4. SmartSense For last 3 months of calendar year for expenses incurred in the 4 th quarter that are less than the deductible 4 th Quarter Deductible Carryover Not covered Maternity Generic: $15 copay or 40%, whichever is greater Generic: $15 copay or 40%, whichever is greater Brand name: $500 annual brand deductible (2-member maximum), then $15 copay or 40%, whichever is greater (up to $500 maximum per prescription) — $4,500 maximum annual out-of-pocket in addition to brand deductible Drug Benefits Generic plan Comprehensive plan 30% after deductible Hospital In/Outpatient 30% after deductible HealthyCheck Centers: $25/$75 copay for basic/ premium screenings, with deductible waived Preventive Care 3 before deductible w/ $30 copay, then 30% after deductible Office Visits Annual Deductible Annual Out-of-Pocket Maximum Single/Family (in addition to deductible) $500, $1,500, $2,500 or $5,000 (single) $1,000, $3,000, $5,000 or $10,000 ( family deductible can be satisfied by 2 or more members ) $2,500/$5,000 ( family out of pocket can be satisfied by 2 or more members )
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13. PPO Share (5000/2500/1500) $5,000 per member 30% of negotiated fee, deductible waived $35 copay deductible waived $10 generic; $30 brand copay after $250 brand deductible $10 generic; $30 brand copay after $500 brand deductible $15 generic; $35 brand copay after $750 brand deductible Drug Benefits (Anthem Blue Cross Formulary) (2-member maximum for brand deductible) 30% of negotiated fee Maternity 30% of negotiated fee Hospital In/ Outpatient Annual physical exam: 30% of negotiated fee, or HealthyCheck Centers: $25/$75 copay for basic/premium screenings Routine mammogram, Pap, PSA ordered by physician: 30% of negotiated fee Well Child: 40% of negotiated fee Preventive Care (deductible waived) $40 copay deductible waived Office Visits $4,500 per member Annual Deductible (2-member maximum) Annual Out-of-Pocket Maximum (in addition to deductible) (2-member maximum, par/non-par) $1,500 per member $2,500 per member $5,000 per member $2,500 per member 1500 2500 5000
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15. RightPlan PPO 40 Inpatient: 40% of negotiated fee plus $500 copay/day; 4-day maximum copay per admission Outpatient: 40% of negotiated fee plus $500 copay per outpatient surgery admission Hospital In/Outpatient No coverage (P958), or Generic coverage (PE48) - $15 generic, or Comprehensive coverage (PE49) - $15 generic, $35 brand copay after $500 brand deductible Drug Benefits (Anthem Blue Cross Formulary) Not covered Maternity HealthyCheck Centers: $25/$75 copay for basic/ premium screenings Routine mammogram, Pap, PSA ordered by a physician: $40 office visit plus 40% of negotiated fee Well Child: $40 office visit plus 40% of negotiated fee Preventive Care $40 copay Office Visits No deductible Annual Deductible $7500/subscriber Annual Out-of-Pocket Maximum (par/non-par)
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17. PPO 3500 (HSA-Compatible) $15 generic; $35 brand copay after Medical/Pharmacy deductible met Drug Benefits (Anthem Blue Cross Formulary) Not covered Maternity HealthyCheck Centers: $25/$75 copay for basic/ premium screenings, deductible waived Routine mammogram, Pap, PSA ordered by physician: $0 after deductible Well Child: $0 after deductible Preventive Care $0 after deductible Hospital In/Outpatient $0 after deductible Office Visits $3500/member, $7,000/family (aggregate) Annual Deductible (Medical/Pharmacy combined, par/non-par) $1500/member, $3,000/family (aggregate) Annual Out-of-Pocket Maximum (in addition to deductible) (Medical/Pharmacy combined, par/non-par)
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19. 3500 Deductible PPO $15 generic; $35 brand copay after $500 brand deductible (2-member maximum) Drug Benefits (Anthem Blue Cross Formulary) Not covered Maternity HealthyCheck Centers: $25/$75 copay for basic/premium screenings, deductible waived Routine mammogram, Pap, PSA ordered by physician: $0 after deductible Well Child: $0 after deductible Preventive Care $0 after deductible Hospital In/Outpatient $0 after deductible Office Visits $3500/member Annual Deductible (2-member maximum) Satisfied in-network once annual deductible is met Annual Out-of- Pocket Maximum (in addition to deductible) (2-member maximum, par/non-par)
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21. Basic PPO (2500/1000) HealthyCheck Centers: $25/$75 copay for basic/ premium screenings Routine mammogram, Pap, PSA ordered by physician: 20% of negotiated fee Preventive Care (deductible waived) Not covered Maternity Not covered Drug Benefits 20% of negotiated fee Hospital In/Outpatient $1000/member $2500/member $2500 No office visit benefits until out-of-pocket maximum is met, then plan pays 100% of negotiated fee Office Visits Annual Deductible (2-member maximum) $2500 Annual Out-of-Pocket Maximum (in addition to deductible) (2-member maximum, par/non-par)
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24. HMO Plans See Office visits and In/Outpatient $3,000 $10 generic; $30 brand copay after $250 brand deductible (2-member maximum) Drug Benefits (Anthem Blue Cross formulary) Office visits: $10 copay Inpatient: no charge Outpatient: 20% of negotiated fee See Office visits and In/Outpatient ( subject to deductible) Maternity Inpatient: 20% of negotiated fee Outpatient: 20% of negotiated fee Inpatient: $250 copay/day first 4 days; then covered at 100% Outpatient: 20% of negotiated fee, $250/surgery $1,500 deductible, then: Inpatient: 20% of negotiated fee Outpatient: 20% of negotiated fee (emergency & non-emergency services subject to deductible) Hospital In/Outpatient $25 copay $10 copay Preventive Care (specific services) $25 copay/visit $10 copay/visit Office Visits (unlimited) No deductible $1,500/member for Inpatient, Outpatient and ASCs only Annual Deductible $1500/member Annual Out-of-Pocket Maximum (in addition to deductible) (2-member maximum) Select HMO Individual HMO HMO Saver
25. Plan Options Based on Prospect’s Needs Lumenos with maternity PPO Share HMO Maternity coverage SmartSense 5000, 3500 HSA, 3500 PPO 2-year anniversary date rate lock Lumenos PPO 3500 (HSA-Compatible) Control over finances, including health care expenses Lumenos HSA/HIA/HIA+ (0% coinsurance plans) 3500 Deductible PPO or PPO 3500 (HSA-Compatible) 100% coverage of most services after deductible RightPlan PPO 40 Individual HMO or Select HMO No deductible PPO Share and HMO (unlimited) SmartSense (up to three) Immediate coverage for office visits before deductible Basic PPO, SmartSense Budget Recommended Plans: If Main Need Is:
26. Rating Methodology Summary NO YES YES YES YES YES YES Anniversary-Rated? NO CONTRACT Basic PPO CONTRACT CONTRACT MEMBER MEMBER MEMBER MEMBER Member-Level or Contract Rated? NO HMO NO PPO Share YES RightPlan YES 3500 HSA, 3500 PPO YES Lumenos YES SmartSense Gender-Rated? Plan
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28. Short-Term Plans 20% of negotiated fee (Accidental injuries not subject to deductible) Ambulatory Surgical Center and ER $10 generic; $30 brand name Brand name maximum $500 Drug Benefits (Anthem Blue Cross Formulary) Not covered Maternity 20% of negotiated fee Hospital In/Outpatient $250, $500, $1,000, $2,000 Deductible $1,000 per member plus deductible Out-of-Pocket Maximum
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31. Individual Dental – Dental Blue The deductible is waived for covered in-network Diagnostic & Preventive services 100% in-network (80% out-of-network) 50% (in-network and OON) Fee schedule (e.g., $57 for stainless steel crown) Not covered Major Services 80% (60% OON) Basic services: 0 Major services: 6 Basic services: 3 Major services: 12 200 Plus 100 Plus 100% in-network (fee schedule out-of-network) Diagnostic Care (cleanings, exams, X-rays) Not covered Orthodontia Fee schedule (e.g., $42 for filling) 80% fillings; 50% stainless steel crowns (fee schedule OON) Basic Services Basic services: 3 Major services: 12 0 Waiting Periods (months) $1000/person/yr $500/person/yr Maximum Benefit $50 single/$150 family $25/person (no family maximum) Deductible 200 Essential 100 Basic
32. Individual Dental – DHMO, SmileNet Not an insurance plan; a very simple, low-priced discount dental program SmileNet Dental Discount Program $5 Office Visits $0 Routine Cleanings Yes Orthodontia Coverage $0 Diagnostic Care (oral exams, X-rays) None for most services Waiting Periods Unlimited Maximum Benefit None Deductible (3) DHMO Plans