MEDICAL PLANS FOR CALENDAR YEAR 2016 **PLAN** BENEFIT PERIOD Primary Care Physician (PCP) Required Dependent age limit Annual Deductible Annual out-of-pocket max (excl deductible) Coinsurance (employee pays) IN-PATIENT CARE Semi-private room and board Surgery Anesthesia Consultations Maternity care Lab and X-ray services Therapy services Drugs and Medications OUT-PATIENT CARE Outpatient surgery Second Surgical Opinion Diagnostic services, lab and x-ray MRI (require prior authorization) Cardiac Rehabilitation Physical, occupational and speech therapy 4 Office visits - PCP Office visits - Specialist4 Urgent Care4 4 Routine Physical exam Routine Testing (5 standard) 1 Well child care (birth to age18) 4 Immunizations Routine Mammogram2 2 Routine Pap test Routine PSA2 Routine Hearing Exam Prenatal and postnatal maternity care Sterilization Allergy test and treatment Durable medical equipment Emergency room services (emergency) 3 - non-emergency use of emergency room Ambulance Biologically Based Mental Illness Services Substance/Chemical Abuse Inpatient Outpatient benefit Skilled nursing facilities Home healthcare Private Duty Nursing Hospice Organ transplants Prescription Drug (CVS Caremark) PPO Option 90/70 (Anthem & Med Mutual) Calendar Year (January 1 to December 31) No age 25, age 26-28 Adult Child BENEFIT Network Non-Network $250/$500 $750/$1,500 $1,500/$3,000 10% 30% PPO Option 80/60 (Anthem & Med Mutual) Calendar Year (January 1 to December 31) No age 25, age 26-28 Adult Child BENEFIT Network Non-Network $350/$700 $900/$1,800 $2,000/$4,000 20% 40% PPO Option 70/50 (Offered by Med Mutual ONLY) Calendar Year (January 1 to December 31) No age 25, age 26-28 Adult Child BENEFIT Network Non-Network $500/$1,000 $1,000/$2,000 $2,500/$5,000 30% 50% 90% 90% 90% 90% 90% 90% 90% 90% $100 copay, then 70% 70% 70% 70% $100 copay, then 70% 70% 70% 70% 80% 80% 80% 80% 80% 80% 80% 80% $100 copay, then 60% 60% 60% 60% $100 copay, then 60% 60% 60% 60% 70% 70% 70% 70% 70% 70% 70% 70% $100 copay, then 50% 50% 50% 50% $100 copay, then 50% 50% 50% 50% 90% 100% 90% 90% 90% 90% $15 copay then 100% $30 copay then 100% $15 copay then 100% $15 copay then 100% 100% $15 copay then 100% 100% 100% $15 copay then 100% 100% $15 copay then 100% 90% 90% 90% 70% 100% 70% 70% 70% 70% 70% 70% 70% not covered not covered 70% 70% 70% no deductible 70% no deductible 70% no deductible 70% no deductible 70% 70% 70% 80% 100% 80% 80% 80% 80% $15 copay then 100% $30 copay then 100% $15 copay then 100% $15 copay then 100% 100% $15 copay then 100% 100% 100% $15 copay then 100% 100% $15 copay then 100% 80% 80% 80% 60% 100% 60% 60% 60% 60% 60% 60% 60% not covered not covered 60% 60% 60% no deductible 60% no deductible 60% no deductible 60% no deductible 60% 60% 60% 70% 100% 70% 70% 70% 70% $15 copay then 100% $30 copay then 100% $15 copay then 100% $15 copay then 100% 100% $15 copay then 100% 100% 100% $15 copay then 100% 100% $15 copay then 100% 70% 70% 70% 50% 100% 50% 50% 50% 50% 50% 50% 50% not covered not covered 50% 50% 50% no deductible 50% no deductible 50% no deductible 50% no deductible 50% 50% 50% 90% 90% $50 copay then 90% 90% 80% 80% $50 copay then 70% $15 copay then 100% 90% 70% 90% 70% 90% 70% 90%, 120 days per calendar year 90%, 120 days per calendar year 90% 90% 90% 70% 10% coinsurance generic, 20% coinsurance brand, 40% coinsurance for brand if generic is available; $60 max per prescription Retail or Mail Service. If a brand name drug is prescribed and a generic is available, the maximum coinsurance is $100 unless the physician has indicated "dispense as written".Mail Service required after 90 days for maintenance medications. 1) EKG, chest x-ray, complete blood count, SMA 12, urinalysis. 2) Once per calendar year for covered persons within eligible groups 3) No coverage for facility charges during non-emergency use of emergency room; benefits cover professional component only. 4) Office visit co-pays apply to cost of the office visit only. 5) All plans are grandfathered. $50 copay then 80% 80% 70% 70% $50 copay then 60% $15 copay then 100% 80% 60% 80% 60% 80% 60% 80%, 120 days per calendar year 80%, 120 days per calendar year 80% 80% 80% 60% $50 copay then 70% 70% $50 copay then 50% $15 copay then 100% 70% 50% 70% 50% 70% 50% 70%, 120 days per calendar year 70%, 120 days per calendar year 70% 70% 70% 50% 10% coinsurance generic, 20% coinsurance brand, 40% coinsurance for brand if generic is available; $60 max per prescription Retail or Mail Service. If a brand name drug is prescribed and a generic is available, the maximum coinsurance is $100 unless the physician has indicated "dispense as written".Mail Service required after 90 days for maintenance medications. 10% coinsurance generic, 20% coinsurance brand, 40% coinsurance for brand if generic is available; $60 max per prescription Retail or Mail Service. If a brand name drug is prescribed and a generic is available, the maximum coinsurance is $100 unless the physician has indicated "dispense as written".Mail Service required after 90 days for maintenance medications. This is a summary. If there is a difference between this summary and the plan documents, benefits will be paid in accordance with the plan documents.