Sample Co., Inc.plan type:copay option

We’re Here to Help.

Call the ActiveUniveracustomer service center at:

1 (800) 499-1275TTY: 1 (315) 448-6764

Monday - Thursday 8:00 a.m. - 9:00 p.m.,Friday 9:00 a.m. - 9:00 p.m. orSaturday 9:00 a.m. - 1:00 p.m.

U050411BZ000_24900

office visit copay (PCP) in-network: $15 copay;

out-of-network: na; other

cost-sharing applies

copay for kids in-network: $0 copay;

out-of-network: na; other

cost-sharing applies

office visit copay (specialist) in-network: $25 copay;

out-of-network: na; other

cost-sharing applies

out-of-network benefits out-of-network benefits are

available, but additional

costs may apply

coinsurance in-network: none;

out-of-network: 20%

deductible in-network: none;

out-of-network: $500

individual/$1,500 family

out-of-pocket maximum in-network: none;

out-of-network: $1,500

individual/$4,500 family

lifetime maximum none

dependent/student coverage dependents and full-time

students are covered to age

26

domestic partner covered

coverage period January 1st - December 31st

earn cash back with

ActiveRewards

you can earn up to $500

individually, or a combined

$1,000 cash back for you

and an eligible adult

member just for doing

healthy stuff that fits into

your day. Then get paid

anytime throughout the

year.

Live Healthier. Earn $500.ActiveUnivera. It’s a new kind of health plan – one that rewards youfor living healthier!

ActiveUnivera offers quality health care coverage with the convenience of:

• Earning you and a spouse or domestic partner up to $500 each in ActiveRewardsSM every year.

• No referrals.

• Preventive health care including well child visits, adult routine physical exams, immunizations, pap smears,

and mammogram and prostate cancer screenings all covered in full.

• Prescription drug savings including a free generic trial program, mail order pharmacy service and unlimited

generic coverage for adults with a $0 copay for children to age 19.

• Coverage that travels with you through BeechStreet.

Step 1 Log in.Go to univerahealthcare.com/activerewards, click on ActiveRewards and complete

your pledge to get started. Then fill out your personal Wellness Profile to help us

design a program that’s right for you.

• If you are new to Univera Healthcare, you will need to register online first as

a member to begin your ActiveUnivera experience.

• If you are already a member of Univera Healthcare, simply log in to your

existing account to access ActiveRewards and begin earning dividends.

Get started at: univerahealthcare.com/activerewards

stress level income level

UN-HB 08/104768-10M9M

Univera Healthcare makes finding the information and support you need easier –resources, savings and tools are available online 24/7.

• Live healthy. Earn up to $1,000 cash back.

• Find a doctor or specialist online while you’re home or far away.

• Get instant access to fitness and nutrition programs.

• Research over 6,000 health topics online.

live healthy. earn some cash.live healthy. earn some cash.

®

Here are definitions* for some health insurance terms we use all the time. Knowing

what they mean will help you understand our plans—and your coverage—better.

Primary Care Physician (PCP)—A doctor who serves as your health care managerand coordinates virtually all of the health care services you routinely receive. Some plans do not require you to choose a PCP.

Referral—Instructions provided by a PCP for specialty care. Most plans do not require referrals.

In-network coverage—The coverage available when you receive services from aprovider who participates in your health plan.

Out-of-network coverage—The coverage available when you receive services froma provider who does not participate in your health plan. Some plans may notinclude out-of-network coverage.

Out-of-area—Types of services listed that are received while outside the geographicservice area of your health plan. Your plan benefits may differ if you live or workbeyond the geographic service area.

Copay—A dollar amount due at the time you receive certain services. A typicalexample would be an office visit copay due when visiting your physician’s office for treatment.

Allowed Amount—The maximum amount your health plan will pay for a specific service. In-network providers agree to accept the allowed amount as payment in full.

Coinsurance—A cost-sharing method that requires you pay a portion of theallowed amount for certain medical services.

Deductible—A set dollar amount you pay for covered services you receive beforeyour insurer will make a payment.

Out-of-pocket maximum—The maximum amount of deductible and coinsurancepayments that you will pay for health services each calendar year.

Precertification—A determination made by your health plan, before you receiveservices, that a medical service is a covered benefit and medically necessary.

*Some definitions may vary slightly by plan. In case of a conflict between your legal plan documents and this information, the plan documents will govern.

Welcome to ActiveUnivera®, a new direction in health care.

ActiveUnivera® is an exciting new kind of health plan –one that pays you back. As a member of ActiveUnivera®,you can earn up to $500 individually, or a combined$1,000 cash back for you and an eligible adult memberjust for doing healthy stuff that fits into your day. So,schedule regular check-ups, eat right and stay active. Then get paid anytime throughout the year.

ActiveUnivera® offers quality health care coverage including:

• Low or no copays for kids.• *No referrals.• Coverage that travels with you through BeechStreet.

And ActiveRewards® is personalized to meet your individual needs. You can earn dividends by participatingin ActiveRewards® programs. Each dividend is equal to one dollar and you and an eligible adult member can eachearn up to 500 every year – all just for living healthy!

At Univera Healthcare, we hope you enjoy theActiveUnivera® health plan and ActiveRewards® program.We’re proud to bring you the health plan that pays you back.

* Precertification may apply.

This benefit summary is not a contract or binding agreement; it is a summary of

benefits and services.

Privacy Policy Notice. We know how important your privacy is and we’re

committed to protecting it. Our policies and practices regarding the collection,

use, and disclosure of personal health information are available at

univerahealthcare.com/activerewards and Member Services.

What does it all mean?

Sample Co., Inc.plan type:copay option

We’re Here to Help.

Call the ActiveUniveracustomer service center at:

1 (800) 499-1275TTY: 1 (315) 448-6764

Monday - Thursday 8:00 a.m. - 9:00 p.m.,Friday 9:00 a.m. - 9:00 p.m. orSaturday 9:00 a.m. - 1:00 p.m.

U050411BZ000_24900

office visit copay (PCP) in-network: $15 copay;

out-of-network: na; other

cost-sharing applies

copay for kids in-network: $0 copay;

out-of-network: na; other

cost-sharing applies

office visit copay (specialist) in-network: $25 copay;

out-of-network: na; other

cost-sharing applies

out-of-network benefits out-of-network benefits are

available, but additional

costs may apply

coinsurance in-network: none;

out-of-network: 20%

deductible in-network: none;

out-of-network: $500

individual/$1,500 family

out-of-pocket maximum in-network: none;

out-of-network: $1,500

individual/$4,500 family

lifetime maximum none

dependent/student coverage dependents and full-time

students are covered to age

26

domestic partner covered

coverage period January 1st - December 31st

earn cash back with

ActiveRewards

you can earn up to $500

individually, or a combined

$1,000 cash back for you

and an eligible adult

member just for doing

healthy stuff that fits into

your day. Then get paid

anytime throughout the

year.

Live Healthier. Earn $500.ActiveUnivera. It’s a new kind of health plan – one that rewards youfor living healthier!

ActiveUnivera offers quality health care coverage with the convenience of:

• Earning you and a spouse or domestic partner up to $500 each in ActiveRewardsSM every year.

• No referrals.

• Preventive health care including well child visits, adult routine physical exams, immunizations, pap smears,

and mammogram and prostate cancer screenings all covered in full.

• Prescription drug savings including a free generic trial program, mail order pharmacy service and unlimited

generic coverage for adults with a $0 copay for children to age 19.

• Coverage that travels with you through BeechStreet.

Step 1 Log in.Go to univerahealthcare.com/activerewards, click on ActiveRewards and complete

your pledge to get started. Then fill out your personal Wellness Profile to help us

design a program that’s right for you.

• If you are new to Univera Healthcare, you will need to register online first as

a member to begin your ActiveUnivera experience.

• If you are already a member of Univera Healthcare, simply log in to your

existing account to access ActiveRewards and begin earning dividends.

ActiveUnivera benefits Prepared for Sample Co., Inc.

type of care/plan benefits in-network out-of-network

continued

plan feature highlights• office visit copay (PCP) • in-network: $15 copay; out-of-network: na; other cost-sharing applies• copay for kids • in-network: $0 copay; out-of-network: na; other cost-sharing applies• office visit copay (specialist) • in-network: $25 copay; out-of-network: na; other cost-sharing applies• out-of-network benefits • out-of-network benefits are available, but additional costs may apply• coinsurance • in-network: none; out-of-network: 20%• deductible • in-network: none; out-of-network: $500 individual/$1,500 family• out-of-pocket maximum • in-network: none; out-of-network: $1,500 individual/$4,500 family• lifetime maximum • none• dependent/student coverage • dependents and full-time students are covered to age 26• domestic partner • covered• coverage period • January 1st - December 31st

type of care/plan benefits in-network out-of-network

ActiveRewards• earn cash back with ActiveRewards • you can earn up to $500 individually,

or a combined $1,000 cash back foryou and an eligible adult memberjust for doing healthy stuff that fitsinto your day. Then get paid anytimethroughout the year.

preventive health care services• well child visits • covered in full • covered in full• adult routine physical exams • covered in full, limited to one exam

per year• covered at 80%, subject to the

deductible, limited to one exam peryear

• adult immunizations • covered in full • covered at 80%, subject to thedeductible

• mammography • covered in full • covered at 80%, subject to thedeductible

• pap smear • covered in full • covered at 80%, subject to thedeductible

• routine gyn exam • covered in full • covered at 80%, subject to thedeductible

• prostate cancer screening • covered in full • covered at 80%, subject to thedeductible

• routine vision • $20 copay per visit, limited to onevisit per year. $60 eyewear allowanceavailable per year

• covered at 80%, subject to thedeductible, for one visit per year. $60eyewear allowance available per year

• colonoscopy • Preventive colonoscopy screeningcovered in full

• covered at 80%, subject to thedeductible

pg. 1

ActiveUnivera benefits Prepared for Sample Co., Inc.

type of care/plan benefits

continued

in-network out-of-network

physician office services• diagnostic office visits • adult: $15 copay per visit to your

PCP; $25 copay per visit to aspecialist. Child: $0 copay per visit toyour PCP; $25 copay per visit to aspecialist.

• covered at 80%, subject to thedeductible

• diagnostic x-rays • $25 copay per visit • covered at 80%, subject to thedeductible

• diagnostic laboratory and pathology • covered in full • covered at 80%, subject to thedeductible

• allergy tests • adult: $15 copay per visit to yourPCP; $25 copay per visit to aspecialist. Child: $0 copay per visit toyour PCP; $25 copay per visit to aspecialist.

• covered at 80%, subject to thedeductible

• allergy injections • Adult: $15 copay per visit to yourPCP; $25 copay per visit to aspecialist. Child: $0 copay per visit toyour PCP; $25 copay per visit to aspecialist.

• covered at 80%, subject to thedeductible

• chemotherapy • $15 copay per visit • covered at 80%, subject to thedeductible

• radiation therapy • $25 copay per visit • covered at 80%, subject to thedeductible

maternity services• prenatal and postpartum care • covered in full • covered at 80%, subject to the

deductible• hospital care for mom (including

delivery)• covered in full • covered at 80%, subject to the

deductible

• newborn nursery care • covered in full • covered at 80%, subject to thedeductible

prescription drugs• short-term and maintenance drugs are

covered up to a 30-day supply at aretail pharmacy; 90-day supply (withadditional cost-sharing per 30-daysupply) is available through a mailorder pharmacy. oral contraceptivescovered.

• $5/$35/$70; no copay for genericdrugs for dependents to age 19

• not covered

inpatient hospital benefits• hospital benefits • subject to a $500 inpatient copay per

admission for unlimited days• covered at 80%, subject to the

deductible for unlimited days• physician visits in the hospital • covered in full • covered at 80%, subject to the

deductible• inpatient physical rehabilitation • subject to a $750 inpatient copay per

admission for up to 60 days per year• covered at 80%, subject to the

deductible for up to 60 days per year• surgery • covered in full • covered at 80%, subject to the

deductible• anesthesia • covered in full • covered in full

pg. 2

ActiveUnivera benefits Prepared for Sample Co., Inc.

type of care/plan benefits

continued

in-network out-of-network

emergency care• emergency room care • $250 copay per visit, unless admitted

within 24 hours• $250 copay per visit, unless admitted

within 24 hours• freestanding urgent care center • $25 copay per visit • covered at 80%, subject to the

deductible• ambulance • $250 copay • $250 copay

outpatient hospital benefits• diagnostic x-rays • $25 copay per visit • covered at 80%, subject to the

deductible• diagnostic laboratory and pathology • covered in full • covered at 80%, subject to the

deductible• surgical care • $250 copay • covered at 80%, subject to the

deductible• chemotherapy • $15 copay per visit • covered at 80%, subject to the

deductible• radiation therapy • $20 copay per visit • covered at 80%, subject to the

deductible

mental health and chemicaldependence

• inpatient mental health care • subject to a $750 inpatient copay forup to 30 days per year

• covered at 80%, subject to thedeductible for up to 30 days per year

• outpatient mental health care • $40 copay for up to 20 visits peryear. services can be provided in anoutpatient facility or in a provider’soffice.

• covered at 80%, subject to thedeductible, for up to 20 visits peryear. services can be provided in anoutpatient facility or in a provider’soffice.

• inpatient chemical dependence care • subject to a $250 inpatient copay forup to 7 days for detoxification and30 days for rehabilitation per year;limited to 2 admissions per lifetime

• covered at 80%, subject to thedeductible for up to 7 days fordetoxification and 30 days forrehabilitation per year; limited to 2admissions per lifetime

• outpatient chemical dependence care • $20 copay per visit for 60 visits peryear

• covered at 80%, subject to thedeductible, for 60 visits per year

pg. 3

ActiveUnivera benefits Prepared for Sample Co., Inc.

type of care/plan benefits in-network out-of-network

Earn up to $500 individually, or a combined $1,000 cash back for you and an eligible adult member. Benefits herein are subject to change as a result of efforts to implement federal health care reform and mentalhealth and substance abuse care parity initiative. There may be additional coverage for biologically-based mental illness and for children with serious emotional disturbances as defined by Timothy’s Law. Thesebenefits should not be interpreted as pre-approval of services. Certain services may be subject to additional requirements described in the member’s insurance policy. Payment of claims related to these benefits are

other services• diabetic insulin and supplies • $15 copay for up to a 30 day supply • covered at 80%, subject to the

deductible for up to a 30 day supply• skilled nursing facility • subject to a $750 inpatient copay for

up to 45 days per year• covered at 80%, subject to the

deductible for up to 45 days per year• home care • covered in full for up to 40 visits per

year• covered at 80%, subject to a $50

deductible for up to 40 visits per year• hospice • covered in full for unlimited days • covered at 80%, subject to the

deductible for unlimited days• outpatient therapy • $40 copay per visit for up to a

combined total of 45 visits per yearfor physical, speech and occupationaltherapy

• covered at 80%, subject to thedeductible for up to a combinedtotal of 45 visits per year for physical,speech and occupational therapy

• durable medical equipment • covered at 80% • covered at 80%, subject to thedeductible

• external prosthetics • covered at 80% • covered at 80%, subject to thedeductible

• chiropractic • $25 copay per visit • covered at 80%, subject to thedeductible

• acupuncture • $25 copay for up to 10 visits per year • covered at 80%, subject to thedeductible, for up to 10 visits peryear

• dental • $25 copay per visit for accidentalinjury to sound, natural teeth and forcare due to congenital disease oranomaly

• covered at 80%, subject to thedeductible for accidental injury tosound, natural teeth and for caredue to congenital disease or anomaly

• hearing • $25 copay per visit for 1 routinehearing exam per year; hearing aidsnot covered

• covered at 80%, subject to thedeductible for 1 routine hearingexam per year; hearing aids notcovered

pg. 4

With Simple, Intermediate and Advanced levels of participation, ActiveRewards® offers the convenience of:

• Fitness and nutrition programs to satisfy your activity preferences.

• A simple diary to make tracking your results simple and easy.

And your program is personalized to meet your individual needs. ActiveRewards® has been improved to

make it even easier to report information, track results or follow a plan. If you want to get started but have

less time, simply report your progress at My Diary and TakeSteps. Track your progress by participating in Fitness

Tracker and Nutrition Tracker. Leverage all of the tools with the advanced option which will give you access

to a personal trainer and food planner and let you customize your participation to ensure success.

continued...

get started now!

Consider using your earnings to invest in your health. Buy a new pair of sneakers, spend a day at the spa or take dance lessons – anything to help you live healthier.

Step 1 Log in.Go to univerahealthcare.com/activerewards, click on ActiveRewards® and complete

your pledge to get started. Then fill out your personal Wellness Profile to help us

design a program that’s right for you.

• If you are new to ActiveRewards®, you will need to register online first

to begin.

• If you are already registered, simply log in to your existing account to

access ActiveRewards® and begin earning dividends.

ActiveRewards 08/104769-10M

Step 2 Earn dividends. Get Healthy.Use your Wellness Profile to get healthy. Choose the program that's

best for you and start earning cash back today.

Fitness and NutritionValue: Earn up to

405 dividends

Fitness and Nutrition programs such as My

Diary and TakeSteps, are designed so you can rack

your steps, servings, exercise and nutrition

activity online.

Preventive HealthValue: Earn up to 45 dividends

Complete recommendationsfor health screenings, routine exams, immuniza-tions, a mammogram, a pap test, prostate cancerscreening and colonoscopy.Participate in Advance CarePlanning - a process of planning for future medicalcare in case you are unableto make your own decisions.

Managing Health ConditionsValue: Earn up to 40 dividends

If you live with a chronic health condition such as Asthma, Coronary Artery Disease, Diabetes or Hypertension, a health care professional can help you manage your care.

Living HealthyValue: Earn up to

30 dividends

A set of programs ranging from stress

management and selfimprovement to

financial discipline or spiritual healing.

Health Tools & ResourcesValue: Earn up to 10 dividends

Research health topics, take health quizzes, use aprescription drug calculatorto measure your savingsusing generic drugs or

estimate cost for treatment.

Smoking or Non-SmokerValue: Earn up to 40 dividends

Earn cash back by completing a tobacco cessation program that helps you quit smoking and otherforms of tobacco. Non-smokers earn dividends just for being healthy and not using tobacco.

Cards are issued by Citibank, N.A. pursuant to a license from Visa U.S.A. Inc. and managed by Ecount, a Citi company. Cards will not have cash access and can beused everywhere Visa debit cards are accepted. Earning up to $500 individually, or a combined $1,000 cash back applies to you and an eligible adult member.

Step 3 Reward yourself. Virtually anything you do to be healthiercan earn you up to $500 annually.

Choose between a reloadable Visa® card, gift card, a variety of health and wellness products or cash payment.

• Reloadable Visa® card. A reloadable Visa

card can be used at millions of locations

everywhere Visa debit cards are accepted,

including retail stores and online merchants.

• Gift Cards. Visa gift cards can be ordered

in fixed denominations and used everywhere

Visa debit cards are accepted.

• Health and Fitness. Redeem your rewards

for lots of fun and healthy products ranging

from fitness mats and weights to golf bags

or soccer balls.

• Cash. You can cash in your dividends for payment by check - or roll them over to a new year.

activities: example:(one dividend = $1)

• Login and complete a wellness profile 38• Exercise more and eat better 375• Quit tobacco/non-smoker 40• Complete preventive health recommendations 45• Use of online tools 2

500

LIFETIME 7/10 UHC

continued on back

convenience. support. day or night.

lifetime h

ealth cen

ters

As a Univera Healthcare member, you get all the comforts of Lifetime Health Medical Group.From Urgent Care by Lifetime Health that fitsyour schedule and saves you hassles, to nurseson the other end of the phone day or night,ready to answer questions.

Urgent Care by Lifetime Health. extra peace of mind.Here’s a place you can get medical help in apinch—especially if your doctor’s office is closed.Urgent Care is open afternoons, evenings, week-ends and holidays. It is a great alternative to theemergency room for injuries and illnesses.

• evaluation, tests, and treatment all in one place

• x-rays and prescriptions on site

• no referral or preauthorization required

• walk in or call ahead for a same day appointment

• staffed by board-certified/board-eligible physicians, physician assistants and nurse practitioners

As a Univera Healthcare member, you’ll just pay your urgent care copay or coinsurance. The Urgent Care staff will send a report to yourdoctor within 48 hours of your visit. Urgent Careby Lifetime Health is conveniently located at allthe Lifetime Health Centers:

• Amherst Health Center

• Hamburg Health Center

• West Seneca Health Center

• William E. Mosher Health Center

See full listing on the back for address and contact information.

nurse advice lineIf you have questions or need medical advice, call 716.568.2454 or toll free at 877.202.8297.Available 24 hours a day, 7 days a week, evenholidays, to all Lifetime Health patients for noadditional cost. Receive important informationand medical advice over the phone.

need a doctor? done.At the Lifetime Health Medical Group, you’ll find skilled pediatricians, internists, family medicine physicians and ob-gyns who are partners in your health care. Medical pros whoare there for you in every stage of your life.Services include:*

• behavioral health counseling

• dental services

• family medicine

• gastroenterology/colonoscopy

• geriatric medicine

• internal medicine

• laboratory

• mammography

• nurse-midwifery

• pediatrics

• pharmacy

• podiatry

• radiology (x-ray)

• specialty care

• sports medicine

• urgent care

• urology

*Not all services available at all locations.

Amherst Health Center 716.689.00401185 Sweet Home Road, Amherst

Hamburg Health Center 716.648.3040151 Elmview Avenue, Hamburg

West Seneca Health Center 716.668.3600120 Gardenville Parkway West, West Seneca

William E. Mosher Health Center 716.878.2700899 Main Street, Buffalo

Urgent Care available at this location

health centers

affiliated doctors

Baez, Maritza, MD, FAAFPBartels, Matthew, MD, FAAPBose, Reena, MDBousader-Armstrong, Nathalie, MDCanfield, Marta, MDChima, Mary, MD (Urgent Care)Cornell, Deborah, MDCruz, Jesenia, MDDao, Tinh, MDEberl, Margaret, MD, MPHFleming Williams, Emily, MD*

Fretz, Stephanie, MDGolding, Douglas, MDJordan, Michael, MD, FAAFPKodial, Sukhwinder, MDKolbert, Mary Katherine, MDMafi, Esfandiar, MDMcCoy, Wayman, MD, FAAPMcLellan, Angela, MD*Penta, Pramila, MDPerry, Mark, MD, FAAPReddy, Bhaskara, MD

Sana, Wajeeh, MD (Urgent Care)Sood, Ritu, MDSteinacher, Robyn, DO, FAAPStouter, Barbara, MD, FAAPSzumigala, Julie, MD*Tarrazona-Yu, Pamela, MDVienne, Richard, DOWands, Ann, DO

*These physicians are employed byGeneral Physician, PC, Women’sHealthcare, but see patients in LifetimeHealth centers.

additional services

Bertha S. Laury Dental Center899 Main Street, Buffalo716.656.4270

UC

UC

UC

UC

UC

NON-MANAGED CARE 1/06 UHC

non-managed care additional information

Under your coverage, we usually do not provide benefits for the following services.However, your group coverage may have purchased additional riders.

We will not cover the following services:

• acupuncture

• blood products

• certification examinations

• cosmetic services

• court-ordered services

• criminal behavior

• custodial care

• dental care

• developmental delay

• durable medical equipment, prosthetic devices, and medical supplies

• experimental and investigational services

• free care

• government hospitals

• government programs

• hypnosis/biofeedback

• inpatient mental care

• inpatient rehabilitation for chemical dependence or abuse

• military service—connected conditions

• no-fault automobile insurance

• non-covered services

• nutritional therapy

• personal comfort services

• prescription drugs

• private duty nursing service

• prohibited referral

• reversal of elective sterilization

• routine care of the feet

• self-help diagnosis, training, and treatment

• services covered under hospice care

• services starting before coverage begins

• smoking cessation programs

• special charges

• social counseling and therapy

• transsexual surgery and related services

• unlicensed providers

• vision and hearing examinations, therapies and supplies

• weight-loss services

• workers’ compensation

This is just a brief summary. Please refer to theofficial contract for a complete and detailedexplanation of the exclusions.

no

n-m

anag

ed care exclu

sion

s

3-tier prescription drug benefit

Your three-tier prescription drug benefit makesit easy for you to make informed choices andencourages savings when choosing yourmedications. Your co-payment will vary basedon the tier placement of your prescription drug.

• Tier One drugs are typically generic drugs.

• Tier Two drugs are brand name drugs thathave unique, significant clinical advantages

and offer greater value over other products

in the same class.

• Tier Three drugs are all other brand namedrugs, including new brand name drugs and

drugs that have generic equivalents.

Visit univerahealthcare.com to view our currentTier Three Formulary Guide.

Special Features:

•Your prescription benefit includes a$0 Co-pay for kids up to age 19 forgeneric (Tier 1) medications.

•Your prescription drug benefit has a$1,000 per member annual maximumon brand drugs. (Generic drugs do notapply to the annual brand maximum.)

• Through PrimeMail®, you can get up to3 months supply of your medication foronly 2 copayments.

Where Can I Purchase MyPrescription Medications?You have access to more than 61,000 participatingpharmacies in our nationwide FLRx PharmacyNetwork, including all national chains and mostindependent chains. Just show your ID card atany participating pharmacy, it identifies you ashaving prescription drug coverage and eligiblefor online claims processing. The pharmacywill transmit your prescription claim online tous and we’ll immediately send a message to thepharmacist with your co-payment amount.

Generic Trial ProgramThe Generic Trial program helps encourage theuse of generic drugs by giving you a one time,free 30-day trial of selected genericmedications. Experience has shown that 90% ofthose who start with a generic drug will continueusing it. You can save hundreds of dollars peryear in out-of-pocket costs when you staywith a generic medication.

The first time you fill a prescription for a genericmedication included in the program at aparticipating FLRx network pharmacy, yourco-payment, for the first 30-day supply, willbe waived.

The cost of all refills and future prescriptionsis your responsibility and will be at your usualgeneric co-payment amount.

Mail Service PharmacyYou have an opportunity to save money on yourprescriptions when you order your medicationsthough our mail service pharmacy, PrimeMail®.

When you fill your prescriptions throughPrimeMail®, you can get three month’s supply(90 days) of your medication for only twocopayments. And the savings can add up overthe course of a year.

3-tierprescrip

tiondrugbenefit

UN-3-Tier RX 10/08

3-tierprescriptiondrugbenefit Using a mail service pharmacy is ideal for

those who take a prescription medication on acontinuing basis. PrimeMail® can fill all of yournew and refill prescriptions. They offer theconvenience of home delivery and the ease ofordering new prescriptions and refills either byphone or on our Web site.

Specialty Pharmacy BenefitSpecialty medications are designed for conditionsthat are difficult to treat with traditionalmedications like multiple sclerosis, rheumatoidarthritis, hepatitis C, and others. These medicationsare self-administered, either taken orally orby injection. Specialty pharmacies workexclusively with specialty medications and areexperts in handling and administering thesecomplex medications.

Your prescription drug benefit provides coveragefor certain specialty medications only whenpurchased at pharmacies participating in theFLRx Specialty Pharmacy Network. If you don’tuse a participating specialty pharmacy for yournew and refill prescriptions, you will be responsiblefor the full cost of the prescription. However, thefirst time you fill a new prescription for a specialtymedication, you may have it filled at any partici-pating FLRx network retail pharmacy of choice.

A complete listing of participating specialtypharmacies is available at univerahealthcare.com.

Initial FillThe first time you get a new prescription at aretail pharmacy, it will be filled with a 30-daysupply, no matter if your benefit allows for agreater supply. This is so you can be sure that themedication works for you. Often times membersfill a prescription only to find after the first fewdays that the medication causes side-effects ordoes not work. By limiting the first fill of a newprescription to 30-days, we can eliminate wasteand unnecessary expense. If you determine thatthe medication is effective all future fills can bepurchased up to the maximum amount allowedby your benefit.

Prior AuthorizationPrior authorization helps assure that aprescribed drug is safe and appropriate foryour medical condition.

Certain medications require prior authorizationwhich means that your doctor will contact us toget approval before the medication is covered.Our clinical pharmacists and physicians reviewmedication requests to make sure that thechoice of drug or dose is appropriatelyprescribed based on FDA and manufacturerguidelines, medical literature, safety, appropriateuse and benefit design.

Step TherapyStep Therapy is a program where you must firsttry a certain drug to treat your condition beforeanother drug will be covered. Your medicationtreatment moves along a series of “steps”.Generic drugs are usually the first step. This firststep lets you begin treatment with a prescriptiondrug that is proven safe and cost effective. If thefirst step drug does not work for you, you thenmove to the next “step”. Brand-name drugsare usually in the second step and have ahigher co-payment.

The goal of step therapy is to minimize risk andcontrol costs.

Generic Advantage Program (GAP)The Generic Advantage Program promotes theuse of generic medications. Under this program,if a member uses a brand-name medicationwhen a generic equivalent is available, themember will pay the generic co-payment orcoinsurance amount plus the difference betweenthe brand-name cost and the generic cost.

For more information about the aboveprograms or to get a specific list of drugsor pharmacies for any of the programs:

• Visit the prescription drug section of ourwebsite at univerahealthcare.com

•Dial the prescription drug number located onthe back of your member ID card.

•Dial the Univera Healthcare FLRx PharmacyHelp Desk toll free at 1-800-724-5033 or

(TTY) 585-454-2845.

Coach U 07/10

health questions? pick up the phone.

the information and support you need,when and where you need it. 24/7 Health Coaching.A whole team of trained health professionalssuch as nurses, dieticians and respiratory therapists are waiting to help you. They can give you support and education for chronic conditions like asthma or diabetes, or generalhealth questions. No matter what the problem is, they’re happy to help 24 hours a day, 7 days a week – by phone or online.

over the phone and in the doctor’s officeIt’s easier for a doctor to answer your questionswhen you know what to ask. Our HealthCoaches can help you with that. They can giveyou insight that helps you have a more produc-tive conversation with your doctor. This is espe-cially helpful if you or a family member have achronic condition that a Health Coach can assistyou in managing.

what a Health Coach can do for you:• Provide a personalized wellness approach basedon your needs and your budget

• Coach and motivate you to help change unhealthy behaviors

• Provide preventive health information for developing healthier habits

• Help you better manage your health

call a Health Coach when you need:

• Caring support from someone who has the time to listen to you and answer your questions

• Assistance managing conditions such as asthma, diabetes and heart disease

• Information to prepare for medical tests, procedures and surgery

• In-depth information on treatment options forcomplex medical issues

• Help making the most of your health careprovider visits

• Educational materials and videos sent to yourhome at no charge when appropriate

• Information on symptoms being experienced

• Tips for communicating concerns with a doctor

can’t get to a phone?You can also contact a Health Coach online,through our Health Coaching Dialog CenterSM

Web site. You get the support you need whenand how you want it.

even more information available onlineIf you’re looking for credible information on conditions, treatments, procedures, preventivecare, medications and more, you’ll find it onlinewith our Healthwise® Knowledgebase. It connectsyou to more than 6,000 health topics with just afew mouse-clicks.

ask a Health Coach todayCall 1-800-348-9786 now or learn more at:

1. Go to univerahealthcare.com

2. Click on “for your health”

3. Click on “health coaching”

4. Click on “log into our secure web site”

health

coach

ing

WP U 08/07

wellness profile —prevention is the best medicine

Our genes, our diets, our lifestyles. They can allhave an effect on our long-term health. One weoften can’t see until a problem arises. That’s whywe created the Wellness Profle. By answering afew basic questions about your lifestyle, goodhabits and bad, we can determine what you’redoing well and identify places you could improve.It’s the first step toward living healthier andreducing the risk of developing a more seriouscondition later.

prevention is the best medicineTaking a Wellness Profile is as simple as it issecure. It’s all online and it takes only a fewminutes to do. Within moments of completingyour profile, you’ll receive your Personal WellnessReport. You’ll see what you’re doing right. You’llalso see where you can make improvements. Andyou’ll get tips and program recommendations tohelp you make healthy changes so you stay inyour best health.

your Personal Wellness Report provides:• Evaluation of your healthy practices and areaswhere improvement can be made

• Recommended programs to help reduceyour risks

• Tips for living healthier

• Insight into your health and lifestyle you canshare with your doctor

• Online storage of your reports for personalprogress reviews

You may want to print out a copy. Not only foryour health records and to track your progress,but to share with your doctor on your next visit.

Go to univerahealthcare.com/activerewards andclick on ActiveRewards to get started.

NOTE: If you are new to Univera Healthcare, youwill need to register online first as a member tobegin your ActiveUnivera experience. If you arealready a member of Univera Healthcare, simplylog in to your existing account.

another way we fit your life betterWith all the plans, programs, Web tools andresources you need to live healthier and behappier every day, it’s no wonder UniveraHealthcare fits your life better.

welln

essp

rofile

© 2001 Michael Best & Friedrich LLCPage 1 of 3

UN-8

AUTHORIZATION TO SHARE MY PROTECTED HEALTH INFORMATION

Making HIPAA as Easy as 1, 2, 3 – and 4, 5, 6!

Five Letters That Protect Your Privacy: Your privacy has always been very important to us and the federal government recently createdHIPAA laws to protect how and when your health care and personal information can be shared.

If you’d like us to share information about you with people or other organizations, please complete this form. This includes sharinginformation with a spouse, friend, or even a parent if you are over the age 18. Giving your consent to share your personal information is aseasy as 1, 2, 3 – and 4, 5, 6 by completing the six sections of this brief form. For your convenience, you can use this form to authorize ourdisclosure of your information to more than one person. However, each person you identify will have the same access to your information. Ifyou would like each person to access different information or to have access to your information for a different period of time, you’ll need tocomplete separate forms for each individual or time period. A little extra paperwork, but protecting your privacy is worth a few minutes ofyour time! Please remember that to provide you with quality service, we will continue to communicate our payment activities in connectionwith your claims, your enrollment in our health plan or your eligibility for benefits to providers of care involved in your treatment.

Important Note: There are state and federal laws that contain special protections for certain conditions. These conditions are genetictesting, alcohol or substance abuse, mental health, abortion, sexually transmitted diseases and HIV/AIDS. If you would like us toshare information with other people or organizations on one of these protected diagnoses, please clearly state this below in Step 2 inthe second option regarding specific information. In order for us to release information about a minor regarding abortion, sexuallytransmitted diseases or substance abuse, the minor must complete the authorization - even to disclose information to a parent. If youwould like to authorize us to release information regarding HIV/AIDS, a different form needs to be completed. We ask that youcontact our office at the telephone number on your identification card, or visit our website for this form at:www.univerahealthcare.com. Go to the Members area and click on Print Forms.

Your authorization is completely voluntary and you don’t have to sign this form. We will not condition our payment activities in connectionwith your claims, your enrollment in our health plan or your eligibility for benefits on you giving this authorization. If additional forms areneeded, you may copy this form, visit our Web site at www.univerahealthcare.com or contact our office at the telephone number listed onyour identification card.

Please check here if you would like to authorize access to psychotherapy notes. If this box is checked, then this authorizationcannot be used for another reason. If checked, steps two and three below can be skipped.

Please be sure to provide us with all of the following information. Step 1: Tell Us Who You Are:

Name: ______________________________________________________________________________________________________

Address: ____________________________________________________________________________________________________

City: _______________________________________________ State: _____________________ Zip: _________________________

© 2001 Michael Best & Friedrich LLCPage 2 of 3

UN-8

Member ID Number(s) as listed on your identification card(s): __________________________________________________

Birth Date: __________/__________/_______

Step 2: Tell Us Why You’d Like Us to Share Your Information:

So Univera Healthcare can:

Respond to all requests for confidential information about me made by the individual(s) or organization(s) I list below.

Respond to requests for only the following specific information (such as claims submitted by a specific provider or informationrelated to one of the protected diagnosis listed above)

Please specify_______________________________________________________________________________________

Respond to inquiries related to a specific date of service:

Please specify_______________________________________________________________________________________

Step 3: Tell Us What Specific Information You’d Like Us to Share: Please list the specific protected health information youwish us to disclose. Please check all that apply:

My claim information (e.g. status, type of service, diagnosis, provider, dates of service, etc.)

My membership information (e.g. coverage information, enrollment dates, eligibility, address, dates of birth, etc.)

My benefit information (e.g. benefits available, benefits used, contract limits, etc.)

My medical records (e.g. physician or hospital records, case management, etc.)

Other information (please specify): ____________________________________________________________________

Please exclude the following information: __________________________________________________________

Step 4: Tell Us With Whom You’d Like Us to Share Your Information: Please list the person(s) and/or organization withwhom you want us to share the information you described above. Please remember if you’d like us to share information with more than oneperson, the information to be disclosed and the expiration date must be the same for each person.

Name/Organization Address

____________________________________________ _________________________________________________________

____________________________________________ _________________________________________________________

____________________________________________ _________________________________________________________

Step 5: Tell Us When You’d Like Us to Share Your Information:

Please share my protected health information during the time period(s) below:

Until Univera Healthcare completes the activities outlined in section 2.

© 2001 Michael Best & Friedrich LLCPage 3 of 3

UN-8

Until I send Univera Healthcare a form canceling my authorization.

From _____/______/_______ through _____/______/_______.

Step 6 (the last one!): Please Give Us Your Signature:

To give Univera Healthcare your consent to share the protected health information noted above, please print your name onthe line below and then provide your signature and today’s date.

I, (please print name here)__________________________________________, have had full opportunity to read andconsider the contents of this authorization. I understand that, by signing this form, I confirm my authorization for the use,request and release of my confidential member information as described in this form. I understand that I may cancel thisauthorization at any time by completing an authorization revocation form and sending it to the address below. I alsounderstand that the revocation of this authorization will not take effect until Univera Healthcare receives my authorizationcancellation form.

I understand that, if the person(s) or organization(s) I authorize to receive information described in this form is not a healthplan, covered provider or health care clearinghouse subject to federal health information privacy laws, s/he may furtherdisclose the information and it may no longer be protected by those laws.

Signature: Date:

(Member or Personal Representative)

If this request is by a personal representative on behalf of our member, please give us the following information:

Personal Representative’s Name: (please print)

Description of Personal Representative’s Authority (a power of attorney, legal guardian or state executor):

___________________________________________________________________________________

Please note: personal representatives must provide legal proof of representation, such as power of attorney documentation.

Please complete and return this form to: Univera Healthcare

P.O. Box 4839 Syracuse, NY 13221

FAX: 1-315-671-7079

PLEASE MAKE A COPY OF THIS FORM FOR YOUR RECORDS

P.O. Box 23000, Rochester, NY 14692 Instructions on Back. All Dates = mm/dd/yy Check if name change Check if new address PLEASE PRINT CLEARLY CHECK DESIRED ACTION Select the medical or dental plan offered by your employer CHECK PERSON(S) COVERED Add Subscriber (AA) Date of Hire/Event ___ / ___ / ___ Coverage Eff Date ___ / ___ / ___ Add Dependent (AB) Date of Event ___ / ___ / ___ Coverage Eff Date ___ / ___ / ___

Copay Option choose 1 copay $10 PCP / $20 Specialist (A4) $15 PCP / $25 Specialist (A1) $25 PCP / $40 Specialist (A2) $30 PCP / $50 Specialist (A3) $40 PCP / $60 Specialist (A5)

HDHP Option choose 1 deductible

$1,300 S / $2,600 F 20% coinsurance (C1) 0% coinsurance (C4) $1,800 S / $3,600 F (C5) $2,600 S / $5,200 F (C2) $5,500 S / $11,000 F (C3)

Copay & Deductible Option choose 1 deductible and 1 copay $250 S / $750 F $10 PCP / $20 Specialist (D1) $15 PCP / $25 Specialist (D3) $25 PCP / $40 Specialist (D5) $30 PCP / $50 Specialist (D7) $40 PCP / $60 Specialist (D9)

$500 S / $1,500 F $10 PCP / $20 Specialist (B7) $15 PCP / $25 Specialist (B1) $25 PCP / $40 Specialist (B3) $30 PCP / $50 Specialist (B5) $40 PCP / $60 Specialist (B9)

$1,000 S / $3,000 F $10 PCP / $20 Specialist (B8) $15 PCP / $25 Specialist (B2) $25 PCP / $40 Specialist (B4) $30 PCP / $50 Specialist (B6) $40 PCP / $60 Specialist (E1)

$2,000 S / $6,000 F $10 PCP / $20 Specialist (D2) $15 PCP / $25 Specialist (D4) $25 PCP / $40 Specialist (D6) $30 PCP / $50 Specialist (D8) $40 PCP / $60 Specialist (E2)

Univera Dental Traditions (DI) Univera Dental Select (DJ)

Self, Spouse &

Child(ren)

( A ) MEDICAL DENTAL

Self &

Child(ren)

( B )

Self & Spouse

( C )

Self

( D )

Change Coverage (AC) Coverage Eff Date ___ / ___ / ___

Transfer to COBRA (AD) (S)ubscriber (M) Dependent (D)isabled Date of Event ___ / ___ / ___ Cancel Subscriber (S) Cancel Dependent (M) (M)edical (D)ental Reason Code (see back) Cancellation Date ___ / ___ / ___

SUBSCRIBER INFORMATION - Must be completed

Social Security # - - Sex: M F Date of Birth ____/____/____ Last Name First

Street

City State Zip

Day Phone: - - Email Address:_________________________________________ Enrolled with Medicare? Yes No If yes, indicate reason: Age Disabled ESRD (first date of dialysis ____/____/____) Medicare Claim #: _________________________________ Medicare Part A Eff Date: ____/____/____ Medicare Part B Eff Date: ____/____/____ Employment status: Active Retired, Provide Retirement date _____/_____/_____

FAMILY MEMBER INFORMATION Check relationship and indicate dependent name or indicate dependent name and birthdate to be cancelled. (S)pouse Domestic (P)artner Last Name: First Name:

Social Security # Sex M F

Date of Birth (mm/dd/yy)

___/___/___ (D)ependent (H)Disabled (F)oster/Adopted Student Other__________ Last Name: First Name:

Sex M F

Date of Birth (mm/dd/yy)

___/___/___ (D)ependent (H)Disabled (F)oster/Adopted Student Other__________ Last Name: First Name:

Sex M F

Date of Birth (mm/dd/yy)

___/___/___ (D)ependent (H)Disabled (F)oster/Adopted Student Other__________ Last Name: First Name:

Sex M F

Date of Birth (mm/dd/yy)

___/___/___ OTHER COVERAGE INFORMATION In addition, please provide a copy of your "Certificate of Coverage" from your former health insurance carrier or employer. 1. Have you or any member of your family been enrolled in any other insurance policy in the last 63 days (including Medicare or Medicaid)? Yes No Check: Medical and/or Dental Are you keeping this coverage? Yes No Check: Medical and/or Dental Other plan covers: Self Spouse Child(ren) Entire family Indicate Other Plan Name: Policy ID number Effective date: / / Termination date: / / 2. While enrolled in Univera Healthcare will any member of your family be covered by Medicare: Yes No If yes, answer the following Name of person with Medicare:___________________________ Spouse Dependent If yes, indicate reason: Disability Retired ESRD (first date of dialysis ____/____/____) MEDICARE CLAIM # __________________________________________________________ Part A effective date: _____/____/____ Part B effective date: ____/____/____

RELEASE - You must sign and date this form to be eligible for insurance. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each such violation. I have thoroughly read, understand and agree to comply with the terms of the Release on the back. Subscriber Signature Date EMPLOYER INFORMATION (Must be completed by Group Administrator/Representative) * Dept. # and Employee # is optional. Was the employee subject to a waiting period before enrolling in your employer health plan? Yes No If yes, what was the start date ____/____/____ and end date ____/____/____

Coverage Group/Sub Group # Check digit Pkg # Employer Name: Medical Employee Status (A)Active (A)COBRA (A)Cancellation (R)etired Dental Department #* Employee #*

Group Rep Signature/Date: APP-303u (01/08), Rev. 3 Return Original to Univera Healthcare at address above - Copy: Employer Group

ActiveUnivera GROUP ENROLLMENT FORM

A Group Enrollment Form is not required for a change of address or correction to a date of birth. Please contact Customer Service at the number listed on your member ID card.DESIRED ACTION Check the appropriate action and indicate the Date(s) in the space provided. An Event Date is the date of a specific occurrence, due to change in status, marriage, divorce, birth or adoption, group's anniversary date, or rate change. Your request must be received within 30 days of the Event Date. Please see your Group Administrator/Representative for events that fall outside the 30-day period. If New Add Subscriber, Add Dependent or Change Coverage, you must also check Desired Coverage and Persons covered, and Family Member Information section. Cancel Request To process a Subscriber or Member Cancellation, please use the Membership Cancellation Worksheet - OR - To Cancel an Employee/Subscriber using the Group Enrollment Form:

To Cancel a Dependent using the Group Enrollment Form:

check Subscriber (S) Box check Products to be cancelled (Medical, Dental) indicate Reason Code in space provided (See codes below) indicate Cancellation Date in space provided complete Subscriber Information

check Dependent (M) box check Products to be cancelled (Medical, Dental) indicate Reason Code in space provided (see codes below) indicate Cancellation Date in space provided complete Subscriber Information complete Member Name and Member Birthdate

Cancel Subscriber Reasons Cancel Dependent Reasons

LE - Left Employer/No Longer Eligible (11) CP -- Commercial (09) CB -- Cobra Begin Date CD -- Cobra Disabled Date TT – Transfer to Traditional TH – Transfer to HMO (73) TP – Transfer to POS (73)

CE – Cobra End Date (29) SR – Subscriber Request (02) SD – Subscriber Deceased (05) SB – Spouse's Excellus BCBS MC – Medicaid MX – Medicare (03)

MA – Marriage (25) OA – Dependent Over Age (20) DM – Deceased (05) MS – Ineligible Student (28)

MB – COBRA Begin Date MR – Subscriber Request (02) DV – Divorce (25) CB – Cobra Begin Date MX- Medicare 03)

DESIRED COVERAGE All products may not be applicable to your employer group. Please check with your Group Administrator/Representative. SUBSCRIBER If you or your dependents are Medicare eligible, complete the questions regarding Medicare Coverage.

FAMILY MEMBER INFORMATION If there are more than five members please use an additional form. QUALIFIED GUIDELINES: A legal spouse (an ex-spouse is not a qualified member as of the divorce date) Must be under the dependent age for your employer group: - Unmarried child, natural, adopted or stepchild

- Chiefly dependent on you for support Other: Please contact your Group Administrator/Representative for the appropriate form. These dependents have additional eligibility requirements.

Dependents pending adoption, foster dependents, foreign exchange students, dependents for whom employee/subscriber has legal custody or legal guardianship, or a handicapped dependent who is over the dependent age for your employer group.

RELEASE I am applying to enroll myself and my eligible dependents, if any, under the medical and/or dental contract.

In the event that a premium contribution is required of me, I agree to pay the premium amounts applicable to the contract under which I am covered. I authorize my employer to deduct from my payroll such applicable amounts and to remit them to Univera Healthcare.

If this application is made on behalf of a minor, the responsible party must complete the application.

By accepting this contract, I grant permission to Univera Healthcare to submit charges to and/or recover payment from any other insurance carrier acting as my primary insurer.

I authorize Univera Healthcare to request and receive medical or dental information regarding me or my covered dependents from my healthcare practitioner or healthcare institution either orally or in writing and to use this information for providing coverage. Providing coverage includes: processing claims, reviewing grievances or complaints involving care and quality assurance reviews of care, whether based on a specific complaint or a routine audit of randomly selected cases. In the use of data for these purposes, we may transmit personal information to third parties with which we contract, including pharmacy benefit managers, disease management vendors or surveyors.

I hereby represent that all information furnished by me hereon is true and complete to the best of my knowledge.

PREFERRED PROVIDER ORGANIZATION (PPO) I understand that the Preferred Provider Organization (PPO) coverage is comprised of an in-network benefit that is dependent on the utilization of medical providers who participate with the PPO and an out-of-network benefit which provides coverage for services of medical providers who do not participate with the PPO. I understand that the in-network benefit provides the highest level of coverage under the plan.

The certificate or contract for which application is being made may impose a waiting period of up to twelve (12) months for preexisting conditions, subject to the provisions of applicable law including creditable coverage requirements. The certificate or contract document will describe any applicable waiting periods.

EMPLOYER INFORMATION This section to be completed and signed by the Employer Group Administrator/Representative. Complete only the coverage section (Medical/Dental) that is applicable to the employee's request.

If you have any questions, please contact your Group Administrator/Representative.

Or, visit us at: www.univerahealthcare.com

http://www.univerahealthcare.com/

Here are definitions* for some health insurance terms we use all the time. Knowing

what they mean will help you understand our plans—and your coverage—better.

Primary Care Physician (PCP)—A doctor who serves as your health care managerand coordinates virtually all of the health care services you routinely receive. Some plans do not require you to choose a PCP.

Referral—Instructions provided by a PCP for specialty care. Most plans do not require referrals.

In-network coverage—The coverage available when you receive services from aprovider who participates in your health plan.

Out-of-network coverage—The coverage available when you receive services froma provider who does not participate in your health plan. Some plans may notinclude out-of-network coverage.

Out-of-area—Types of services listed that are received while outside the geographicservice area of your health plan. Your plan benefits may differ if you live or workbeyond the geographic service area.

Copay—A dollar amount due at the time you receive certain services. A typicalexample would be an office visit copay due when visiting your physician’s office for treatment.

Allowed Amount—The maximum amount your health plan will pay for a specific service. In-network providers agree to accept the allowed amount as payment in full.

Coinsurance—A cost-sharing method that requires you pay a portion of theallowed amount for certain medical services.

Deductible—A set dollar amount you pay for covered services you receive beforeyour insurer will make a payment.

Out-of-pocket maximum—The maximum amount of deductible and coinsurancepayments that you will pay for health services each calendar year.

Precertification—A determination made by your health plan, before you receiveservices, that a medical service is a covered benefit and medically necessary.

*Some definitions may vary slightly by plan. In case of a conflict between your legal plan documents and this information, the plan documents will govern.

Welcome to ActiveUnivera®, a new direction in health care.

ActiveUnivera® is an exciting new kind of health plan –one that pays you back. As a member of ActiveUnivera®,you can earn up to $500 individually, or a combined$1,000 cash back for you and an eligible adult memberjust for doing healthy stuff that fits into your day. So,schedule regular check-ups, eat right and stay active. Then get paid anytime throughout the year.

ActiveUnivera® offers quality health care coverage including:

• Low or no copays for kids.• *No referrals.• Coverage that travels with you through BeechStreet.

And ActiveRewards® is personalized to meet your individual needs. You can earn dividends by participatingin ActiveRewards® programs. Each dividend is equal to one dollar and you and an eligible adult member can eachearn up to 500 every year – all just for living healthy!

At Univera Healthcare, we hope you enjoy theActiveUnivera® health plan and ActiveRewards® program.We’re proud to bring you the health plan that pays you back.

* Precertification may apply.

This benefit summary is not a contract or binding agreement; it is a summary of

benefits and services.

Privacy Policy Notice. We know how important your privacy is and we’re

committed to protecting it. Our policies and practices regarding the collection,

use, and disclosure of personal health information are available at

univerahealthcare.com/activerewards and Member Services.

What does it all mean?

Get started at: univerahealthcare.com/activerewards

stress level income level

UN-HB 08/104768-10M9M

Univera Healthcare makes finding the information and support you need easier –resources, savings and tools are available online 24/7.

• Live healthy. Earn up to $1,000 cash back.

• Find a doctor or specialist online while you’re home or far away.

• Get instant access to fitness and nutrition programs.

• Research over 6,000 health topics online.

live healthy. earn some cash.live healthy. earn some cash.

®

SUBSCRIBER INFORMATION - Must be completed Employer Name: