Meritus 2016 Broker Handbook

2016 Broker Handbook
Your resource to plans, services and support
for groups, individuals and family plans.
for broker use only

meritusaz.com • Broker Use Only 2016 MERITUS BROKER MANUAL | 1
Working together to improve
healthcare for Arizona
We are excited about the third year of Open Enrollment and the opportunity to
bring new innovations to the healthcare marketplace in Arizona.
We remain dedicated to helping you serve your clients through responsive
service, user-friendly technology and accessible information. This handbook is
one of many tools you can expect from us. Use it as a resource to learn about
us, the Marketplace, our plans, services and more.
This year, Meritus has invested in technology enhancements that will allow for
a more efficient management of member records and data, while giving us
the tools necessary to meet the needs of our growing membership.
Working together, we can help Arizonans achieve better health through
the kind of care they demand and deserve. We invite you to join us as we
work together with brokers, healthcare professionals, organizations and our
members to provide individuals, families and businesses with a wide array of
affordable plans and benefits.
We invite you to become part of the effort - Meritus – Together for better health.
Questions? We’re here for you.
meritusaz.com | 855.755.2700 | 602.957.2113
Table of Contents
About Meritus. . . . . . . . . . . . . . . . . . . 2
Meritus Provider Networks. . . . . . . . . 5
Summary of Pharmacy Benefits. . . . 19
Understanding the Marketplace. . . 21
Rules of Enrollment. . . . . . . . . . . . . . 25
Plans to Meet All Your Needs. . . . . 27
Individual and Family. . . . . . . . . . . . 31
Enrollment Guide. . . . . . . . . . . . . 33
Individual Plans. . . . . . . . . . . . . . . 43
Exclusions and Limitations . . . . . 59
Individual Rates. . . . . . . . . . . . . . . 65
Group Plans. . . . . . . . . . . . . . . . . . . . 77
Underwriting Guidelines. . . . . . . 78
Group Enrollment Guide. . . . . . . 81
Group Plans. . . . . . . . . . . . . . . . . 101
Broker Resources and Support. . . 113November 2015
Together for better health
Meritus products and services are provided through Meritus Mutual Health Partners (a PPO) and
Meritus Health Partners (an HMO).

2 | 2016 MERITUS BROKER MANUAL 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, Meritus is a 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 to create better access to affordable, quality
healthcare choices for Arizonans. The Meritus team, comprised of experienced
leaders in healthcare and the health insurance industry, brings a broad range of
expertise and innovation to our efforts.
ABOUT MERITUS

About Meritus
How we’re different
We want our members to utilize their insurance
coverage with confidence, helping them to be
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 both serve and have the opportunity to
vote on the Board of Directors, we answer to and
focus on our members. We reinvest our excess
revenue for the good of our members, helping
to control premiums, improve benefits, promote
wellness and encourage preventive care.
“Putting our members first” means:
• Affordable healthcare that Arizonans can
count on.
• Focusing on maximizing consumer value,
not shareholder value.
• Select innovative plans that include coverage for
Naturopathy, Acupuncture, Massage Therapy
and reward members for keeping healthy like
reimbursement for a gym membership.
• Building strong broker partnerships.
What’s a CO-OP?
CO-OPs (Consumer Operated and Oriented
Plans) exist to serve their members. A CO-OP
must use excess revenue to support members
through premium control, expanded benefits and
innovations in service models. Rather than focusing
on money-saving short cuts, we focus on quality
care and services for our members. As a non-profit
organization, we are prohibited by law from ever
being sold or re-organized as a for-profit corporation.
Meritus is Arizona-owned and operated, with
headquarters in Tempe.
What’s New for 2016?
• New Pharmacy Tier Structure
• Improved Benefits
- Lab, pathology, radiology copay
on a per visit basis.
- ER copay waived in the event
of an accident.
• Pinal County Expansion - Meritus HMO
Complete and Meritus HMO Banner
Networks available in Pinal County.
• Mohave County - Meritus HMO Mohave
Network name changed to Meritus
HMO WARMC; Meritus HMO Complete
Network added.
• Individual PPO Plans - Not offered ON
Exchange. Only Silver and Bronze levels
offered OFF Exchange.
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 consumer
operated and oriented plan (CO-OP)
• Certified by the Federal Government as
a Qualified Health Plan
ABOUT MERITUS

CO-OPs under the ACA
The CO-OP program under the
Patient Protection and Affordable
Care Act (ACA) is intended
to foster the creation of new
consumer-governed, private,
non-profit health insurance issuers.
Arizona’s insurance market is
dominated by large commercial
carriers; there is a need for
competition and innovation. As a
healthcare cooperative established
under the ACA, Meritus is a new
and different way of providing
healthcare coverage.
The success of other health plan
CO-OPs, such as Health Partners
and Group Health, have served
as a model for the design and
development of Meritus. Our
predecessors have demonstrated
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 (QHP).
Meritus 2016 product offerings
• Our HMO and PPO products remain structured around copays for
most services, no hidden fees and predictable out-of-pockets costs.
• We have plans with a range of deductibles and copays.
• Revised Pharmacy benefit tiers. Two levels of Generics: Adherence
Generic Drugs and Other Generic Drugs. Adherence Generic
Drugs includes those medications which promote heart health,
treat high blood pressure, high cholesterol, along with oral diabetic
medication.
• Complementary and alternative medicine benefits are included
in all of our PPO plans and in our Platinum and Gold HMO plans.
This includes Naturopathy, Acupuncture, Therapeutic Massage and
rewards for staying healthy, including up to $25 per month gym
membership reimbursement.
Meritus Financial Information
• Meritus is a Qualified Health Plan licensed as Meritus Health
Partners (HMO) and Meritus Mutual Health Partners (PPO) in
Arizona.
• Meritus is subject to the same reserve requirements as all carriers in
the state of Arizona.
• Arizona Department of Insurance requires all carriers to maintain
at least 300% risk based capital to ensure solvency – CMS requires
Meritus to maintain 500% risk based capital – an even higher
standard!
• Meritus is supported by a $90 million loan from CMS to ensure its
capital position is strong.
• Meritus has reinsurance coverage from the federal government up
to $250K per claim.
• Meritus also has commercial reinsurance coverage in excess of the
federal limits.
ABOUT MERITUS

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 is 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 better.
Meritus Provider Networks

Meritus Provider
Network Design
Building better health in
communities through our
Provider Networks.
HMO
• 7,200 physicians
• 37 Acute Hospitals
and 7 Behavioral
Health Hospitals
PPO
• 11,700 physicians and
mid-level providers
• 68 Acute Hospitals
and 14 Behavioral
Health Hospitals
Source: Arizona Foundation
Source: Meritus Contracted Network
Meritus built our
Complete HMO
network of doctors
with the help from
our primary care
physicians. Working
in partnership with
these PCPs, we
reached out to other
physicians, specialists
and hospitals to
create a broad and
complimentary
HMO network for
our members.
HMO Networks ONLY
There are no out-of-network benefits for an HMO. The only out-
of-network services are for emergencies or for services which are
arranged by Meritus for the member due to provider network
coverage.
Maricopa County
Meritus Complete HMO Network. . . . . . . . . . . . . . . . . . 7
Meritus HMO Abrazo Network . . . . . . . . . . . . . . . . . . . . 9
Meritus HMO Banner Network . . . . . . . . . . . . . . . . . . . 10
Meritus HMO MIHS Network . . . . . . . . . . . . . . . . . . . . 11
Mohave County
Meritus HMO WARMC Network. . . . . . . . . . . . . . . . . . 11
Pima and Santa Cruz Counties
Meritus HMO Pima Network. . . . . . . . . . . . . . . . . . . . . 12
Pinal County
Meritus HMO Banner Network . . . . . . . . . . . . . . . . . . . 10
Meritus Complete HMO Network
Page
PROVIDER NETWORKS

PROVIDER NETWORKS
Hospitals/Facilities
• Carondelet Health
Network
• Tucson Medical
Center
Pima and Santa
Cruz Counties
Nogales
Holy Cross Hospital
• HonorHealth
Network
• Banner Health
• Abrazo Health
• Maricopa Medical
Center
Maricopa County

Bullhead City
Fort
Mohave
Lake Havasu City
Kingman
Peach Springs
Dolan Springs
Colorado City
Wikieup
Meadview
Needles
• Western Arizona
Regional Medical
Center
• Havasu Regional
Medical Center
• Valley View Medical
Center
Mohave County
Maricopa
Florence
Mammoth
Arizona City
Apache Junction
Casa Grande
Kearny
Coolidge
Dudleyville
SanTan
Valley
Cold Canyon
Oracle
• Banner Hospitals
• Banner Clinics
• Banner Children’s
Clinics
Pinal County
PROVIDER NETWORKS

Other Meritus HMO Networks
In order to offer low premiums and quality benefits to our members, Meritus also
created other HMO network options in partnership with some of the best hospital
based healthcare systems in Arizona.
• Meritus HMO MIHS Network - Maricopa Integrated Healthcare Systems
• Meritus HMO Banner Network - Banner Health System
• Meritus HMO Pima Network - Carondelet Health Network
• Meritus HMO Abrazo Network - Abrazo Health System
• Meritus HMO WARMC Network - Western Arizona Regional Medical Center
Meritus HMO Abrazo Network
Maricopa County
Three popular community network plans from 2014 and 2015 will continue to be
offered in 2016:
• Meritus Neighborhood Network Silver HMO MIHS
• Meritus Community Network Silver HMO Banner
• Meritus Community Network Silver HMO Pima
These are the only three individual plans which include Pediatric Dental.
Hospitals/Networks
• Arizona Heart
Hospital
• Arizona Heart Institute
• Arrowhead Hospital
• Maryvale Hospital
• Paradise Valley
Hospital
• Phoenix Baptist
Hospital
• West Valley Hospital
PROVIDER NETWORKS

Meritus HMO Banner Network
Serving both Maricopa and Pinal Counties
• All of the Banner
Hospitals
• MD Anderson
Cancer Center
• Cardon Children’s
Medical Center
• Banner Heart
Hospital
Maricopa County
Maricopa
Florence
Mammoth
Arizona City
Apache Junction
Casa Grande
Kearny
Coolidge
Dudleyville
SanTan
Valley
Cold Canyon
Oracle
• Banner Hospitals
• Banner Clinics
• Banner Children’s
Clinics
Pinal County
PROVIDER NETWORKS

Meritus HMO MIHS Network
Center
• Phoenix Cancer Center
• Arizona Burn Center
• Behavior Health
• McDowell Health
Care Center
• 16 MIHS/DMG
Family Health and
Community Centers
Maricopa County
Bullhead City
Fort
Mohave
Lake Havasu City
Kingman
Peach Springs
Dolan Springs
Colorado City
Wikieup
Meadview
Needles
• Western Arizona
Regional Medical Center
• Valley Health System, Las Vegas
- Centennial Hills Hospital Medical Center
- Desert Springs Hospital Medical Center
- Spring Valley Hospital Medical Center
- Summerlin Hospital Medical Center
- Valley Hospital Medical Center
Mohave County
Meritus HMO WARMC Network
PROVIDER NETWORKS

© 2015 Meritus. Meritus products and services are provided through Meritus Mutual Health
Partners – PPO and Meritus Health Partners – HMO.
For a complete listing of benefits available for all plans as well as limitations and exclusions,
please contact Meritus. 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.
Nogales
Holy Cross Hospital
Meritus HMO Pima Network
• St. Mary’s Hospital
• St. Joseph’s Hospital
- Tucson
• Cardonelet Heart &
Vascular Institute
• Carondet
Neurological Institute
• Holy Cross Hospital
Pima and Santa
Cruz Counties
PROVIDER NETWORKS

COUNTY CITY FACILITY NAME
Apache Ganado Sage Memorial Hospital
Springerville White Mountain Regional Medical Center
Cochise Benson Benson Hospital
Bisbee Copper Queen Community Hospital
Douglas Southeast Arizona Medical Center
Sierra Vista Sierra Vista Regional Health Center
Willcox Northern Cochise Community Hospital
Coconino Flagstaff Flagstaff Medical Center
Page Page Hospital
Tuba City Tuba City Regional Healthcare
Gila Globe Cobre Valley Regional Medical Center
Payson Payson Regional Medical Center
Safford Mt Graham Regional Medical Center
Graham & Greenlee Safford Mt. Graham Regional Medical Center
La Paz Parker La Paz Regional Hospital
Maricopa Chandler Arizona Orthopedic & Surgical Specialty
Chandler Regional Medical Center
Gilbert Banner Gateway Medical Center
Banner MD Anderson Cancer Center
Mercy Gilbert Medical Center - Dignity
Glendale Abrazo Arrowhead Campus
Banner Thunderbird Medical Center
St. Joseph’s Westgate Medical Center - Dignity
Goodyear Abrazo West Campus
Laveen Village Arizona General Hospital - Dignity
The Arizona Foundation for Medical Care Network is the backbone of the Meritus
PPO Network. We contract directly with additional providers to make up our entire
PPO network. We have a provider search tool on our website at meritusaz.com
where you can find a complete list of doctors and facilities that are part of the Meritus
PPO network.
Meritus Complete PPO Network
Continued on page 14
PROVIDER NETWORKS

Maricopa Mesa Arizona Spine & Joint Hospital
Banner Baywood Medical Center
Banner Desert Medical Center
Banner Heart Hospital
Cardon Children’s Medical Center
Mountain Vista Medical Center
Phoenix Abrazo Arizona Heart Hospital
Abrazo Central Campus
Abrazo Maryvale Campus
Abrazo Scottsdale Campus
Banner Estrella Medical Center
Banner University Medical Center
HonorHealth Deer Valley Medical Center
HonorHealth John C. Lincoln Hospital Medical Center
Maricopa Medical Center
Oasis Hospital
Phoenix Children’s Hospital
Select Specialty Hospital - Phoenix
St. Joseph’s Hospital & Medical Center - Dignity
St. Luke’s Medical Center
San Tan Valley Banner Ironwood Medical Center
Scottsdale HonorHealth Scottsdale Osborn Medical Center
HonorHealth Scottsdale Shea Medical Center
HonorHealth Scottsdale Thompson Peak Medical Center
Sun City Banner Boswell Medical Center
Sun City West Banner Del E Webb Medical Center
Tempe Tempe St. Luke’s Hospital
Wickenburg Wickenburg Community Hospital
Mohave Fort Mohave Valley View Medical Center
Kingman Kingman Regional Medical Center
Lake Havasu City Havasu Regional Medical Center
Navajo Show Low Summit Healthcare Regional Medical Center
Winslow Little Colorado Medical Center
Pima Tucson Carondelet St. Joseph’s Hospital
Carondelet St. Mary’s Hospital
Northwest Medical Center
Tucson Medical Center
Oro Valley Oro Valley Hospital
Pinal Apache Junction Banner Goldfield Medical Center
Casa Grande Banner Casa Grande Medical Center
Florence Florence Hospital at Anthem
Sacaton Hu Hu Kam Memorial Hospital
Santa Cruz Nogales Carondelet Holy Cross Hospital
Yavapai Cottonwood Verde Valley Medical Center
Prescott Yavapai Regional Medical Center
Prescott Valley Mountain Valley Regional Rehab Hospital
Yavapai Regional Medical Center-East
Yuma Yuma Yuma Regional Medical Center
PPO Networks
ONLY
Members are not required
to go to a an in-network
provider. At the time of
services, they may obtain
treatment from an in-
network provider or an
out-of-network provider.
However, to maximize the
benefit reimbursement
level under a policy, an
in-network provider should
be used. The insured will
incur higher out-of-pocket
costs if they choose to
receive services from an
out-of-network provider,
and will be responsible for
the difference between
billed charges and the
amount paid by Meritus,
other than copayments,
co-insurance, or any
amounts that may remain
on their annual deductible.
If they plan to use a non-
network provider, they
should inquire about the
fees they can expect to
be charged before they
receive services.
COUNTY CITY FACILITY NAME
Continued from page 13
PROVIDER NETWORKS
Our PPO network
offers the convenience
of utilizing the PHCS
Network outside of
Arizona. Our PPO
members can use
the PHCS Network
to access in-network
providers and facilities
for their care needs.
Meritus PPO
Out-of-State Network

Hospitals/Networks
• HonorHealth
Network
• Banner Health
• Abrazo Health
Center
• Dignity Health
• Phoenix Children’s
Hospital
Hospitals/Networks
• Carondelet Health
Network
• Tucson Medical
Center
• Northwest
Medical Center/
Oro Valley
Nogales
Holy Cross Hospital
Maricopa County
Pima and Santa
Cruz Counties
PROVIDER NETWORKS

It is very important for us to help
our members find doctors that
are in their network. We want to
help them avoid unnecessary
medical bills and confusion that
could result from using doctors
that are not contracted in their
Meritus plan.
Steps to View Providers
• Go to meritusaz.com
• Click the Find a Provider button
• Click Meritus Provider Directory or
Meritus Facility Directory. See the
screen shot shown below.
• Under the box marked PLAN scroll
down to select the network you wish to
access, and click on the desired network
Accessing the Meritus PPO and HMO Networks
The Meritus Networks are:
• Meritus PPO Complete
Network - all PPO Plans
• Meritus HMO Complete
Network
• Meritus HMO Abrazo
• Meritus HMO Banner
• Meritus HMO MIHS
• Meritus HMO WARMC
• Meritus HMO Pima
• Enter the Provider’s Zip Code
SUGGESTION: Google the provider’s name
to obtain the correct spelling and zip code
• You must select either Primary Care
Physician (PCP) or a Specialist
• See Quick Links on the right side of the
page for easy website navigation options
PROVIDER NETWORKS

A Quality Holistic
Provider Network that
works for you.
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 you to create a
personalized wellness plan to help you
achieve a healthier lifestyle as well as
address specific conditions when you are ill.
Check out the current list of CAM providers
on meritusaz.com under Find a Provider.*
Our network providers are experts in holistic
and integrative medical care and have
extensive training in CAM benefits including:
medical nutrition, acupuncture, counseling
and stress management, bio-identical
hormones and other natural therapies.
Whether your goal is to have more energy,
decrease pain, reduce stress, learn to eat
better or to simply stay healthy and active,
our CAM benefits were created to support
your overall health and well-being.
You asked for health plan benefits with
CAM choices and Meritus listened. Benefits
include 12 visits of each modality at a $20
copay 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.
Acupuncture $20 copay per visit*
Therapeutic
Massage Therapy
$20 copay per visit*
Naturopathy $20 copay per visit*
Gym Membership**
Up to $25/month reimbursement
* Complimentary and Alternative Therapies (CAM) are limited to 12 visits per year
for each modality. In-network providers must be used for this benefit.
** 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.
Complementary and Alternative Lifestyle Benefits
Plus
+Plus is available on Meritus Healthy Platinum and Gold
HMO, Meritus Choice Gold, Silver and Bronze PPO, and
Meritus Saver Gold, Silver and Bronze PPO plans.
PROVIDER NETWORKS

More Healthcare Options Available to Members!
PROVIDER NETWORKS
Easy as
1-2-3!
Available
Nationwide
Receive treatment from home, the office
or even when you’re on vacation!
*MinuteClinic®
employs physician assistants in MN, NC, NV andTX. **When medically appropriate.
†
Copayment, copay or coinsurance means the amount a member is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage
of the prescription price, a fixed amount or other charge, with the balance, if any paid by a Plan.
Your privacy is important tous. Our employees are trained regarding the appropriate way to handle your private health information. 106-3411Ob 030615
Convenient, quality health care for the
entire family.
Certified nurse practitioners and
physician assistants* diagnose, treat and
write prescriptions.**
Visit summary is sent to your primary care
doctor, with your permission.
Open every day, evenings and
weekends. No appointment necessary.
• Open extended hours and weekends
• Adults and children
(18 months and older)
for most services
• Routine lab tests
• Walk-ins Welcome
• Same Copay as a PCP Visit
• Visit a Nearby Location Today
From ah-choo!
allergies to vaccinations
and more. . .
Close to home or work.
Get a dose of care
at MinuteClinic
®
.

Pharmacy benefit programs are an important aspect of any healthcare
coverage plan, and are a significant contributor to medical costs. Meritus
has easy-to-use pharmacy benefits built into our various plans.
Summary of Pharmacy Benefits

Metal Level Platinum Gold Silver
Silver
NEIGHBORHOOD &
COMMUNITY PLANS
Bronze
RX Deductible -
Does not apply
to Generics
$0 $0 $300 $250 $300
ACA Preventative
$0 Copay -
Retail
$0 Copay -
Retail
$0 Copay -
Retail
$0 Copay -
Retail
$0 Copay –
Retail
Adherence
Generic
$0 Copay -
Retail
$0 Copay -
Retail
$5 Copay -
Retail
$0 Copay -
Retail
$10 Copay -
Retail
Other Generic
$2 Copay -
Retail
$5 Copay -
Retail
$15 Copay -
Retail
$20 Copay -
Retail
$30 Copay -
Retail
Preferred Brand
$15 Copay -
Retail
$30 Copay -
Retail
$60 Copay -
Retail
$72 Copay -
Retail
$90 Copay -
Retail
Non-Preferred
Brand
$60 Copay -
Retail
$75 Copay -
Retail
$150 Copay -
Retail
$150 Copay -
Retail
$200 Copay -
Retail
Specialty –
Preferred and
Non-Preferred
50% Copay -
Retail
50% Copay -
Retail
50% Copay -
Retail
40% Copay -
Retail
50% Copay -
Retail
CVS Caremark Contracted Pharmacies include, but are not limited to the following (please check meritusaz.com
for the nearest contracted pharmacy):
Please see plan descriptions for more detailed benefit information.
Mail order is available for 90 day prescriptions and the member cost share is 3 times the 30-day retail copay
utilizing CVS Caremark’s mail order service.
Meritus has moved to a 6-tier pharmacy benefit offered
through CVS Caremark. There are two Generic Drug tier
classifications for 2016 which are “Adherence Generic”
and “Other Generic.”
Adherence Generic drugs include certain medications
for chronic conditions. This tier includes those
medications which promote heart health, treat high
blood pressure, high cholesterol, along with oral diabetic
medications as provided in the Meritus drug formulary.
2016 Formulary Tier Guide
Tier 0 – ACA Preventative Drugs
Tier 1 – Adherence Generic Drugs
Tier 2 – Other Generic Drugs
Tier 3 – Preferred Brand Drugs
Tier 4 – Non-Preferred Brand Drugs
Tier 5 – Preferred Specialty Drugs
Tier 6 – Non-Preferred Specialty Drugs
2016 Pharmacy Benefits
SUMMARY OF PHARMACY BENEFITS
• Albertsons
• Bashas’
• Costco
• CVS Pharmacies
• Food City
• Fry’s
• K-Mart
• Osco
• Safeway
• Sam’s Club
• Sav-on
• Target
• Walmart
• Walmart Neighborhood
Market
HSA Plans
Under the HSA plan benefits, RX benefits are subject to the medical plan deductible,
coinsurance and out-of-pocket maximums.
*IMPORTANT: Walgreens is NOT in the Meritus pharmacy network. For more information on the contracted
pharmacies and to view the Meritus drug formulary, please visit meritusaz.com.

The health insurance market as we
know it has changed.
The ACA includes several provisions geared to create greater access to
health insurance benefits to more people. As of 2014, most Americans
must purchase a minimum amount of health insurance or be taxed by
the government. This tax is paid through Federal Income Tax reporting
in April each year.
For more details about the ACA, visit Healthcare.gov.
Understanding the MarketplaceUnderstanding the Marketplace

Marketplace Benefit to Consumers
Advanced Premium Tax Credit (APTC) and Cost-Sharing
Reductions (CSR) will provide many Arizonans with access to
affordable health insurance.
Consumers can get lower costs on coverage
Our online quoting tool allows you and your clients to find
out if they are eligible for subsidies or tax credits to help
lower the cost of 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 AHCCCS.
Pre-existing conditions are covered
Plans are not able to deny consumers coverage or charge
them more due to pre-existing health conditions, including a
pregnancy or disability.
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 $11,770 to $47,080 per year for
an individual and $24,250 to $97,000 per year for a family of
four (see income table on page 24).
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 CSR
amount will vary according to income. Examples of
cost-sharing that may be reduced include deductibles,
co-insurance, copayments or similar charges and do
not include balance billing for non-network providers or
spending on non-covered services. (See table on page 24).
Penalties for Uninsured Individuals
Legal U.S. citizens who do not carry a minimum amount of
health coverage will receive a penalty. The annual penalty for
not having minimum essential coverage will be greater of a
percentage of the individual’s taxable income or a flat dollar
amount per individual. For any dependent under the age 18,
the penalty is one half of the individual amount.
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
(FFM) – also known as an Exchange.
People can purchase coverage from
private companies like Meritus that
have been approved as Qualified
Health Plans (QHPs). All QHPs must
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, copayments and
co-insurance, and value added
benefits.
Essential health benefits package
must include services and items for
the following categories of care:*
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
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)
UNDERSTANDING THE MARKETPLACE

2016: The annual individual responsibility
payment is the greater of
- 2.5% of the taxpayer’s household
income that is above the tax return filing
threshold for the taxpayer’s filing status,
or
- The taxpayer’s flat dollar amount, which
is $695 per adult and $347.50 per child.
However, the total payment amount is
capped at the cost of the national average
premium for a Bronze level health plan
available through the Marketplaces in 2016.
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:
- Reside in the state in which
coverage is being applied for
- 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 page 24)
These calculations represent the amount of the payment
for not having health insurance coverage for the entire year.
Individuals will owe 1/12th of the annual payment for each
month they (or their dependents) do not have coverage
and are not exempt. Individuals without coverage for less
than three consecutive months during the year may qualify
for the short coverage gap exemption and will not have to
make a payment for those months. The short coverage gap
exemption only applies to the first coverage gap during
a year.
After 2016, the same method of calculation will be used, and
the payment will be adjusted for inflation.

Actuarial Value 70% AV 94% AV 87% AV 73% AV
Deductible (Individual) $4,000 $150 $500 $2,300
Coinsurance 30% 0% 0% 30%
Office Visit – PCP/ $30 copay/ $0 copay/ $0 copay/ $20 copay/
Non-PCP $60 copay $10 copay $30 copay $60 copay
Max Out-of-Pocket $6,800 $1,200 $2,250 $5,450
Example Meritus Healthy Silver $4,000 Network benefits including CSR benefit levels
Standard Silver –
No CSR
CSR Plan for
up to 150% FPL
(up to $17,655)
CSR Plan for
151-200% FPL
($17,655 to $23,540)
CSR Plan for
201-250% FPL
($23,540 to $29,425)
How your clients can get coverage.
Connecting Individuals and Families to coverage, benefits and services.
You may qualify for lower premiums
on a Marketplace Insurance plan
if your yearly income is between. . .
See next row if your income is at the
lower end of this range.
You may qualify for lower premiums
AND lower out-of-pocket costs
for Marketplace insurance if your
yearly income is between. . .
If your state is expanding Medicaid
in 2014: You may qualify for
Medicaid coverage if your yearly
income is between. . .
If your state isn’t expanding Medicaid
in 2014: You may not qualify for any
Marketplace savings programs if
your yearly income is between. . .
$11,770 -
$47,080
$15,930 -
$63,720
$20,090 -
$80,360
$24,250 -
$97,000
$28,410 -
$113,640
$32,570 -
$130,280
1 2 3 4 5 6
$11,770 -
$29,425
$15,930 -
$39,825
$20,090 -
$50,225
$24,250 -
$60,625
$28,410 -
$71,025
$32,570 -
$81,425
$16,242 $21,983 $27,724 $33,465 $39,205 $44,946
$11,770 $15,930 $20,090 $24,250 $28,410 $32,570
MedicaidcoveragePrivateMarketplacehealthplans
Number of people in your household
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 CSR amount will vary according to income. Examples of cost-
sharing that may be reduced include deductibles, co-insurance, copayments or similar charges and do not
include balance billing for non-network providers or spending on non-covered services.

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

*Minimum Essential Coverage
Rules for Special Enrollment Period changes (SEP)
If a client applies on the FFM, and they qualify for a SEP to change plans or enroll for the first time, they will have
60 days from the life event to enroll. After reporting life changes to the Marketplace, they will get a new eligibility
notice that will explain if they have a Qualifying Life Event (QLE), are eligible for a Special Enrollment Period, and
are allowed to re-enroll. At this time, they may select a new plan that might lower their costs.
If your client qualifies for a SEP, you can assist them by phone with the FFM or through your Meritus direct link.
When the application is finished and they get to the “To-do list” page, you’ll see a statement that they can
enroll only if they have a SEP. You can then continue the process and enroll in a plan.
Type of SEP
Termination Date of
Existing Enrollment,
if currently Enrolled
Plan Selection Date Effective Date
Eligible for the
following QLE:
1. Move to a new exchange
service area
2. Release from
incarceration
3. Becoming lawfully
present
4. Gain status as an Indian
First day of the
following month
First day of the
second following
month
Day before
effective date.
Loss of MEC* and gaining
a dependent through
marriage SEP
Future loss of MEC*
(loss up to 60 days
in the future)
Birth, adoption, or
placement for adoption
or foster care SEP
Day before
effective date
Day before
effective date
Day before
effective date
First day of the
following month
First day of the
month following
the date of the
loss of MEC
Day the child was
born, adopted, or
placed for adoption
or foster care
Any day of the month
Between the 1st and
15th day of the month
Between the 16th and
last day of the month
RULES OF ENROLLMENT

Affordable coverage that Arizonans
can count on.
With a focus on health and wellness, our plans have a 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,
pediatric vision and Complementary and Alternative Medicine including
Naturopathy, Acupuncture and Therapeutic Massage.*
*Available in specified plans.
Plans to Meet All Your Needs.

Meritus Plans and Rates*
Covered Benefits
Once enrolled, members will receive a
Summary of Benefits and Coverage and
a Comprehensive Health Policy including
information about:
• Benefits that are covered and not covered
• Copayments 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 and glasses for children
• Hearing aids
Meritus benefits and services are offered
by Meritus Health Partners - HMO and
Meritus Mutual Health Partners - PPO.
Non-Covered Benefits
Benefits not included in your health insurance plan
would also 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
• 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.
PLAN DESIGNS

The Meritus Plans
Meritus Plans are separated into four
health plan categories consistent with the
Federal Marketplace – Bronze, Silver, Gold
and Platinum – (Meritus does not offer
a Catastrophic 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), 80%
(Gold), and 90% (Platinum, HMO only). This
isn’t the same as coinsurance, in which your
client pays a specific percentage of the cost of
a specific service.
* Select the Find a Provider option at meritusaz.com to see a complete list of physicians and facilities.
** Complementary and Alternative Medicine includes Naturopathy, Acupuncture and Therapeutic Massage, are available on certain
Individual and Group plans, check outlines of Coverage for details. In-network providers must be used for this benefit.
PLAN DESIGNS
Catastrophic Less Than 60% Coverage
Bronze 60% Coverage
Silver 70% Coverage
Gold 80% Coverage
Platinum 90% Coverage
Metal Levels
Gold
Silver
Bronze
Platinum
MONTHLY PREMIUM OUT-OF-POCKET COST
$$$$ $
$$$ $$
$$ $$$
$ $$$$
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 low copays for primary care in most plans and
Gold and Platinum plans include Complementary and
Alternative Medicine (Naturopathy, Acupuncture and
Massage Therapies).
Meritus is carrying over three Individual plans from
2015: Meritus Neighborhood Network Silver HMO
MIHS, Meritus Community Network Silver HMO
Banner, and Meritus Community Network Silver HMO
Pima; which include pediatric dental for children
under the age of 19. Meritus will utilize Delta Dental’s
provider network for these benefits. Dental providers
can be found at deltadentalaz.com.
Our PPO products are designed similar to the HMO
products, but offer an out-of-network benefit at
higher out-of-pocket costs. Our PPO plans utilize
a very broad network (a variation of the Arizona
Foundation for Medical Care Network*). The PPO
products include low copays for primary care in most
plans as well as Complementary and Alternative
Medicine**
and up to a $25 gym reimbursement.
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.

Deductibles
EMBEDDED – Our HMO plans, PPO plans,
Silver PPO HSA plan and Bronze PPO HSA plan
include embedded deductibles. An embedded
deductible works like a traditional PPO health
plan deductible. Benefits begin for a single family
member once the individual deductible is met –
whichever comes first. For example, for a family
of four with an individual embedded deductible
of $2000 and a family deductible of $4000, plan
benefits begin for a single family member after
the $2,000 deductible has been met for that
person. Any combination of the remaining three
family members can incur claims that will apply
towards the remaining $2,000 to meet the Family
deductible. Once a total of $4,000 has been
applied toward the family deductible, benefits
begin for all family members.
PLAN DESIGNS
AGGREGATE (For the Group Gold HSA plan only)
– To qualify as a tax-advantaged Health Savings
Account – HSA – the Meritus Gold PPO HSA Plan
has an aggregate (non-embedded) deductible.
An Aggregate deductible works differently than
traditional PPO plans. When covering more than
one person, the family deductible must be met first
before anyone in the family is covered for services.
For example, if the family deductible is $3,000,
there must be $3,000 paid to meet the deductible
before the plan pays any benefits for any family
member. Out-of Pocket maximum amounts are
also aggregate, requiring the family out-of-pocket
maximum to first be met before services are covered
in full for any single family member in accordance
with the plan policy.

Here is a step-by-step guide to help
you through Individual and Family
enrollment.
The following pages contain instructions on how to process a quote or
application using a Meritus populated link, or the Meritus Broker Sales
Portal at meritusaz.com for Individuals and Families.
Individual and Family

Individual and Family
Enrollment Guide
1 Proposal
Enter demographic information,
select plan and create proposal.
2 Application
Fill out the enrollment application and sign form.
3 Sent to Membership
Applications is sent to membership
for processing.
4 Member
Individual is now an active member.

The Quote and Enrollment Process
To quote and enroll Individual and Family plans, go to the meritusaz.com website, click on
the Broker tab, and select Broker Sales Portal Login. After you access the Broker Portal, you
will see the online Meritus Dashboard where you can select the Individual or Tools tabs.
Individual and Family Applications for both On and Off the Marketplace
You can sell both On or Off Market plans with Meritus. Your Meritus Broker Sales Portal can
be used for Off Market enrollment and/or help determine whether your client may qualify
for assistance from the FFM. The Meritus Direct Enrollment tool can be utilized for quick
and efficient placement for On Market business during Open Enrollment. The Direct
Enrollment tool will assist in determining APTC information for clients, verifying eligibility
with Healthcare.gov and completing enrollment.
1Proposal
Determining Marketplace Eligibility
Primary Subscriber and ACA Eligibility
From the main Meritus Dashboard, select Tools and then click on ACA Individual Calculator
to initiate the Individual quote process. The ACA Calculator will determine whether your
client is eligible for premium assistance credits or cost-sharing reductions and it will calculate
their shared responsibility penalty.
INDIVIDUAL AND FAMILY ENROLLMENT

Using the ACA Calculator, you can determine if affordable employer coverage is
available or there is a certificate of exemption from the Marketplace.
The ACA Individual Calculator will present estimates
and show results for Individual and Family profiles,
shared responsibility (tax penalty) and coverage and
assistance eligibility.
For those who do not qualify, continue
with Off Market, on page 39.
For those qualified for On Market, go
to Direct Enrollment link on page 36.
NOTE: If your
client appears to
be eligible for an
On Market plan,
please proceed
to the instructions
of how to assist
clients with the
Broker Direct
Enrollment Tool
during Open
Enrollment.
See page 39.

On Market Direct Enrollment Tool – During Open Enrollment
The Direct Enrollment tool will allow you to assist your clients to apply with the FFM and
qualify for a tax credit and/or to determine whether they may qualify for plans with cost-
sharing reductions. This online process will help you to streamline the FFM/CMS qualification
process and connect you directly back to Meritus for an online application.
How to Access The Direct Enrollment Tool
Once you have set up your Broker Sales Portal you will be able to access the Direct Enrollment
tool to assist your clients who wish to apply On the Market.
2Direct Enrollment - On Market Application
Step 1: Direct
Enrollment Application
Enter your client’s first
and last name and then
click the Marketplace
button only if your client
will qualify for a plan
with the FFM.
Set Up
Log onto your Broker Sales Portal by going to meritusaz.com and then click on My Account. It is recommended to use
Google Chome when utilizing the Direct Enrollment tool.
After clicking on My Account, fill in the fields including your National Producer Number (NPN) and your Federal
Marketplace User ID (this is the ID you used to access portal.cms.gov). Now save the information and you are ready to
assist your client on the FFM for assistance and apply for a Meritus plan.

Step 2: Redirection
to FFM Site
You will now
be taken to
HealthCare.gov
where your User
Name will be auto-
populated. Now
enter in your
Marketplace
password, which
is the password
you used to access
portal.cms.gov.
Now click on
LOG IN.
Step 3: Start the
FFM Eligibility
Application on
HealthCare.gov.
NOTE: It is
recommended
to bypass all
“optional”
questions as this
may hinder your
client’s application.
The Next Steps
page will describe
what happens next
and what you’ll
need to complete
the application
with the FFM.
Click Next.

Step 6: Selecting the Plan
Click on Browse Plans to continue the enrollment, and you will be redirected
to Meritus.
You will be able to assist your client and help them choose the plan and
complete the Meritus application.
Step 5: Now click the
Return to Enrollment
Website button to
return to your Broker
Sales Portal.
Step 4: View Eligibility.
Once you reach the Eligibility Results, click
on View Eligibility Results.
This will display, showing you your client’s
Premium Tax Credits and whether they also
qualify for a Cost-Sharing Reduction plan.
These amounts will match the Eligibility
Results which were displayed on the
Healthcare.gov page.
Now proceed to picking a plan.

Proposal and Application
The Proposal screen
will allow you to:
• Make any necessary
edits prior to sending
the quote.
• SAVE the client’s name and
proposal so you can work
on it or refer back to the
quote at a later date.
• Email the proposal to
your client.
• Save and send the proposal
as a PDF.
• Start the application. Be
sure not to select the
marketplace application.
Select and Compare Plans
Compare plans (see above) by checking the small Compare box next to
each plan that you would like to compare, and then click on one of the large
Compare buttons to display your results. Note, that you can only compare up
to four plans at any one time.
Then select the desired plan(s) for quoting by clicking on Select or for initiating
an email or enrollment of a final plan with an application.
Plan Choices
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 copays
• Lifestyle benefits
• HSA compatibility
• Provider network type
2Off Market Application

Electronic Signature
After reviewing
sections and
completing the
Electronic Signature,
the client’s name
needs to be typed
into the box under
E-Sign section.
Now you are ready
to proceed to the
Payment page.
Fill out all required fields
as indicated and then
click on the Complete
this Section button on
the lower right side of
the screen.
Payment
The next step in the
Individual Application
process is to select the
method for the Initial
Premium Payment.
This is the final step
of submitting the
application.
NOTE: A debit card is
considered the same
as a credit card in our
payment system.
Initial Payament with the
application does NOT establish
a reoccurring payment

On Market
Click on Continue on the lower right side of the Collect Payment screen. The
application has now been submitted to Meritus through the FFM.
NOTE: You will not be able to see FFM submissions on your Broker Sales Portal. Please
allow 7 – 10 business days before checking to see if the submission has been noted in our
Customer Care system.
Off Market
Click on Continue on the lower right side of the Collect Payment screen. The
application has now been submitted to Meritus and can be seen in your Broker Sales
Portal. To see this, click on Individual and then click on Applications.
3Sent to Membership
Direct Enrollment Tool Updates
For the latest updates, on the Direct Enrollment Tool, go to meritusaz.com,
click on Broker, click on Resources and click on Direct Enrollment Tool.
NOTE: The application will be approved within 5 – 7 business days, at which time, you
can look in your Broker Sales Portal under Individual and then click on Members.

On Market
Once the application is sent through the FFM, the Member will be assigned a Member
number by our Customer Care system within 7 – 10 business days. When the binder payment
is received by Meritus the Membership Packet will then be mailed out to them in 7 – 10
business days.
NOTE: If a Member does not receive their Meritus card and packet prior to their live date, the
Member may call Meritus Customer Care (877.755.2700) for instructions on how to proceed
until their card is received. Please also note that the Member will only be effectuated by
Meritus once their binder payment has been received. It is also important to remember that
ID Cards will not be sent until initial payment has been made.
Off Market
Once the application is approved, the Member will be assigned a Member number by our
Customer Care system. When the binder payment is received by Meritus the Membership
Packet will then be mailed out in 7 – 10 business days.
NOTE: If a Member does not receive their Meritus card and packet prior to their live date, the
Member may call Meritus Customer Care (877.755.2700) for instructions on how to proceed
until their card is received. Please also note that the Member will only be effectuated by
Meritus once their binder payment has been received. It is also important to remember that
ID Cards will not be sent until initial payment has been made.
4Member

Individual Plans
PLAN TYPE - METAL NAME PAGES
HMO - Platinum Meritus Healthy Platinum Complete HMO Plus 500 44
Meritus Healthy Platinum HMO Plus Abrazo 500 44
Meritus Healthy Platinum HMO Plus Banner 500 44
Meritus Healthy Platinum HMO Plus MIHS 500 44
Meritus Healthy Platinum HMO Plus Pima 500 44
Meritus Healthy Platinum HMO Plus WARMC 500 44
HMO - Gold Meritus Healthy Gold Complete HMO Plus 2000 45
Meritus Healthy Gold HMO Plus Abrazo 2000 45
Meritus Healthy Gold HMO Plus Banner 2000 45
Meritus Healthy Gold HMO Plus MIHS 2000 45
Meritus Healthy Gold HMO Plus Pima 2000 45
Meritus Healthy Gold HMO Plus WARMC 2000 45
HMO - Silver Meritus Neighborhood Network Silver HMO MIHS - Pediatric Dental Included 46 - 49
Meritus Community Network Silver HMO Banner - Pediatric Dental Included 46 - 49
Meritus Community Network Silver HMO Pima - Pediatric Dental Included 46 - 49
Meritus Healthy Silver Complete HMO 4000 50 - 53
Meritus Healthy Silver HMO Abrazo 4000 50 - 53
Meritus Healthy Silver HMO Banner 4000 50 - 53
Meritus Healthy Silver HMO MIHS 4000 50 - 53
Meritus Healthy Silver HMO Pima 4000 50 - 53
Meritus Healthy Silver HMO WARMC 4000 50 - 53
HMO - Bronze Meritus Healthy Bronze Complete HMO 6800 54
Meritus Healthy Bronze HMO Abrazo 6800 54
Meritus Healthy Bronze HMO Banner 6800 54
Meritus Healthy Bronze HMO Pima 6800 54
Meritus Healthy Bronze HMO WARMC 6800 54
PPO Meritus Choice Silver Complete PPO Plus 4000 - OFF Market Only 55
Meritus Choice Bronze Complete PPO Plus 6800 - OFF Market Only 56
PPO HSA Meritus Saver Silver Complete PPO HSA Plus 2750 - OFF Market Only 57
Meritus Saver Bronze Complete PPO HSA Plus 6300 - OFF Market Only 58
HMO PROVIDER NETWORKS - Counties Served
Meritus Complete HMO Network - Maricopa, Mohave, Pima, Pinal and Santa Cruz Counties
Meritus Community Network Abrazo - Maricopa County
Meritus Community Network Banner - Maricopa and Pinal Counties
Meritus Neighborhood Network MIHS - Maricopa County
Meritus Community Network Pima - Pima County
Meritus Community Network WARMC - Mohave County
INDIVIDUAL AND FAMILY PLANS

Deductible - per calendar year $500 single/$1,000 family
Out-of-Pocket Maximum (includes deductible and copays) - per calendar year $2,000 single/$4,000 family
Office Visit Primary Care Physician $5 copay per visit
Specialist $30 copay per visit
Prenatal and Postnatal Care $5 copay per visit
Preventative Care, including Well Baby Care $0 copay per visit
Telemedicine - MeMD $0 copay per visit
In-Store Health Care Clinic $5 copay per visit
Emergency Urgent Care $30 copay per visit
Emergency Room - copay waived if admitted, copay waived if accident $200 copay per visit
Ambulance - Medical Emergency $150 copay per transport
Hospital Inpatient and Outpatient hospital services 10%, after deductible
Ambulatory Surgical Center $200 copay per visit
Outpatient Laboratory/Pathology
Performed in a physician’s office or free-standing independent lab facility $25 copay per visit
Performed in a hospital 10%, after deductible
Outpatient Radiology - General
Performed in a physician’s office $50 copay per visit
Performed in an independent, non-hospital-affiliated radiology facility $150 copay per visit
Outpatient Radiology/Imaging Testing -
Including, but not limited to, CT scans, MRIs, MRAs and PET/SPECT scans
Performed in an independent, non-hospital affiliated radiology facility $200 copay per visit
Chiropractic Care - Maximum 20 visits per calendar year $30 copay per visit
Short Term Physical Therapy, Occupational Therapy, Speech Therapy
Limited to 60 visits per calendar year combined $30 copay per visit
Office Psychiatric and Substance Abuse Visits $30 copay per visit
Pediatric Vision Exam - one exam per calendar year $25 copay per exam
Glasses or Contacts - one item per calendar year $25 copay per item
Naturopathy - Maximum 12 visits per calendar year $20 copay per visit
Acupuncture - Maximum 12 visits per calendar year $20 copay per visit
Therapeutic Massage - Maximum 12 visits per calendar year $20 copay per visit
Gym Membership Reimbursement Up to $25 per month
Outpatient Prescription Drugs - Quantity limits may apply.
Prescription Deductible - per calendar year $0 single/$0 family
Up to a 30 Day Prescription - Retail, 90 Day Prescription-Mail Order 30 Day Retail 90 Day Mail Order
ACA $0 Preventative $0 copay $0 copay
Adherence Generic* $0 copay $0 copay
Other Generic $2 copay $6 copay
Preferred Brand $15 copay $45 copay
Non-Preferred Brand $60 copay $180 copay
Specialty – Preferred and Non-Preferred 50% 50%
Meritus Healthy Platinum
Networks: Complete HMO Plus 500 • HMO Plus Abrazo 500 • HMO Plus Banner 500 • HMO Plus MIHS 500
HMO Plus Pima 500 • HMO Plus WARMC 500
Pediatric Dental NOT included.
Plus
*Adherence Generic drugs include those medications which promote heart health, treat high blood pressure, high cholesterol, along with oral diabetic medication.
See page 59 for disclaimers, exclusions and limitations.
INDIVIDUAL HMO

Deductible - per calendar year $2,000 single/$4,000 family
Naturopathy - Maximum 12 visits per calendar year $20 copay per visit
Acupuncture - Maximum 12 visits per calendar year $20 copay per visit
Therapeutic Massage - Maximum 12 visits per calendar year $20 copay per visit
INDIVIDUAL HMO
Meritus Healthy Gold
Networks: Complete HMO Plus 2000 • HMO Plus Abrazo 2000 • HMO Plus Banner 2000 • HMO Plus MIHS 2000
HMO Plus Pima 2000 • HMO Plus WARMC 2000
Plus

Hospital Inpatient hospital services $1,000 copay per admission, after deductible
Outpatient hospital services $500 copay per admission
Performed in a hospital $100 copay per visit
Performed in a hospital $600 copay per visit, after deductible
Pediatric Dental Class I - limit 1 visit every 6 months 0%
Class II 45%
Class III 65%
Orthodontia - 24 month waiting period 50%
Up to a 30 Day Prescription - Retail, 90 Day Prescription-Mail Order. 30 Day Retail 90 Day Mail Order
Preferred Brand $67 copay** $201 copay**
Non-Preferred Brand $150 copay** $450 copay**
Specialty – Preferred and Non-Preferred 40%** 40%**
Meritus Neighborhood Network Silver HMO MIHS
Meritus Community Network Silver HMO Banner
Meritus Community Network Silver HMO Pima
**After separate prescription drug deductible. See page 59 for disclaimers, exclusions and limitations.
INDIVIDUAL HMO

Meritus Neighborhood Network Silver HMO MIHS-CSR73
Meritus Community Network Silver HMO Banner- CSR73
Meritus Community Network Silver HMO Pima- CSR73
ON
MARKET
ONLY
INDIVIDUAL HMO
Hospital Inpatient hospital services $1,000 copay per admission
Class II 45%
Class III 65%

Meritus Neighborhood Network Silver HMO MIHS-CSR87
Meritus Community Network Silver HMO Pima- CSR87
ON
MARKET
ONLY
Deductible - per calendar year $400 single/$800 family
Hospital Inpatient hospital services $500 copay per admission
Class II 45%
Class III 65%
INDIVIDUAL HMO

Meritus Neighborhood Network Silver HMO MIHS- CSR94
Meritus Community Network Silver HMO Pima-CSR94
ON
MARKET
ONLY
INDIVIDUAL HMO
Hospital Inpatient hospital services $150 copay per admission
Class II 45%
Class III 65%

Naturopathy - Maximum 12 visits per calendar year Not Covered
Acupuncture - Maximum 12 visits per calendar year Not Covered
Therapeutic Massage - Maximum 12 visits per calendar year Not Covered
Gym Membership Reimbursement Not Covered
Prescription Deductible - per calendar year - Does not apply to Generic Drug Tiers $300 single/$600 family
Meritus Healthy Silver
Networks: Complete HMO 4000 • HMO Abrazo 4000 • HMO Banner 4000 • HMO MIHS 4000
HMO Pima 4000 • HMO WARMC 4000
**After separate prescription drug deductible. See page 59 for disclaimers, exclusions and limitations.
INDIVIDUAL HMO

Meritus Healthy Silver- CSR73
ON
MARKET
ONLY
INDIVIDUAL HMO

Deductible - per calendar year $500 single/$1,000 family
ON
MARKET
ONLY
INDIVIDUAL HMO

ON
MARKET
ONLY
INDIVIDUAL HMO

Ambulance - Medical Emergency 0%, after deductible
Ambulatory Surgical Center 0%, after deductible
Performed in a physician’s office 0%, after deductible
Performed in an independent, non-hospital affiliated radiology facility 0%, after deductible
Limited to 60 visits per calendar year combined 0%, after deductible
Prescription Deductible - per calendar year - Does not apply to Generic Drug Tiers $300 single/$600 family
Meritus Healthy Bronze
Networks: Complete HMO 6800 • HMO Abrazo 6800 • HMO Banner 6800 • HMO Pima 6800 • HMO WARMC 6800
INDIVIDUAL HMO

INDIVIDUAL PPO
Meritus Choice Silver Complete PPO Plus 4000
Networks: Meritus Complete PPO
Plus
Deductible - per calendar year $4,000 single/$8,000 family $12,000 single/$24,000 family
Out-of-Pocket Maximum (includes deductible and copays) - per calendar year $6,800 single/$13,600 family $20,400 single/$40,800 family
Office Visit Primary Care Physician $30 copay per visit 50%, after deductible
Specialist $60 copay per visit 50%, after deductible
Prenatal and Postnatal Care $30 copay per visit 50%, after deductible
Preventative Care, including Well Baby Care $0 copay per visit 50%, after deductible
In-Store Health Care Clinic $30 copay per visit 50%, after deductible
Emergency Urgent Care $60 copay per visit 50%, after deductible
Emergency Room - copay waived if admitted, copay waived if accident $500 copay per visit $500 copay per visit
Ambulance - Medical Emergency $250 copay per transport $250 copay per transport
Hospital Inpatient and Outpatient hospital services 30%, after deductible 50%, after deductible
Ambulatory Surgical Center $500 copay per visit 50%, after deductible
Performed in a physician’s office or free-standing independent lab facility $25 copay per visit 50%, after deductible
Performed in a hospital 30%, after deductible 50%, after deductible
Performed in a physician’s office $50 copay per visit 50%, after deductible
Performed in an independent, non-hospital-affiliated radiology facility $150 copay per visit 50%, after deductible
Performed in a physician’s office $500 copay per visit 50%, after deductible
Performed in an independent, non-hospital affiliated radiology facility $500 copay per visit 50%, after deductible
Chiropractic Care - Maximum 20 visits per calendar year $60 copay per visit 50%, after deductible
Limited to 60 visits per calendar year combined $60 copay per visit 50%, after deductible
Office Psychiatric and Substance Abuse Visits $30 copay per visit 50%, after deductible
Pediatric Vision Exam - one exam per calendar year $50 copay per visit 50%, after deductible
Glasses or Contacts - one item per calendar year $50 copay per item 50%, after deductible
Naturopathy - Maximum 12 visits per calendar year $20 copay per visit Not Covered
Acupuncture - Maximum 12 visits per calendar year $20 copay per visit Not Covered
Therapeutic Massage - Maximum 12 visits per calendar year $20 copay per visit Not Covered
Prescription Deductible - per calendar year - Does not apply to Generic Drug Tiers $300 single/$600 family Combined with Medical Ded
Up to a 30 Day Prescription - Retail, 90 Day Prescription-Mail Order 30 Day Retail 90 Day Mail
ACA $0 Preventative $0 copay $0 copay 50%, after deductible
Adherence Generic* $5 copay $15 copay 50%, after deductible
Other Generic $15 copay $45 copay 50%, after deductible
Preferred Brand $60 copay** $180 copay** 50%, after deductible
Non-Preferred Brand $150 copay** $450 copay** 50%, after deductible
Specialty – Preferred and Non-Preferred 50%** 50%** 50%, after deductible
Benefits In-Network Out-of-Network
OFF
MARKET
ONLY

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