Group Forms United Healthcare

APPLICATIONS AND FORMS

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United 2014 Plans Network Office Visits Prescriptions Deductible & Coinsurance Out-of-Pocket Limits
Platinum XEU/GJ (U-1) Choice Plus $10/$20 $10/$35/$60/$250 $250 + 10% $2500 Ind/$5000 Family
Gold XDU/F6 (U-2) Choice Plus $25/$50 $15/$35/$70/$250 $1000 + 20% $5000 Ind/$10,000 Family
Gold XDV/F6 (U-3) Choice Plus $25/$50 $15/$35/$70/$250 $1500 + 20% $4750 Ind/$9500 Family
Gold XDW/F6 (U-4) Choice Plus $20/$40 $15/$35/$70/$250 $2000 + 10% $5000 Ind/$10,000 Family
Gold XEM/F6 (U-5) Choice Plus $35/$70 $15/$35/$70/$250 $0 + 20% ($1000 hospital copay) $5000 Ind/$10,000 Family
Gold XEN/F6 (U-6) Choice Plus $35/$70 $15/$35/$70/$250 $0 + 30% ($1500 hospital copay) $6000 Ind/$12,000 Family
Silver XDX/GG (U-7) Choice Plus $35/$70 $250 deductible then $15/$40/$80/$250 $1500 + 40% $6000 Ind/$12,000 Family
Silver XDY/GG (U-8) Choice Plus $35/$70 $250 deductible then $15/$40/$80/$250 $1750 + 40% $6000 Ind/$12,000 Family
Silver XD2/GG (U-9) Choice Plus $35/$70 $250 Deductible then $15/$40/$80/$250 $2000 + 30% $6000 Ind/$12,000 Family
Silver XDZ/GG (U-10) Choice Plus $35/$70 $250 Deductible then $15/$40/$80/$250 $2000 + 40% $6000 Ind/$12,000 Family
Gold XFO/F6 (U-11) Choice Plus $40/$80, Designated Network $20/$40 $15/$35/$70/$250 $500 + 20%/50% $4000 Ind/$8000 Family
Gold XFQ/F6 (U-12) Choice Plus $40/$80, Designated Network $20/$40 $15/$35/$70/$250 $1000 + 20%/50% $4000 Ind/$8000 Family
Silver XFS/F6 (U-13) Choice Plus $60/$100, Designated Network $30/$70 $15/$35/$70/$250 $1500 + 20%/50% $6000 Ind/$12,000 Family
Silver XFU/F6 (U-14) Choice Plus $60/$100, Designated Network $30/$70 $15/$35/$70/$250 $2000 + 20%/50% $6000 Ind/$12,000 Family
Gold XIY/F6 (U-15) Choice $20/$40 $15/$35/$70/$250 $500 + 10% $4500 Ind/$9000 Family
Gold XIZ/F6 (U-16) Choice $15/$30 $15/$35/$70/$250 $750 + 10% $4000 Ind/$8000 Family
Silver XF5/GG (U-17) Choice $35/$70 $250 deductible then $15/$40/$80/$250 $1500 + 30% $5000 Ind/$10,000 Family
Silver XF6/GG (U-18) Choice $35/$70 $250 deductible then $15/$40/$80/$250 $2000 + 30% $6000 Ind/$12,000 Family
Silver XF7/GG (U-19) Choice $35/$70 $250 deductible then $15/$40/$80/$250 $2500 + 30% $6000 Ind/$12,000 Family
Silver XFW/GG (U-20) Choice Plus $35/$70 $250 Deductible then $15/$40/$80/$250 $1500 + 30% $5000 Ind/$10,000 Family
Silver XFX/GG (U-21) Choice Plus $35/$70 $250 deductible then $15/$40/$80/$250 $2000 + 30% $6000 Ind/$12,000 Family
Silver XFZ/GG (U-22) Choice Plus $35/$70 $250 deductible then $15/$40/$80/$250 $3000 + 30% $6000 Ind/$12,000 Family
Gold HSA WLV/1T (U-23) Choice Plus Deductible and Coinsurance Deductible, then $10/$30/$50/$250 $1300 + 5% $5000 Ind/$10,000 Family
Silver HSA WLW/F8 (U-24) Choice Deductible and Coinsurance Deductible then $15/$40/$80/$250 $1500 + 20% $6000 Ind/$12,000 Family
Silver HSA WK7/F8 (U-25) Choice Plus Deductible and Coinsurance Deducible then $15/$40/$80/$250 $1500 + 30% $6000 Ind/$12,000 Family
Silver HSA WK6/F8 (U-26) Choice Plus Deductible and Coinsurance Deductible then $15/$40/$80/$250 $2000 + 20% $5300 Ind/$10,600 Family
Bronze HSA WLY/GH (U-27) Choice Plus Deductible and Coinsurance Deductible then $20/$50/$100/$250 $3500 + 20% $6250 Ind/$12,500 Family
Platinum XFK/GJ (U-28) Navigate HMO $10/$20 $10/$35/$60/$250 $250 + 10% $2500 Ind/$5000 Family
Platinum XFL/GJ (U-29) Navigate HMO $10/$20 $10/$35/$60/$250 $400 + 10% $1750 Ind/$3500 Family
Gold XFM/F6 (U-30) Navigate Direct HMO $20/$40 $15/$35/$70/$250 $500 + 10% $4500 Ind/$9000 Family
Gold XFN/F6 (U-31) Navigate Direct HMO $15/$30 $15/$35/$70/$250 $750 + 10% $4000 Ind/$8000 Family
Silver XEW/F6 (U-32) Navigate Direct HMO $35/$70 $15/$35/$70/$250 $1250 + 20% $6000 Ind/$12,000 Family
Silver XEX/F6 (U-33) Navigate Direct HMO $35/$70 $15/$35/$70/$250 $1500 + 20% $6000 Iind/$12,000 Family
Silver XEY/F6 (U-34) Navigate Direct HMO $35/$70 $15/$35/$70/$250 $2000 + 20% $6000 Ind/$12,000 Family
Silver XEZ/GG (U-35) Navigate Direct HMO $35/$70 $250 Deductible then $15/$40/$80/$250 $2000 + 30% $6000 Ind/$12,000 Family
Silver XE1/GG (U-36) Navigate Direct HMO $35/$70 $250 Deductible then $15/$40/$80/$250 $2500 + 30% $6000 Ind/$12,000 Family
 
Current Plans SBC Office Visit
Copay
Prescription Deductible &
Coinsurance
Out-of-Pocket
Limit
CE-C PPO SBC $25/$50 $10/$35/$70/$250 $500 + 20% $3500
CE-F PPO SBC $25/$50 $10/$35/$70/$250 $1,000 + 20% $4500
CE-I PPO SBC $30/$60 $10/$35/$70/$250 $1,000 + 30% $5000
CE-J PPO SBC $25/$50 $10/$35/$70/$250 $1,500 + 20% $4500
CE-Q PPO GenRx SBC $25/$50 Generic Only
$10/$45/$85
$2,000 + 30% $5000
CE-R PPO SBC $30/$60 $10/$35/$70/$250 $2,000 + 30% $5500
CE-W PPO SBC $30/$60 $10/$35/$70/$250 $3,000 + 30% $6500
CE-#1 PPO GenRx SBC $30/$60 Generic Only
$10/$45/$85
$5,000 +0% $5000
AP-8 HSA SBC Deductible &
Coinsurance
Deductible, then
$10/$35/$70/$250
$2,000 + 20% $4000
CI-#1 HSA SBC Deductible &
Coinsurance
Deductible, then
$10/$35/$70/$250
$2,850 + 20% $5000
CG-3 HSA SBC Deductible &
Coinsurance
$10/$35/$70/$250 $3,000 10% to $3000
CG-4 HSA SBC Deductible $10/$35/$70/$250 $3,500 None
CG-6 HSA SBC Deductible $10/$35/$70/$250 $5,000 None
CE-Y HRA SBC Deductible &
Coinsurance
$10/$35/$70/$250 $3,000 20% to $3000
CE-Z HRA SBC $30/$60 $10/$35/$70/$250 $5,000 None
CF-1 $250 PPO SBC $25/$50 $10/$35/$70/$250 $1,000 20% to $2000
CF-2 $250 PPO SBC $30/$60 $10/$35/$70/$250 $1,000 20% to $3000
CF-4 $250 PPO SBC $30/$60 $10/$35/$70/$250 $1,500 20% to $3000
CF-6 $250 PPO SBC $30/$60 $10/$35/$70/$250 $2,000 20% to $3000
CE-P $250 PPO SBC $30/$60 $10/$35/$70/$250 $2,000 20% to $3500
CF-7 $250 PPO SBC $35/$70 Generic Only
$10/$45/$85
$2,500 30% to $4000
CF-8 $250 PPO SBC $35/$70 $10/$35/$70/$250 $3,000 30% to $4500
4G-1 Navigate SBC $35/$70 $10/$35/$70/$250 $500 20% to $2500
4G-2 Navigate SBC $35/$70 $10/$35/$70/$250 $1,000 20% to $3000
4G-3 Navigate SBC $35/$70 $10/$35/$70/$250 $2,000 20% to $3000
2G-9 Navigate SBC $35/$70 $10/$35/$70/$250 $3,000 20% to $3000
Standard PPO SBC $30/$50 $15/$40/$60 $1,500 + 20% $4000
Basic PPO SBC $40/$60 $150 Deductible,
then $20/$50/$70
$4,000 + 30% $10,000
Standard HMO SBC $30/$50 $15/$40/$60 Copays $4000
Basic HMO SBC $40/$60 $150 Deductible,
then $20/$50/$70
Copays $10,000
Old plans valid until 6-30-2012
Plan Office Visit Copay In-Network Deductible In-Network Coinsurance Rate
C2-K $25/$50 $500 20%
C2-L $25/$50 $1,000 20%
C2-S $30/$60 $1,000 30%
C2-M $25/$50 $1,500 20%
C2-Q $25/$50 $2,000 30%
C2-U $30/$60 $2,000 30%
C2-V $30/$60 $3,000 30%
C2-Z $30/$60 $5,000 0%
Q3-M HSA Ded & Coins. $2,000 20%
Q3-Q HSA Ded & Coins $3,500 0%
Q3-R HSA Ded & Coins $5,000 0%
1I-Z Ded & Coins $3,000 20%
C8-1 $25/$50 $1,000 20%
C8-2 $30/$60 $1,000 20%
C8-4 $30/$60 $1,500 20%
C8-6 $30/$60 $2,000 20%
C7-2 $30/$60 $2,000 20%
C8-7 $35/$70 $2,500 30%
Old/Discontinued Plans prior to 1-1-2011
C2-X $30/$60 $3,000 0%
Q3-O HSA Ded & Coins. $2,000 0%
Q3-P HSA Ded & Coins $2,850 0%
Y3C $30/$60 $1,000 0-30%
C1-B $20/$35 $1,000 30%
C1-E $25/$50 $1,000 30%