UHC Small Group Medical Plan Network

  2016 Small Group Medical Network Plan Benefits Carrier Network Limited Limited Limited Limited Limited Limited Limite...

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  2016 Small Group Medical Network Plan Benefits Carrier

Network Limited Limited Limited Limited Limited Limited Limited Limited Limited Limited Limited Limited Limited Limited Limited Limited Limited Limited Limited Limited Limited Limited Limited Limited Limited Limited Limited Limited Limited Limited Limited Full Full Full Full Full Full Full Full Full

Product EPO EPO EPO EPO EPO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO

Metal Tier Platinum Gold Silver Bronze Bronze Platinum Gold Gold Silver Bronze Platinum Gold Gold Silver Bronze Platinum Platinum Gold Gold Silver Bronze Platinum Gold Silver Platinum Gold Silver Silver Bronze Silver Bronze Platinum Platinum Platinum Gold Gold Gold Silver Silver Bronze

Plan Name State Core Essential 20/90%  State Core Essential 35/80% State Core Essential 45/1500/80%  State Core Essential 70/6500/0% State Core Essential HSA 4500/60% Advantage 20‐40/30% Advantage 30‐50/30% Advantage 30‐50/30%/1000ded Advantage 45‐65/40%/2000ded Advantage 55‐85/0%/6600ded Alliance 20‐40/30% Alliance 30‐50/30% Alliance 30‐50/30%/1000ded Alliance 45‐65/40%/2000ded Alliance 55‐85/0%/6600ded Focus 15‐30/250a Focus 20‐40/30% Focus 30‐50/30% Focus 30‐50/30%/1000ded Focus 45‐65/40%/2000ded Focus 55‐85/0%/6600ded State Alliance 20‐40/10% State Alliance 35‐55/20% State Alliance 45‐70/20%/1500ded State Focus 20‐40/10% State Focus 35‐55/20% State Focus 45‐70/20%/1500ded Alliance HSA 25%/2000ded Alliance HAS 40%/4500ded State Alliance HSA 25%/2000ded State Alliance HSA 40%/4500ded Signature 15‐30/250a Signature 20‐40/30% State Signature 20‐40/10% Signature 30‐50/30% Signature 30‐50/30%/1000ded State Signature 35‐55/20% Signature 45‐65/40%/2000ded State Signature 45‐70/20%/1500ded Signature 55‐85/0%/6600ded

Plan Ded. $0 $0 $1,500 $6,000 $4,500 $0 $0 $1,000 $2,000 $6,600 $0 $0 $1,000 $2,000 $6,600 $0 $0 $0 $1,000 $2,000 $6,600 $0 $0 $1,500 $0 $0 $1,500 $2,000 $4,500 $2,000 $4,500 $0 $0 $0 $0 $1,000 $0 $2,000 $1,500 $6,600

OOP Max. $4,000 $6,200 $6,500 $6,500 $6,500 $3,000 $5,000 $5,000 $6,500 $6,850 $3,000 $5,000 $5,000 $6,500 $6,850 $2,000 $3,000 $5,000 $5,000 $6,500 $6,850 $4,000 $6,200 $6,500 $4,000 $6,200 $6,500 $6,500 $6,500 $6,500 $6,500 $2,000 $3,000 $4,000 $5,000 $5,000 $6,200 $6,500 $6,500 $6,850

Office Visit $20/$40 $35/$55 $45/$70 $70/$90⁺ 40%/40% $20/$40 $30/$50 $30/$50 $45/$65 $55/$85 $20/$40 $30/$50 $30/$50 $45/$65 $55/$85 $15/$30 $20/$40 $30/$50 $30/$50 $45/$65 $55/$85 $20/$40 $35/$55 $45/$70 $20/$40 $35/$55 $45/$70 25%/25% 40%/40% 25%/25% 40%/40% $15 / $30 $20 / $40 $20 / $40 $30 / $50 $30 / $50 $35 / $55 $45 / $65 $45 / $70 $55 / $85

This is an overview for comparison purposes only. Please refer to carrier benefit summaries for full details.

Inpatient 10% 20% 20% 0% after OOP 40% 30% 30% 30% 40% 0% 30% 30% 30% 40% 0% $250/admit 30% 30% 30% 40% 0% 10% 20% 20% 10% 20% 20% 25% 40% 25% 40% $250/admit 30% 10% 30% 30% 20% 40% 20% 0%

Rx $5/$15/$25 $15/$50/$70 $15/$55/$75 0%/0%/0%   ͌ 40%/40%/40% $15/$35/$50 $15/$35/$70 $15/$35/$70 $20/$50/$100 $25/$50/$125 $15/$35/$50 $15/$35/$70 $15/$35/$70 $20/$50/$100 $25/$50/$125 $15/$35/$50 $15/$35/$50 $15/$35/$70 $15/$35/$70 $20/$50/$100 $25/$50/$125 $5/$15/$25 $15/$50/$70 $15/$55/$75 $5/$15/$25 $15/$50/$70 $15/$55/$75 $20/$50/$100 $20/$50/$100 $20/$50/$100 40%/40%/40% $15/$35/$50 $15/$35/$50 $5/$15/$25 $15/$35/$70 $15/$35/$70 $15/$50/$70 $20/$50/$100 $15/$55/$75 $25/$50/$125

Rx Ded. $0 $0 *$250 $500 Plan ded $0 $0 $0 $0 *$250 $0 $0 $0 $0 *$250 $0 $0 $0 $0 $0 *$250 $0 $0 *$250 $0 $0 *$250 Plan ded Plan ded $0 Plan ded $0 $0 $0 $0 $0 $0 $0 $250 $250

  2016 Small Group Medical Network Plan Benefits

UnitedHealthcare (continued)

Carrier

Network Full Limited Limited Limited Limited Limited Limited Limited Limited Limited Limited Full Full Full Full Full Full Full Full Full Full

Product HMO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO

Metal Tier Platinum Platinum Gold Gold Gold Silver Silver Silver Bronze Platinum Bronze Platinum Gold Gold Gold Silver Silver Silver Bronze Bronze Silver

Plan Name Select Plus 5/10% Core 15/85% Core 20/1000/80% Core 20/250/80% Core 20/750/80% Core 2000/70% Core 30/1800/70% Core 40/1800/70% Core 40/6600/100% Core 5/90% Core HSA 4500/60% Select Plus 15/15% Select Plus 20/250/20% Select Plus 20/750/20% Select Plus 20/1000/20% Select Plus 30/1800/30% Select Plus 40/1800/30% Select Plus 30/2000/30% Select Plus 40/6600/0% Select Plus HSA 4500/40% Non‐Differential PPO 2000/20%

͒ Deductible waived for first four (4) office visitsded                         ͌ up to $500 max/script

Plan Ded. $0 $0 $1,000 $250 $750 $2,000 $1,800 $1,800 $6,600 $0 $4,500 $0 $250 $750 $1,000 $1,800 $1,800 $2,000 $6,600 $4,500 $2,000

OOP Max. $3,500 $4,500 $5,400 $5,000 $5,000 $6,500 $6,500 $6,500 $6,850 $3,500 $6,500 $4,500 $5,000 $5,000 $5,400 $6,500 $6,500 $6,500 $6,850 $6,500 $5,000

Office Visit $5 / $10 $15/$30 $20/$40 $20/$40 $20/$40 30%/30% $30/$60 $40/$60    ͒ $40/$60    ͒ $5/$10 40%/40% $15 / $30 $20 / $40 $20 / $40 $20 / $40 $30 / $60 $40/$60    ͒ 30% / 30% $40 / $60 40% 20%

* Rx deductible applies only to tiers 2 & 3

This is an overview for comparison purposes only. Please refer to carrier benefit summaries for full details.

Inpatient 10% 15% $250+20% after ded $250+20% after ded $250+20% after ded 30% $250+30% after ded $250+30% after ded 0% after OOP 10% 40% 15% 20% 20% 20% 30% 30% 30% 0% 40% 20%

Rx $10/$30/$60 $10/$30/$60 $15/$35/$60 $15/$35/$60 $15/$35/$60 $15/$35/$70 $15/$35/$70 $20/$50/$100 $20/$50/$100 $10/$30/$60 $20/$50/$100 $10/$30/$60 $15/$35/$60 $15/$35/$60 $15/$35/$60 $15/$35/$70 $20/$50/$100 $15/$35/$70 $20/$50/$100 40%/40%/40% $20/$35/$60

Rx Ded. $0 $0 $0 $0 $0 *$150 *$200 *$200 *$250 $0 $0 $0 $0 $0 $0 $200 $200 $150 $250 Plan ded $0