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 Gold 1250-3 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: $1,250 Generally, you must pay all of the costs from providers up to the deductible
deductible? Individual / $3,750 Family amount before this plan begins to pay. If you have other family members on the
out-of-Network: $10,000 Individual / $20,000 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: $6,900 The out-of-pocket limit is the most you could pay in a year for covered services. If
out-of-pocket limit Individual / $13,800 Family you have other family members in this plan, they have to meet their own
for this plan? 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 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?

CWEF 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 $15 copay per visit, $15 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 $50 copay per visit, $100 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 20% coinsurance 20% coinsurance 50% coinsurance Priorauthorization required for out-of-Network or
(CT/PET benefit reduces to the lesser of 50% or $500.
scans, MRIs)

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

If you have Facility fee 20% coinsurance 20% coinsurance 50% coinsurance Priorauthorization required for certain services for
outpatient (e.g., out-of-Network or benefit reduces to the lesser of 50%
surgery ambulatory or $500.
surgery
center)

Page 3 of 8
 What You Will Pay
Services Designated
Common You May Network Out-of-Network Limitations, Exceptions, & Other Important
Medical Event Network Information
Need Provider (You Provider Provider (You
will pay the will pay the
least) most)
Physician/ 20% coinsurance 20% coinsurance 50% coinsurance None
surgeon fees
If you need Emergency 20% coinsurance 20% coinsurance 20% coinsurance $300 Emergency per occurrence copay applies prior to
immediate room care the overall deductible.
medical attention
Emergency 20% coinsurance 20% coinsurance 20% coinsurance None
medical
transportati-
on
Urgent care $25 copay per visit, $25 copay per visit, 50% coinsurance If you receive services in addition to urgent care visit,
deductible does not deductible does not additional copays, deductibles, or coinsurance may
apply apply apply e.g. surgery.
If you have a Facility fee 20% coinsurance 20% coinsurance 50% coinsurance Priorauthorization required for out-of-Network or
hospital stay (e.g., benefit reduces to the lesser of 50% or $500.
hospital
room)
Physician/ 20% coinsurance 20% coinsurance 50% coinsurance None
surgeon fees
If you need Outpatient $15 copay per visit, $15 copay per visit, 0% coinsurance Network partial hospitalization /intensive outpatient
mental health, services deductible does not deductible does not treatment: 20% coinsurance
behavioral apply apply Priorauthorization required for certain services for
health, or out-of-Network or benefit reduces to the lesser of 50%
substance abuse or $500.
services
Inpatient 20% coinsurance 20% coinsurance 50% coinsurance Priorauthorization required for out-of-Network or
services benefit reduces to the lesser of 50% or $500.
If you are Office visits No Charge No Charge 50% coinsurance Cost sharing does not apply for preventive services.
pregnant Depending on the type of services, a copayment,
deductibles, or coinsurance may apply.
Childbirth / 20% coinsurance 20% coinsurance 50% coinsurance Maternity care may include tests and services described
delivery elsewhere in the SBC (i.e. ultrasound.)
professional
services

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 What You Will Pay
Services Designated
Common You May Network Out-of-Network Limitations, Exceptions, & Other Important
Medical Event Network Information
Need Provider (You Provider Provider (You
will pay the will pay the
least) most)
Childbirth / 20% coinsurance 20% coinsurance 50% coinsurance Inpatient priorauthorization apply for out-of-Network
delivery if stay exceeds 48 hours (C-Section: 96 hours) or
facility benefit reduces to the lesser of 50% or $500.
services
If you need help Home 20% coinsurance 20% coinsurance 50% coinsurance Limited to 60 visits per calendar year.
recovering or health care Priorauthorization required for out-of-Network or
have other benefit reduces to the lesser of 50% or $500.
special health
needs
Rehabilitati- $15 copay per $15 copay per 50% coinsurance Limits per calendar year: Physical, Occupational,
on services outpatient visit, outpatient visit, Pulmonary, Cardiac: 35 visits each. Speech: Unlimited.
deductible does not deductible does not
apply apply
Habilitation $15 copay per $15 copay per 50% coinsurance Limits per calendar year: Physical, Occupational 35
services outpatient visit, outpatient visit, visits each. Speech: Unlimited.
deductible does not deductible does not Priorauthorization required for out-of-Network
apply apply inpatient services or benefit reduces to the lesser of
50% or $500.
For Inpatient Services, limited to 60 days per calendar
year.
Skilled 20% coinsurance 20% coinsurance 50% coinsurance Skilled Nursing Facility is limited to 60 days per
nursing care calendar year (combined with Inpatient Rehabilitation) .
Priorauthorization required for out-of-Network or
benefit reduces to the lesser of 50% or $500.
Durable 20% coinsurance 20% coinsurance 50% coinsurance Priorauthorization required for out-of-Network
medical Durable medical equipment over $1,000 or benefit
equipment reduces to the lesser of 50% or $500.
Hospice 20% coinsurance 20% coinsurance 50% coinsurance Priorauthorization required for out-of-Network before
services admission for an Inpatient Stay in a hospice facility or
benefit reduces to the lesser of 50% or $500. .
If your child Children’s $10 copay per visit, $10 copay per visit, 50% coinsurance One exam every 12 months.
needs dental or eye exam deductible does not deductible does not
eye care apply apply

Page 5 of 8
 What You Will Pay
Services Designated
Common You May Network Out-of-Network Limitations, Exceptions, & Other Important
Medical Event Network Information
Need Provider (You Provider Provider (You
will pay the will pay the
least) most)
Children’s $25 copay per frame, $25 copay per frame, 50% coinsurance One pair every 12 months.
glasses deductible does not deductible does not Costs may increase depending on the frames selected.
apply apply You may choose contact lenses instead of eyeglasses.
The benefit does not cover both.
Children’s 0% coinsurance 0% coinsurance 0% coinsurance Cleanings covered 2 times per 12 months.
dental
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 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 $ 1,250 The plan’s overall deductible $ 1,250 The plan’s overall deductible $ 1,250
Specialist copayment $100 Specialist copayment $100 Specialist copayment $100
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 $1,200 Deductibles $200 Deductibles $1,200
Copayments $10 Copayments $1,000 Copayments $100
Coinsurance $1,900 Coinsurance $0 Coinsurance $100
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 $3,170 The total Joe would pay is $1,200 The total Mia would pay is $1,400

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.