Traditional PPO Plans

MEDICAL PLAN BENEFITS

Deductible

(does not include copays) • Individual • Family

Coinsurance (you pay) Out-of-Pocket Maximum

(includes deductible and copays) • Individual • Family

Physician Services

• Primary Physician Visit • Specialist Visit • Premium Designated Providers • Virtual Visit

• Preventive Care • Outpatient Mental Health Visit

Inpatient Hospital Care Outpatient Surgery Emergency Room Care Urgent Care Center

Prescription Drugs – Retail Pharmacy

(up to a 31-day supply) • Generic Diabetic • Tier 1 – Your Lowest Cost Option • Tier 2 – Your Mid-Range Cost Option • Tier 3 – Your Highest Cost Option

Prescription Drugs – Mail-Order

(up to a 90-day supply) • Tier 1 – Your Lowest Cost Option • Tier 2 – Your Mid-Range Cost Option • Tier 3 – Your Highest Cost Option

BASE PPO PLAN

In-Network Out-of-Network

$4,000 $12,000 25% $8,000 $24,000 50%

BUY-UP PPO PLAN In-Network Out-of-Network

$1,000 $3,000 20% $2,000 $6,000 50%

$8,000 $16,000 $16,000 $32,000 $3,500 $7,000 $7,000 $14,000

$30 copay $100 copay $30 copay $0 copay $0 copay $0 copay

50% after deductible 50% after deductible 50% after deductible Not covered Not covered 50% after deductible $30 copay $100 copay $30 copay

$0 copay

$0 copay

$0 copay

50% after deductible 50% after deductible 50% after deductible Not covered Not covered 50% after deductible 25% after deductible 50% after deductible 20% after deductible 50% after deductible 25% after deductible 50% after deductible 20% after deductible 50% after deductible 25% after deductible 25% after deductible 50% after deductible $200 copay per visit $100 copay 50% after deductible

No charge $20 copay $50 copay $75 copay

You pay the in-network copay plus all charges above UHC’s allowed amount No charge $10 copay $40 copay $60 copay

You pay the in-network copay plus all charges above UHC’s allowed amount.

$50 copay $125 copay $187.50 copay Not covered $25 copay $100 copay $150 copay Not covered

All prescription drugs on OptumRx’s Prescription drug list are assigned to Tier 1, Tier 2, or Tier 3. Find individualized information on your benefits coverage, determine tier status, check the status of claims, and search for network pharmacies by logging on to www.optumrx.com or calling the Customer Care number on your ID card.

ACCESSING MEDICAL CARE

The Emergency Room (ER) is a costly experience if you’re seeking care for an issue that is not a true emergency or a medical issue that could cause death or permanent injury if not treated quickly. There are alternatives to the ER that can offer you quick care at a more affordable cost. The key is finding these alternatives today when you’re happy and healthy. Where you go for care matters. • Primary Care Physician (PCP): care from the doctor who knows you best. For symptoms that aren’t extreme, call and let them know your symptoms require immediate attention. • Virtual Visits: available 24/7 for some health concerns like cough, fever, sinus problems, pink eye, minor rashes and more. You can virtually visit a board-certified doctor from the comfort of your home. • Convenient Care Clinics: when you do not have a primary doctor or cannot get an appointment. Useful for fever, sore throat/strep, coughs/congestion, sports physicals, etc. • Urgent Care (UC): less costly than the ER; can treat sprains, minor breaks, mild asthma, minor infections, rashes, small cuts, burns, etc.