Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services

Coverage Period: Based on group plan year

UHC Choice Plus Plat 1000-10 with IVF Coverage for: Employee/Family | Plan Type: POS
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan
would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be
provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit
www.welcometouhc.com or by calling 1-800-782-3158. For general definitions of common terms, such as allowed amount, balance billing, coinsurance,
copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary or call
1-866-487-2365 to request a copy.
Important Answers Why This Matters:
Questions
What is the overall Designated Network and Network: $1,000 Generally, you must pay all of the costs from providers up to the deductible
deductible? Individual / $3,000 Family amount before this plan begins to pay. If you have other family members on the
out-of-Network: $5,000 Individual / $15,000 plan, each family member must meet their own individual deductible until the total
Family amount of deductible expenses paid by all family members meets the overall family
Per calendar year. deductible.
Are there services Yes. Preventive care and categories with a copay This plan covers some items and services even if you haven’t yet met the deductible
covered before you are covered before you meet your deductible. amount. But a copayment or coinsurance may apply. For example, this plan covers
meet your certain preventive services without cost-sharing and before you meet your
deductible? deductible. See a list of covered preventive services at
www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other No. You don’t have to meet deductibles for specific services.
deductibles for
specific services?
What is the Designated Network and Network: $2,000 The out-of-pocket limit is the most you could pay in a year for covered services. If
out-of-pocket limit Individual / $6,000 Family you have other family members in this plan, they have to meet their own
for this plan? out-of-Network: $10,000 Individual / $30,000 out-of-pocket limits until the overall family out-of-pocket limit has been met.
Family
What is not included Premiums, balance-billing charges (unless Even though you pay these expenses, they don’t count toward the out-of-pocket
in the out-of-pocket balanced billing is prohibited), health care this limit.
limit? plan doesn’t cover and penalties for failure to
obtain priorauthorization for services.
Will you pay less if Yes. See www.welcometouhc.com or call You pay the least if you use a provider in the Designated Network. You pay more if
you use a network 1-800-782-3158 for a list of network providers. you use a provider in the Network. You will pay the most if you use an
provider? out-of-Network provider, and you might receive a bill from a provider for the
difference between the provider’s charge and what your plan pays (balance billing).
Be aware, your Network provider might use an out-of-Network provider for some
services (such as lab work). Check with your provider before you get services.
Do you need a No. You can see the specialist you choose without a referral.
referral to see a
specialist?

COD6 Page 1 of 8
 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

What You Will Pay

Common Services Designated Limitations, Exceptions, & Other Important
Medical You May Network Provider Out-of-Network
Event Need Network Provider Provider (You Information
(You will pay the
least) will pay the
most)
If you visit a Primary care $20 copay per visit, $20 copay per visit, 50% coinsurance If you receive services in addition to office visit,
health care visit to treat an deductible does not deductible does not additional copays, deductibles, or coinsurance may
provider’s injury or apply apply apply e.g. surgery.
office or clinic illness Virtual visits (Telehealth) - No Charge by a Designated
Virtual Network Provider.
Children under age 19: No Charge.
Specialist visit $20 copay per visit, $40 copay per visit, 50% coinsurance If you receive services in addition to office visit,
deductible does not deductible does not additional copays, deductibles, or coinsurance may
apply apply apply e.g. surgery.
Preventive No Charge No Charge * 50% Includes preventive health services specified in the
care/screening coinsurance health care reform law. You may have to pay for
/immunizatio- services that aren’t preventive. Ask your provider if the
n services needed are preventive. Then check what your
plan will pay for.
*Deductible/coinsurance may not apply to certain
services.
If you have a Diagnostic test 20% coinsurance 20% coinsurance 50% coinsurance Priorauthorization required for out-of-Network for
test (x-ray, blood certain services or benefit reduces to the lesser of 50%
work) or $500.
Imaging $400 copay per $400 copay per 50% coinsurance Priorauthorization required for out-of-Network or
(CT/PET service, deductible service, deductible benefit reduces to the lesser of 50% or $500.
scans, MRIs) does not apply does not apply

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 What You Will Pay
Designated
Common Services You Network Out-of-Network Limitations, Exceptions, & Other Important
Medical Event May Need Network Information
Provider (You Provider Provider (You
will pay the will pay the
least) most)
If you need drugs Tier 1 - Your Deductible does Deductible does Deductible does Provider means pharmacy for purposes of this section.
to treat your Lowest-Cost not apply. Retail: not apply. Retail: not apply. Retail: Retail: Up to a 31 day supply. Mail-Order*: Up to a 90
illness or Option $10 copay $10 copay $10 copay day supply or *Preferred 90 Day Retail Network
condition Mail-Order: $25 Mail-Order: $25 Specialty Drugs: Pharmacy. If you use an out-of-Network pharmacy
copay copay $10 copay (including a mail order pharmacy), you may be
More information Specialty Specialty responsible for any amount over the allowed amount.
about prescription Drugs** : $10 Drugs** : $10 **Your cost shown is for a Preferred Specialty Network
drug coverage is copay copay Pharmacy. Non-Preferred Specialty Network
available at www.
Deductible does Pharmacy: Copay is 2 times the Preferred Specialty
welcometouhc.com. Tier 2 - Your Deductible does Deductible does Network Pharmacy Copay or the coinsurance (up to
Midrange-Cost not apply. Retail: not apply. Retail: not apply. Retail: 50% of the Prescription Drug Charge) based on the
Option $40 copay $40 copay $40 copay applicable Tier.
Mail-Order: $100 Mail-Order: $100 Specialty Drugs: Copay is per prescription order up to the day supply
copay copay $40 copay limit listed above.
Specialty Specialty You may need to obtain certain drugs, including certain
Drugs** : $40 Drugs** : $40 specialty drugs, from a pharmacy designated by us.
copay copay Certain drugs may have a priorauthorization
Tier 3 - Your Deductible does Deductible does Deductible does requirement or may result in a higher cost. See the
Midrange-Cost not apply. Retail: not apply. Retail: not apply. Retail: website listed for information on drugs covered by your
Option $125 copay $125 copay $125 copay plan. Not all drugs are covered. Prescription Drug List
Mail-Order: Mail-Order: Specialty Drugs: (PDL): Essential . Network: National You may be
$312.50 copay $312.50 copay $125 copay required to use a lower-cost drug(s) prior to benefits
Specialty Specialty under your policy being available for certain prescribed
Drugs** : $125 Drugs** : $125 drugs. Certain preventive medications and Tier 1
copay copay contraceptives are covered at No Charge.
Tier 4 - Additional Deductible does Deductible does Deductible does If a dispensed drug has a chemically equivalent drug,
High-Cost Options not apply. Retail: not apply. Retail: not apply. Retail: the cost difference between drugs in addition to any
$300 copay $300 copay $300 copay applicable copay and/or coinsurance may be applied.
Mail-Order: $750 Mail-Order: $750 Specialty Drugs:
copay copay $500 copay
Specialty Specialty
Drugs** : $500 Drugs** : $500
copay copay

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 What You Will Pay
Designated
Common Services You Network Out-of-Network Limitations, Exceptions, & Other Important
Medical Event May Need Network Information
Provider (You Provider Provider (You
will pay the will pay the
least) most)
If you have Facility fee (e.g., 20% coinsurance 20% coinsurance 50% coinsurance Priorauthorization required for certain services for
outpatient surgeryambulatory surgery out-of-Network or benefit reduces to the lesser of 50%
center) or $500.
Physician/surgeon 20% coinsurance 20% coinsurance 50% coinsurance None
fees
If you need Emergency room $350 copay per $350 copay per $350 copay per None
immediate medical care visit. After copay visit. After copay visit. After copay
attention , 20% , 20% , 20%
coinsurance, coinsurance, coinsurance,
deductible does deductible does deductible does
not apply not apply not apply
Emergency medical 20% coinsurance 20% coinsurance 20% coinsurance None
transportation
Urgent care $50 copay per $50 copay per 50% coinsurance
If you receive services in addition to urgent care visit,
visit, deductible visit, deductible additional copays, deductibles, or coinsurance may
does not apply does not apply apply e.g. surgery.
If you have a Facility fee (e.g., 20% coinsurance 20% coinsurance 50% coinsurance
Priorauthorization required for out-of-Network or
hospital stay hospital room) benefit reduces to the lesser of 50% or $500.
Physician/surgeon 20% coinsurance 20% coinsurance 50% coinsurance None
fees
If you need mental Outpatient services $20 copay per $20 copay per 0% coinsurance
Network partial hospitalization /intensive outpatient
health, behavioral visit, deductible visit, deductible treatment: 20% coinsurance
health, or does not apply does not apply Priorauthorization required for certain services for
substance abuse out-of-Network or benefit reduces to the lesser of 50%
services or $500.
Inpatient services 20% coinsurance 20% coinsurance 50% coinsurance Priorauthorization required for out-of-Network or
benefit reduces to the lesser of 50% or $500.
If you are pregnant Office visits No Charge No Charge 50% coinsurance Cost sharing does not apply for preventive services.
Depending on the type of services, a copayment,
deductibles, or coinsurance may apply.
Childbirth/delivery 20% coinsurance 20% coinsurance 50% coinsurance Maternity care may include tests and services described
professional elsewhere in the SBC (i.e. ultrasound.)
services

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 What You Will Pay
Designated
Common Services You Network Out-of-Network Limitations, Exceptions, & Other Important
Medical Event May Need Network Information
Provider (You Provider Provider (You
will pay the will pay the
least) most)
Childbirth/delivery 20% coinsurance 20% coinsurance 50% coinsurance Inpatient priorauthorization apply for out-of-Network
facility services if stay exceeds 48 hours (C-Section: 96 hours) or
benefit reduces to the lesser of 50% or $500.
If you need help Home health care 20% coinsurance 20% coinsurance 50% coinsurance Limited to 60 visits per calendar year.
recovering or have Priorauthorization required for out-of-Network or
other special benefit reduces to the lesser of 50% or $500.
health needs
Rehabilitation $20 copay per $20 copay per 50% coinsurance Limits per calendar year: Physical, Occupational,
services outpatient visit, outpatient visit, Pulmonary, Cardiac 35 visits each. Speech: Unlimited.
deductible does deductible does
not apply not apply
Habilitation services $20 copay per $20 copay per 50% coinsurance Limits per calendar year: Physical, Occupational 35
outpatient visit, outpatient visit, visits each. Speech: Unlimited.
deductible does deductible does Priorauthorization required for out-of-Network
not apply not apply inpatient services or benefit reduces to the lesser of
50% or $500.
For Inpatient Services, limited to 60 days per calendar
year.
Skilled nursing care 20% coinsurance 20% coinsurance 50% coinsurance Skilled nursing is limited to 60 days per calendar year
(combined with Inpatient Rehabilitation) .
Priorauthorization required for out-of-Network or
benefit reduces to the lesser of 50% or $500.
Durable medical 20% coinsurance 20% coinsurance 50% coinsurance Priorauthorization required for out-of-Network
equipment Durable medical equipment over $1,000 or benefit
reduces to the lesser of 50% or $500.
Hospice services 20% coinsurance 20% coinsurance 50% coinsurance Priorauthorization required for out-of-Network before
admission for an Inpatient Stay in a hospice facility or
benefit reduces to the lesser of 50% or $500.
If your child needs Children’s eye exam $10 copay per $10 copay per 50% coinsurance One exam every 12 months.
dental or eye care visit, deductible visit, deductible
does not apply does not apply

Page 5 of 8
 What You Will Pay
Designated
Common Services You Network Out-of-Network Limitations, Exceptions, & Other Important
Medical Event May Need Network Information
Provider (You Provider Provider (You
will pay the will pay the
least) most)
Children’s glasses $25 copay per $25 copay per 50% coinsurance One pair every 12 months.
frame, frame, Costs may increase depending on the frames selected.
deductible does deductible does You may choose contact lenses instead of eyeglasses.
not apply not apply The benefit does not cover both.
Children’s dental 0% coinsurance 0% coinsurance 0% coinsurance Cleanings covered 2 times per 12 months.
check-up

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded
services.)
Acupuncture Bariatric Surgery Cosmetic Surgery Dental Care (Adult) Infertility Treatment
Long-Term Care Non-emergency care when Private Duty Nursing Routine Eye Care (Adult) Routine Foot Care
traveling outside the U.S.
Weight Loss Programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
Chiropractic care-35 visits Hearing Aids - 1 every 3
per calendar year years

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those
agencies is: 1-866-444-3272 or www.dol.gov/ebsa/healthreform for the U.S. Department of Labor, Employee Benefits Security Administration. You may also
contact us at 1-800-782-3158 . Other coverage options may be available to you too, including buying individual insurance coverage through the Health
Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is
called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan
documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about
your rights, this notice, or assistance, contact: 1-800-782-3158 ; or the Employee Benefits Security Administration at 1-866-444-EBSA (3272) or
www.dol.gov/ebsa/healthreform or the Texas Department of Insurance at 1-800-252-3439 or www.tdi.texas.gov.

Page 6 of 8
Does this plan provide Minimum Essential Coverage? Yes.
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare,
Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the
premium tax credit.

Does this plan meet Minimum Value Standards? Yes.

If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
Language Access Services:
Spanish (Espa ol): Para obtener asistencia en Espa ol, llame al 1-800-782-3158 .
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-782-3158 .
Chinese 1-800-782-3158 .
Navajo (Dine): Dinek ehgo shika at ohwol ninisingo, kwiijigo holne 1-800-782-3158 .
To see examples of how this plan might cover costs for a sample medical situation, see the next section.

Page 7 of 8
About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be
different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing
amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of
costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby Managing Joe’s Type 2 Mia’s Simple Fracture

(9 months of in-network pre-natal Diabetes (in-network emergency room visit and
care and a hospital delivery) (a year of routine in-network care of follow up care)
a well-controlled condition)
The plan’s overall deductible $ 1,000 The plan’s overall deductible $ 1,000
Specialist copayment $40 The plan’s overall deductible $ 1,000 Specialist copayment $40
Hospital (facility) coinsurance 20% Specialist copayment $40 Hospital (facility) coinsurance 20%
Other coinsurance 20% Hospital (facility) coinsurance 20% Other coinsurance 20%
Other coinsurance 20%
This EXAMPLE event includes services This EXAMPLE event includes services
like: This EXAMPLE event includes services like:
Specialist office visits (prenatal care) like: Emergency room care (including medical supplies)
Childbirth/Delivery Professional Services Primary care physician office visits (including Diagnostic test (x-ray)
Childbirth/Delivery Facility Services disease education) Durable medical equipment (crutches)
Diagnostic tests (ultrasounds and blood work) Diagnostic tests (blood work) Rehabilitation services (physical therapy)
Specialist visit (anesthesia) Prescription drugs
Durable medical equipment (glucose meter) Total Example Cost $2,800
Total Example Cost $12,700 In this example, Mia would pay:
In this example, Peg would pay: Total Example Cost $5,600
Cost Sharing
Cost Sharing In this example, Joe would pay:
Deductible $1,000
Deductible $1,000 Cost Sharing
Copayments $100
Copayments $0 Deductible $200
Coinsurance $200
Coinsurance $1,000 Copayments $1,000
What isn’t covered
What isn’t covered Coinsurance $0 Limits or exclusions $0
Limits or exclusions $60 What isn’t covered
The total Mia would pay is $1,300
The total Peg would pay is $2,060 Limits or exclusions $0
The total Joe would pay is $1,200

The plan would be responsible for the other costs of these EXAMPLE covered services
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Notice of Non-Discrimination
We do not treat members differently because of sex, age, race, color, disability or national origin.
If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can
send a complaint to the Civil Rights Coordinator.
Online: [email protected]
Mail: Civil Rights Coordinator. UnitedHealthcare Civil Rights Grievance. P.O. Box 30608 Salt Lake City, UTAH
84130
You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within
30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with
your complaint, please call the toll-free number listed within this Summary of Benefits and Coverage (SBC), TTY
711, Monday through Friday, 8 a.m. to 8 p.m.
You can also file a complaint with the U.S. Dept. of Health and Human Services.
Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD)
Mail: U.S. Dept. of Health and Human Services.
200 Independence Avenue, SW Room 509F, HHH
Building Washington, D.C. 20201
We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or,
you can ask for an interpreter. To ask for help, please call the number contained within this Summary of Benefits
and Coverage (SBC), TTY 711, Monday through Friday, 8 a.m. to 8 p.m.