Return to flip book view

Message B2B_24-AI-851529_0624 UnitedHealthcare Insurance Company Page 1 of 8 Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: mm/dd/yyyy – mm/dd/yyyy UnitedHealthcare Insurance Company: Surest Plan F7000 RX2 Coverage for: Family | Plan Type: PPO 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 Join.Surest.com or by calling Surest Member Services at 1-866-683-6440. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copay, 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 Questions Answers What is the overall deductible? $0 See the Common Medical Events chart below for your costs for services this plan covers. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copay or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/. Are there other deductibles for specific services? No What is the out-of-pocket limit for this plan? For network providers: $7,000 individual / $14,000 family For out-of-network providers: $14,000 individual / $28,000 family The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, 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 the out-of-pocket limit? Premiums, balance billing charges and health care this plan doesn’t cover. Even though you pay these expenses, they don't count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. See Join.Surest.com, or call 1-866-683-6440 for a list ofnetwork providers.This plan uses a provider network. You will pay less if you use a provider in the plan'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 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 referral to see a specialist? No You can see the specialist you choose without a referral.

B2B_24-AI-851529_0624 UnitedHealthcare Insurance Company Page 2 of 8 All copay and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information* Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $45 - $155 copay/visit $465 copay/visit Certain procedures performed in the office may have a higher office visit copay. Copays are listed as a range. Providers are assigned copays within the range based on treatment outcomes and cost information that identifies network providers that provide cost-efficient care. Virtual visits – $0 - $155 copay per visit by a Designated Virtual Network Provider. *Cost share applies to any other Telehealth servicebased on provider type. If you receive services inaddition to office visit, additional copays may apply.Specialist visit $45 - $155 copay/visit $465 copay/visit Preventive care/screening/ immunization No charge $235 copay/visit You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. If you have a test Diagnostic test (e.g. x-ray, blood work)Routine diagnostic test: No charge Non-routine diagnostic test: $40 - $1,800 copay/visit Routine diagnostic test: No charge Non-routine diagnostic test: Up to $5,400 copay/visit Copays are listed as a range. Providers are assigned copays within the range based on treatment outcomes and cost information that identifies network providers that provide cost-efficient care. Out-of-Network preauthorization is required for certain non-routine diagnostic tests or your benefits may be reduced or there may be no coverage. Imaging (CT/PET scans, MRIs) $200 - $1,150 copay/visit Up to $3,450 copay/visit Copays are listed as a range. Providers are assigned copays within the range based on treatment outcomes and cost information that identifies network providers that provide cost-efficient care. Out-of-Network preauthorization is required for certain imaging tests or your benefits may be reduced or there may be no coverage. *For more information about limitations and exceptions, see plan or policy document at Join.Surest.com for prospective members.

B2B_24-AI-851529_0624 UnitedHealthcare Insurance Company Page 3 of 8 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information* Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need drugs to treat your illness or condition More information about prescription drug coverage is available at Optumrx.com. Tier 1 drugs 30-Day Supply$10 copay90-Day Supply$25 copay30-Day Supply$10 copay90-Day Supply$25 copayCertain Tier 1 drugs are available with $0 copays, including prescribed generic contraceptives and tobacco cessation medications. To learn more about drug tiers and about copays for specific drugs, visit Optumrx.com. Out-of-Network preauthorization is required for certain drugs or may result in a higher cost. Tier 2 drugs 30-Day Supply$60 copay90-Day Supply$150 copay30-Day Supply$60 copay90-Day Supply$150 copayTier 3 drugs 30-Day Supply$90 copay90-Day Supply$225 copay30-Day Supply$90 copay90-Day Supply$225 copaySpecialty drugs 30-Day SupplyTier 1: $10 copayTier 2: $150 copayTier 3: $300 copay30-Day SupplyTier 1: $10 copayTier 2: $150 copayTier 3: $300 copaySpecialty drugs are not covered at a 90-day supply. Out-of-Network preauthorization is required for certain specialty drugs or may result in a higher cost. *For more information about limitations and exceptions, see plan or policy document at Join.Surest.com for prospective members.

B2B_24-AI-851529_0624 UnitedHealthcare Insurance Company Page 4 of 8 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information* Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) $80 - $5,500 copay/visit Up to $13,000 copay/visit Copays are listed as a range. Providers are assigned copays within the range based on treatment outcomes and cost information that identifies network providers that provide cost-efficient care. Out-of-Network preauthorization is required for certain outpatient surgery or your benefits may be reduced or there may be no coverage. Physician/surgeon fees No charge No charge If you need immediate medical attention Emergency room care $1,000 copay/visit $1,000 copay/visit Copay is waived if admitted within 24 hours. Out-of-network emergency room care visit copay applies to the in-network out-of-pocket limit. Emergency medical transportation $500 copay/transport $500 copay/transport Out-of-network emergency medical transportation copay applies to the in-network out-of-pocket limit. Urgent care $110 copay/visit $330 copay/visit None If you have a hospital stay Facility fee (e.g., hospital room) $400 - $5,500 copay/stay Up to $13,000 copay/stay Copays are listed as a range. Providers are assigned copays within the range based on treatment outcomes and cost information that identifies network providers that provide cost-efficient care. Out-of-Network preauthorization is required for non-emergency facility admissions and inpatient surgery or your benefits may be reduced or there may be no coverage. Physician/surgeon fees No charge No charge *For more information about limitations and exceptions, see plan or policy document at Join.Surest.com for prospective members.

B2B_24-AI-851529_0624 UnitedHealthcare Insurance Company Page 5 of 8 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information* Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need mental health, behavioral health, or substance abuse services Outpatient services Home/Office: $45 copay/visit Outpatient Facility: $200 copay/visit Home/Office: $235 copay/visit Outpatient Facility: $600 copay/visit Certain procedures/services in the outpatient setting may have a lower copay. Out-of-Network preauthorization is required for certain outpatient services or your benefits may be reduced or there may be no coverage. Inpatient services $4,500 copay/stay $13,000 copay/stay Certain procedures/services in the inpatient setting may have a lower copay. Out-of-Network preauthorization is required for certain inpatient services or your benefits may be reduced or there may be no coverage. If you are pregnant Office visits No charge $235 copay/visit Cost sharing does not apply to preventive services with network providers. Depending on the type of service, a copay may apply. Childbirth/delivery professional services No charge No charge One copay for all covered services related to childbirth/delivery, including the newborn, unless discharged after mother. Copays are listed as a range. Providers are assigned copays within the range based on treatment outcomes and cost information that identifies network providers that provide cost-efficient care. Out-of-Network preauthorization is required for inpatient stays beyond 48 hours following a normal vaginal delivery or 96 hours following a cesarean section delivery or your benefits may be reduced or there may be no coverage. Childbirth/delivery facility services $2,500 - $4,500 copay/stay $13,000 copay/stay *For more information about limitations and exceptions, see plan or policy document at Join.Surest.com for prospective members.

B2B_24-AI-851529_0624 UnitedHealthcare Insurance Company Page 6 of 8 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information* Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need help recovering or have other special health needs Home health care $50 copay/visit $100 copay/visit Limited to 120 visits per person per plan year. Out-of-Network preauthorization is required for certain home health care services or your benefits may be reduced or there may be no coverage. Rehabilitation services $35 - $150 copay/visit Up to $450 copay/visit Limits per person per plan year: Occupational, physical and speech therapy: 60 visits each. No limit for speech therapy. No limits apply for treatment of autism or early childhood intervention. Limits are a combination of network providers and out-of-network providers per person per plan year. Copays are listed as a range. Providers are assigned copays within the range based on treatment outcomes and cost information that identifies network providers that provide cost-efficient care. For mental health related therapies, see Section 1: Covered Health Care Services*. Habilitation services $35 - $150 copay/visit Up to $450 copay/visit Skilled nursing care $3,500 copay/stay $10,500 copay/stay Limited to 120 days per person per plan year. Out-of-Network preauthorization is required or your benefits may be reduced or there may be no coverage. Durable medical equipment $0 - $1,000 copay/ equipment based on DME tier Up to $2,000 copay / equipment based on DME tier For durable medical equipment (DME) tiers and limitations, visit Join.Surest.com. Out-of-Network preauthorization is required for certain DME or your benefits may be reduced or there may be no coverage. Hospice services Home: $90 copay/visit Inpatient: $4,500 copay/stay Home: $270 copay/visit Inpatient: $13,000 copay/stay None. If your child needs dental or eye care Children’s eye exam No Charge $465 copay/visit Limited to 1 exam every year. Children’s glasses Not covered Not covered No coverage for Children’s glasses. Children’s dental check-up Not covered Not covered No coverage for Children’s dental check-up. *For more information about limitations and exceptions, see plan or policy document at Join.Surest.com for prospective members.

B2B_24-AI-851529_0624 UnitedHealthcare Insurance Company Page 7 of 8 Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your plan document for more information and a list of any other excluded services.) • Bariatric surgery• Cosmetic surgery• Dental Care (Adult)• Infertility treatment• Long-term care• Non-emergency care when travelingoutside the U.S.• Private-duty nursing• Weight loss programsOther Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Acupuncture• Chiropractic care• Hearing aids (Limitations apply)• Routine Eye Care (Adult) (Limited to 1exam every year.)• Routine foot care (for certain conditions)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: the Department of Labor’s Employee Benefit Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. You may also contact Surest Member Services at 1-866-683-6440. 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: Surest Member Services at 1-866-683-6440; or www.dol.gov/ebsa/healthreform or the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or the Texas Department of Insurance at 1-800-252-3439 or www.tdi.texas.gov. 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 the 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 (Español): Para obtener asistencia en Español, llame al 1-866-683-6440. To see examples of how this plan might cover costs for a sample medical situation, see the next section. PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1146. The time required to complete this information collection is estimated to average 0.08 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

B2B_24-AI-851529_0624 UnitedHealthcare Insurance Company Page 8 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 (9 months of in-network pre-natal care and a hospital delivery) Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well-controlled condition) Mia’s Simple Fracture (in-network emergency room visit and follow up care) ▪ The plan’s overall deductible$0 ▪ The plan’s overall deductible$0 ▪ The plan’s overall deductible$0 ▪ Specialist copayment$45 ▪ Specialist copayment$45 ▪ Specialist copayment$45 ▪ Hospital (facility)copayment $400 - $5,500▪ Hospital (facility)copayment $400 - $5,500▪ Hospital (facility)copayment $400 - $5,500 ▪ Other coinsurance$0 ▪ Other coinsurance$0 ▪ Other coinsurance$0 This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Emergency room care (including medical supplies) Diagnostic tests (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) 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 $0 Deductibles $0 Deductibles $0 Copayments $7,000 Copayments $1,600 Copayments $1,600 Coinsurance $0 Coinsurance $0 Coinsurance $0 What isn’t covered What isn’t covered What isn’t covered Limits or exclusions $60 Limits or exclusions $20 Limits or exclusions $0 The total Peg would pay is $7,060 The total Joe would pay is $1,620 The total Mia would pay is $1,600 The plan would be responsible for the other costs of these EXAMPLE covered services.

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_Rights@uhc.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: 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.