WHAT YOU NEED TO KNOW ABOUT YOUR …

1 2017 plan GuideWHAT YOU NEED TO know ABOUT your medicare advantage unitedhealthcare GroupMedicareAdvantage(HMO)Effective:Jan uary1,2017throughDecember31,2017 GroupNumber: 40527 PlansareinsuredthroughUnitedHealthcareIn suranceCompanyoroneofitsaffiliatedcompan ies, Here' the Benefits of a unitedhealthcare medicare advantage PLANDear Retiree, your employer group or plan sponsor has selected unitedhealthcare to offer health care coverage for all eligible retirees. At unitedhealthcare we believe you should have more than just a good insurance plan to help maintain your health.

2 We want to work with you to help you live a healthier re just a phone call away. Learn more online at GYM MEMBERSHIPHOUSECALLSWe want to: Help you get access to the care you may need when you need it Give you tools and resources to help you be in more control of your health Try to help you find ways to save money on health care costs, so you can spend more on the things that matter most to youIn this book you will find: A description of this plan and how it works Information on benefits, programs and services and how much they cost Details on how to enroll What you can expect after you enrollEnrolling is Find the Enrollment Request Form(s) in the Enrollment section of this Fill out completely make sure you sign and date the form(s).

3 3 Return your completed form(s) in the enclosed envelope before your enrollment UHEX17MP3837172_002 SPRJ26716 your 2017 plan information is also available online. You will need your group Number found on the front cover of your booklet to access the advantage of healthy MEMBER PERK FOR HEALTHIER LIVING31-877-714-0178, , _____ _____ UHEX16MP3700082_001 Benefit HighlightsNew York University40527 EffectiveJanuary 1, 2017 toDecember 31, 2017 This is a short description of plan benefits. For complete information, please refer to your Summaryof Benefits or Evidence of Coverage. Limitations, exclusions, and restrictions may BenefitsIn-NetworkBenefits covered by Original medicare and your planDoctor s office visitPrimary Care Provider:$15 co-paySpecialist:$15 co-payPreventive services$0 co-pay for medicare -covered in-network preventiveservices.

4 Refer to the Evidence of Coverage for hospital care$0 co-pay per admissionSkilled nursing facility (SNF)$0 co-pay per day up to100 daysOutpatient surgery$0 co-payOutpatient rehabilitation(physical, occupational, orspeech/language therapy)$15 co-payDiagnostic radiology services(such as MRIs, CT scans)$0 co-payLab services$0 co-payOutpatient x-rays$0 co-payTherapeutic radiology services(such as radiation treatment forcancer)$0 co-payAmbulance$0 co-payEmergency care$50 co-pay (worldwide)Urgently needed services$15 co-pay (worldwide)Annual out-of-pocket maximum$6,700 Additional benefits and programs not covered by Original MedicareRoutine physical$0 co-pay; 1 per plan yearDentalIncluded.

5 See your Summary of Benefits or Evidence ofCoverage for more detailsFoot care - routine$0 co-pay(Up to6visits per plan year)Hearing - routine exam$0 co-pay(1 exam every 12 months)Hearing aidsPlan pays up to$500for one hearing aid per ear (every3 years)Vision - routine eye exams$0 co-pay(1 exam every 12 months)Vision eyewearPlan pays up to$130 eyewear allowanceafter$25 materialsco-payevery2 years. plan pays up to$65 contact lensallowance, after$25 materials co-pay, in lieu of eyewearallowance every2 program throughSilverSneakers Fitness programStay active with a basic membership at a participating locationat no extra cost to you6 Medical BenefitsIn-NetworkNurseLineSMSpeak with a registered nurse (RN) 24 hours a day, 7 days aweekVirtual Doctor VisitsSpeak to specific doctors using your computer or mobiledevice.

6 Find participating doctors online DrugsYour CostInitial Coverage StageNetwork Pharmacy(30-day retailsupply)Mail Service Pharmacy(90-day supply)Tier 1: Preferred generic$10 co-pay$20 co-payTier 2: Preferred brand (includessome generic)$20 co-pay$40 co-payTier 3: Non-preferred drug(includes some generic)$35 co-pay$70 co-payTier 4: Specialty tier$35 co-pay$70 co-payCoverage gap stageAfter your total drug costs reach$3,700, the plan continues topay its share of the cost of your drugs and you pay your shareof the costCatastrophic coverage stageAfter your total out-of-pocket costs reach$4,950, you will paythe greater of$ co-pay for generic (including brand drugstreated as generic),$ co-pay for all other drugs, or5% ofthe costPlans are insured through unitedhealthcare Insurance Company or one of its affiliated companies,a medicare advantage organization with a medicare contract and a medicare -approved Part Dsponsor.

7 Enrollment in the plan depends on the plan s contract renewal with plan prospects must meet the eligibility requirements to enroll for group coverage. Thisinformation is not a complete description of benefits. Contact the plan for more , co-payments, and restrictions may ,premium and/or co-payments/co-insurance may change each plan employer group or plan sponsor has chosen a unitedhealthcare group medicare advantage plan . The word group means this is a plan designed just for an employer group or plan sponsor, like yours. Only eligible retirees of your employer group or plan sponsor can enroll in this plan .

8 medicare advantage is also known as medicare Part C. These plans combine all the benefits of Original medicare including medicare Part A (hospital coverage) and medicare Part B (doctor and outpatient care) plus extra programs that go beyond Original must be entitled to medicare Part A and enrolled in medicare Part B to enroll in this plan . If you re not sure if you are enrolled in medicare Part B, check with your local Social Security office You must continue paying your medicare Part B premium to keep your coverage under this group -sponsored plan If you stop your payments, you may be disenrolled from this planOne drug plan at a time.

9 This plan includes prescription drug coverage. You can only have prescription drug coverage under one plan . If you enroll in another stand-alone medicare Part D plan or a medical plan that includes prescription drug coverage, you may be disenrolled from this : If you drop your group -sponsored retiree health coverage, you may not be able to re-enroll. Limitations and restrictions vary by employer group or plan group medicare advantage (HMO)Y0 0 6 6 _16 0 624 _141253 medicare Part AHospitalMedicare Part BDoctor and outpatientExtra ProgramsBeyond Original MedicareMedicare Part DPrescription drugsMake sure you know what parts of medicare you In-NetworkOut-Of-NetworkWill the doctor or hospital accept my plan ?

10 Ye sNoWhat is my co-pay or co-insurance?Co-pays and co-insurance vary by must pay the full cost for I need to choose a primary care provider (PCP)?Ye sN/ADo I need a referral to see a specialist?N/AAre emergency and urgently needed services covered?Ye sYe sDo I have to pay the full cost for all covered doctor or hospital services?No, you will pay your standard co-pay or co-insurance for the service you sIs there a limit on how much I spend on medical services each year?Ye sN/AHow your medical coverage works. your plan is a Health Maintenance Organization (HMO) plan . That means you must get care through a network of local doctors and hospitals.