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UnitedHealthcare Multi-Choice® Package
Health Plan Product Offering
Kentucky
UnitedHealthcare Multi-Choice® allows you to purchase one health plan package with multiple benefit design
options to meet a variety of health care and financial needs. Your employees can choose the option that meets
their individual needs, whether it’s saving money on essential coverage or paying additional dollars for more
comprehensive coverage. And you can keep or change your benefit design package year after year, ensuring
that your health plan will evolve with the changing needs of your business and your employees.
2-50 Eligible Employees
Effective 01/01/2015
Standard UnitedHealthcare Choice Plans
Coinsurance
Metallic
Level
2015
Plan
Code
Plan
Type
Network
Out-ofNetwork
Deductible
Network
Out-of-Pocket Maximum
Out-of-Network
Network
Copay / Per-Occurrence
Out-of-Network
Single
Family
Single
Family
Single
Family
Single
Family
PCP1
Spec
Urgent
Care
ER4
Deductible5
Type
Rx Plan15
Gold
6L-S
Standard
80%
50%
$500
$1,000
$1,500
$3,000
$4,500
$9,000
$13,500
$27,000
$25
$50
$100
$300+20%
Emb
10/35/60
Gold
6L-T
Standard
80%
50%
$1,000
$2,000
$3,000
$6,000
$4,500
$9,000
$13,500
$27,000
$25
$50
$100
$300+20%
Emb
10/35/60
Silver
6L-X
80/50/5016
80%
50%
$1,000
$2,000
$3,000
$6,000
$6,250
$12,500
$18,750
$37,500
$30
$60
$100
$300+20%
Emb
15/40/70
Silver
6L-Y
80/50/50
80%
50%
$1,500
$3,000
$4,500
$9,000
$6,250
$12,500
$18,750
$37,500
$35
$70
$100
$300+20%
Emb
15/40/70
Silver
6L-U
Standard
80%
50%
$1,500
$3,000
$4,500
$9,000
$6,250
$12,500
$18,750
$37,500
$35
$70
$100
$300+20%
Emb
15/45/85
Silver
6L-V
Standard
80%
50%
$2,000
$4,000
$6,000
$12,000
$6,250
$12,500
$18,750
$37,500
$35
$70
$100
$300+20%
Emb
15/40/70
Silver
6L-W
Standard
80%
50%
$3,000
$6,000
$9,000
$18,000
$6,250
$12,500
$18,750
$37,500
$35
$70
$100
$300+20%
Emb
15/40/70
Silver
6M-V
Standard
80%
50%
$5,000
$10,000
$15,000
$30,000
$6,250
$12,500
$18,750
$37,500
$30
$60
$100
$300+20%
Emb
15/40/70
Silver
6M-Y
Flexpoint6, 16
80%
50%
$2,000
$4,000
$6,000
$12,000
$6,400
$12,800
$19,200
$38,400
$35
$70
$100
$300+20%
Emb
10/35/60
Silver
6M-Z
Flexpoint6, 16
80%
50%
$3,000
$6,000
$9,000
$18,000
$6,400
$12,800
$19,200
$38,400
$30
$60
$100
$300+20%
Emb
10/35/60
Silver
6M-W
Flexpoint
80%
50%
$4,000
$8,000
$12,000
$24,000
$6,400
$12,800
$19,200
$38,400
$25
$50
$100
$300+20%
Emb
10/35/60
Silver
6M-X
Flexpoint6
80%
50%
$5,000
$10,000
$15,000
$30,000
$6,400
$12,800
$19,200
$38,400
$35
$70
$100
$300+20%
Emb
10/35/60
Gold
6L-9
Std Insurance
80%
50%
$1,000
$2,000
$3,000
$6,000
$4,500
$9,000
$13,500
$27,000
$25
$50
$100
$300+20%
Emb
10/35/60
16
6, 16
Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates.
Administrative services provided by United HealthCare Services, Inc. or their affiliates.
10/14 BROKER
©2014 United HealthCare Services, Inc.
UHCKY660254-001
UnitedHealthcare Multi-Choice® Package | Kentucky
2-50 Eligible Employees
Effective 01/01/2015
UnitedHealthcare Health Savings Account (HSA) Plans
Metallic
Level
2015
Plan
Code
Plan
Type
Silver
GM-7
Silver
Coinsurance
Deductible
Network
Out-of-Pocket Maximum
Out-of-Network
Network
Copay / Per-Occurrence9
Out-of-Network
Network
Out-ofNetwork
Single
Family
Single
Family
Single
Family
Single
Family
HSA9
100%
70%
$2,500
$5,000
$7,500
$15,000
$6,250
$12,500
$18,750
$37,500
GM-6
HSA
80%
50%
$2,500
$5,000
$7,500
$15,000
$6,250
$12,500
$18,750
$37,500
Silver
GM-8
HSA9
100%
70%
$3,000
$6,000
$9,000
$18,000
$6,250
$12,500
$18,750
$37,500
9
Deductible5
Type
Rx Plan15
Spec
Urgent
Care
ER4
$30
$60
$100
$300
NonEmb
10/35/60
80%
80%
80%
80%
NonEmb
10/35/60
$30
$60
$100
$300
Emb
10/35/60
PCP1
Silver
GM-9
HSA
100%
70%
$3,000
$6,000
$9,000
$18,000
$6,250
$12,500
$18,750
$37,500
$30
$60
$100
$300
NonEmb
10/35/60
Bronze
GM-J
HSA9
100%
70%
$4,500
$9,000
$13,500
$27,000
$6,250
$12,500
$18,750
$37,500
$35
$70
$100
$300
NonEmb
10/35/60
Bronze
6L-Z
HSA
80%
60%
$5,000
$10,000
$15,000
$30,000
$6,250
$12,500
$18,750
$37,500
80%
80%
80%
80%
NonEmb
10/35/60
UnitedHealthcare Navigate® Plans
Single
Family
ER4
Deductible5
Type
Rx Plan15
80% 50% 50%
$500
$1,500
$1,500 $3,000
$4,500
$9,000
$13,500 $27,000 $30
$60
$90
$100
$300+20%
Emb
10/35/60
80% 50% 50% $1,000
$2,000
$3,000 $6,000
$4,500
$9,000
$13,500 $27,000 $25
$50
$80
$100
$300+20%
Emb
10/35/60
50%
80% 50% 50% $1,500
$3,000
$4,500 $9,000
$6,250
$12,500 $18,750 $37,500 $35
$70
$100
$100
$400+20%
Emb
15/45/85
50% 80%
50%
80% 50% 50% $2,000
$4,000
$6,000 $12,000 $6,250
$12,500 $18,750 $37,500 $35
$70
$100
$100
$300+20%
NonEmb
15/40/70
80%
50% 80%
50%
80% 50% 50% $2,500
$5,000
$7,500 $15,000 $6,250
$12,500 $18,750 $37,500 $35
$70
$100
$100
$300+20%
NonEmb
15/40/70
Navigate Plus
80%
50% 80%
50%
80% 50% 50% $3,000
$6,000
$9,000 $18,000 $6,250
$12,500 $18,750 $37,500 $35
$70
$100
$100
$300+20%
NonEmb
15/40/70
6N-9
Navigate Plus
80%
50% 80%
50%
80% 50% 50% $3,000
$6,000
$9,000 $18,000 $6,250
$12,500 $18,750 $37,500 $35
$70
$100
$100
$300+20%
NonEmb
15/40/70
Gold
6M-7
Navigate
80%
N/A
80%
N/A
80% N/A
N/A
$500
$1,000
N/A
N/A
$4,500
$9,000
N/A
N/A
$30
$60
N/A
$100
$300+20%
Emb
10/35/60
Gold
6M-8
Navigate
80%
N/A
80%
N/A
80% N/A
N/A
$1,000
$2,000
N/A
N/A
$4,500
$9,000
N/A
N/A
$25
$50
N/A
$100
$300+20%
Emb
10/35/60
Silver
6N-N
Navigate
80%
N/A
80%
N/A
80% N/A
N/A
$2,000
$4,000
N/A
N/A
$6,250
$12,500
N/A
N/A
$35
$70
N/A
$100
$300+20%
NonEmb
15/40/70
Silver
6N-1
Navigate
80%
N/A
80%
N/A
80% N/A
N/A
$2,500
$5,000
N/A
N/A
$6,250
$12,500
N/A
N/A
$35
$70
N/A
$100
$300+20%
NonEmb
15/40/70
Silver
6N-2
Navigate
80%
N/A
80%
N/A
80% N/A
N/A
$3,000
$6,000
N/A
N/A
$6,250
$12,500
N/A
N/A
$35
$70
N/A
$100
$300+20%
NonEmb
15/40/70
$12,500 $18,750 $37,500 $35
$70
$100
$100
$300
NonEmb
10/35/60
Network
Gold
6M-1
Navigate Plus
80%
50% 80%
50%
Gold
6M-2
Navigate Plus
80%
50% 80%
50%
Silver
6M-3
Navigate Plus
80%
50% 80%
Silver
6M-4
Navigate Plus
80%
Silver
6M-5
Navigate Plus
Silver
6M-6
Silver
Bronze
Network
6N-3 Navigate Plus HSA9 100% 70% 100% 70% 100% 70% 70% $4,500
Network
$9,000 $13,500 $27,000 $6,250
Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates.
Administrative services provided by United HealthCare Services, Inc. or their affiliates.
10/14 BROKER
Out-of-Network
Out-of-Network
Single
Family
PCP1
Plan
Type8
Inpatient
2015
Plan
Code
Outpatient
w/o Referral
Family
Metallic
Level
Outpatient
Single
Inpatient w/o
Referral
Family
Network w/o
Referral
Single
Urgent Care
Copay / Per-Occurrence
Spec w/o
Referral
Out-of-Pocket Maximum
Spec
Deductible
Out of
Network
Coinsurance
©2014 United HealthCare Services, Inc.
UHCKY660254-001
UnitedHealthcare Multi-Choice® Package | Kentucky
2-50 Eligible Employees
Effective 01/01/2015
Premium Tiered Plans
Coinsurance
Deductible
Out-of-Pocket Maximum
Copay / Per-Occurrence
Outpatient
Facility10
Deductible5
Type
Rx Plan15
NonEmb
15/45/85
Silver
GM-P Advanced Tier
80%
50% 50% 50% $1,500
$3,000 $15,000 $30,000 $6,250
$12,500 $20,000 $40,000 $30
50%
$60
50%
$100 $300+20%
N/A
N/A
NonEmb
15/45/85
Silver
GM-Q Advanced Tier
80%
50% 50% 50% $2,500
$5,000 $15,000 $30,000 $6,250
$12,500 $20,000 $40,000 $30
50%
$60
50%
$100 $300+20%
N/A
N/A
NonEmb
15/45/85
Silver
GM-R Advanced Tier
80%
50% 50% 50% $4,000
$8,000 $15,000 $30,000 $6,250
$12,500 $20,000 $40,000 $30
50%
$60
50%
$100 $300+20%
N/A
N/A
NonEmb
10/35/60
Single
Single
ER4
N/A
Urgent Care
N/A
PCP1,2 Prem
Des
$100 $300+20%
Family
50%
Single
$60
Family
50%
Family
$12,500 $20,000 $40,000 $30
Single
$2,000 $15,000 $30,000 $6,250
Family
50% 50% 50% $1,000
Out-of-Network
80%
Plan
Type
Network Facility
GM-O Advanced Tier
2015
Plan
Code
Network
Physician3
Silver
Metallic
Level
Network
Physician Prem
Des2
Inpatient
Hospital10
Out-of-Network
Spec3
Network
Spec2 Prem
Des
Out-of-Network
PCP1
Network
Pharmacy Plans
2015
Rx Plan
Code
Deductible
NS
Copays15
Tier 1
Tier 2
Tier 3
Mail
Order
Ratio
$0
$10
$35
$60
2.5
NS
Comb
$10
$35
$60
2.5
GV
$0
$15
$45
$85
2.5
DT
$0
$15
$40
$70
2.5
Plans with combined deductible (Comb) are used for HSA plans
Primary Care Physicians include Family Practice, Internal Medicine, Obstetrics-Gynecology, and Pediatrics.
This tier of benefits applies to UnitedHealth Premium quality and efficiency designated providers. Please visit myuhc.com for details.
3
This tier of benefits applies to physicians in specialties where there is no UnitedHealth Premium designation program and for physicians who are not quality and efficiency designated
4
Plan deductible is waived for Emergency Room visits on plans where copay or copay+coinsurance is listed.
5
“Embedded” deductible means once an individual meets their portion of the deductible, services are paid for that person without the entire family deductible being met. “Non-Embedded” deductible means no covered family member will satisfy an
individual deductible until the entire family deductible is met.
6
“Flexpoint” plans feature a copay for office visits one through three during the calendar year or plan year, depending on plan type selected. Office visits four and over will be subject to plan deductible/coinsurance. This is a separate limit for both
Physician Office Visits and Urgent Care visits. Plans feature one Preventive Care visit per year, which does not count against the office visit copay limit.
8
“Navigate” plans (Navigate, Balanced, Plus) require referrals for certain services. Failure to obtain a referral may result in either non-payment of claims or in a reduction of benefits.
9
Copayments on HSA plans will be required after the deductible has been met and will continue to be required until the annual out-of-pocket maximum is met.
10
Copayments for Inpatient Hospital admissions and Outpatient Facility services are prior to and in addition to any required deductible and coinsurance.
11
EPO plans exclude coverage for services provided by Out-of-Network Providers with the exception of (1) Services performed in a Network Facility by hospital-based providers; and (2) Services performed under the Emergency Care benefit
15
Pharmacy plans feature copays of $100 (Tier 2) and $300 (Tier 3) for specialty medications. This is in lieu of the listed copayments. Refer to plan documents for more information.
16
80/50/50 plans cover inpatient and outpatient facilities at 50% and physician services at 80%
1
2
Premium rates and/or product forms included herein are subject to approval by regulators. If rates or product forms offered herein are subsequently modified by regulators, we will
immediately advise you of the change in plan design and retroactively adjust premium in subsequent billings.
Please note: The information in this grid is provided for informational purposes only and is not intended for use as a contract. For a complete listing of coverage and
exclusions, please refer to the Certificate of Coverage or talk to your UnitedHealthcare representative for additional details that could impact the benefits. Different
UnitedHealthcare plans may have varying approaches to whether pharmacy costs are included or excluded from the medical deductible.
The UnitedHealthcare plan with Health Savings Account (HSA) is a high deductible health plan (HDHP) that is designed to comply with IRS requirements so eligible enrollees may
open a Health Savings Account (HSA) with a bank of their choice or through Optum Bank,SM Member of FDIC. The HSA refers only and specifically to the Health Savings Account
that is provided in conjunction with a particular bank, such as Optum Bank, and not to the associated HDHP.
Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by United HealthCare Services, Inc. or their affiliates.
10/14 BROKER
©2014 United HealthCare Services, Inc.
UHCKY660254-001