R-2023-302 - 9/28/2023 RESOLUTION NO. R-2023-302
WHEREAS, the City of Round Rock (the "City") previously entered into an Administrative
Services Agreement ("Agreement") with United Healthcare Insurance Company ("United Healthcare")
for the provision of employee medical and pharmacy insurance benefits on September 9, 2021 by
Resolution No. R-2021-236, and
WHEREAS, the City Council desires to execute a Financial Renewal of said Agreement for
the guarantee period of January 1, 2024 through December 31, 2026, Now Therefore
BE IT RESOLVED BY THE COUNCIL OF THE CITY OF ROUND ROCK, TEXAS,
That the Council hereby authorizes the Financial Renewal of the Administrative Services
Agreement with United Healthcare for insurance coverage for the guarantee period of January 1, 2024
through December 31, 2026 as set forth in the Financial Renewal document from United Healthcare
attached as Exhibit"A."
That the Mayor is hereby authorized and directed to execute on behalf of the City the any
related documents required for the renewal of said benefits.
The City Council hereby finds and declares that written notice of the date, hour, place and
subject of the meeting at which this Resolution was adopted was posted and that such meeting was
open to the public as required by law at all times during which this Resolution and the subject matter
hereof were discussed, considered and formally acted upon, all as required by the Open Meetings Act,
Chapter 551, Texas Government Code, as amended
0112.20232;4865-7871-5776/ss2
RESOLVED this 28th day of September, 2023.
, R1
CRAIG MO GAN, yor
City of Round Roc V
exas
ATTEST:
L4zae9l�
MEAGAN S&
KS, Aty Clerk
EXHIBIT
"All
UnitedHealthcar6 A
August 30,2023
City of Round Rock
221 East Main Street
Round Rock,TX 78664
RE: January 1,2024 Financial Renewal under the Administrative Services Agreement("ASA")between United
HealthCare Services,Inc.and City of Round Rock
This letter is confirmation of your Financial Renewal per the attached exhibits.
Please feel free to contact me with any questions regarding the attachments. Please file this letter and its attachments
with your ASA.
Thank you,
IpDaMAl � xQ_;nan y
Bambi Kenney
Associate Contract Manager
CC:Laurie Macina,Strategic Account Executive
Attachments:Exhibit B and C
Renewal 2Q2023
Agreement No.66492.3
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Confidential Information of UnitedHealth Group
EXHIBIT B-FEES
This Exhibit describes the Fees Customer agrees to pay to United in exchange for the Services.
Medical Fees
The following financial terms are effective for the period January 1, 2024 through December 31,2024, unless
otherwise specified.
Final Claims Fiduciary: United
Prescription Drug List: Traditional
Effective January 1,2024 through December 31,2024
Average Contract Size: 2.25
The Fees include a Pharmacy Administrative Fee credit in the amount of$40.00 per Employee per month.
The Fees listed below are based upon an estimated minimum of 954 enrolled Employees.
Choice Plus Plan: $10.79 per Employee per month.
Choice Plan: $10.79 per Employee per month.
Effective January 1,2025 through December 31,2025
Choice Plus Plan: $52.31 per Employee per month.
Choice Plan: $52.31 per Employee per month.
Effective January 1,2026 through December 31,2026
Choice Plus Plan:$53.88 per Employee per month.
Choice Plan: $53.88 per Employee per month.
Credits
Communication Credit
United will provide a communication credit to help Customer mitigate costs associated with communications to
Participants. The communication credit will be paid through a credit to Customer's fees after(a)the Agreement is
executed and(b)the first month's fees have been received by United. If Customer terminates the Agreement prior to
December 31,2026,Customer will pay United a prorated portion of this credit.
$5,000 Communication credit per year
Wellness Allowance
United will provide a wellness allowance so Customer may enhance Customer medical benefits during the term of the
Agreement. The wellness allowance may be used at Customer's discretion as Customer utilizes wellness
programming and services from United. If Customer terminates the Agreement prior to December 31,2026,Customer
will pay United a prorated portion of this credit.
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Confidential Information of UnitedHealth Group
$25,000 Wellness allowance per year
Payment Integrity Services
Service Description Fee
Advanced Analytics and Recovery 24%of the gross recovery amount
• United's large-scale analytics to identify additional
recovery opportunities.
• Claims re-examined every month for up to 12 months.
• Post-adjudicated claims.
Coordination of Benefits("COB") No additional Fee.
• Verify primary/secondary payer accuracy
• Identify claims to be investigated using a layered
approach to identify other primary payers:
1.Eligibility match to other commercial payers
2.Eligibility match to Medicare
• Correct pre-adjudicated claims prior to claim payment
• Update claims systems with other primary/secondary
payers'information
• COB indicators set to edit subsequent claims with
rima /seconda payers'information
Credit Balance Recovery 10%of the gross recovery amount.
• Review,validate,and recover credit balances(dollars)
on existing patient accounts through a combination of
analysis and technology.
• On-site at hospitals and facilities.
• Post-adjudicated claims.
Focused Claim Review 22%of the gross recovery amount.
• Review of claims for inappropriate billing of services
not documented in clinical notes.
• Board certified,same-specialty medical directors.
Pre-adjudicated claims orpost-adjudicated claims.
Fraud,Waste,and Abuse Management 22%of the gross recovery or prevented amount
• Detection and recovery of wasteful,abusive,and/or
fraudulent claims.
• Search claims for patterns which indicate possible
waste or error by identifying specific claims for
additional review.
• Evaluate claims to identify inappropriate levels of care,
coding and/or resource utilization.
• Management can include pre-adjudicated claims or
post-adjudicated claims.
Hospital Bill and Premium Audit Services 22%of the gross recovery amount
• In-depth review of hospital medical records or other
related documentation compared to claimed amounts to
ensure billing accuracy.
• Post-adjudicated claims.
Litigation and Arbitration Fees for Recoveries Outside attorneys' fees and costs or administrative process
• Litigation,arbitration,or other judicial process to fees will be deducted from the gross recovery prior to the
recover any Overpayments and other Plan recovery assessment of any applicable United fees(as indicated in this
opportunities. Exhibit).
• Outside attorneys'fees and costs or administrative
process fees directly incurred with litigation,
arbitration,or other judicial process.
• Pre-adjudicated claims orpost-adjucation claims
Third Party Liability-Subrogation and Injury 33.33%of the applicable savings amount.
Coverage Coordination
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Confidential Information of UnitedHealth Group
Service Description Fee
• Services to prevent the payment of Plan benefits,or
recover Plan benefits,which should be paid by a third
party.
• Does not include benefits paid in connection with
coordination of benefits,Medicare,or other
Overpayments.
• Pre-adjudicated claims or post-adjudicated claims.
• Customer will not engage any entity except United to
provide such services without prior United approval.
Other Fees
Service Description IN Fee
Naviguard Program $2.50 per Employee per month
• Offers reimbursement methodologies for emergent
and non-emergent out of network claims which
calculates allowed amounts based on what a
healthcare provider generally accepts for the same or
similar service.
• Includes an advocacy component where
Participants can access resources,and on-line tools
and materials to help Participants stay in network
and where assistance is provided in explaining
reimbursement methodologies.
• For claims above a threshold established by United,
the advocacy component includes United negotiating
with a provider on behalf of a Participant with
respect to Participant's balance billed amount(e.g.,
non-emergent,choice claim).
• If the provider objects to what it was paid from the
application of the allowed amount,or member
contacts United for support with resolving a balance
bill,United will increase compensation for a
particular claim if.(a)United reasonably concludes
that the particular facts and circumstances related to
a claim provide justification for reimbursement
greater than that which would result from the
application of the allowed amount,and(b)
United believes that it would serve the best interests
of the Plan and its Participants(including interests in
avoiding costs and expenses of disputes over
payment of claims).
External Reviews If and when applicable,for each subsequent external review
beyond the limited number of free reviews based upon
Customer's total enrollment,a fee of$500 will apply per
review.
Interest Rate on Unpaid Fees and Underfunding Bank Prime rate plus 4%
Account
Run-out Claims Administration 6 months of runout
No charge after the Initial Term.
Pharmacy Benefit Rebates-Termination Pursuant to the termination section of this Agreement, if
Customer terminates the Pharmacy Benefit Services portion
of this Agreement only during the Term of the Agreement
and termination is for any reason other than for cause,United
may retain all Rebates that have not been remitted to
Customer as of the effective date of such termination.
Medical Benefit Drug Rebate Compensation 80%to Customer,the balance is retained by United as
compensation for the services.
Allocation and Payment of Gene Therapy Medical If Customer purchases gene therapy stop loss though United
Benefit Drug Rebates or an affiliate, United will retain rebates for gene therapy
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Confidential Information of UnitedHealth Group
Service Description
drugs when Customer is reimbursed by stop loss for any gene
therapy claim.
Prior Authorization Fee $50.00 per occurrence
Direct Member Reimbursement Fee $2.50 per occurrence
Consolidated Appropriations Act,2021 ("CAA") For the 2024 plan year,United will not charge separate
Support Services. United will support Customer's services fees outside of base rates for the CAA Support
compliance with the requirements of the CAA,including Services. United shall notify Customer of United's intent to
the No Surprises Act("NSA"),by the respective apply a charge for any support services or information
enforcement date as follows: provided if additional regulatory guidance changes the final
compliance requirements. Customer remains responsible
• NSA medical billing and the independent dispute for the government agency administration assessment and
resolution("IDR"): fees charged by the IDR arbitrator.
o United will determine if a claim is subject to the
NSA billing protections. Fees for CAA Support Services for plan years after 2024
o If United and a provider are unable to come to will be provided at a future date once regulatory guidance is
an agreement within the prescribed negotiation received and final compliance requirements are determined.
period for a claim subject to the NSA billing
protections,United will manage,direct,and
make decisions and submissions to support the
IDR for Customer.
o All qualifying payment amounts under the NSA
will be calculated based on an insurance market
across all self-insured group health plans
administered by United.
o United will not be using third party provider
networks for services covered by the NSA.
o The fees for programs in which the parties share
in the savings achieved off a provider's billed
charge will continue to apply to all services
covered under the NSA.
o Customer shall fund all settlement amounts and
payments required as a result of any IDR process
decision through the Bank Account.
o Customer shall fund the IDR administration fee
and all IDR arbitrator fees through the Bank
Account.
• Revised medical Plan ID cards(if United provides
Plan Participants with ID cards currently).
• Provider directory enhancements.
• Continuity of care and external appeals support for
surprise medical bills.
• Support related to Mental Health Parity Non-
Quantitative Treatment Limitations audits initiated by
the U.S.Department of Labor,U.S.Department of
Health and Human Services or the U.S.Department
of Treasury.
• Provide language to support Customer's anti-gag
clause attestation requirement.
• Prepare and file pharmacy benefits and drug cost
reports.
• Prepare and file air ambulance claims reports.
• Provide and maintain price comparison information
to Participants by telephone and online.
Health Plan Transparency in Coverage Rule("TiC") For the 2024 plan year,United will not charge separate
Support Services. United will support Customer's services fees outside of base rates for the TiC Support
compliance with the requirements of the TiC by the Services.
respective enforcement date as follows:
• Machine-readable files accessible via a publicly
available website,which Customer will be able to
access and link to Customer's own website.
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Confidential Information of UnitedHealth Group
Service Description Fee
• A cost estimator tool available online for Plan
Participants for the items and services as required
each year.
Disclosures: A United affiliate provides payment services to the healthcare industry and offers medical providers
with various payment methods and options, including electronic payments, virtual cards and checks. Some options
are available to medical providers for a fee and may result in the receipt of transaction fees or other compensation
(e.g., 1%to 3%of the total transaction amount,or at the election of the provider a per transaction fee of up to$10)by
a United affiliate. This has no impact on the Fees paid by Customer under this Agreement.
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Confidential Information of UnitedHealth Group
EXHIBIT C-GUARANTEES
The Fees at risk do not include Customer-elected optional and non-standard programs Fees, all credits, Payment
Integrity Programs Fees, Out-of-Network Programs Fees, Commission Funds, Consultant Funds, and ancillary
product Fees.
The Fees payable by Customer under this Agreement will be adjusted through a credit to Customer's fees in
accordance with the guarantees set forth below unless otherwise defined in the guarantee. Unless otherwise specified,
these guarantees are effective for the period beginning January 1, 2024 through December 31, 2024 ("Guarantee
Period"). With respect to the aspects of United's performance addressed in this exhibit, these fee adjustments are
Customer's exclusive financial remedies.
United shall not be required to meet any of the guarantees provided for in this Agreement or amendments thereto to
the extent United's failure is due to Customer's actions or inactions or if United fails to meet these standards due to
fire, embargo, strike, war, accident, act of God, acts of terrorism or United's required compliance with any law,
regulation,or governmental agency mandate or anything beyond United's reasonable control.
Prior to the end of the Guarantee Period,and on the condition that this Agreement remains in force,United may specify
to Customer in writing new guarantees for the subsequent Guarantee Period. If United specifies new guarantees,
United will also provide Customer with a new Exhibit that will replace this Exhibit for that subsequent Guarantee
Period.
Claim is defined as an initial and complete written request for payment of a Plan benefit made by an enrollee,
physician, or other healthcare provider on an accepted format. Unless stated otherwise, the claims are limited to
medical claims processed through the UNET claims systems. Claims processed and products administered through
any other system, including claims for other products such as vision, dental, flexible spending accounts, health
reimbursement accounts, health savings accounts, or pharmacy coverage, are not included in the calculation of the
measurements. Also, services provided under capitated arrangements are not processed as a typical claim,therefore
capitated payments are not included in the measurements.
In the event any of the terms herein are inconsistent with the requirements of any federal,state or other applicable law
or regulation, then the inconsistent terms will be null and void and United will have the right to revise, reprice or
revoke this arrangement.
Claim Operations
Time to Process in 10 Days
Definition The percentage of all claims United receives will be processed within the designated number of business days
of receipt.
Percentage of claims processed 94%
Measurement Time to process,in business days or less after receipt of claim business
days 10
Criteria Standard claim operations reports
Level Site Level
Period Annually
Payment Period Annually
Fees at Risk Total Dollars at Risk for this metric $15,408
Payment Amount Of the Fees at Risk for this metric,percentage at risk for each gradient 20%
Gradients 11 business days
12 business days
13 business days
14 business days
15 business days or more
Procedural Accuracy
Definition Procedural accuracy rate of not less than the designated percent.
Measurement Percentage of claims processed without procedural(i.e.non-fmancial)errors 97%
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Confidential Information of UnitedHealth Group
Criteria Statistically significant random sample of claims processed is reviewed to determine the percentage of claim
dollars processed without procedural i.e.non-financial errors.
Level Office Level
Period Annually
Payment Period Annually
Fees at Risk Total Dollars at Risk for this metric $15,408
Payment Amount Of the Fees at Risk for this metric,percentage at risk for each gradient 20%
Gradients 96.99%-96.50%
96.49%-96.00%
95.99%-95.50%
95.49%-95.00%
Below 95.00%
Dollar Accuracy AR
Definition Dollar accuracy rate of not less than the designated percent in any quarter.
Measurement Percentage of claims dollars processed accurately99%
Criteria Statistically significant random sample of claims processed is reviewed to determine the percentage of claim
dollars processed correctly out of the total claim dollars paid.
Level Office Level
Period Annually
Payment Period Annually
Fees at Risk Total Dollars at Risk for this metric $15,408
Payment Amount Of the Fees at Risk for this metric,percentage at risk for each gradient 20%
Gradients 98.99%-98.50%
98.49%-98.00%
97.99%-97.50%
97.49%-97.00
Below 97.00%
Wmember Phone Service
Phone service guarantees and standards apply to Participant calls made to the customer care center that primarily services
Customer's Participants. If Customer elects a specialized phone service model the results may be blended with more than one call
center and/or level. They do not include calls made to care management personnel and/or calls to the senior center for Medicare
Participants,nor do they include calls for services/products other than medical,such as mental health/substance abuse,pharmacy
(except when United is Customer's pharmacy benefit services administrator),dental,vision,Health Savings Account,etc.
Average Speed of Answer
Definition Calls will sequence through United's phone system and be answered by customer service within the
parameters set forth.
Measurement Percentage of calls answered 100%
Time answered in seconds,on average seconds 30
Criteria Standard tracking reports produced by the phones stem for all calls
Level Team that services Customer's account
Period Annually
Payment Period Annually
Fees at Risk Total Dollars at Risk for this metric $15,408
Payment Amount Of the Fees at Risk for this metric,percentage at risk for each gradient 20%
Gradients 32 seconds or less
34 seconds or less
36 seconds or less
38 seconds or less
Greater than 38 seconds
Abandonment Rate
Definition The average call abandonment rate will be no greater than the percentage set forth
Measurement Percentage of total incomingcalls to customer service abandoned,on average
1.80%
Criteria Standard tracking reports produced by the phones stem for all calls
Level Team that services Customer's account
Period Annually
Payment Period Annually
Fees at Risk Total Dollars at Risk for this metric $15,408
Payment Amount Of the Fees at Risk for this metric,percentage at risk for each gradient 20%
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Confidential Information of UnitedHealth Group
Gradients 1.81%-2.30%
2.31%-2.80%
2.81%-3.30%
3.31%-3.80%
Greater than 3.80%
Call Quality Score
Definition Maintain a call quality score of not less than the percent set forth
Measurement Call quality score to meet or exceed 93%
Criteria Random sampling of calls is each assigned a customer service quality score,using United's standard internal
call quality assurance program.
Level Office that services Customer's account
Period Annually
Payment Period Annually
Fees at Risk Total Dollars at Risk for this metric $15,408
Payment Amount Of the Fees at Risk for this metric,percentage at risk for each gradient 20%
Gradients 92.99%-91.00%
90.99%-89.00%
88.99%-87.00%
86.99%-85.00%
Below 85.00%
Satisfaction
Employee ember Satisfaction
Definition The overall satisfaction will be determined by the question that reads"Overall,how satisfied are you with the
way we administer your medical health insuranceplan?"
Measurement Percentage of respondents,on average,indicating a grade of satisfied or higher 80%
Criteria Operations standard survey,conducted over the course of the year;may be customer specific for an additional
charge.
Level Office that services Customer's account
Period Annually
Payment Period Annually
Fees at Risk Total Dollars at Risk for this metric $7,704
Payment Amount Of the Fees at Risk for this metric,percentage at risk for each gradient N/A
Gradients Not applicable
Customer Satisfaction
Definition The overall satisfaction will be determined by the question that reads"How satisfied are you overall with
UnitedHealthcare?"
Measurement Minimum score on a 10-point scale score 5
Criteria Standard Customer Scorecard Survey
Level Customerspecific
Period Annually
Payment Period Annually
Fees at Risk Total Dollars at Risk for this metric $7,704
Payment Amount Of the Fees at Risk for this metric,percentage at risk for each gradient N/A
Gradients Not applicable
Pharmacy Financials
Definition Pharmacy rate guarantees.
Measurement 01/01/2024
and Criteria Combined Discount Guarantee-Broad Network
Retail Brand,Average Wholesale Price(AWP)less 19.40%
_ Retail Brand--90 Day Supply,AWP less 23.30%
Retail Generic-30 and 90 Day Supply,AWP less 83.40%
Mail Order Brand,AWP less 25.50%
Mail Order Generic,AWP less 85.50%
The Guaranteed Discount amount will be determined by multiplying the AWP by the guaranteed discount off
AWP by each component and adding the amounts together.
Dispensing Fees-Broad Network
Retail Brand-30 Day $0.60
_ Retail Brand--90 Day Supply $0.10
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Confidential Information of UnitedHealth Group
Retail Generic-30 Day $0.60
Retail Generic--90 Day Supply $0.10
Dispensing fee totals are calculated by multiplying the actual scripts for each type by the contracted rate for that
script type.
Fixed Rebate Guarantee(Traditional PDL)
Basis,per script Brand
Retail-30 Day $64.86
Retail-90 Day Supply $182.77
_ Mail Order $135.29
Specialty $338.82
Credits and Allowances
Administrative Fee Credit(PEPM) $40.00
Pharmacy Management Allowance flat amount $20,000.00
Fees
Prior Authorizations(per review) $50.00
Direct Member Reimbursement(per paper claim $2.50
Level Customer Specific
Period Annually
Payment Period Annually
Payment The amount the actual discounts are less than the combined guaranteed Retail,Mail,and Specialty discount
Amount --
amount.
Discounts
Payment
Amount -- The amount the combined actual dispensing fee exceeds the combined contracted dispensing fee.
Dispensing Fees
Payment
Amount -- The amount the combined actual Rebate amount is less than the combined guaranteed Rebate amount.
Rebates
Conditions Discount&Dispense Fee Specific Conditions
•Discounts are based on actual Network Pharmacy brand and generic usage of retail and mail order drugs. The
guaranteed discount amount will be determined by multiplying the AWP by the contracted discount rate off
_ AWP by component.
•Does not apply to items covered under the Plan for which no AWP measure exists.
•Discounts calculated based on AWP less the ingredient cost;discount percentages are the discounts divided by
the AWP. Discounts for retail and mail order generic prescriptions represent the average AWP based on
savings off Maximum Allowable Cost(MAC)pricing for MAC generics and percentage discount savings off
AWP for non-MAC generics. All other discounts represent the percentage discount savings off of AWP.
•The arrangement excludes generic medications launched as an'at-risk'product,generic medication with
pending litigation,compound drugs,retail out of network claims,mail order drugs(for dispensing fee
_ arrangement)and Indian Health Service Claims.
_ •The Arrangement excludes usual&customary claims,vaccines,long term care facility claims.
_ •The Arrangement includes veterans'affairs facility claims,over-the-counter claims.
•The 90 day supply Retail guarantee includes drugs dispensed for 84 days or greater.
•The Mail Order guarantee includes drugs dispensed for 46 days or greater.
•When a drug is identified as a brand name drug,it will be considered a brand name drug for the calculation of
discount guarantees.When a drug is identified as a generic drug,it will be considered a generic drug for the
calculation of discount guarantees.
•Specialty drugs dispensed outside United's specialty Pharmacy Network are included in the retail guarantees.
Specialty drugs dispensed through United's specialty Pharmacy Network are excluded from the Retail and Mail
guarantees.
•Drugs in the following Specialty therapeutic categories are included in the retail guarantees:None.
Rebate Specific Conditions
•Assumes implementation of United's Traditional PDL
•Client directed deviations from the PDL and PDL exclusions or uptiers,or clinical programs may result in
changes to pricing and guarantees,which will be factored in at the time of rebate payment and/or reconciliation.
•Calculation of the guaranteed rebate amount will exclude ineligible claims including:
-claims where the plan is not the primary payer(e.g.,coordination of benefits and subrogation claims)
-claims approved by formulary exception
-claims not covered by Customer's benefit design or PDL
-claims receiving 340B pricing
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Confidential Information of UnitedHealth Group
-long term care pharmacy claims
-federal government pharmacy claims
-claims for non-FDA approved products
-compound drug claims
-direct member reimbursement claims
•Devices are excluded from the claim counts;Insulins and Test Strips are not excluded.
•Vaccines are excluded from the claim counts.
•Limited distribution drugs are excluded from the claim counts
•Rebate guarantee payments or reconciliations may be adjusted in the event of a change impacting the level of
Rebates due to the introduction of therapeutically equivalent,lower Rebate drugs(e.g.biosimilar,authorized
brand alternative,lower cost non-Generic Drug alternative)or the reduction of Wholesale Acquisition Cost on a
Brand Drug subject to Rebates. In the event a payment or reconciliation adjustment is required,such
adjustment will be based on the difference between a)pharmaceutical manufacturer revenue prior to the
introduction of the lower Rebate drugs and b)the actual pharmaceutical manufacturer revenue received after the
introduction of the lower Rebate drugs. Such adjustment does not apply to Generic Drugs that launch after the
Brand Drug no longer has patent protection.
•The Rebate guarantees and any Administrative Fee Credits funded by retained Rebates set forth herein do not
incorporate the impact of the elimination of the Average Manufacturer's Price(AMP)Cap pursuant to the
American Rescue Plan Act of 2021. United reserves the right to modify or eliminate any Rebate guarantees and
Administrative Fee Credits once it has been able to determine that impact and the resulting changes to Rebates
received from pharmaceutical manufacturers.
United reserves the right to modify or eliminate this arrangement as follows based upon changes in Rebates:
•if changes made to United's PDL,for the purpose of achieving a lower net drug cost for Customer and
United's other ASO customers,result in significant reductions to the Rebate level
•in the event that there are material deviations to the anticipated timing of drugs that will come off patent and
no longer generate Rebates
•if there is a change impacting the availability or amount of Rebates offered by drug manufacturer(s),including
changes related to the elimination or material modification of a drug manufacturer(s)historic models or
practices related to the provision of Rebates
•United will pay Fixed Rebates consistent with the Agreement. To the extent Rebates paid to United exceed
the Fixed Rebate amount,We will retain the excess,including any Rebates United may earn on prescription
drug products in any tiers not included in this arrangement and any related interest.
•Rebate Administrative Fee: United maintains systems and processes necessary for managing and
administering Rebate programs. As consideration for these efforts,pharmaceutical manufacturers pay United
administrative fees in addition to Rebates. Rebate Administration fees are included in the guaranteed rebate
arrangement.
•If Customer terminates pharmacy benefit services with United prior to the end of the Pharmacy Pricing Term,
United will retain any and all pending or future Rebates payable under the Agreement as of the effective date of
the termination of pharmacy benefit services.
•Drugs in the following Specialty therapeutic categories are included in the retail per-Brand guarantees:None.
_ Credits and Allowances
•Administrative Fee Credit: In addition to the guaranteed Rebates,Customer will receive an administrative fee
credit. Under this arrangement,Rebates retained by United are used to lower the medical administration fee.
•Pharmacy Management Allowance: United will provide a credit allowance to help Customer mitigate costs
appropriately associated with the administration of the pharmacy program. This credit allowance is available
once the parties have an executed Agreement and the first month of service fees under the Agreement has been
received by United. Upon presentation of receipts of allowable costs,a credit will be issued in United's fee
billing system in the amount of the receipted expenses,the total amount not to exceed the full credit.
•If Customer terminates pharmacy benefit services with United prior to the end of the Pharmacy Pricing Term,
Customer will repay United a prorated portion of the amount of the Pharmacy Management Allowance that has
been paid as of the termination date. All unpaid credits are forfeit.
General Conditions
•All pricing guarantees shall remain in effect for the entire contract period of 01/01/2024 through 12/31/2024
("Pharmacy Pricing Term"). Each twelve month period is a Guarantee Period.
•Specialty drugs typically covered under the medical benefit(administered/handled by a provider,
administered in a physician's office,ambulatory or home infusion),and/or transitioned to the pharmacy benefit,
are excluded from all guarantees.
•Drugs,products,supplies approved,covered and/or prescribed for the diagnosis,treatment or prevention of
COVID-19 are excluded from all guarantees.
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Confidential Information of UnitedHealth Group
•On mail order drugs,specialty drugs,and retail pharmacy drugs and services including dispensing fees,United
will retain the difference between what United reimburses the Network Pharmacy and Customer's payment for a
prescription drug product or service.
• Pricing and guarantees assume enrollment of 954 Employees and 2,146 Participants;pricing and guarantees
may be revised or withdrawn if actual enrollment varies by 10%or more from assumptions.
•The lesser of three logic(non-ZBL)will apply to Participant payments. Participants pay the lesser of the
discounted price,the usual and customary charge or the cost share amount.
•All pricing guarantees require the selection of United as the exclusive mail provider.
United will have no financial guarantee obligation under the Agreement for any partial Guarantee Period if
Customer terminates with an effective date prior to the end of the Pharmacy Pricing Term.
•United shall on Customer's behalf,administer a fee("Consultant Fee")to be paid to HonestRX
("Consultanf'). The Consultant Fees are included in Customer's pharmacy financial terms. United shall
provide Consultant with an annual audit credit of$20,000 and monthly payment for all Consultant Fees
collected in the amount(s)of$4.00 pmpm. The Customer acknowledges there is a contract between Customer
and Consultant. Therefore,in the event that there is a dispute between Customer and Consultant over
continuing to make the Consultant Fee payment(s)or in the delivery of consulting services,Customer shall hold
United harmless in such disputes.In the event of any change whatsoever in the Consultant Fee,Customer shall
immediately notify United of such change and United may propose changes to the pharmacy financial terms.
•United reserves the right to revise or revoke this arrangement if: a)changes in federal,state or other
applicable law or regulation require modifications;b)there are material changes to the AWP as published by
the pricing agency that establishes the AWP as used in these arrangements;c)Customer makes benefit changes
that impact the arrangements;d)there is a material industry change in pricing methodologies resulting in a new
source or benchmark;e)it is not accepted within ninety(90)days of the issuance of our quote;f)if Customer
changes their mail service benefit;g)Customer utilizes a vendor,that facilitates steering members to different
drugs or pharmacies to the extent these services impact the financial guarantees under this Agreement.
Brand/Generic Reconciliation Definition
•Brand Drug: An FDA approved drug,or a drug that is designated by FDA a DESI(Drug Efficacy Study
Implementation)drug,or product,which is manufactured and distributed by an innovator drug company,or its
licensee,set forth in Medi-Span's National Drug Data File as a brand drug identified by all of the products
meeting at least one of the following criteria:
- Medi-Span Multi-Source Code("MSC")is equal to M,O,or N.
•Generic Drug: An FDA approved drug,or a drug that is designated by FDA a DESI(Drug Efficacy Study
Implementation)drug,or product,that is therapeutically equivalent to other pharmaceutically equivalent
products,as set forth in Medi-Span's National Drug Data File as a generic drug identified by all products
meeting at least one of the following criteria:
- Medi-Span Multi-Source Code("MSC")is equal to Y.
TRRX 05/2023
Specialty Pharmacy
Specialty Pharmacy Discount Guarantee
Definition Specialty drug discount level based on actual specialty drug utilization for the specialty drugs
dispensed through United's specialty Pharmacy Network. United reserves the right to change
the designation of a drug from specialty to non-specialty based on market conditions.
Measurement Listed 01101/2024
All Include LDD 19.00%
Unlisted 01/01/2024
All Include LDD 14.00%
Actual utilization, using Average Wholesale Price (AWP)in dollars, using our data,of listed
Criteria specialty drugs through Our specialty Pharmacy Network will be multiplied against the discount
target to determine the overall discount target dollars.
The overall discount target dollars may be adjusted based on utilization of unlisted drugs to
which the separate unlisted discount applies. This total will be compared to actual discounts
achieved for these drugs during the Guarantee Period.
Level
Customer Specific
Period Annual
12
Confidential Information of UnitedHealth Group
Payment
Period Annual
Payment The amount the actual discounts are less than the combined guaranteed
Amount Retail, Mail, and Specialty discount amount.
Conditions • Discounts calculated based on the AWP less the ingredient cost; discount percentages are the
discounts divided by the AWP. Discounts for retail generic prescriptions represent the average
savings off AWP based on Maximum Allowable Cost(MAC) pricing for MAC generics and
percentage discount savings off AWP for non-MAC generics. All other discounts represent the
percentage discount savings off of AWP.
• Specialty drugs dispensed outside United's specialty Pharmacy Network and drugs for which no
AWP measure exists are excluded.
• Listed drugs which cease to be defined as specialty drugs during the Guarantee Period will be
reconciled outside of the Specialty Pharmacy guarantee in the channel in which they are
dispensed (retail or mail order).
• Limited Distribution (LDD)status is subject to change based on manufacturer decision.
• Specialty drugs typically covered under the medical benefit(administered/handled by a
provider, administered in a physician's office, ambulatory or home infusion), and/or transitioned
to the pharmacy benefit, are excluded from all guarantees.
• United reserves the right to revise or revoke this guarantee if: a)material changes in federal,
state or other applicable law or regulation require modifications; b)there are material changes to
the AWP as published by the pricing agency that establishes the AWP as used in this
guarantee; c)Customer makes benefit changes that impact the guarantee; d)there is a material
industry change in pricing methodologies resulting in a new source or benchmark;
• On specialty drugs, United will retain the difference between what United reimburses the
Network Pharmacy and Customer's payment for a prescription drug product or service.
Specialty Included/Ex Specialty Included/Ex
LDD cluded LDD cluded
Drug Drug Name Indicator From Drug Drug Name Indicator From
Category Guarantee Category Guarantee
I NFLAMMAT
O RY
CONDITION
ANEMIA ARANESP No Included S COSENTYX No Included
I NFLAMMAT
O RY
CONDITION
ANEMIA EPOGEN No Included S DUPIXENT No Included
I NFLAMMAT
O RY
CONDITION
ANEMIA PROCRIT No Included S EMFLAZA Yes Included
I NFLAMMAT
O RY
CONDITION
ANEMIA RETACRIT No Included S ENBREL No Included
I NFLAMMAT
O RY
ANTICONVU CONDITION
LSANT DIACOMIT Yes Included S HUMIRA No Included
I NFLAMMAT
O RY
ANTICONVU CONDITION
LSANT EPIDIOLEX Yes Included S ILUMYA No Included
I NFLAMMAT
O RY
ANTICONVU CONDITION
LSANT FINTEPLA Yes Included S KEVZARA No Included
I NFLAMMAT
O RY
ANTICONVU CONDITION
LSANT ZTALMY Yes Included S KINERET Yes Included
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Confidential Information of UnitedHealth Group
I NFLAMMAT
O RY
ANTIHYPER CONDITION
LIPIDEMIC JUXTAPID Yes Included S OLUMIANT Yes Included
I NFLAMMAT
O RY
ANTI- CONDITION
INFECTIVE ARIKAYCE Yes Included S OPZELURA No Included
I NFLAMMAT
O RY
ANTI- CONDITION
INFECTIVE DARAPRIM Yes Included S ORENCIA No Included
I NFLAMMAT
O RY
ANTI- PYRIMETHA CONDITION
INFECTIVE MINE No Included S OTEZLA No Included
I NFLAMMAT
O RY
CONDITION
ANTIVIRAL LIVTENCITY Yes Included S RIDAURA No Included
I NFLAMMAT
O RY
CONDITION
ASTHMA FASENRA Yes Included S RINVOQ No Included
I NFLAMMAT
O RY
CONDITION
ASTHMA NUCALA Yes Included S SILIQ Yes Included
I NFLAMMAT
O RY
CONDITION
ASTHMA XO LAIR Yes Included S SIMPONI No Included
I NFLAMMAT
O RY
CARDIOVAS CONDITION
CULAR CAMZYOS Yes Included S SKYRIZI No Included
I NFLAMMAT
O RY
CARDIOVAS DROXIDOP CONDITION
CULAR A Yes Included S SOTYKTU No Included
I NFLAMMAT
O RY
CARDIOVAS CONDITION
CULAR NORTHERA Yes Included S STELARA No Included
I NFLAMMAT
O RY
CARDIOVAS CONDITION
CULAR VYNDAMAX Yes Included S TALTZ No Included
I NFLAMMAT
O RY
CARDIOVAS CONDITION
CULAR VYNDAQEL Yes Included S TREMFYA No Included
I NFLAMMAT
O RY
CNS CONDITION
AGENTS AUSTEDO No Included S XELJANZ No Included
I NFLAMMAT
O RY
CNS CONDITION XELJANZ
AGENTS ENSPRYNG Yes Included S XR No Included
CNS EXSERVAN Yes Included IRON DEFERASIR Yes Included
AGENTS OVERLOAD OX
CNS IRON DEFERIPRO
AGENTS FIRDAPSE Yes Included OVERLOAD NE Yes Included
CNS IRON
AGENTS HETLIOZ Yes Included OVERLOAD EXJADE Yes Included
CNS IRON
AGENTS INGREZZA I Yes I Included I OVERLOAD I FERRIPROX Yes Included
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Confidential Information of UnitedHealth Group
CNS IRON
AGENTS RADICAVA Yes Included OVERLOAD JADENU No Included
CNS KIDNEY
AGENTS RELYVRIO Yes Included DISEASE TARPEYO Yes Included
CNS LIVER
AGENTS RILUTEK No Included DISEASE OCALIVA Yes Included
MONOCLON
AL
ANTIBODY
CNS MISCELLAN
AGENTS RILUZOLE No Included EOUS BENLYSTA Yes Included
MOOD
CNS DISORDER
AGENTS RUZURGI Yes Included DRUGS SPRAVATO No Included
CNS MULTIPLE
AGENTS SABRIL Yes Included SCLEROSIS AMPYRA Yes Included
CNS SODIUM MULTIPLE
AGENTS OXYBATE Yes Included SCLEROSIS AUBAGIO No Included
CNS TASIMELTE MULTIPLE
AGENTS ON Yes Included SCLEROSIS AVONEX No Included
CNS TETRABEN MULTIPLE
AGENTS AZINE No Included SCLEROSIS BAFIERTAM Yes Included
CNS MULTIPLE BETASERO
AGENTS TIGLUTIK Yes Included SCLEROSIS N No Included
CNS VIGABATRI MULTIPLE
AGENTS N No Included SCLEROSIS COPAXONE No Included
CNS VIGADRON MULTIPLE DALFAMPRI
AGENTS E Yes Included SCLEROSIS DIN Yes Included
CNS MULTIPLE DIMETHYL
AGENTS XENAZINE Yes Included SCLEROSIS FUMARATE Yes Included
CNS MULTIPLE
AGENTS XYREM Yes Included SCLEROSIS EXTAVIA No Included
CNS MULTIPLE FINGOLIMO
AGENTS XYWAV Yes Included SCLEROSIS D No Included
CYSTIC MULTIPLE
FIBROSIS BETHKIS No Included SCLEROSIS GILENYA No Included
CYSTIC BRONCHIT MULTIPLE GLATIRAME
FIBROSIS OL Yes Included SCLEROSIS R No Included
CYSTIC MULTIPLE
FIBROSIS CAYSTON Yes Included SCLEROSIS GLATOPA No Included
CYSTIC MULTIPLE
FIBROSIS KALYDECO Yes Included SCLEROSIS KESIMPTA No Included
CYSTIC KITABIS MULTIPLE MAVENCLA
FIBROSIS PAK No Included SCLEROSIS D Yes Included
CYSTIC MULTIPLE
FIBROSIS ORKAMBI Yes Included SCLEROSIS MAYZENT No Included
CYSTIC PULMOZYM MULTIPLE
FIBROSIS E No Included SCLEROSIS PLEGRIDY Yes Included
CYSTIC MULTIPLE
FIBROSIS SYMDEKO Yes Included SCLEROSIS PONVORY Yes Included
CYSTIC MULTIPLE
FIBROSIS TOBI No Included SCLEROSIS REBIF No Included
CYSTIC TOBI MULTIPLE REBIF
FIBROSIS PODHALER No Included SCLEROSIS REBIDOSE No Included
CYSTIC TOBRAMYCI MULTIPLE
FIBROSIS N No Included SCLEROSIS TECFIDERA Yes Included
CYSTIC MULTIPLE
FIBROSIS TRIKAFTA Yes Included SCLEROSIS VUMERITY Yes Included
ENDOCRIN MULTIPLE
E BETAINE Yes Included SCLEROSIS ZEPOSIA Yes Included
MUSCULOS
ENDOCRIN KELETAL
E BUPHENYL No Included AGENTS EVRYSDI Yes Included
MUSCULOS
ENDOCRIN KELETAL
E BYNFEZIA No Included AGENTS VOXZOGO Yes Included
ENDOCRIN NARCOLEP
E CARBAGLU Yes Included SY WAKIX Yes Included
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Confidential Information of UnitedHealth Group
ENDOCRIN CARGLUMI NEUTROPE
E C Yes Included NIA FULPHILA No Included
ENDOCRIN NEUTROPE
E CHENODAL Yes Included NIA GRANIX No Included
ENDOCRIN NEUTROPE
E CLOVIQUE No Included NIA LEUKINE No Included
ENDOCRIN CORTROPH NEUTROPE
E IN Yes Included NIA NEULASTA No Included
ENDOCRIN NEUTROPE
E CUPRIMINE No Included NIA NEUPOGEN No Included
ENDOCRIN CYSTADAN NEUTROPE
E E Yes Included NIA NIVESTYM No Included
ENDOCRIN CYSTADRO NEUTROPE
E PS Yes Included NIA NYVEPRIA No Included
ENDOCRIN NEUTROPE
E CYSTARAN Yes Included NIA UDENYCA No Included
ENDOCRIN DEPEN NEUTROPE
E TITRATABS No Included NIA ZARXIO No Included
ENDOCRIN DICHLORPH NEUTROPE
E ENAMIDE Yes Included NIA ZIEXTENZO No Included
ONCOLOGY
ENDOCRIN D- INJECTABL
E PENAMINE No Included E ELIGARD No Included
ONCOLOGY
ENDOCRIN INJECTABL
E EGRIFTA Yes Included E INTRON A Yes Included
ONCOLOGY
ENDOCRIN INJECTABL LEUPROLID
E FIRMAGON No Included E E No Included
ONCOLOGY
ENDOCRIN INJECTABL
E GATTEX Yes Included E SYNRIBO Yes Included
ENDOCRIN H.P. ONCOLOGY ABIRATERO
E ACTHAR Yes Included -ORAL NE No Included
ENDOCRIN ONCOLOGY
E IMCIVREE Yes Included -ORAL AFINITOR No Included
ENDOCRIN ONCOLOGY AFINITOR
E ISTURISA Yes Included -ORAL DISPERZ No Included
ENDOCRIN ONCOLOGY
E JAVYGTOR Yes Included -ORAL ALECENSA Yes Included
ENDOCRIN ONCOLOGY
E JYNARQUE Yes Included -ORAL ALKERAN No Included
ENDOCRIN ONCOLOGY
E KEVEYIS Yes Included -ORAL ALUNBRIG Yes Included
ENDOCRIN ONCOLOGY
E KORLYM Yes Included -ORAL AYVAKIT Yes Included
ENDOCRIN ONCOLOGY
E KUVAN Yes Included -ORAL BALVERSA Yes Included
ENDOCRIN LANREOTID ONCOLOGY BEXAROTE
E E No Included -ORAL NE No Included
ENDOCRIN ONCOLOGY
E MYALEPT Yes Included -ORAL BOSULIF Yes Included
ENDOCRIN ONCOLOGY
E MYCAPSSA Yes Included -ORAL BRAFTOVI Yes Included
ENDOCRIN ONCOLOGY
E NATPARA Yes Included -ORAL BRUKINSA Yes Included
ENDOCRIN ONCOLOGY CABOMETY
E NITYR Yes Included -ORAL X Yes Included
ENDOCRIN OCTREOTID ONCOLOGY CALQUENC
E E ACETATE No Included -ORAL E Yes Included
ENDOCRIN PENICILLAM ONCOLOGY CAPECITABI
E INE No Included -ORAL NE No Included
ENDOCRIN ONCOLOGY
E PROCYSBI Yes Included ORAL I CAPRELSA Yes Included
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Confidential Information of UnitedHealth Group
ENDOCRIN ONCOLOGY
E RAVICTI Yes Included -ORAL COMETRIQ Yes Included
ENDOCRIN ONCOLOGY
E RECORLEV Yes Included -ORAL COPIKTRA Yes Included
ENDOCRIN ONCOLOGY
E SAMSCA Yes Included -ORAL COTELLIC Yes Included
ENDOCRIN SANDOSTA ONCOLOGY
E TIN No Included -ORAL DAURISMO Yes Included
ENDOCRIN SAPROPTE ONCOLOGY
E RIN Yes Included -ORAL ERIVEDGE Yes Included
ENDOCRIN ONCOLOGY
E SIGNIFOR Yes Included -ORAL ERLEADA No Included
SODIUM
ENDOCRIN PHENYLBU ONCOLOGY
E TYRATE No Included -ORAL ERLOTINIB Yes Included
ENDOCRIN SOMATULIN ONCOLOGY
E E DEPOT No Included -ORAL ETOPOSIDE No Included
ENDOCRIN ONCOLOGY EVEROLIMU
E SOMAVERT Yes Included -ORAL S No Included
ENDOCRIN ONCOLOGY
E SYPRINE No Included -ORAL EXKIVITY Yes Included
ENDOCRIN ONCOLOGY
E THIOLA Yes Included -ORAL FARYDAK Yes Included
ENDOCRIN ONCOLOGY
E TIOPRONIN No Included -ORAL FOTIVDA Yes Included
ENDOCRIN ONCOLOGY
E TOLVAPTAN No Included -ORAL GAVRETO Yes Included
ENDOCRIN ONCOLOGY
E TRIENTINE No Included -ORAL GILOTRIF Yes Included
ENDOCRIN ONCOLOGY
E XERMELO Yes Included -ORAL GLEEVEC No Included
ENDOCRIN ONCOLOGY
E XURIDEN Yes Included -ORAL GLEOSTINE No Included
ENZYME
DEFICIENC ONCOLOGY
Y CHOLBAM Yes Included -ORAL HYCAMTIN No Included
ENZYME
DEFICIENC ONCOLOGY
Y CYSTAGON Yes Included -ORAL IBRANCE Yes Included
ENZYME
DEFICIENC ONCOLOGY
Y GALAFOLD Yes Included -ORAL ICLUSIG Yes Included
ENZYME
DEFICIENC ONCOLOGY
Y MIGLUSTAT No Included -ORAL IDHIFA No Included
ENZYME
DEFICIENC ONCOLOGY IMATINIB
Y NITISINONE No Included -ORAL MESYLATE No Included
ENZYME
DEFICIENC ONCOLOGY
Y ORFADIN No Included -ORAL IMBRUVICA Yes Included
ENZYME
DEFICIENC ONCOLOGY
Y PALYNZIQ Yes Included -ORAL INLYTA Yes Included
ENZYME
DEFICIENC ONCOLOGY
Y STRENSIQ Yes Included -ORAL INQOVI Yes Included
ENZYME
DEFICIENC ONCOLOGY
Y SUCRAID Yes Included -ORAL INREBIC Yes Included
ENZYME
DEFICIENC ONCOLOGY
Y TEGSEDI Yes Included -ORAL IRESSA Yes Included
ENZYME
DEFICIENC ONCOLOGY
Y ZAVESCA Yes Included -ORAL JAKAFI Yes Included
GAUCHERS ONCOLOGY
DISEASE CERDELGA Yes Included -ORAL KISQALI No Included
17
Confidential Information of UnitedHealth Group
GENETIC ONCOLOGY KISQALI
DISORDER I DOJOLVI Yes Included -ORAL FEMARA No Included
GENETIC ONCOLOGY
DISORDER VIJOICE No Included -ORAL KOSELUGO Yes Included
GENETIC ONCOLOGY
DISORDER ZOKINVY Yes Included -ORAL LAPATINIB No Included
GROWTH
HORMONE
DEFICIENC GENOTROP ONCOLOGY LENALIDOM
Y IN No Included -ORAL IDE Yes Included
GROWTH
HORMONE
DEFICIENC HUMATROP ONCOLOGY
Y E No Included -ORAL LENVIMA Yes Included
GROWTH
HORMONE
DEFICIENC ONCOLOGY
Y INCRELEX Yes Included -ORAL LONSURF Yes Included
GROWTH
HORMONE
DEFICIENC NORDITRO ONCOLOGY
Y PIN No Included -ORAL LORBRENA Yes Included
GROWTH
HORMONE
DEFICIENC NUTROPIN ONCOLOGY
Y AQ No Included -ORAL LUMAKRAS Yes Included
GROWTH
HORMONE
DEFICIENC OMNITROP ONCOLOGY
Y E No Included -ORAL LYNPARZA Yes Included
GROWTH
HORMONE
DEFICIENC ONCOLOGY
Y SAIZEN No Included -ORAL MATULANE Yes Included
GROWTH
HORMONE
DEFICIENC ONCOLOGY
Y SEROSTIM Yes Included -ORAL MEKINIST Yes Included
GROWTH
HORMONE
DEFICIENC ONCOLOGY
Y SKYTROFA No Included -ORAL MEKTOVI Yes Included
GROWTH
HORMONE
DEFICIENC ONCOLOGY MELPHALA
Y ZOMACTON No Included -ORAL N No Included
GROWTH
HORMONE
DEFICIENC ONCOLOGY
Y ZORBTIVE Yes Included -ORAL MESNEX No Included
HEMATOLO ONCOLOGY
GIC BERINERT Yes Included -ORAL NERLYNX Yes Included
HEMATOLO ONCOLOGY
GIC CABLIVI Yes Included -ORAL NEXAVAR Yes Included
HEMATOLO ONCOLOGY
GIC CINRYZE Yes Included -ORAL NILANDRON No Included
HEMATOLO ONCOLOGY NILUTAMID
GIC DOPTELET Yes Included -ORAL E No Included
HEMATOLO ONCOLOGY
GIC FIRAZYR Yes Included -ORAL NINLARO No Included
HEMATOLO ONCOLOGY
GIC HAEGARDA Yes Included -ORAL NUBEQA Yes Included
HEMATOLO ONCOLOGY
GIC ICATIBANT Yes Included -ORAL ODOMZO No Included
HEMATOLO ONCOLOGY
GIC MOZOBIL No Included -ORAL ONUREG No Included
HEMATOLO ONCOLOGY
GIC MULPLETA No Included ORAL ORGOVYX Yes Included
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Confidential Information of UnitedHealth Group
HEMATOLO ONCOLOGY
GIC OXBRYTA Yes Included -ORAL PEMAZYRE Yes Included
HEMATOLO ONCOLOGY
GIC PROMACTA Yes Included -ORAL PIQRAY No Included
HEMATOLO ONCOLOGY
GIC REZUROCK Yes Included -ORAL POMALYST Yes Included
HEMATOLO ONCOLOGY
GIC RUCONEST Yes Included -ORAL PURIXAN No Included
HEMATOLO ONCOLOGY
GIC SAJAZIR Yes Included -ORAL PYRUKYND Yes Included
HEMATOLO ONCOLOGY
GIC TAKHZYRO Yes Included -ORAL QINLOCK Yes Included
HEMATOLO ONCOLOGY
GIC TAVALISSE Yes Included -ORAL RETEVMO Yes Included
HEMOPHILI ONCOLOGY
A-INFUSED ADVATE No Included -ORAL REVLIMID Yes Included
HEMOPHILI ADYNOVAT ONCOLOGY ROZLYTRE
A-INFUSED E No Included -ORAL K No Included
HEMOPHILI ONCOLOGY
A-INFUSED AFSTYLA No Included -ORAL RUBRACA Yes Included
ALPHANATE
/VON
HEMOPHILI WILLEBRAN ONCOLOGY
A-INFUSED D No Included -ORAL RYDAPT No Included
HEMOPHILI ALPHANINE ONCOLOGY
A-INFUSED SD No Included -ORAL SCEMBLIX No Included
HEMOPHILI ONCOLOGY
A-INFUSED ALPROLIX No Included -ORAL SORAFENIB Yes Included
HEMOPHILI ONCOLOGY
A-INFUSED BENEFIX No Included -ORAL SPRYCEL No Included
HEMOPHILI ONCOLOGY
A-INFUSED COAGADEX Yes Included -ORAL STIVARGA Yes Included
HEMOPHILI ONCOLOGY
A-INFUSED CORIFACT No Included -ORAL SUNITINIB Yes Included
HEMOPHILI ONCOLOGY
A-INFUSED ELOCTATE No Included -ORAL SUTENT Yes Included
HEMOPHILI ONCOLOGY
A-INFUSED ESPEROCT No Included -ORAL TABLOID No Included
HEMOPHILI ONCOLOGY
A-INFUSED FEIBA No Included -ORAL TABRECTA No Included
HEMOPHILI ONCOLOGY
A-INFUSED HEMOFIL M No Included -ORAL TAFINLAR Yes Included
HEMOPHILI ONCOLOGY
A-INFUSED HUMATE-P No Included -ORAL TAGRISSO Yes Included
HEMOPHILI ONCOLOGY
A-INFUSED IDELVION No Included -ORAL TALZENNA Yes Included
HEMOPHILI ONCOLOGY
A-INFUSED IXINITY No Included -ORAL TARCEVA Yes Included
HEMOPHILI ONCOLOGY
A-INFUSED JIVI No Included -ORAL TARGRETIN No Included
HEMOPHILI ONCOLOGY
A-INFUSED KOATE No Included -ORAL TASIGNA Yes Included
HEMOPHILI ONCOLOGY
A-INFUSED KOATE-DVI No Included -ORAL TAZVERIK Yes Included
HEMOPHILI KOGENATE ONCOLOGY
A-INFUSED FS No Included -ORAL TEMODAR No Included
HEMOPHILI ONCOLOGY TEMOZOLO
A-INFUSED KOVALTRY No Included -ORAL MIDE No Included
HEMOPHILI ONCOLOGY
A-INFUSED MONONINE No Included -ORAL TEPMETKO Yes Included
HEMOPHILI NOVOEIGH ONCOLOGY
A-INFUSED T No Included -ORAL THALOMID Yes Included
HEMOPHILI NOVOSEVE ONCOLOGY
A-INFUSED N RT No Included -ORAL TIBSOVO Yes Included
HEMOPHILI ONCOLOGY
A-INFUSED NUWIQ No Included -ORAL TRETINOIN No Included
HEMOPHILI PROFILNIN ONCOLOGY
A-INFUSED E No Included ORAL TRUSELTIQ Yes Included
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Confidential Information of UnitedHealth Group
HEMOPHILI ONCOLOGY
A-INFUSED REBINYN No Included -ORAL TUKYSA Yes Included
HEMOPHILI RECOMBIN ONCOLOGY
A-INFUSED ATE No Included -ORAL TURALIO Yes Included
HEMOPHILI ONCOLOGY
A-INFUSED RIXUBIS No Included -ORAL TYKERB No Included
HEMOPHILI SEVENFAC ONCOLOGY
A-INFUSED T No Included -ORAL UKONIQ Yes Included
HEMOPHILI ONCOLOGY
A-INFUSED TRETTEN Yes Included -ORAL VENCLEXTA Yes Included
HEMOPHILI ONCOLOGY
A-INFUSED VONVENDI Yes Included -ORAL VERZENIO Yes Included
HEMOPHILI ONCOLOGY
A-INFUSED WILATE No Included -ORAL VITRAKVI Yes Included
HEMOPHILI ONCOLOGY
A-INFUSED XYNTHA No Included -ORAL VIZIMPRO Yes Included
HEMOPHILI
A-
INJECTABL ONCOLOGY
E HEMLIBRA Yes Included -ORAL VONJO Yes Included
HEPATITIS ADEFOVIR ONCOLOGY
B DIPIVOXIL No Included -ORAL VOTRIENT Yes Included
HEPATITIS BARACLUD ONCOLOGY
B E No Included -ORAL WELIREG Yes Included
HEPATITIS ONCOLOGY
B EMPAVELI Yes Included -ORAL XALKORI Yes Included
HEPATITIS ONCOLOGY
B ENTECAVIR No Included -ORAL XELODA No Included
HEPATITIS ONCOLOGY
B EPIVIR HBV No Included -ORAL XOSPATA Yes Included
HEPATITIS ONCOLOGY
B HEPSERA No Included -ORAL XPOVIO Yes Included
HEPATITIS LAMIVUDIN ONCOLOGY
B E HBV No Included -ORAL XTANDI Yes Included
HEPATITIS ONCOLOGY
B VEMLIDY No Included -ORAL YONSA No Included
HEPATITIS ONCOLOGY
C EPCLUSA No Included -ORAL ZEJULA Yes Included
HEPATITIS ONCOLOGY
C HARVONI No Included -ORAL ZELBORAF Yes Included
LEDIPASVIR
HEPATITIS /SOFOSBUV ONCOLOGY
C IR No Included -ORAL ZOLINZA No Included
HEPATITIS ONCOLOGY
C MAVYRET No Included -ORAL ZYDELIG Yes Included
HEPATITIS ONCOLOGY
C PEGASYS No Included -ORAL ZYKADIA Yes Included
HEPATITIS ONCOLOGY
C PEGINTRON No Included -ORAL ZYTIGA No Included
SOFOSBUVI
HEPATITIS R/VELPATA ONCOLOGY
C SVIR No Included -TOPICAL TARGRETIN No Included
HEPATITIS ONCOLOGY
C SOVALDI No Included -TOPICAL VALCHLOR Yes Included
HEPATITIS VIEKIRA OPHTHALMI
C PAK No Included C OXERVATE Yes Included
HEPATITIS OSTEOPOR
C VOSEVI No Included OSIS FORTEO No Included
HEPATITIS OSTEOPOR TERIPARATI
C ZEPATIER No Included OSIS DE No Included
HEPATOLO OSTEOPOR
GY BYLVAY Yes Included OSIS TYMLOS No Included
HEPATOLO PARKINSON
GY LIVMARLI Yes Included S DISEASE APOKYN Yes Included
HEREDITAR
Y
ANGIODEM PARKINSON APOMORPH
A ORLADEYO Yes Included S DISEASE INE Yes Included
20
Confidential Information of UnitedHealth Group
IMMUNE
MODULATO ACTIMMUN PARKINSON
R E Yes Included S DISEASE INBRIJA Yes Included
IMMUNE
MODULATO PARKINSON
R ARCALYST Yes Included S DISEASE KYNMOBI Yes Included
IMMUNOLO
GICAL PULMONAR
AGENTS LUPKYNIS Yes Included Y DISEASE ESBRIET Yes Included
IMMUNOLO
GICAL PULMONAR
AGENTS PALFORZIA Yes Included Y DISEASE OFEV Yes Included
IMMUNOLO
GICAL PULMONAR PIRFENIDO
AGENTS TAVNEOS Yes Included Y DISEASE NE Yes Included
PULMONAR
Y
INFERTILIT CETRORELI HYPERTEN
Y X No Included SION ADCIRCA No Included
PULMONAR
Y
INFERTILIT HYPERTEN
Y CETROTIDE No Included SION ADEMPAS Yes Included
PULMONAR
CHORIONIC Y
INFERTILIT GONADOTR HYPERTEN
Y OPIN No Included SION ALYQ No Included
PULMONAR
Y
INFERTILIT FOLLISTIM HYPERTEN AMBRISENT
Y AQ No Included SION AN Yes Included
PULMONAR
Y
INFERTILIT FYREMADE HYPERTEN
Y L No Included SION BOSENTAN No Included
PULMONAR
Y
INFERTILIT GANIRELIX HYPERTEN
Y ACETATE No Included SION LETAIRIS Yes Included
PULMONAR
Y
INFERTILIT HYPERTEN
Y GONAL-F No Included SION OPSUMIT Yes Included
PULMONAR
Y
INFERTILIT GONAL-F HYPERTEN ORENITRA
Y RFF No Included SION M Yes Included
PULMONAR
Y
INFERTILIT HYPERTEN
Y MENOPUR No Included SION REVATIO No Included
PULMONAR
Y
INFERTILIT HYPERTEN
Y NOVAREL No Included SION SILDENAFIL No Included
PULMONAR
Y
INFERTILIT HYPERTEN
Y OVIDREL No Included SION TADALAFIL No Included
PULMONAR
Y
INFERTILIT HYPERTEN
Y PREGNYL No Included SION TADLIQ Yes Included
INFLAMMAT PULMONAR
O RY Y
CONDITION HYPERTEN
S ACTEMRA No Included SION TRACLEER Yes Included
INFLAMMAT PULMONAR
ORY ADBRY Yes Included Y TYVASO Yes Included
21
Confidential Information of UnitedHealth Group
CONDITION HYPERTEN
S SION
INFLAMMAT PULMONAR
O RY Y
CONDITION HYPERTEN
S AMJEVITA No Included SION UPTRAVI Yes Included
INFLAMMAT PULMONAR
O RY Y
CONDITION HYPERTEN
S CIBINQO No Included SION VENTAVIS* Yes Included
INFLAMMAT
O RY
CONDITION
S CIMZIA No Included
"Includes
Nebulizer
202023
Generic
equivalents
may be
dispensed in
lieu of brands.
22
Confidential Information of UnitedHealth Group
Summary of Benefits and Coverage: What this Plan Covers &What You Pay For Covered Services Coverage Period: 0110112024—1213112024
UnitedHealtheare` Choice EPO Plan Coverage for: Family I Plan Type: EP1
The Summary of Benefits and Coverage(SBC)document will help you choose a healthIlan. The SBC shows you how you and the plan would share
the cost for covered health care services. NOTE: Information about the cost of thisIlan (called thepremium)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, call 1-888-331-3408 or visit
welcometouhc.com. For general definitions of common terms, such as allowed amount, balance billin , 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.
. a
What is the overall Network: $500 Individual /$1,500 Family Generally, you must pay all of the costs from providers up to the deductible
deductible? Per calendar year. amount before thisIlan begins to pay. If you have other family members on the
Ilan, each family member must meet their own individual deductible until the
total amount of deductible expenses paid by all family members meets the
overall family deductible.
Are there services covered Yes. Preventive care is covered before you meet ThisIlan covers some items and services even if you haven't yet met the
before you meet your your deductible. deductible amount. But a copayment or coinsurance may apply. For example,
deductible? thisIlan covers certain preventive services without cost-sharing and before you
meet your 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 out-of-pocket Network: $2,500 Individual /$5,000 Family The out-of-pocket limit is the most you could pay in a year for covered services. If
limit for thisIlan? Per calendar year. you have other family members in thisIlan, they have to meet their own out-of-
pocket limits until the overall family out-of-pocket limit has been met.
What is not included in Premiums, balance-billing charges, and health care Even though you pay these expenses, they don't count toward the out-of-pocket
the out-of-pocket limit? this pLan doesn't cover. Jimit.
Will you pay less if you use Yes. See myuhc.com or call 1-888-331-3408 for a ThisIlan uses a provider network. You will pay less if you use a provider in the
a network provider? ; list of network providers. Ip an's network. You will pay the most if you use an out-of-network provider, and
you might receive a bill from a provider for the difference between theprovider's
charge and what yourIlan pays (balance billing). Be aware, your network
provide r might use an out-of-network provider for some services (such as lab
work). Check with your_provide r before you get services.
Do you need a referral to No. You can see the s ecialist you choose without a referral.
see a specialist?
Page 1 of 6
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
MedicalCommon What Yo Will Pay
(You will •.y the least)_ (You will pay the most)_j_
If you visit a health Primary care visit to treat ' $25 copav per visit, Not Covered Under age 19 - Network visits are covered at No Charge
care provider's an injury or illness deductible does not apply. Virtual visits - $25 copav per visit by a Designated Virtual
office or clinic Network Provider, deductible does not apply.
If you receive services in addition to office visit, additional
copays, deductibles or coinsurance may apply e.g.
surgery.
Specialist visit $35 copav per visit, Not Covered If you receive services in addition to office visit, additional
deductible does not apply. copays, deductibles or coinsurance may apply e.g.
surgery.
Preventive No Charge Not Covered You may have to pay for services that aren't preventive.
care/screening/ Ask your provider if the services needed are preventive.
immunization Then check what yourIlan will pay for.
If you have a test Diagnostic test(x-ray, 10% coinsurance Not Covered None
blood work)
Imaging (CT/PET scans, 10% coinsurance Not Covered None
MRIs)
If you need drugs Tier 1 —Your Lowest Retail: Retail: Provider means pharmacy for purposes of this section.
to treat your illness Cost Option No Charge No Charge, deductible Retail: Up to a 31 day supply.
or condition Mail-Order: does not apply Mail-Order: Up to a 90 day supply or Preferred 90 Day Retail
No Charge Network Pharmacy
Tier 2—Your Mid-Range Retail: Retail: You may need to obtain certain drugs, including certain
More information Cost Option $30 copav, deductible $30 copav, deductible specialty drugs,from a pharmacy designated by us.
about prescription does not apply. does not apply. Certain drugs may have a preauthorization requirement or
drug coverage is Mail-Order: may result in a higher cost.
available at _ $90 copav, deductible If you use an out-of-network pharmacy(including a mail
welcometouhc.com does not apply. order pharmacy), you may be responsible for any amount
Tier 3—Your Mid-Range Retail: Retail: over the allowed amount.
Cost Option $50 copav, deductible $50 copay, deductible Certain preventive medications (including certain
does not apply. does not apply. contraceptives) are covered at No Charge.
Mail-Order: See the website listed for information on drugs covered by
$150 copav, deductible yourIlan. Not all drugs are covered.
does not apply.
* For more information about limitations and exceptions, see theIlan or policy document at welcometouhc.com. Page 2 of 6
Common I What You Will Pay
Services You May Need Network Provider Limitations, Exceptions, &Other Important Information
Medical
(You will • . • • . •
Tier 4—Your Highest Not Applicable Not Applicable You may be required to use a lower-cost drug(s) prior to
Cost Option benefits under your policy being available for certain
prescribed drugs.
If you have Facility fee (e.g., 10% coinsurance Not Covered None
outpatient surgery ambulatory surgery
center)
Physician/surgeon fees 10% coinsurance Not Covered None
If you need Emergency room care $300 copav per visit, then $300 copav per visit, then Deductible applies.
immediate medical 10% coinsurance 10% coinsurance
attention Emergency medical 10% coinsurance 10% coinsurance Deductible applies.
transportation
Urgent care $35 copav per visit, $35 copav per visit, Virtual visits - $25 copav per visit by a Designated Virtual
deductible does not apply. deductible does not apply. Network Provider, deductible does not apply.
If you receive services in addition to Urgent care visit,
additional copays, deductibles, or coinsurance may apply
e.g. surgery.
If you have a Facility fee (e.g., hospital 10% coinsurance Not Covered None
hospital stay room)
Physician/surgeon fees 10% coinsurance Not Covered None
If you need mental Outpatient services $35 copav per visit, Not Covered Network Partial hospitalization/intensive outpatient
health, behavioral deductible does not apply. treatment: No Charge
health, or Inpatient services 10% coinsurance Not Covered None
substance abuse
services
If you are pregnant Office visits No Charge Not Covered Cost sharing does not apply for preventive services.
Childbirth/delivery 10% coinsurance Not Covered Depending on the type of service a copayment,
professional services coinsurance or deductible may apply. Maternity care may
include tests and services described elsewhere in the SBC
_ (i.e. ultrasound.)
Childbirth/delivery facility 10% coinsurance Not Covered None
services
Home health care 10% coinsurance I Not Covered Limited to 120 visits per calendar year.
* For more information about limitations and exceptions, see theIlan or policy document at welcometouhc.com. Page 3 of 6
Common I What You Will Pay
Medical Event Services You May Need Network Provider Limitations, Exceptions, &Other Important Information
(Ypg wi I I pay th~ • na •
If you need help Rehabilitation services $35 copay per visit, Not Covered Limits per calendar year: Physical, Speech, Occupational:
recovering or have deductible does not apply. combined limit 60 visits; Cardiac: 36 visits; Pulmonary: 20
other special health visits.
needs Habilitative services $35 copay per visit, Not Covered Services are provided under and limits are combined with
deductible does not apply. Rehabilitation Services above.
Skilled nursing care 10% coinsurance Not Covered Limited to 100 days per calendar year(combined with
inpatient rehabilitation).
Durable medical 10% coinsurance Not Covered Covers 1 per type of DME (including repair/replacement)
e ui ment every 3 years.
Hospice services 10% coinsurance Not Covered None
If your child needs Children's eye exam Not Covered Not Covered No coverage for Children's eye exams.
dental or eye care Children's glasses Not Covered Not CoveredNo coverage for Children's lasses.
Children's dental check- Not Covered Not Covered No coverage for Children's Dental check-up.
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.)
• Cosmetic surgery • Infertility treatment • Routine eye care
• Dental care • Long-term care • Routine foot care—Except as covered for
• Glasses • Non-emergency care when travelling outside - Diabetes
I the U.S. • Weight loss programs
Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see yourIlan document.)
• Acupuncture Chiropractic(Manipulative care)—20 visits per • Hearing aids- $4,000 per calendar year
• Bariatric surgery calendar year . Private duty nursing - 70 visits per calendar year
Outpatient only
* For more information about limitations and exceptions, see theIlan or policy document at welcometouhc.com. Page 4 of 6
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:
U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-
877-267-2323 x61565 or www.cciio.cros.gov. 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 yourIlan 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. YourIlan documents also provide
complete information on how to submit a claim, appeal, ora grievance for any reason to yourIlan. For more information about your rights, this notice, or assistance,
contact: the Member Service number listed on the back of your ID card or myuhc.com or the Employee Benefits Security Administration at 1-866-444-3272 or
dol.gov/ebsa/health reform.
Additionally, a consumer assistance program may help you file your appeal. Contact dol.gov/ebsa/healthreform.
Does this plan provide Minimum Essential Coverage? Yes
Minimum Essential Coverage generally includesIp ans, 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 the Minimum Value Standards? Yes
If yourIlan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay foraIlan through the Marketplace.
Language Access Services:
Spanish (Espanol): Para obtener asistencia en Espanol, Ilame al 1-866-633-2446.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-866-633-2446.
Chinese (rP�C): 01MVrP�CMXM, MMT 1-866-633-2446.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-866-633-2446.
To see examples of how this plan might cover costs for a sample medical situation, see the next section.
* For more information about limitations and exceptions, see theIlan or policy document at welcometouhc.com. Page 5 of 6
About these Coverage Examples:
_ This is not a cost estimator. Treatments shown are just examples of how this Ilan might cover medical care. Your actual costs will be different
Adepending 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 theIlan. Use this information to compare the portion of costs you might
pay under different health Ip ans. 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 care and a (a year of routine in-network care of a well- (in-network emergency room visit and
hospital delivery) controlled condition) follow up care)
i — AkL
■ The Ip an's overall deductible $500 ■ TheIp an's overall deductible $500 ■ TheIp an's overall deductible $500
Specialist copav $35 Specialist copav $35 Specialist copav $35
Hospital (facility) coinsurance 10% Hospital (facility) coinsurance 10% Hospital (facility) coinsurance 10%
Other coinsurance 10% Other coinsurance 10% Other coinsurance 10%
This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:
Specialist office visits (pre-natal care) Primary care physician office visits (including disease Emergency room care (including medical supplies)
Childbirth/Delivery Professional Services 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 $500 _Deductibles $250 Deductibles $500
Copayments $0 Copayments $600 Copayments $500
Coinsurance $1,100 Coinsurance $0 Coinsurance $80
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 $1,660 The total Joe would pay is $850 The total Mia would pay is $1,080
TheIlan would be responsible for the other costs of these EXAMPLE covered services. Page 6 of 6
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: UHC Civil Rights0uhc.com
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: ht tps:Hocp2ortal.hhs.gov/ocr/portal/lobby.tsf
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.
ATENCION_ Si habla espanol (Spanish), hay senicios de asistencia deidiomas, sin cargo, a su disposicio-n- Dame al 1lumero gratuito que
aparece en este Resumell de Belleflclos y Cobertura ( umman- of Benefits and Coverage_ SBC)-
Ai 4. : A -' 1� (C'hinese) , f9 - A1A A�, AE . a�RIT J 9 7A 0 19 (Summary ofBeneflts and Coverage,
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thoai mien phi ghi trong bars T6m luac ve quv6n 1oi va dai thq bao hi em (Summary of Benefits and Coverage, SBC)nay
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PAUNAIVA:Dung nagsasalita ka ng Tagalog (Tagaing}_ may makukuha kang mga libreng serbisvo ng tulong sa 7..?ika- Pakitav,,agan ang
toll-free n num erong nakalista sa Buod na ito ng Mga Benepisv o at Sak1av (Summate ofBenefits and Coy erage o SBC)-
BMIMAHME: aecn.iarxLie cJryrx nepez0,�2_,J0CTynH AUA , leii po-Txorl A2,M K MBTAereA p�-ccKa-%e (Russian)- II02.xOxxre no
oecri.zarxoMn'xo%lepy rezeC�oxa, -,,Ka3axxo s �axxo:u<<O53ope .ibror x rioKpbi=5i>) (Summary ofBenefits and Coverage, SBC}-
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ATAN YON: Si wpale Krevbl avisven (Haitian Creole)- ou kapab benefisve selis ki gratis you edev.. nan long pa v..-. Tanpri rete nimeNvo
gratis ki nan Rezime avantaj ak pr.,oteksvon sa a (Summar- of Benefits and Coverage- SBC)-
ATTENTION : Si nous parlez franpis (French), des ser%ices d-aidelin guistique nous sant proposes gratuitement-Veuillez appeler le
numero sans frais figurant dans ce Sommaire des prestations et de la couverture (Summar- of Benefits and Coverage, SBC).
UWAOA:Jezeli mov-.•isz po polsku (Polish), udostepnilism-,- darmov.•euslugi tlumacza- Prosiniv zadzvvonic pod bezplatnr-numer podanvw.
niniejsnm estay..•ieniu S-7.iadczen i refundacji (Summar- of Benefits and Coverage- SBC)-
ATENQ O: Se voce falx portugues (Portuguese)_ contate o seri�o de assistencia deidiomas gratuito- Ligue para o humero gratuito listado
nesse Resumo de Beneficios e Cobertura (Summary of Benefits and Coverage - SBC)-
ATTE.NIONE:in caso 1a lingua parlata sia 1:ital'ianG (Italian), sono disponibili servizi di assistenza linguistics gratuiti- Chi am ate it num ero
verde indicato all'interno di questa Sommario dei Benefit e della Copertura (Summary of Benefits and Coverage, SBC)-
ACHTU O: Falls Sie Deutsch (German) sprechen_ stehen Ihnenkostenlos sprachliche Hilfsdienstleistungen zur V,erfugung- Bimrufen Sie
die in dieser Zusaininenfassun g der Lei stung en and Ko st endb ernahm en (Summar' o f Benefits and Coverage- SBC:)angegebene g ebaliren frei e
Rufiiummer an-
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and Coverage_ SBC} ttc f q-.T
CEEB TC}0M: Yo g koj hais Lus HmoA (Hmong)_ muaj key- pab txhais lus pub da-v.•b rau koj- Thor liu rau tus xo,,-tooj hu dav:b teevmua],
nyob ntaN-,-m Ts ab NtaN,-•Nthuav Qhia CovTxiaj Ntsim Zoo thiab Key- Kam Them N qi (Summar- of Benefits acid Coverage, SBC:)no-
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('overd c, S B( )12"1
PAKDAAR:Nu saritaem ti Hocana (Ho cano), ti serbis o para ti baddang ti Iengguahe ng a. aw.anan bavadna,ket sidadaati para kenr-am.
Mai da:w-at nga a„4.?agan ti a-v.:aii bavad n nu tav-.'agan riga humero n g a nakalista iti uneg na davtovnga Dagup dagiti Benipi:5yo kers
Pannakasakup (Summar- of Benefits and Coverage, SBC.)-
DII BAA'AKO T IZIN:Dine(-Navajo)bizaad bee vanilti'go, saad bee aka'anida'av-.7e'igii, t'aa j iii-'ell, bee ua'alio-o-t'i'- T'aa shoodi Naaltsoos
Bee 'Aa'ahavani duo- Bee 'Ak-Vasti'Bee Baa Hane'i (Summary of Benefits and Coverage_ SBC”}bi-iT t'aa j i3k'eligo be-e-sh bee hane'i bika'igii
bee hodiihuh-
O OW:Haddii aad ku hadasho SGGmaah (Snmab)- adeegvadataageeradalugadda, ee bila-ash all, aA-aad lieu kartaa- Fadlan v..-ac lambarka
bilaashka ah ee ku vaalla Soo-koobitaanka Dheefaha ivo Ca-miska (Summary of Benefits and Coverage- SBC:)-