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

Coverage Period: Based on group plan year

Choice Plus CWWJ /K50Y 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 1-800-782-3740. 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 Network: $4,000 Individual / $8,000 Family Generally, you must pay all of the costs from providers up to the deductible
deductible? out-of-Network: $6,000 Individual / $12,000 amount before this plan begins to pay. If you have other family members on the
Family plan, each family member must meet their own individual deductible until the total
Per calendar year. amount of deductible expenses paid by all family members meets the overall family
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 Yes, prescription drugs - $250 Individual/ $500 You must pay all of the costs for these services up to the specific deductible
deductibles for Family amount before this plan begins to pay for these services.
specific services? Does not apply to Tier 1 and 2 drugs.
There are no other specific deductibles.
What is the Network: $9,100 Individual / $18,200 Family The out-of-pocket limit is the most you could pay in a year for covered services. If
out-of-pocket limit out-of-Network: $12,000 Individual / $24,000 you have other family members in this plan, they have to meet their own
for this plan? Family out-of-pocket limits until the overall family out-of-pocket limit has been met.
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 preauthorization for services.
Will you pay less if Yes. See www.welcometouhc.com or call This plan uses a provider network. You will pay less if you use a provider in the
you use a network 1-800-782-3740 for a list of network providers. plan’s network. You will pay the most if you use an out-of-network provider, and
provider? 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?

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

Common What You Will Pay

Medical Event Services You May Need
Network Out-of-Network Limitations, Exceptions, & Other Important
Provider (You Provider (You Information
will pay the will pay the
least) most)
If you visit a Primary care visit to treat an $40 copay per 20% coinsurance Virtual visits (Telehealth) - No Charge by a Designated Virtual
health care injury or illness visit, deductible Network Provider
provider’s office does not apply If you receive services in addition to office visit, additional
or clinic copays, deductibles, or coinsurance may apply e.g. surgery.
Specialist visit $80 copay per 20% coinsurance If you receive services in addition to office visit, additional
visit, deductible copays, deductibles, or coinsurance may apply e.g. surgery.
does not apply
Preventive No Charge * 20% Includes preventive health services specified in the health care
care/screening/immunizati- coinsurance reform law. You may have to pay for services that aren’t
on preventive. Ask your provider if the services needed are
preventive. Then check what your plan will pay for.
*Deductible/coinsurance may not apply to certain services.
If you have a test Diagnostic test (x-ray, blood Free Free Preauthorization required for out-of-Network for certain
work) Standing/Office: standing/Office: services or benefit reduces to 50% of allowed.
$40 copay per 20% coinsurance , X-ray -Free Standing $80 copay per service, deductible does not
service, deductible Hospital: 40% apply . Hospital Based 20% coinsurance .
does not apply . coinsurance .
Hospital: 20%
coinsurance .
Imaging (CT/PET scans, Free Free $500 Hospital-Based per occurrence deductible applies prior to
MRIs) Standing/Office: standing/Office: the overall deductible.
$500 copay per 20% coinsurance , Preauthorization required for out-of-Network or benefit
service, deductible Hospital: 40% reduces to 50% of allowed.
does not apply . coinsurance
Hospital: 20%
coinsurance .

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 Common Services You What You Will Pay
Medical Event May Need
Network Out-of-Network Limitations, Exceptions, & Other Important
Provider (You Provider (You Information
will pay the will pay the
least) most)
If you need drugs Tier 1 - Your Deductible does not Deductible does Provider means pharmacy for purposes of this section.
to treat your Lowest-Cost apply. Retail: $10 copay not apply. Retail: Retail: Up to a 31 day supply. Mail-Order*: Up to a 90 day
illness or Option Mail-Order: $25 copay $10 copay supply or *Preferred 90 Day Retail Network pharmacy. If you
condition Specialty Drugs** : $10 Specialty Drugs: use an out-of-Network pharmacy (including a mail order
copay $10 copay pharmacy), you may be responsible for any amount over the
More information allowed amount.
about prescription Tier 2 - Your Deductible does not Deductible does
Midrange-Cost apply. Retail: $60 copay not apply. Retail: **Your cost shown is for a Preferred Specialty Network
drug coverage is Pharmacy. Non-Preferred Specialty Network Pharmacy: Copay
available at www. Option Mail-Order: $150 $60 copay
is 2 times the Preferred Specialty Network Pharmacy Copay or
welcometouhc.com. copay Specialty Drugs: the coinsurance (up to 50% of the Prescription Drugs Charge)
Specialty Drugs** : $60 $60 copay based on the applicable Tier.
copay Copay is per prescription order up to the day supply limit listed
Tier 3 - Your Retail: $150 copay Retail: $150 copay above.
Midrange-Cost Mail-Order: $375 Specialty Drugs: You may need to obtain certain drugs, including certain specialty
Option copay $150 copay drugs, from a pharmacy designated by us.
Specialty Drugs** : Certain drugs may have a preauthorization requirement or may
$150 copay result in a higher cost. You may be required to use a lower-cost
Tier 4 - Additional Retail: $300 copay Retail: $300 copay drug(s) prior to benefits under your policy being available for
High-Cost Options Mail-Order: $750 Specialty Drugs: certain prescribed drugs.
copay $500 copay See the website listed for information on drugs covered by your
Specialty Drugs** : plan. Not all drugs are covered.
$500 copay Prescription drug List (PDL): Essential . Network: Standard
Select - CVS. .
If a dispensed drug has a chemically equivalent drug, the cost
difference between drugs in addition to any applicable copay
and/or coinsurance may be applied. Certain preventive
medications and Tier 1 contraceptives are covered at No Charge.
If you have Facility fee (e.g., Ambulatory Surg Ambulatory Surg Preauthorization required for certain services for
outpatient surgery ambulatory surgery Center: 20% Center: 40% out-of-Network or benefit reduces to 50% of allowed.
center) coinsurance Hospital: coinsurance , $250 Ambulatory Surg Center per occurrence deductible applies
20% coinsurance Hospital: 40% prior to the overall deductible.
coinsurance $500 Hospital-based per occurrence deductible applies prior to
the overall deductible.

Page 3 of 8
 Common Services You What You Will Pay
Medical Event May Need
Network Out-of-Network Limitations, Exceptions, & Other Important
Provider (You Provider (You Information
will pay the will pay the
least) most)
Physician/surgeon 20% coinsurance 40% coinsurance None
fees
If you need Emergency room 20% coinsurance 20% coinsurance $500 Emergency per occurrence deductible applies prior to the
immediate care overall deductible.
medical attention
Emergency medical 20% coinsurance 20% coinsurance None
transportation
Urgent care $80 copay per visit, 20% coinsurance If you receive services in addition to urgent care visit, additional
deductible does not copays, deductibles, or coinsurance may apply e.g. surgery.
apply
If you have a Facility fee (e.g., 20% coinsurance 40% coinsurance Preauthorization required for out-of-Network or benefit
hospital stay hospital room) reduces to 50% of allowed.
$750 Inpatient Stay per occurrence deductible applies prior to
the overall deductible.
Physician/surgeon 20% coinsurance 40% coinsurance None
fees
If you need Outpatient services $40 copay per visit, 20% coinsurance Network partial hospitalization /intensive outpatient treatment:
mental health, deductible does not 20% coinsurance
behavioral health, apply Preauthorization required for certain services for
or substance out-of-Network or benefit reduces to 50% of allowed.
abuse services
Inpatient services 20% coinsurance 40% coinsurance Preauthorization required for out-of-Network or benefit
reduces to 50% of allowed.
If you are Office visits No Charge 20% coinsurance Cost sharing does not apply for preventive services. Depending
pregnant on the type of service, a copayment, deductibles, or coinsurance
may apply.
Childbirth/delivery 20% coinsurance 40% coinsurance Maternity care may include tests and services described
professional elsewhere in the SBC (i.e. ultrasound.)
services

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 Common Services You What You Will Pay
Medical Event May Need
Network Out-of-Network Limitations, Exceptions, & Other Important
Provider (You Provider (You Information
will pay the will pay the
least) most)
Childbirth/delivery 20% coinsurance 40% coinsurance Inpatient preauthorization apply for out-of-Network if stay
facility services exceeds 48 hours (C-Section: 96 hours) or benefit reduces to
50% of allowed.
$750 Inpatient Stay per occurrence deductible applies prior to
the overall deductible.
If you need help Home health care 20% coinsurance 40% coinsurance Preauthorization required for out-of-Network or benefit
recovering or have reduces to 50% of allowed.
other special
health needs
Rehabilitation $40 copay per 20% coinsurance Limits per calendar year: Physical and Occupational: 44 visits
services outpatient visit, each. Pulmonary: 20 visits. Speech and Cardiac: Unlimited.
deductible does not
apply
Habilitation services $40 copay per 20% coinsurance Limits per calendar year: Physical, Occupational: 44 visits each.
outpatient visit, Speech: Unlimited.
deductible does not Cost share applies for outpatient services only.
apply Preauthorization required for out-of-Network inpatient services
or benefit to 50% of allowed.
Skilled nursing care 20% coinsurance 40% coinsurance Skilled Nursing Facility is limited to 100 days per calendar year.
(Inpatient Rehabilitation and Habilitation limited to 60 days
each).
Preauthorization required for out-of-Network or benefit
reduces to 50% of allowed.
Durable medical 20% coinsurance 40% coinsurance Preauthorization required for out-of-Network Durable medical
equipment equipment over $1,000 or no coverage.
Hospice services 20% coinsurance 40% coinsurance Preauthorization required for out-of-Network before admission
for an Inpatient Stay in a hospice facility or benefit reduces to
50% of allowed.
If your child needs Children’s eye exam $30 copay per visit, 20% coinsurance One exam every 12 months.
dental or eye care deductible does not
apply
Children’s glasses 50% coinsurance, 50% coinsurance One pair every 12 months.
deductible does not
apply

Page 5 of 8
 Common Services You What You Will Pay
Medical Event May Need
Network Out-of-Network Limitations, Exceptions, & Other Important
Provider (You Provider (You Information
will pay the will pay the
least) most)
Children’s dental 0% coinsurance 20% 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 Cosmetic surgery Dental care (Adult) Long-term care Non-emergency care when
traveling outside the U.S.
Private-duty nursing Routine foot care

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
Bariatric surgery Chiropractic care Hearing aids - $2,000 every Infertility treatment Routine eye care (Adult)-1
36 months exam/12 months
Weight loss programs

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 1-800-782-3740 . 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: 1-800-782-3740 ; or the Employee Benefits Security Administration at 1-866-444-EBSA (3272) or
www.dol.gov/ebsa/healthreform or the Massachusetts Division of Insurance at 617-521-7794 or www.mass.gov/ocabr/government/oca-agencies/doi-lp.

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.

Page 6 of 8
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 1-800-782-3740 .
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-782-3740 .
Chinese 1-800-782-3740 .
Navajo (Dine): Dinek ehgo shika at ohwol ninisingo, kwiijigo holne 1-800-782-3740 .
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 Diabetes Mia’s Simple Fracture
(9 months of in-network pre-natal (a year of routine in-network care of (in-network emergency room visit and
care and a hospital delivery) a well-controlled condition) follow up care)

The plan’s overall deductible $ 4,000 The plan’s overall deductible $ 4,000 The plan’s overall deductible $ 4,000
Specialist copayment $80 Specialist copayment $80 Specialist copayment $80
Hospital (facility) coinsurance 20% Hospital (facility) coinsurance 20% Hospital (facility) coinsurance 20%
Other coinsurance 20% Other coinsurance 20% Other coinsurance 20%

This EXAMPLE event includes services This EXAMPLE event includes services This EXAMPLE event includes services
like: like: like:
Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical supplies)
Childbirth/Delivery Professional Services disease education) Diagnostic test (x-ray)
Childbirth/Delivery Facility Services Diagnostic tests (blood work) Durable medical equipment (crutches)
Diagnostic tests (ultrasounds and blood work) Prescription drugs Rehabilitation services (physical therapy)
Specialist visit (anesthesia) Durable medical equipment (glucose meter)

Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800
In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:
Cost Sharing Cost Sharing Cost Sharing
Deductibles $4,000 Deductibles $400 Deductibles $2,100
Copayments $400 Copayments $1,500 Copayments $300
Coinsurance $1,100 Coinsurance $0 Coinsurance $0
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions $60 Limits or exclusions $0 Limits or exclusions $0
The total Peg would pay is $5,560 The total Joe would pay is $1,900 The total Mia would pay is $2,400

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.