15 $35 $65 $500 80% 50% $4,000Navigate Balanced VS-1 25/750/80% $25 $45 $75 $750 80% 50% $4,500Navigate Balanced VS-2 15/1000/80% $15 $35 $65 $1,000 80% 50% $4,500Navigate Balanced VS-3 25/1000/80% $25 $45 $75 $1,000 80% 50% $5,000Navigate Balanced VS-4 20/1500/80% $20 $40 $70 $1,500 80% 50% $5,000Navigate Balanced VS-5 25/1500/80% $25 $45 $75 $1,500 80% 50% $5,000Navigate Balanced VS-8 25/1500/70% $25 $45 $75 $1,500 70% 50% $5,000Navigate Balanced VS-6 25/2000/80% $25 $45 $75 $2,000 80% 50% $5,500Navigate Balanced VS-9 25/2000/70% $25 $45 $75 $2,000 70% 50% $5,500Navigate Balanced VS-7 25/2500/80% $25 $45 $75 $2,500 80% 50% $6,000

• Network-only Split Copay plans that utilize PCP managed referrals while oering lower coverage levels for network services received without a referral

• Member cost share including o ce visits, deductible, coinsurance and pharmacy apply to the out-of-pocket maximum• Family deductibles and out-of-pocket maximums are embedded and 2x family• Routine lab and X-ray are covered at plan coinsurance, deductible is waived• Urgent care is $75• Emergency room is $250, then network coinsurance with deductible waived

UnitedHealthcare Navigate Balanced

6


PCP Office Visit


with Referral


without Referral

Network



Out-of-Pocket

MaximumNavigate HSA VF-O 1500/80% 80% 80% N/A $1,500 80% N/A $4,000

Navigate HSA VF-T 1500/70% 70% 70% N/A $1,500 70% N/A $4,000

Navigate HSA VF-P 2000/80% 80% 80% N/A $2,000 80% N/A $4,500

Navigate HSA VF-U 2000/70% 70% 70% N/A $2,000 70% N/A $4,500

Navigate HSA VF-Q 2500/80% 80% 80% N/A $2,500 80% N/A $5,500

Navigate HSA VF-R 3000/80% 80% 80% N/A $3,000 80% N/A $6,000

Navigate HSA VF-V 3000/70% 70% 70% N/A $3,000 70% N/A $6,000

Navigate HSA VF-S 5000/80% 80% 80% N/A $5,000 80% N/A $6,250

Navigate HSA VF-W 5000/70% 70% 70% N/A $5,000 70% N/A $6,250

Navigate HSA• Network-only HSA eligible plans that require PCP-managed referrals• All services, except preventive services, are subject to the deductible and apply to the out-of-pocket maximum• Only HSA-eligible pharmacy plans can be selected with HSA-eligible medical plans


PCP Office Visit


with Referral


without Referral

Network



Out-of-Pocket

MaximumNavigate Balanced HSA VF-X 1500/80% 80% 80% 50% $1,500 80% 50% $4,000

Navigate Balanced HSA VF-Y 2000/80% 80% 80% 50% $2,000 80% 50% $4,500

Navigate Balanced HSA VF-7 2000/70% 70% 70% 50% $2,000 70% 50% $4,500

Navigate Balanced HSA VF-Z 3000/80% 80% 80% 50% $3,000 80% 50% $6,000

Navigate Balanced HSA VF-8 3000/70% 70% 70% 50% $3,000 70% 50% $6,000

• Network-only plans that utilize PCP managed referrals while oering lower coverage levels for network services received without a referral

• Member cost share including o ce visits, deductible, coinsurance and pharmacy apply to the out-of-pocket maximum• Family deductibles and out-of-pocket maximums are embedded and 2x family• All services, except preventive services, are subject to the deductible and apply to the out-of-pocket-maximum• Only HSA-eligible pharmacy plans can be selected with HSA-eligible medical plans

Navigate Balanced HSA

7


PCP Office Visit

Children’s PCP

Office Visit

Children’s Office

Visit Age Limit


Network


Out-of-Pocket

MaximumChoice Plus $0 Copay for Children VO-X 15/250/70% $15 $0 19 $15 $250 70% $3,500

Choice Plus $0 Copay for Children VO-2 20/500/80% $20 $0 19 $20 $500 80% $4,000

Choice Plus $0 Copay for Children VO-Y 20/500/70% $20 $0 19 $20 $500 70% $3,500

Choice Plus $0 Copay for Children VO-3 25/750/80% $25 $0 19 $25 $750 80% $4,500

Choice Plus $0 Copay for Children VO-Z 20/750/70% $20 $0 19 $20 $750 70% $4,000

Choice Plus $0 Copay for Children VO-4 25/1000/80% $25 $0 19 $25 $1,000 80% $4,000



$0 Copay for Children• Member cost share including o ce visits, deductible, coinsurance and pharmacy apply to the out-of-pocket maximum• Family deductible and out-of-pocket maximum amounts are embedded and 2x individual• Bene�ts with plan coinsurance are subject to deductible, unless noted• Emergency room is covered at $200, deductible is waived• Urgent care is $75• Routine lab and X-ray are covered at100%, deductible waived• Choice Plus non-network bene�ts are covered at 20% less than network coinsurance or 50%, whichever is greater, and are

subject to the separate non-network deductible and out-of-pocket maximums (2x network amount)

Non-Differential PPO• Single coinsurance level for network and non-network providers• Member cost share including o ce visits, deductible, coinsurance and pharmacy apply to the out-of-pocket maximum• Family deductible is 2x individual amount and family out-of-pocket maximum is 2x individual amount• Routine lab and X-ray, urgent care, and emergency room are covered at deductible and coinsurance




MaximumNon-Differential PPO VC-5 1000/80% 80% 80% $1,000 80% $5,000

Non-Differential PPO VC-9 25/1000/80% $25 $25 $1,000 80% $4,500

Non-Differential PPO VC-6 1500/80% 80% 80% $1,500 80% $5,000



8

Pharmacy

Plan Code Individual Deductible Family Deductible Tier 1 Copayment

Tier 2 Copayment

Tier 3 Copayment

Tier 4 Copayment Mail Service Ratio

K6 - - $10 $20 $40 - 2.5

K4 - - $10 $25 $40 - 2.5

K5 - - $10 $25 $50 - 2.5

H9 - - $10 $30 $50 - 2.5

2V - - $10 $35 $60 - 2.5

5U - - $10 $35 $60 $100 2.5

0I - - $10 $35 $70 - 2.5

UV - - $15 $30 50% - 2.5

I1 - - $15 $30 $50 - 2.5

EM - - $15 $30 $60 - 2.5

FE - - $15 $35 $70 - 2.5

DM - - $15 $35 $75 - 2.5

EJ - - $15 $45 $85 $200 2.5

3S - - $20 $40 $60 - 2.5

UW - - $25 $50 $75 - 2.5

Pharmacy Deductible Plans WL $100 $300 $10 $35 $60 - 2.5

X8 $100 $300 $10 $35 $60 $100 2.5

OM $100 $300 $15 $30 $60 - 2.5

DK $100* $300* $15 $35 $75 - 2.5

X9 $100 $300 $15 $45 $85 $200 2.5

HSA-Eligible Plans*H9 Same as Medical Same as Medical $10 $30 $50 - 2.5

2V Same as Medical Same as Medical $10 $35 $60 - 2.5

EM Same as Medical Same as Medical $15 $30 $60 - 2.5

3B Same as Medical Same as Medical $15 $35 $60 - 2.5

FE Same as Medical Same as Medical $15 $35 $70 - 2.5

3S Same as Medical Same as Medical $20 $40 $60 - 2.5

* Deductible applies to Tier 1, Tier 2, and Tier 3.

• All pharmacy member cost share applies to the combined medical/pharmacy out-of-pocket maximum• Individual deductible applies to Tiers 2-4 unless noted; deductible is waived for Tier 1• Only HSA-eligible plans can be selected for HSA medical plans

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The UnitedHealthcare plan with Health Savings Account (HSA) high deductible health plan (HDHP) is designed to comply with IRS requirements so eligible enrollees may open a Health Savings Account through Optum Bank, Member FDIC. The “HSA” refers generally to the UnitedHealthcare HSA product, which includes a HDHP, although at times “HSA” may refer only and specifically to the UnitedHealthcare Health Savings Account, provided in conjunction with Optum Bank and not to the associated HDHP.

For a complete description of the UnitedHealth Premium® Designation program, including details on the methodology used, geographic availability, program limitations and medical specialties participating, please see myuhc.com®.

Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by United HealthCare Services, Inc. or their affiliates.

©2013 United HealthCare Services, Inc.10/13 UHCOR547577-002

Contact your UnitedHealthcare representative for more information.

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