Meritus 2014 Broker Handbook

Meritus Plans and Rates 11.855.755.2700 | 602.957.2113
When it comes to healthcare,
we’re changing everything.
Starting with building great
working relationships with
brokers like you.
Coming together to improve healthcare for Arizona.
Our goals are the same: to help Arizonans achieve better health through the kind of care they demand
and deserve. Which is why we invite you to join us as we work together with brokers, healthcare
professionals, organizations and our members to provide individuals, families and small businesses with
a wide array of affordable plans and benefits.
We’re dedicated to helping you serve your clients through responsive service, user-friendly technology
and easy access to information. This handbook is one of many tools you can expect from us. Use it as a
resource to learn more about us, the Marketplace, our plans, services, and more.
Improving the health and wellbeing of Arizonans will take a team effort. Be a part of Meritus – together
for better health. Meritus products and services are provided through Meritus Mutual Health Partners
(a PPO) and Meritus Health Partners (an HMO).
Questions? We’re here for you.
www.meritusaz.com
855.755.2700 | 602.957.2113
Title Page
About Meritus 2
Provider Networks 5
Understanding the Marketplace 8
How to Obtain Coverage for Your Clients Under the Affordable Care Act 11
Assistance: Making Healthcare Affordable for All 13
Meritus Rules Regarding Federal Marketplace Enrollments, Terminations, SEPs, and Plan Changes 14
Meritus Rules for New Group Business 17
Step-by-Step Guide to the Application Process 21
Meritus Health Plans and Rates 26
Meritus Pharmacy Benefits 85
Meritus Dental Benefits 86
Meritus Pricing Sheets 87
Broker Resources and Support 91
Table of Contents

2 Meritus Broker Manual 1.855.755.2700 | 602.957.2113
Focused on maximizing
consumer value,
not shareholder value.
Welcome to a whole
new kind of healthcare.
New to the market, but not to the healthcare world, we are a recently formed
non-profit health insurance company and Arizona’s first and only cooperative model.
We started as a community coalition, and we’ve been actively involved at the
community level, working for years to create better access to affordable, quality
choices of healthcare for Arizonans. Today, as Meritus, our team is comprised of
highly experienced leaders in medical, technology, business and legal industries,
bringing a broad range of expertise and innovation to our efforts.

www.meritusaz.com • Broker Use Only Meritus Broker Manual 3
“Putting our members first” means:
• Striving to measurably improve their health
with preventive care and wellness benefits
• Fostering a community of care to make sound
healthcare decisions for patients and improve
the overall health of members
• Working to reduce costs due to waste and error
• Building relationships with members through
easy-to-access channels
• Being an innovative partner to the
communities we serve
• Building strong broker partnerships
What’s a CO-OP?
CO-OPs (Consumer Operated and Oriented Plans)
exist to serve their members. As a CO-OP makes
a profit and exceeds its required reserves, it is
required to use those profits to support members
through premium control, expanded benefits and
innovations in service models. Rather than focusing
on profits, we focus on quality care for our mem-
bers. In addition to reinvesting profits in the form
of lower premiums or enhanced services for mem-
bers, CO-OPs are motivated to keep costs down
by implementing member-centric offerings such as
wellness programs, chronic disease management,
mental health services and integrated care. Meritus
is also a not-for-profit organization. We are prohib-
ited by law from ever being sold to or re-organized
as a for-profit corporation. Meritus is Arizona-owned
and managed, with headquarters in Tempe.
CO-OP Principles
• Voluntary and Open Membership
• Democratic Member Control
• Member Economic Participation
• Autonomy and Independence
• Education, Training and Information
• Cooperation among Cooperatives
• Concern for Community
CO-OPs under the ACA
The CO-OP program under the Patient Protec-
tion and Affordable Care Act (ACA) is intended
to foster the creation of new consumer-governed,
private, non-profit health insurance issuers, in ev-
ery state. Arizona’s insurance market is dominated
by a small number of insurers; there is a need for
competition. And, there is a need for innovation.
As a healthcare cooperative established under the
ACA, Meritus is a new and different way of provid-
ing healthcare coverage.
The success of other health plan CO-OPs has
served as a model for the design and develop-
ment of Meritus. Our predecessors have dem-
onstrated that the healthcare CO-OP model can
realign the financial goals of providers, insurers,
brokers and patients.
CO-OPs are subject to the same rules as all other
insurance plans under healthcare reform. We’re
fully licensed by the Department of Insurance and
certified by the Federal Government as a Qualified
Health Plan.
About Meritus
How we’re different
Our goal is to put healthcare back into health insurance, by promoting wellness, lowering healthcare
costs and providing easy access to quality care. We want our members healthier than when they first
joined us!
Our cooperative (CO-OP) model is different from traditional health insurance companies. As a
member-governed organization, one in which members serve on the Board of Directors, we answer
to and focus on our members – coordinating their care and coverage as affordable as possible.
We reinvest our profits for the good of our members, helping to control premiums, improve benefits,
promote wellness and encourage preventive care.

Our Background and Approach
The Meritus team invested time and resources in early 2013
to obtain consumer feedback regarding their impressions
and expectations of health insurance products and compa-
nies post 2014. We spoke with more than 100 consumers,
providers and brokers in all income categories. We learned
some very important information that helped drive our ben-
efit design and pricing strategy.
On What Consumers Want
• Affordable health insurance
• No surprises or hidden fees
• Predictable out-of-pocket costs
• Low deductible(s)/co-pays
• Comprehensive coverage, including Rx benefits
• Preventive care/wellness programs/mental health
• “Good providers” and a robust network
• Easy-to-use insurance
• Catastrophic care
• Pre-existing conditions included
How we designed our plans and services
Based on our group’s feedback:
• We designed HMO products structured around co-pays
for most services, no hidden fees and predictable out-
of-pocket costs.
• We created a range of deductibles and
co-pays.
• We designed pharmacy benefits that provided generic
maintenance medications without co-pays in most plans.
• We structured most of our plans with no
co-pay for primary care visits, sick visits or well visits, to
help promote preventive care and wellness.
• We included healthy lifestyle benefits such as acupunc-
ture, therapeutic massage, naturopathy and rewards for
staying healthy, including up to $25/month gym mem-
bership reimbursement. The Healthy Lifestyle benefits
are included on many of our Individual and Group plans.
Meritus At a Glance
• Headquartered in Tempe
• Organized in 2012, physician-founded
local coalition
• Licensed by the Arizona
Department of Insurance in 2013
• Arizona’s first and only health
insurance cooperative
• Member-governed, non-profit con-
sumer operated and oriented plan
(CO-OP)
• Certified by the Federal Government
as a Qualified Health Plan

Building better health in
communities through our
Provider Networks.
We believe in developing long-term partnerships
with providers by working together to improve health
outcomes and better control healthcare costs for our
members and the people of Arizona.
It’s this friendly approach to achieving real change that we
believe creates a positive payer/provider dynamic - one
we believe will change healthcare as we know it, for the
good.

Meritus PPO Network
Meritus has entered into a relationship
with the Arizona Foundation for
Medical Care.
The Arizona Foundation’s PPO
network, along with some additional
providers, represents our PPO network.
Meritus contracted directly with
some additional providers because
some specialities were not available
through our contract with the Arizona
Foundation. Chiropractic, Naturopathic, Acupuncture, and
Therapeutic Massage contracts were negotiated directly.
Please instruct your clients to always utilize the Meritus
PPO search tool on our website. Some providers may be
contracted with the Foundation, but may not have signed the
amendment to be affiliated with the Meritus PPO Network.
To see a complete listing of the Meritus PPO network, visit
meritusaz.com.
Meritus HMO Network
Meritus built our HMO network of preferred specialist
relationships with the assistance of primary care physicians.
Working in partnership with these PCPs, we reached out to
other physicians, specialists and hospitals to create a natural
model for building networks.
Since competitive pricing is our key success in the market,
both on and off the Marketplace, we created community
and neighborhood HMO products. These are priced within
an affordable range, lower than the other HMO products
because we received significant discounts from the
underlying health systems.
The listing of the participating Meritus HMO Network
providers can be found on our website at
www.meritusaz.com.
Meritus Neighborhood Network Maricopa*
Maricopa Integrated Health System (MIHS) includes
Maricopa Medical Center, Phoenix Cancer Center, Arizona
Burn Center and McDowell Health Care Center. MIHS also
includes 11 family health and community health centers.
District Medical Group (DMG) physicians provide clinical
services at all of the MIHS Facilities.
The listing of the participating Meritus Neighborhood
Network providers can be found on our website at www.
meritusaz.com
Meritus Community Network Phoenix*
As one of our community-based networks, the Meritus
Community Network includes all of the Banner hospitals and
health clinics, primary care and specialty care in Maricopa
County, as well as MD Anderson Cancer Center, Cardon
Children’s Medical Center and Banner Heart Hospital. This
network does not include the Banner Health Network
physicians. These physicians are affiliated with Banner but
not employed by Banner.
Note: Please do not use the Banner provider search on the
Banner website for Meritus Community Network Phoenix
Providers. Some of their providers are from other states and
also are part of the Banner Health Network, which is not
part of Meritus Community Network Phoenix.
The listing of the participating Meritus Community Network
– Phoenix providers can be found on our website at
www.meritusaz.com.
Network Design
PPO Products
Arizona Foundation for Medical Care Network
14,000 providers in 39,000 locations
Alternative Therapies
In and out-of-network coverage
HMO Products
Narrower and more strategic network
Focus on access to care, improved outcomes controlling costs
FQHC and PCMH
No out-of-network coverage
Exclusive HMO Networks

Meritus Community Network - Pima*
The Meritus Community network in Pima County uses
the Carondelet hospitals, its express care clinics, and
physicians.
Along with the Carondelet Medical (PCP) and Specialty
Groups this Network includes:
• El Rio Health Centers
• Marana Health Centers
• St. Elizabeth’s Health Center
• United Community Health Centers
• Select Carondelet affiliated specialists
The aforementioned plans are Silver level HMO products
offered primarily on the Marketplace. Services are
available ONLY in the single-system network underlying
the product, and like all HMO products, no services are
available out-of-network (other than emergency). These
health systems will be reaching out to their current, and
primarily uninsured, populations in an effort to convert
this population to insured through the Meritus product.
* Note: Available on Silver Plans only.
An Integrative Holistic Provider Network
At Meritus, we know that health isn’t something that
you only fix when it’s broken.
That’s why we’ve teamed up with Complementary
and Alternative Medicine** (CAM) experts including
Naturopathic Medical Doctors, Licensed Acupuncturists
and Licensed Massage Therapists who can partner with
members to create a personalized wellness plan to help
achieve a healthier lifestyle as well as address specific
conditions when they are ill.
Our network providers are experts in holistic
approaches, and our plans include benefits such as:
• medical nutrition;
• acupuncture;
• counseling and stress management;
• naturopathy;
• and therapeutic massage.
Whether the goal is to have more energy, decrease
pain, reduce stress, learn to eat better, or or seek a
natural solution to your concerns, our CAM benefits
were created to support overall health and well-being.
Members asked for health plan benefits with CAM
choices and Meritus listened. Benefits include 12 visits
of each modality at a $20 co-pay per visit: naturopathy,
acupuncture and therapeutic massage, and up to a
***$25/month gym membership reimbursement.
Meritus is putting healthcare back into health insurance,
by promoting wellness, lowering healthcare costs and
providing easy access to quality care. We want our
members healthier than when they first joined us.
Through these various product
offerings, our goal is to provide
health insurance solutions that
meet the needs of everyone – those
looking for choice who are willing
to pay for it and those willing
to sacrifice choice for a limited
network.
**Complimentary and Alternative Therapies (CAM) are not a covered benefit in all plans. CAM therapies include Therapeutic Massage, Acupuncture and
Naturopathy. CAM Therapies are limited to 12 visits per year, per therapy.
***
The $25/Month Gym Reimbursement is only available for certain plan options. In order to obtain a gym membership reimbursement, you must submit a
claim. Meritus will pay up to $25 per month for each covered person, age 18 and above, who has a gym membership. “Gym” means a business licensed
by the state or +local government to conduct business as: (1) a gym; (2) fitness center; or (3) health club. The gym must have exercise/fitness equipment
and have personnel to assist gym members.

1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder
services, including behavioral health treatment
6. Prescription drugs
The ACA includes several provisions geared to extend greater access to health insur-
ance benefits to more people. Beginning in 2014, most Americans must purchase a
minimum amount of health insurance or be taxed by the government. This tax is paid
through your Federal Income Tax reporting in April.
For more details about the ACA, visit healthcare.gov.
The health insurance
market as we know it
has changed.
Understanding the Marketplace.
Understanding the Marketplace
Under the ACA, each state is required to operate a Health Insurance Marketplace, or in Arizona’s case, the
Federally Facilitated Marketplace – also known as an Exchange – where people can purchase coverage from
private companies like Meritus that have been approved as Qualified Health Plans (QHPs). To be certified by
the Marketplace, Meritus must meet a number of coverage and other requirements, and offer the same core
set of benefits called “essential health benefits.” The difference between plans will be in what and how they
offer “non-essential” health benefits, their deductibles, co-payments and co-insurance.
Essential health benefits package must include services and items for the following categories of care:*
7. Rehabilitative and habilitative services
and devices
8. Laboratory services
9. Preventive and wellness services and chronic
disease management
10. Pediatric services, including oral and
vision care
*Healthcare.gov: Essential health benefits (accessed October 2012)

Benefits to Consumers
The Health Insurance Marketplace will give your clients more choices and control over their health coverage, re-
gardless of whether they’ve been uninsured, have been denied coverage in the past or simply wish to explore new
options.
Consumers can get lower costs on coverage:
Through the application process, you and your clients will find out if they are eligible for subsidies or tax credits
to help lower costs on their monthly premiums or out-of-pocket costs for private insurance. You’ll also learn if
they qualify for free or low-cost coverage through Medicaid or the Children’s Health Insurance Program (CHIP).
Pre-existing conditions are covered:
Plans won’t be able to deny consumers coverage or charge them more due to pre-existing health conditions,
including a pregnancy or disability.
Determining Requirements
See if your clients are required to buy coverage under the Affordable Care Act.
Do any of the following apply?
• You are part of a religion opposed to acceptance
of benefits from a health insurance policy.
• You are an undocumented immigrant.
• You are incarcerated.
• You are a member of a Native American tribe.
• Your family income is below the minimum threshold for filing a
tax return ($10,000 for an individual, $20,000 if you're married,
filing a joint return with no exemptions in 2013).
• You have to pay more than 8% of your income for health
insurance, after taking into account any employer
contributions or tax credits.
Were you insured for the whole year through a combination of
any of the following sources?
• Medicare.
• Medicaid or the Children’s Health Insurance Program (CHIP).
• TRICARE (for service members, retirees and their families).
• The veteran’s health program.
• A plan offered by an employer.
• Insurance bought on your own that is at least at the Bronze level.
• A grandfathered health plan in existence before the health
reform law was enacted.
There is no
penalty for being
without health
insurance.
The requirement
to have health
insurance is satisfied
and no penalty is
assessed.
There is a penalty for being
without health insurance.
Income is defined as total income in excess of the filing threshold ($10,000 for an individual and $20,000 for married, filing jointly with no exemptions in 2013).
The penalty is pro-rated by the number of months without coverage, though there is no penalty for a single gap in coverage of less than 3 months in a year. The penalty cannot
be greater than the national average premium for Bronze coverage in an Exchange. After 2016, penalty amounts are increased annually by the cost of living.
2014
Penalty is $95 per adult and $47.50 per
child (up to $285 for a family) or 1% of
family income, whichever is greater.
2015
Penalty is $325 per adult and $162.50
per child (up to $975 for a family) or 2%
of family income, whichever is greater.
2016 and Beyond
Penalty is $695 per adult and $347.50
per child (up to $2,085 for a family) or 2.5%
of family income, whichever is greater.
NO
NO
YES
YES

Key Information for Consumers:
• Purchasing insurance using the Marketplace
provides “guaranteed coverage”
• All pre-existing conditions are covered and
companies can’t charge more for a policy
because of past or present health conditions
• To be eligible for health coverage through
the Marketplace, consumers must:
- Live in the United States
- Be a U.S. citizen or national
(or be lawfully present)
- Not be currently incarcerated
• You might be eligible for tax subsidies (see
chart on next page)
offering QHPs must offer at least one plan at the
Silver level and one plan at the Gold level on the
Marketplace. Under each metal level there can
be several plans available, which will vary
according to the deductibles, co-insurance and
co-pays offered.
Some plans offer lower monthly premiums that
may charge more out-of-pocket fees for care,
while others have higher-premium plans that
cover more costs when you need care; other
plans will fall in between.
Purchasing Health Insurance:
On Off the Marketplace
While all insurance plans are offered by
private companies, the online Marketplace
for Arizona is run by the federal government
at healthcare.gov.
With you as their guide, individuals and small
businesses can compare health plans, get an-
swers to questions and find out if they are eligible
for tax credits or health programs. Once they
choose to enroll in a health plan, there are two
ways to buy plans. As required by the ACA, QHPs
must include standardized benefits on and
off the Marketplace.
Brokers can sell plans through one of two
channels using the Meritus portal:
• On the Marketplace
• Off the Marketplace
Standard benefits packages
There are five levels of plans, four represented
by “metal” values and one catastrophic, and are
defined by the percentage each plan will pay to-
ward healthcare expenses for an average person
(known as the actuarial value). Health insurers
Catastrophic Less Than 60% Coverage
Bronze 60% Coverage
Silver 70% Coverage
Gold 80% Coverage
Platinum 90% Coverage
See Meritus Plans and Rates for more details.

Health Coverage Under the
Affordable Care Act
How your clients can get
coverage.

.
Start
Is employer
coverage
available?
YES
Is family income
less than or equal
to 1.33%
of the FPL?
YES
Family may be
eligible for
coverage through
AHCCCS
Family may be
eligible for
coverage through
AHCCCS
YES
Is family income
or = 133%
of the FPL?
*See chart.
NO
NO
Is the family
income between
the FPL and
4x the FPL?
*See chart.
NO
Family is
guaranteed access
to unsubsidized
insurance through
an exchange or the
non-group market.
YES
Family is
guaranteed access
to insurance
through an
exchange and is
eligible
for a tax credit.
Does the employer
plan cover at least
60% of health
expenses on
average? Get this
information from
the employer.
YES
Does the employee
pay more than 9.5%
of income for the
premium in the
employer plan?
YESYES
Is the family income
between the FPL
and 4x the FPL?
*See chart.
Employee can choose
coverage in the employer
plan or buy insurance
through the Marketplace.
Dependents are eligible for
the Marketplace.
NO
NO
NONO
NO
NO
Employee can
choose coverage
in the employer
plan or buy
unsubsidized
insurance through
the Marketplace or
in the non-group
market.
Dependents are
NOT eligible for
the Marketplace.
Resources
www.meritusaz.com
www.azahcccs.gov
www.healthcare.gov
www.healthearizonaplus.gov
Format taken from The Journal of the American Medical Association:
jama.jamanetwork.com/data/journals/jama/926137/m_jvh120007fa.png
Persons in Family 100% 133% 150% 200% 300% 400%
1 $11,490 $15,282 $17,235 $22,980 $34,470 $45,960
2 $15,510 $20,628 $23,265 $31,020 $46,530 $62,040
3 $19,530 $25,975 $29,295 $39,060 $58,590 $78,120
4 $23,550 $31,322 $35,325 $47,100 $70,650 $94,200
5 $27,570 $36,668 $41,355 $55,140 $82,710 $110,280
6 $31,590 $42,015 $47,385 $63,180 $94,770 $126,360
7 $35,610 $47,361 $53,415 $71,220 $106,830 $142,440
8 $39,630 $52,708 $59,445 $79,260 $118,890 $158,520
For each additional person, add $4,020 $5,347 $6,030 $8,040 $12,060 $16,080
Connecting Individuals and Families to coverage, benefits and services.

Assistance:
Making
Healthcare
Affordable for All
To address the needs of those who fall
in certain income levels and cannot
afford insurance, the law includes
provisions for federal subsidies to
reduce the cost of premiums.
Eligibility for Tax Credits Cost-Sharing Reductions
Individuals or families who purchase coverage in the Marketplace are eligible for a tax credit as long as their household income
is up to 400 percent of federal poverty level guidelines; that equals $11,490 to $45,960 per year for an individual and $23,550 to
$94,200 per year for a family of four (see income table).
The assistance amount that a person can receive varies with income. The tax credit may be applied to any plan level (Catastrophic,
Bronze, Silver, Gold or Platinum).
Cost-Sharing Reductions
Those who earn up to 250 percent of federal poverty guidelines and enroll at the Silver level only may also be eligible for cost-
sharing reductions (CSR). The subsidy amount will vary according to income. Examples of cost-sharing that may be reduced
include deductibles, co-insurance, co-payments or similar charges and do not include balance billing for non-network providers
or spending on non-covered services.
Standard Silver – No CSR CSR Plan for up to 150%
FPL (up to $17,235)
CSR Plan for 151-200% FPL
($17,236 to $22,980)
CSR Plan for 201-250%
FPL ($22,981 to $28,725)
Actuarial Value 70% AV 94% AV 87% AV 73% AV
Deductible (Individual) $5,000 $0 $0 $2,200
Maximim OOP Limit
(Ind.)
$6,350 $2,250 $2,250 $1,000 co-pay,
deductible
Office Visit – PCP/
Non-PCP
$0 co-pay/$100 co-pay $0 co-pay/$15 co-pay $0 co-pay/$50 co-pay $0 co-pay/$75 co-pay
Penalties for Uninsured Individuals
In 2014, legal U.S. citizens who do not carry a minimum amount of health coverage will receive a penalty of $95 for adult
individuals, $285 for families or 1 percent of their taxable income, whichever is greater. Penalties will increase each year through
2016. In future years, the penalties will adjust annually.

Meritus Rules Regarding Federal
Marketplace Enrollments
Enrollment, Termination,
Special Enrollment Periods
and Plan Changes

Consumer-Initiated Application and Enrollment Changes: Change in Circumstance (CIC)
Consumers are allowed to make some limited types of changes that must be reported to the Marketplace or both the
Marketplace and the issuer. Changes which do not impact eligibility, such as an address change within the same zip code and
county, must be reported to both the issuer and the Marketplace, as an 834 will not be generated.
Rules for Special Enrollment Period changes (SEP)
If the consumer has changes to report that may affect eligibility, a new copy of their application is created, pre-populating some
information and attestations from their earlier application. The consumer completes the new application and answers questions
which determine whether the applicants for whom new information is being provided are eligible for QHP enrolment through
the FFM, and if so, whether the new information triggers a Special Enrollment Period (SEP). If the consumer is eligible for an SEP,
the consumer’s eligibility determination notice will contain SEP eligibility language. If any applications for whom information is
being provided are eligible to enroll in a QHP through a Marketplace (i.e., they are qualified individuals), the qualified individual
will proceed to the enrollment to-do list page.
If the applicant for whom new information is being provided is a qualified individual and his/her addition to coverage is based
on an event that triggers an SEP, the qualified individual will have the ability to compare and select from all QHPs available to
the applicants in the service area.
If the new information being provided does not trigger an SEP, the qualified individual will be limited to updating his or her
enrollment information in the QHP in which he or she is currently enrolled.
The qualified individual will select a new plan (or the existing plan, depending on the situation) and set the amount of APTC**
the tax household will use.
Once the qualified individual selects a plan, the system will generate an 834 termination transaction to the issuer with whom the
individual was initially enrolled, and an 834 enrollment transaction will be sent to the gaining issuer (in cases where the qualified
individual updates his or her existing enrollment, the enrollment transaction will go to the same issuer and should be treated as
a modification, rather than a new enrollment).
Type of SEP
Termination Date of Existing
Enrollment, if currently
Enrolled
Plan Selection Date Effective Date
Not eligible for an SEP or
eligible for the following SEPs:
1. Move to a new exchange
service area
2. Release from incarceration
3. Becoming lawfully present
4. Gain status as an Indian
Day before effective date.
Between the 1st and 15th day of
the month (1/1/14 and 3/15/14)
First day of the following
month
Between the 16th and last day of
the month (1/16/14 and 3/31/14)
First day of the second
following month
Loss of MEC* and gaining a
dependent through marriage
SEP
Day before effective date Any day of the month
First day of the following
month
Future loss of MEC* (loss up
to 60 days in the future)
First day of the month
following the date of the
loss of MEC
Birth, adoption, or placement
for adoption or foster care
SEP
Day the child was born,
adopted, or placed for
adoption or foster care
*Minimum Essential Coverage | ** Advanced Premium Tax Credit

Enrollee-Initiated Terminations
Enrollees have the right to terminate their coverage
in a QHP. CMS has developed new functionality on
healthcare.gov that allows enrollees to terminate
enrollments through the FFM and allows enrollees to
select an effective date of termination that can be 14
days from the present date or greater.
Upon terminating, individuals will not be able to enroll
in a new QHP unless they qualify for an SEP.
Note: Consumers who are notified that their
enrollment has been canceled by the issuer for
non-payment of premiums will need to create a new
account, complete an application and make a new
plan selection. The effective date of coverage will be
based on the date of the new plan selection under the
regular effective date schedule.
Process for enrollee-initiated terminations:
• The enrollee logs into their “My Account” on the FFM
and navigates to the “My plans programs” tab.
• The qualified individual then selects the red button
labeled “End (Terminate) All Coverage”.This will
terminate the entire enrollment group.
• This process will apply when the enrollee is single
(enrollment group of 1) or requests termination of the
entire enrollment group.
• If the enrollee would like to terminate less than a full
enrollment group, the enrollment group must use the
“report a life change” functionality.
Flexibility to Change Plans at the
Same Metal Level
CMS will now allow enrollees to change plans during
the Initial Open Enrollment Period after the effective
date of their enrollment under certain, discrete
circumstances.
This process can be used for individuals who have
paid their first month’s premium and whose coverage
is already effective may change plans provided the
change meets ALL of the following criteria:
• Change is to another plan offered by the same
issuer,
• Change is to another plan offered at the same
metal level and Cost Sharing Reduction (CSR) level,
if applicable (i.e. bronze to bronze, silver to silver,
87% actuarial value (AV) silver plan variation to 87%
AV silver plan variation, etc.),
• Change is made in order to move to a plan with
a more inclusive provider network or for other
isolated circumstances determined by CMS, and
• Change is being requested within the Initial Open
Enrollment Period.
• The individual who makes a change that meets
the criteria above must notify Meritus who will
initiate the plan change. Meritus will determine the
effective date for the plan change.
Meritus makes it easier than
ever to help you sell and
retain clients on Individual
and Small Group Affordable
Care Act (ACA) healthplans.

Meritus Rules for
New Group Business
How your employer clients can
get coverage.

Area Guideline
Employer Requirements
Participation Minimum of 2 eligible enrolling employees
Minimum of 70% participation regardless of plan selection
Valid waivers include Medicare, Champus, AHCCCS, Indian Health Services and Spousal Coverage
Individual coverage is not a valid waiver
Out-of-Area Employees 75% or more of eligible employees must reside in the Meritus Arizona service area (Maricopa County or Pima County)
Employer Contribution Minimum 50% of the employee-only premium cost.
Workers’ Compensation All employees, except those not required by law, must be covered by workers’ compensation
Newly Formed Group Meritus will accept a newly formed group provided a quarterly wage tax report is available – 2 wks of payroll is required
PEO Client Acceptance Available
PEO agreement and PEO’s wage and tax form must be provided
Employer must retain the right to hire and fire employees
Separate Companies with Common Ownership Available
Common Ownership form must be submitted
Census must show employees by company
Must have wage and tax for each company
COBRA Maximums None
Eligibility
1099 Employees Total number of employees may not exceed 20%; Sole contract with that employer
Work hour requirement equal to that of eligible W-2 employees; Employer must provide working environment
1099 affidavit must be completed and signed by employer and 1099
Dependent Age Maximum 26 years
Domestic Partners Available
Full-Time Definition Employer determines definition of full-time status; no full-time status defined as less than 20 hours a week
New Hire Waiting Periods Cannot exceed 90 days
Eligibility – Owners and Partners Must submit legal ownership documents that show affiliation with the group
Applies when owners are not on the wage and tax
Administration
Effective Dates 1st of the month
Submission Deadlines No later than the 23rd of the month prior to the effective date
Wage and Tax Report Required; unless PEO/payroll
Accept 2 weeks of payroll if wage and tax report does not exist
Any group that has been in business long enough to have a wage and tax report must submit one
For new employees not listed on the report, indicate names and dates of hire on wage and tax statement or payroll report
New hires not on the wage and tax report are required to submit two weeks of payroll
If LLC, all owners must be listed
If submitting a PEO, payroll service report required
Plan Availability
Network HMO – Meritus
PPO – Arizona Foundation; some limitations may apply.
Please check online at www.meritusaz.com
Dual Choice Options Available; No restrictions
Triple Choice Options Available; no restrictions
Rules for Group Business

Meritus Rules for SHOP plans on the Marketplace
The Small Business Health Options Program (SHOP) is a new program that simplifies the process for small business
owners buying health insurance for their employees.
SHOP was postponed for 2014, but we expect it to look something like the following:
• The SHOP Marketplace will be open to employers with 50 or fewer full-time-equivalent employees (FTEs).
• Employers control the coverage they offer and how much they pay toward employee premiums.
• Employers can compare different health plans online, helping them choose the right plan for their business.
• Employers may qualify for a small business healthcare tax credit worth up to 50% of their premium costs.
As an Agent or Broker, you may receive additional questions from employers regarding their SHOP eligibility.
Some additional requirements to consider include:
• Employers that are part of the same controlled group must count all employees at the combined entities
when answering eligibility questions.
• Employers must have at least one common-law employee; sole proprietors reporting on Schedule C cannot
form a group health plan without having a common-law employee.
• A group cannot consist solely of S corporation shareholders or spouses (S corporations are corporations
that pass corporate income, losses, deductions and credit through to their shareholders for federal tax
purposes).
• Under the common-law standard, an employer-employee relationship exists when the business has the
right to direct and control the worker.
Who is eligible for SHOP?
Eligibility Requirements for SHOP
Employer’s business must: Be located in a SHOP’s service area.
Have at least one eligible employee on payroll (generally excludes owners,
including sole proprietors, and owners’ spouses and
dependents on payroll).
Have no more than 50 full-time equivalent (FTE) employees on payroll.*
Offer coverage to all full-time employees full-time status is
defined as working more than 30 hours per week).
Eligibility Requirements for the Small Business Tax Credit
The small business must: Have an average of fewer than 25 FTE employees (based on a
40-hour work week and excluding owners, owner’s family members and
seasonal employees).
Have average annual employee wages below $50,000.
Pay a uniform percentage (at least 50%) of the cost of each
employee’s health insurance.
Offer coverage to all full-time employees (full-time status is defined as working
more than 30 hours per week).
*Part-time workers must be counted as fractions of an FTE when determining employer size, even if part-time workers are not
offered coverage, but does not include seasonal employees who work fewer than 120 days per year.

Additional information on eligibility:
• If a business grows beyond 50 FTE employees after 2014, that does not disqualify the employer for the SHOP.
• Employers will not be reassessed for eligibility in SHOP until their annual renewal.
Building Group Premiums in SHOP
Under the Affordable Care Act, premiums will be built differently than they have been in the past in many states. Under the
Affordable Care Act:
• Individual premiums reflect age, geographic location and tobacco use.
• The family premium is the sum of premiums attributable to each family member (with a limit on the number of rated
children under age 21).
• Group premiums are built from the members of the group, and each group’s rates will be based on the individual rates of
its members.
• Employers can choose to vary each employee’s premium by age (referred to as “list billing”), or use the traditional
method of charging the same amount for all employees for the same coverage. Premiums for adult dependents and
children will always reflect a per-member calculated rate and will not be averaged.
Enrollment and Annual Renewal in SHOP
For the employer to be able to offer coverage to employees, at least 70% of the total number of employees must participate
and sign up for coverage (excluding employees who have other creditable coverage, such as another group plan or public
health insurance). If an employer offers affordable coverage to an employee, the employee is ineligible for premium tax credits
in the individual Marketplace. Employer-sponsored insurance is considered unaffordable if an employee’s share of the self-only
coverage is more than 9.5% of the worker’s household income.
Under the Affordable Care Act, employers participating in SHOP are not required to offer dependent coverage in 2014.
Dependents covered through a SHOP plan are ineligible for premium tax credits and cost-sharing reductions in the individual
Marketplace as well.
An employer must submit the application for SHOP with the first month’s premium by the 15th of the month for coverage to
begin the first of the following month.
Annual Renewal consists of:
• Employers are notified 90 days ahead of renewal.
• Employers have 30 days to revisit health coverage decisions from the previous year and make changes if desired.
• Employees then have 30 days to make a health plan selection.
• Employers must submit the final renewal submission by the 15th of the month, prior to the end of the plan year.
• Employees who do not confirm or switch health plans will be automatically re-enrolled in their existing plans (assuming
those plans still exist in the current form).
New hires throughout the year will be effective based on the waiting period that the employer sets during the initial application
process. The length of the new hire waiting period cannot exceed 90 days and can only be changed during the employer’s
annual renewal.
Under certain circumstances, a Special Enrollment Period (SEP) may be triggered outside of the Annual Open Enrollment
Period. In most cases, SEPs last for 30 days from the date of the triggering event. Individuals who do not take action by this
deadline will have to wait until the annual open enrollment period to join a plan.

A step-by-step guide
to help you through
the application process.
The next few pages contain instructions on how Brokers
can process a quote or application using a Meritus
populated link, or the Meritus Broker Sales Portal at
MeritusAZ.com for Individuals and Groups.

The Quote and Enrollment Process
To quote and enroll Individual or Group plans, go to the Meritusaz.com
website, and enter the Broker tab and select Broker Sales Portal to login,
or use your Meritus populated broker link. After you access the Broker
Portal, you will see the online Meritus Dashboard where you can select the
Individual, Group or Tools tabs.
Individual Enrollment Checklist
1. Brokers can use the Meritus Sales Portal to quote, verify Marketplace subsidy eligibility
and send quotes to clients.
2. Using the Meritus Direct enrollment tool, brokers can receive APTC information for their clients,
verify eligibility with Healthcare.gov, and then complete the enrollment on the Meritus broker
sales portal.
3. Consumers or brokers can use Meritus broker populated links to Shop and Enroll for off
marketplace plans offered by Meritus.
4. Make first month’s premium payment via:
• Credit Card
• ACH Transfer
• Personal Check
Individual Plans
Step 1 – Primary Subscriber and ACA Eligibility
From the main Meritus Dashboard select Tools ACA Individual Calculator to initiate the Individual quote process. The
ACA Calculator will determine the eligibility for premium assistance credits, cost-sharing reductions and shared-
responsibility penalty.
To initiate the New Quote process using the ACA Calculator, you will need to enter primary subscriber and any dependents
information for:
• Gender, tobacco use, date of birth (Note: tobacco usage will carry an additional 10% premium.)
• Service area, ZIP code and effective date
Note: applications submitted from the 1st to the 15th of the month will be effective the 1st of the following month.
Applications submitted on or after the 16th will be effective the 1st of the second following month. For example,
applications submitted 1/1/14 – 1/15/14 coverage will be effective on 2/1/14, whereas applications submitted 1/16/14
– 1/31/14 coverage will be effective on 3/1/14.
• Annual household income and size.
• Determination whether affordable employer coverage is available or there is a certificate of exemption from the public
Marketplace.
The ACA Individual Calculator will present estimates and show results for:
• Individual/Family Profile (household income and household size with % of federal poverty level) – option to update
profile if needed (“what if”)
• Shared Responsibility (tax penalty) – based on profile
• Coverage and Assistance Eligibility – based on profile

Step 2 – Who’s Covered
You can choose “Update Profile” to enter additional
dependent information. Then continue with Get a Quote to
change and update Who’s Covered if additional coverage
is needed to Add Spouse or Add Dependents. For each
additional individual to be covered, you will need to provide
information for gender, tobacco use and birth date.
After updating or confirming Who’s Covered, you will be
presented with a list of eligible plans for the Individual
subscriber and household. You may further Filter Results to
customize plan selection views for your clients based on:
• Benefit (metal) level
• Premium range
• Deductible
• Out of pocket (OOP)
• Office visit co-pays
• Lifestyle benefits
• HSA compatibility
• Provider network type
Step 3 – Select and Compare Plans
Compare plans by checking the box next to each plan
that you would like to compare and clicking the Compare
button on the screen to display results. You can compare up
to four plans at any one time. Select the desired plan(s) for
quoting by clicking on Select or for initiating enrollment of a
final plan with an Application, select Continue button.
Step 4 – Proposal and Application
The Proposal screen will appear and allow you to:
• Save the proposal for work at a later date
• Email the proposal or save and send as a pdf
• Securely send you and your client’s account information
to Healthcare.gov
• Determine eligibility, and return to the Meritus website
to select and complete enrollment
To complete the sections for application, required
information will be needed for each person to be covered:
primary home address, phone number(s) and contact
information. In addition, information will be asked regarding
medical and other insurance, proof of residency, family
member application and Health Savings Account election.
Step 5 – Payment and Electronic Signature
Next step in the Individual Application process is the
selection of method for Initial Premium Payment and
information needed for initiating Automatic Bank Payments
for monthly premiums.
After reviewing sections and completing the Electronic
Signature (E-Sign) for Applicant’s Authorization and
Representation, the final step is to Submit Application.

Group Plans
Step 1 – Company Information and ACA Group Calculator
To quote Meritus Group plans, go to the meritusaz.com website
and enter the Broker Portal to login or use your Meritus populated
broker link. At the Meritus Dashboard, select Tools ACA Group
Calculator and enter requested information for:
• ZIP code
• Number of full-time employees
• Total part-time employees
• Total wages for the year
• Non-profit – yes or no
The ACA Group Calculator will display results for:
• Company overview (equivalent full-time employees, average
annual wage)
• 2015 Shared Responsibility (subject to)
• Tax credit, if eligible
Note: To qualify, an employer must contribute 50% of the employee’s
premium of the lowest cost plan available in SHOP.
Step 2 – Create Group Quote
Next, Get a Quote launches the Company Information screen where
you will enter and review/update defaulted (from step 1) information
for:
• Company name
• ZIP code
• Full-time employees
• How many part-time hours company has per year
• Total wages for the year
• Non-profit – yes or no
• Date coverage will begin
Step 3 – Enter Company Employees and Profiles
Next, the Company Employees screen will launch. Here, you will
need to provide information about the employees who will be
offered coverage. Simply enter additional employee(s) by clicking
on the Add Employee button. Add all the employees that need
coverage and fill out all information for each employee:
• Gender
• Date of birth
• Salary
• ZIP code
• Employee class as defined for the Company (e.g. exempt, hourly,
manager)
For each employee entered for coverage, you will need to select Edit
Profile, which asks for:
• Employee name, gender, date of birth
• Employee address and ZIP code
• Spouse and dependents covered:
gender, date of birth
Employees list can also be entered with the import of a formatted
Excel or .csv file – an example of the upload file format is available
online.
Step 4 – Select Contribution and Benefit Choices
Next, the Contributions screen will launch and you will be asked to
enter the monthly employer contribution for the Employee, De-
pendents, and the Annual HSA Amount for each Employee Class
defined.
Note: Total contribution per year will calculate when you enter the
monthly amount for Subscriber and Family. It is displayed next to the
monthly amount. You can also click on the Switch Contribution to
PERCENT button to switch employer contribution to percent or click
on the Switch Contribution to DOLLAR button to switch employer
contribution back to dollar amounts.
Once Employer Contributions have been entered, the Benefit Choic-
es screen will launch next. If more than one benefit type is available,
choose a benefit by clicking on the icon of the benefit of your choice
and then click Next. Note: the benefit type that you clicked on is
highlighted.
1. Fill out Employee census
2. Complete Application
3. Provide Wage and Tax report
4. Fill out and submit Employee Enrollment Forms
5. Make first month’s premium payment
Group Enrollment Checklist

Step 5 – Select Plan Choices
The Plan Choices screen will appear, showing all plan choices
that are available.
Here, you can do the following:
• Filter results based on benefit level, premium, family name,
deductible, out-of-pocket limits, office visits or
prescription drugs.
• Select plans for comparison. The number of
plans selected will display next to the shopping cart icon
and the plan name will display below the shopping cart.
• Compare up to four plans at a time by checking the Add
to Compare box under each plan. Select some or all plans
to prepare a quote. Broker or employer can choose up to
three plans to offer to their employee’s to choose from.
Note: The selected plans’ names are shown at the top left of the
screen under Selected Items.
Step 6– Start a Group Proposal and Application
After a plan has been selected, you can create a Group
Proposal, which can be:
• Saved for later review 
• Sent as a proposal to the employer as an email or as a pdf
After a Group Proposal has been created, you can start a Group
Application by selecting the company and requesting Apply.
The Apply screen will require information for:
Company legal name and DBA name
• Tax ID and type of organization (e.g. Corporation)
• Non-profit designation
• SIC code
• Date business established
Enrollment information will be required for the date coverage
begins, start date and length of the Enrollment Period.
Other information required in the application process includes:
Eligibility information:
• number of active eligible employees;
• taking coverage;
• waiving coverage;
• on Medicare;
• or on COBRA.
Company contact information:
• Name, address, phone, email is entered for primary
contacts; and
• Primary (company) address, including any required
documents (e.g., Wage and Tax file) for upload.
Choose “Submit” once you have reviewed the Benefits Summary
and Applications Summary display, which shows all sections
required for the application as complete.
Meritus will review the group to ensure eligibility criteria are met.
Once the group is approved the employer will receive an email
to set up their employer account where they review and approve
employee enrollments. A broker can also do this on behalf of the
employer.
At the close of open enrollment, once the employer has
approved all employees, the employer or broker will submit the
enrollments to Meritus and submit initial payment.

Affordable coverage that
Arizonans can count on.
Plans designed
to meet all needs.
With a focus on health and wellness, our plans are strong, competitive benefit
packages that are designed to provide Arizonans with the kind of coverage they
want and deserve. This includes access to affordable, quality care, as well as added
benefits offering coverage for prescription drugs, vision, dental and acupuncture.

*Meritus Plans and Rates
Covered Benefits
Once enrolled, employees will receive a Sum-
mary of Benefits and Coverage and an Individual
Comprehensive Health Policy including information
about:
• Benefits that are covered and not covered
• Co-payments and other charges for which
they are responsible
They will also have access to their own secure area
of the online Member Portal to find this information.
Basic List of Benefits*
• Primary care doctor visits for wellness
or to treat an injury or illness
• Specialist doctor visits
• Preventive care, screening and immunization
• Prescription drugs
• Hospitalizations
• Emergency room services
• Urgent care services
• Maternity care services
• Lab and X-ray services
• Mental health, behavioral health
and substance abuse services
• Home healthcare
• Rehabilitation services
• Habilitation services
• Skilled nursing facilities
• Durable medical equipment
• Hospice services
• Eye exams, glasses and dental
services for children
• Hearing aids
Non-Covered Benefits
Benefits not included in your health insurance plan
would include any service that is not medically
necessary.
What is medically necessary?
These are services which will be covered to
prevent, diagnose, correct, improve or cure
conditions that endanger life, cause pain, result
in illness or could cause or worsen a handicap or
physical defect. In addition, these services must
be appropriate for the specific health issue or
when no other equally effective care is an option.
Other services not covered by your Meritus Health
Insurance Plan include, but are not limited to:
• Elective cosmetic surgery
• Experimental and/or investigational drugs,
procedures or equipment
• Infertility treatment
• Weight loss programs
• Prescriptions not on our list of covered
medications, unless approved by Meritus
The lists above are not complete lists. If your
clients have questions about benefits, please
call Customer Care at 602.957.2113 or toll-free at
1.855.755.2700. TTD/TTY users should call 7.1.1.
A Range of Options
Some plans offer lower monthly premiums that
may charge more out-of-pocket fees for care,
while others offer higher-premium plans that
cover more costs when members need care.
Others fall in between.*Meritus benefits and services are
offered by Meritus Health Partners
- HMO and Meritus Mutual Health
Partners - PPO.

The Meritus Plans
Meritus Plans are separated into four health plan categories
consistent with the Federal Marketplace – Bronze, Silver, Gold,
and Catastrophic – (Meritus does not offer a Platinum level plan)
based on the percentage the plan pays of the average overall
cost of providing essential health benefits to members. The plan
category chosen affects the total amount Meritus members will
likely spend for essential health benefits during the year. The
percentages Meritus will spend, on average, are 60% (Bronze),
70% (Silver), and 80% Gold. This isn’t the same as coinsurance,
in which you pay a specific percentage of the cost of a specific
service.
Our HMO products are structured to provide more predictable
out of pocket costs and fixed out of pocket costs for copays. Our
HMO network is not as broad as our PPO network. The HMO
products include zero copays for primary care in most plans and
alternative therapies (naturopathy, acupuncture and massage
therapies).
Our PPO products are designed in a more traditional sense,
with coinsurance amounts and a very broad network (Arizona
Foundation for Medical Care*). The PPO products include
zero coinsurance for primary care in most plans as well as the
alternative therapies**.
Catastrophic plans are designed to provide coverage at high
levels and are only available to younger members.
Individual Plans
Type Gold Silver Bronze Catastrophic
HMO Meritus Healthy Together Gold
HMO Meritus Cooperatively Together Gold
PPO Meritus Healthy Gold
PPO Meritus Clear Choice Gold
PPO-HSA Meritus Smart Choice Gold
HMO Meritus Healthy Together Silver
HMO Meritus Cooperatively Silver
PPO Meritus Affordable Silver
PPO Meritus Reliable Silver
PPO-HSA Meritus Secure Silver
HMO/
Neighborhood
Meritus Neighborhood
Maricopa Silver-MIHS
HMO/
Community
Meritus Community Network-
Phoenix/Banner
HMO/
Community
Meritus Community Network-
Pima/Carondelet
HMO Meritus Premium
Saver Bronze
PPO Meritus Saver Choice
Bronze
PPO-HSA Meritus Lifestyle
Choice Bronze
Catastrophic-
PPO
Meritus
Confident
Choice
* Select the Find a Provider option at Meritusaz.com to see a complete list of physicians and facilities.
**Alternative therapies are available on certain Individual and Group plans, check outlines of Coverage for details.

Group Plans
HMO Gold Silver Bronze
Meritus Gold Healthy
Meritus Gold Coopertively
Meritus Silver Healthy
Meritus Silver Together
Meritus Bronze Healthy Saver
PPO Gold Silver Bronze
Meritus Gold Healthy Choice
Meritus Gold Clear Choice
HSA Meritus Gold Smart Choice
Meritus Silver Affordable
Choice
Meritus Silver Affordable
HSA Meritus Silver Secure
Meritus Bronze Saver
HSA Meritus Bronze Lifestyle
Individual Cost Sharing Plans
Type Silver-Cost Sharing Reductions CSR%
HMO
Meritus Healthy Together Silver
73
87
94
HMO
Meritus Cooperatively Silver
73
87
94
PPO
Meritus Affordable Silver
73
87
94
PPO
Meritus Reliable Silver
73
87
94
PPO-HSA
Meritus Secure Silver
73
87
94
HMO/Neighborhood
Meritus Neighborhood Network Maricopa Silver - MIHS
73
87
94
HMO/Community
Meritus Community Network - Phoenix/Banner
73
87
94
HMO/Community
Meritus Community Network - Pima/Carondelet
73
87
94

Title Page(s)
INDIVIDUAL HMO Plans
Meritus Neighborhood Network Maricopa Silver* 31-34
Meritus Community Network - Phoenix (Banner Health Network)* 35-38
Meritus Community Network - Pima / Carondelet Health Network* 39-42
Meritus Healthy Together Silver* 43-46
Meritus Cooperatively Silver* 47-50
Meritus Healthy Together Gold 51
Meritus Cooperatively Together Gold 52
Meritus Premium Saver Bronze 53
INDIVIDUAL PPO Plans
Meritus Affordable Silver* 54-57
Meritus Reliable Silver* 58-61
Meritus Healthy Gold 62
Meritus Clear Choice Gold 63
Meritus Saver Choice Bronze 64
Meritus Confident Choice 65
INDIVIDUAL HSA – PPO Plans
Meritus Smart Choice Gold 66
Meritus Lifestyle Choice Bronze 67
Meritus Secure Silver* 68-71
All Meritus group plans are also available through the Arizona Small Business Association (ASBA)
GROUP HMO Plans
Meritus Gold Healthy 72
Meritus Gold Cooperatively 73
Meritus Silver Healthy 74
Meritus Silver Together 75
Meritus Bronze Healthy Saver
GROUP PPO Plans
Meritus Gold Healthy Choice 77
Meritus Gold Clear Choice 78
Meritus Silver Affordable Choice 79
Meritus Silver Reliable 80
Meritus Bronze Saver 81
GROUP HSA – PPO Plans
Meritus Gold Smart Choice 82
Meritus Silver Secure 83
Meritus Bronze Lifestyle 84
AVAILABLE PLANS – Table of Contents
*Cost-Share Plans Available

*Meritus Neighborhood Network Maricopa Silver
HMO plan for customers who want more cost predictability; this plan offers a wide range of services at predictable out-of-pocket costs.
Benefits Costs
Deductible- per calendar year Individual $5,000 | Family $10,000
Out-of-pocket maximum (Includes deductible and/or co-pay) Individual $6,350 | Family $12,700
Inpatient Hospital (Per admit co-pay) $1,000 co-pay after deductible
Outpatient Surgery - ASC $400 co-pay per surgery
Outpatient Surgery - Hospital $500 co-pay per surgery
ER Visit, no admit $500 co-pay per visit
Office Visit PCP / Non-PCP $0 PCP / $100 Non-PCP
Preventive $0 co-pay
Ambulance $0 co-pay
Urgent Care Visit $100 co-pay per visit
**Outpatient / Office Psychiatric SA Visits $0 co-pay 1st, 2nd and 3rd visit; then $100 co-pay for each visit
Radiology - General - Office / Outpatient $100 Office / $150 Outpatient per test
1
Radiology - CT / MRI / PET-Office / Outpatient $300 Office / $600 Outpatient1
after deductible, per scan
Pathology / Lab-Office / Outpatient $100 Office / $100 Outpatient, per test
Glasses / Contacts - Pediatric $50 co-pay per item; 1 item per year
Vision Exam - Pediatric $50 co-pay per exam; 1 exam per year
Hearing Speech Exams $50 co-pay per exam; 1 exam per year
PT / OT / ST Visit $100 co-pay; per visit
Home Health Visits $50 co-pay; per visit, limited to 42 visits per year
DME / Supplies / Prosthetics $50 co-pay; per item
Rx- 90 day supply x3
Maintenance / Non-Maintenance Drugs- 30 Day Retail
Rx deductible $250
Generic (not subject to Rx deductible) Maintenance $0 co-pay | Non-Maintenance $20 co-pay
Preferred Brand $72 co-pay; after deductible
Non- Preferred Brand $150 co-pay; after deductible
Specialty 40% co-insurance; after deductible
Therapy
Acupuncture - Limited to 12 visits Benefit Not Available
Therapeutic Massage Therapy - Limited to 12 visits Benefit Not Available
Naturopathy - Limited to 12 visits Benefit Not Available
Prevention
Gym Membership Reimbursement Benefit Not Available
Pediatric Dental
Class I 0% co-insurance
Class II 45% co-insurance
Class III 65% co-insurance
Orthodontia 50% co-insurance
Adult Dental
FQHC Adult Dental Covered? Yes
Individual HMO
*Meritus products and services are provided through Meritus Mutual Health Partners - PPO and Meritus Health Partners - HMO. A licensed health insurance producer may contact
you to discuss enrollment in a Meritus health plan. Meritus Mutual Health Partners - PPO and Meritus Health Partners - HMO are licensed only in Arizona and are Qualified Health
Plan issuers in the Health Insurance Marketplace.
**1st 3 MH / SA visits at $0 cost sharing for Gold and Silver Plans (does not apply to HSAs).
1
Deductible applies to Outpatient Radiology - CT / MRI / PET.
This benefit table is only a brief summary of the major benefits. This benefit table is only a brief summary of the major benefits. For more information, please refer to your
Schedule of Benefits, your Compreshensive Health Insurance Policy, or call Meritus.

*Meritus Neighborhood Network Maricopa Silver (CSR73)
Cost Share - Maricopa Integrated Health System Network
Benefits Costs
Office Visit PCP / Non-PCP $0 PCP / $75 Non-PCP per visit
Ambulance $0 co-pay
**Outpatient / Office Psychiatric SA Visits $0 co-pay 1st, 2nd and 3rd visits; then $50 copay per visit
Radiology- General- Office / Outpatient $75 Office / $100 Outpatient; per test
1
Radiology- CT / MRI / PET-Office / Outpatient $250 Office / $500 Outpatient1
after deductible; per scan
Pathology / Lab-Office / Outpatient $75 Office / $100 Outpatient
Home Health Visits $50 co-pay per visit; limited to 42 times, per year
Maintenance / Non-Maintenance Drugs - 30 Day Retail
Rx deductible $0
Generic Maintenance- $0 copay | Non-Maintenance- $15 copay
Preferred Brand $65 co-pay
Non- Preferred Brand $150 co-pay
Specialty 40% co-insurance
Therapy
Prevention
Pediatric Dental
Adult Dental
1
Individual HMO

Benefits Costs
Deductible - per calendar year Individual $0 | Family $0
Inpatient Hospital (Per admit co-pay) $500 co-pay
Ambulance $0 co-pay
**Outpatient / Office Psychiatric SA Visits $0 co-pay 1st, 2nd and 3rd visit; then $25 co-pay per visit
Radiology- CT / MRI / PET-Office / Outpatient $125 Office / $250 Outpatient; per scan
Pathology / Lab-Office / Outpatient $25 Office / $50 Outpatient; per test
Home Health Visits $25 co-pay; per visit; limited to 42 times per year
Rx deductible $0
Generic Maintenance $0 co-pay | Non-Maintenance $10 co-pay
Therapy
Prevention
Pediatric Dental
Adult Dental
Individual HMO

Benefits Costs
Deductible- per calendar year Individual $0 | Family $0
Out-of-pocket maximum (Includes deductible and /or co-pay) Individual $2,250 | Family $4,500
Outpatient Surgery - ASC $65 co-pay; per surgery
Outpatient Surgery - Hospital $150 co-pay; per surgery
ER Visit, no admit $85 co-pay; per visit
Ambulance $0 co-pay
Urgent Care Visit $15 co-pay
**Outpatient / Office Psychiatric SA Visits $0 co-pay 1st, 2nd and 3rd visit; then $10 co-pay per visit
Radiology- CT / MRI / PET-Office / Outpatient $40 Office / $125-Outpatient; per scan
Home Health Visits $10 co-pay per visit; limited to 42 visits per year
Rx deductible $0
Therapy
Acupuncture- Limited to 12 visits Benefit Not Available
Therapeutic Massage Therapy- Limited to 12 visits Benefit Not Available
Naturopathy- Limited to 12 visits Benefit Not Available
Prevention
Pediatric Dental
Adult Dental
Individual HMO

*Meritus Community Network - Phoenix (Banner Health Network)
Benefits Costs
Deductible - per calendar year Individual $5,000 | Family $10,000
Office Visit PCP / Non-PCP $0 PCP / $100 Non-PCP; per visit
Ambulance $0 co-pay
Urgent Care Visit $100 co-pay; per visit
**Outpatient / Office Psychiatric SA Visits
$0 co-pay 1st, 2nd and 3rd visit; then $100 co-pay per
visit
Radiology- General - Office / Outpatient $100 Office / $150 Outpatient; per test
1
Rx deductible $250
Generic (not subject to Rx deductible) Maintenance $0 copay | Non-Maintenance $20 copay
Preferred Brand $72 co-pay; after deductible
Non- Preferred Brand $150 co-pay; after deductible
Specialty 40% co-insurance; after deductible
Therapy
Prevention
Pediatric Dental
Adult Dental
1
Individual HMO

Benefits Costs
Deductible per calendar year Individual $2,200 | Family $4,400
Ambulance $0 co-pay
**Outpatient / Office Psychiatric SA Visits $0 co-pay for 1st, 2nd and 3rd visit; then $50 co-pay per visit
Radiology - General Office / Outpatient $75 Office / $100 Outpatient; per test
1
Home Health Visits $50 co-pay; per visit; limited to 42 visits per year
Maintenance / Non-Maintenance Drugs 30 Day Retail
Rx deductible $0
Therapy
Acupuncture- Limited to 12 visits Benefit Not Available
Therapeutic Massage Therapy- Limited to 12 visits Benefit Not Available
Naturopathy- Limited to 12 visits Benefit Not Available
Prevention
Pediatric Dental
Adult Dental
*Meritus Community Network Phoenix Banner Health Network (CSR73)
1
Individual HMO

Benefits Costs
Ambulance $0 co-pay
Radiology - General Office / Outpatient $25 Office / $50 Outpatient; per test
Radiology - CT / MRI / PET-Office / Outpatient $125 Office / $250 Outpatient; per scan
Home Health Visits $25 co-pay per visit; limited to 42 times per year
Rx deductible $0
Generic Maintenance $0 copay | Non-Maintenance $10 copay
Specialty 40% coinsurance
Therapy
Prevention
Pediatric Dental
Adult Dental
Individual HMO

Benefits Costs
Ambulance $0 co-pay
Radiology- General - Office / Outpatient $10 Office / $25 Outpatient; per test
Radiology- CT / MRI / PET-Office / Outpatient $40 Office / $125 Outpatient; per scan
PT / OT / ST Visit $10 co-pay; per exam
Rx deductible $0
Therapy
Prevention
Pediatric Dental
Adult Dental
Individual HMO

Benefits Costs
Ambulance $0 co-pay
Radiology - General- Office / Outpatient $100 Office / $150 Outpatient; per test
1
Rx deductible $250
Generic (not subject to Rx deductible) Maintenance $0 co-pay | Non-Maintenance $20 co-pay
Preferred Brand $72 co-pay, after deductible
Non- Preferred Brand $150 co-pay ,after deductible
Specialty 40% co-insurance, after deductible
Therapy
Prevention
Pediatric Dental
Adult Dental
*Meritus Community Network - Pima / Carondelet Health Network
1
Individual HMO

Benefits Costs
Ambulance $0 co-pay
**Outpatient / Office Psychiatric SA Visits $0 co-pay 1st, 2nd, 3rd visit; then $50 co-pay per visit
1
DME / Supplies / Prosthetics $50 co-pay; per visit
Rx deductible $0
Specialty 40% coinsurance
Therapy
Prevention
Pediatric Dental
Adult Dental
*Meritus Community Network - Pima CSR73 / Carondelet Health Network
1
Individual HMO

*Meritus Community Network - Pima CSR87/Carondelet Health Network
HMO plan- for customers who want more cost predictability, our HMO plan offers a wide range of services at predictable out-of-pocket costs.
Benefits Costs
Ambulance $0 co-pay
**Outpatient / Office Psychiatric SA Visits $0 co-pay for 1st, 2nd and 3rd visits; then $25 co-pay per visit
Rx deductible $0
Therapy
Prevention
Pediatric Dental
Adult Dental
Individual HMO

Benefits Costs
Inpatient (Per admit co-pay) $150 co-pay
Ambulance $0 co-pay
Rx deductible $0
Generic Maintenance $0 co-pay | Non-Maintenance $5 coay
Therapy
Prevention
Pediatric Dental
Adult Dental
*Meritus Community Network - Pima CSR94/Carondelet Health Network
Individual HMO

*Meritus Healthy Together Silver
Benefits Costs
Deductible- per calendar year Individual $2,700 | Family- $5,400
Inpatient (Per admit co-pay) $1,000 co-pay after deductible
Office Visit- PCP / Non-PCP $0 PCP / $75 Non-PCP; per visit
Ambulance $0 co-pay
1
Rx deductible $0
Therapy
Acupuncture - Limited to 12 visits $20 co-pay; per visit
Therapeutic Massage Therapy - Limited to 12 visits $20 co-pay; per visit
Naturopathy - Limited to 12 visits $20 co-pay; per visit
Prevention
Gym Membership Reimbursement up to $25 per month maximum
Pediatric Dental
Adult Dental
1
Individual HMO

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