2016 Massachusetts Small Group Plan Design Comparison Plan Year or Calendar Year Available for All Plans Plan Name

Coinsurance

Deductible Ind/Fam

Combined Medical/RX/ Pedi Dental OOPM

PCP

Specialist

High-Tech Imaging

Inpatient Services

Outpatient Services

ER

RX Tier 1

RX Tier 2

RX Tier 3

RX Tier 4

RX Deductible Ind/Fam

HMO Copay Plans HMO Value 250 Platinum

0%

$0

$3,500/$7,000

$20

$35

$100

$250

$250

$150

$15

$30

$50

$75

$0

HMO Basic 25 Platinum

0%

$0

$2,000/$4,000

$25

$25

$150

$500

$500

$150

$20

$40

$60

$100

$0

HMO Deductible Plans Advantage HMO 500 Gold

0%

$500/$1,000

$6,850/$13,700

$25

$50

$250

Deductible

$250

$250

$20

$55

$70

$100

$0

Advantage HMO 1000 Gold

0%

$1,000/$2,000

$6,500/$13,000

$25

$50

$250

Deductible

$250

$250

$20

$55

$70

$100

$0

Advantage HMO 1500 Gold

0%

$1,500/$3,000

$6,500/$13,000

$25

$50

Deductible Deductible

Deductible

$250

$20

$55

$70

$100

$0

Advantage HMO 2000 Gold

0%

$2,000/$4,000

$4,500/$9,000

$25

$50

Deductible Deductible

Deductible

Deductible

$20

$40

$60

$100

$0

New Plan Advantage HMO 2500 Silver

0%

$2,500/$5,000

$6,500/$13,000

$30

$55

$250

Deductible

$250

Deductible

$25

$70

$100

10%*

$0

Advantage HMO 3000 Silver

0%

$3,000/$6,000

$6,850/$13,700

$40

$60

$250

Deductible

$250

Deductible

$30

$75

$100

10%*

$0

HMO Low Option / Coinsurance Plans Advantage HMO 1000 Silver Low Option

10%

$1,000/$2,000

$6,600/$13,200

$50

$75

$250

Deductible then 10%

$250

$250

$30

$75

$100

10%*

$0

Advantage HMO 1500 Silver Low Option**

10%

$1,500/$3,000

$6,600/$13,200

$35

$50

$250

Deductible then 10%

$250

$250

$35

$85

$100

10%*

$250/ $500

Advantage HMO 2000 Silver Low Option

0%

$2,000/$4,000

$6,600/$13,200

$50

$75

$250

Deductible

$250

$250

$25

$75

$100

10%*

$0

Advantage HMO 2000 (80%) Silver**

20%

$2,000/$4,000

$6,850/$13,700

$40

$60

Deductible Deductible then 20% then 20%

Deductible then 20%

Deductible then 20%

$25

$75

$100

10%*

$0

Advantage HMO 2000 (65%) Silver**

35%

$2,000/$4,000

$6,850/$13,700

$40

$60

Deductible Deductible then 35% then 35%

Deductible then 35%

Deductible then 35%

$25

$75

$100

10%***

$0

*Plan has 10% coinsurance on the fourth tier with a max cost of $250 per fill. **These plans feature the generic preferred program formulary. If a brand name drug has a generic equivalent, and a member requests a fill for a brand name drug, the member must pay the difference in cost between the generic copay and cost of the brand name drug. ***Plan has 10% coinsurance on the fourth tier with a max cost of $350 per fill. These charts provide benefit highlights for general comparison purposes only. There are also services that the plans do not cover. Please see a Summary of Benefits and Coverage for more information or refer to your Member Benefit Document for complete information. 11/15

2016 Massachusetts Small Group Plan Design Comparison Plan Year or Calendar Year Available for All Plans Plan Name

Coinsurance

Deductible Ind/Fam

Combined Medical/RX/ Pedi Dental OOPM

Advantage HMO 1500 Saver Gold

0%

$1,500/$3,000

$6,550/$13,100

New Plan Advantage HMO 2000 (90%) Saver Silver

10%

$2,000/$4,000

Advantage HMO 2500 Saver Silver

0%

New Plan Advantage HMO 3000 Saver Silver

PCP

Specialist

High-Tech Imaging

Inpatient Services

Outpatient Services

ER

RX Tier 1

RX Tier 2

RX Tier 3

RX Tier 4

RX Deductible Ind/Fam

Deductible Deductible Deductible Deductible

Deductible

Deductible

$20

$75

$100

$125

$1,500/ $3,000

$6,550/$13,100

Deductible Deductible Deductible Deductible then 10% then 10% then 10% then 10%

Deductible then 10%

Deductible then 10%

$20

$75

$100

$125

$2,000/ $4,000

$2,500/$5,000

$6,550/$13,100

Deductible Deductible Deductible Deductible

Deductible

Deductible

$20

$75

$100

$125

$2,500/ $5,000

0%

$3,000/$6,000

$6,550/$13,100

Deductible Deductible Deductible Deductible

Deductible

Deductible

$25

$75

$100

$125

$3,000/ $6,000

Select Basic 35 Gold**

0%

$0

$6,500/$13,000

$35

$35

$250

$1500

$500

$250

$25

$80

$100

10%*

$0

Select AHMO 500 Gold**

0%

$500/$1,000

$6,850/$13,700

$25

$50

$250

Deductible

Deductible

$250

$25

$75

$100

10%*

$0

Select AHMO 1000 Gold**

0%

$1,000/$2,000

$6,500/$13,000

$25

$50

Deductible Deductible

Deductible

$250

$25

$75

$100

10%*

$0

Select AHMO 1500 Gold**

0%

$1,500/$3,000

$6,000/$12,000

$25

$50

Deductible Deductible

Deductible

$250

$20

$60

$80

10%*

$0

Select AHMO 2000 Silver**

0%

$2,000/$4,000

$6,850/$13,700

$40

$65

$250

Deductible

$250

$250

$30

$75

$100

10%*

$0

Steward Copay Plan Platinum

0%

$0

$4,000/$8,000

$25

$40

$100

$250

$250

$150

$15

$30

$50

10%*

$0

Steward 1000 Gold

0%

$1,000/$2,000

$6,500/$13,000

$25

$55

$250

Deductible

$250

$250

$20

$60

$80

10%*

$0

Steward 1500 Gold

0%

$1,500/$3,000

$6,500/$13,000

$25

$55

Deductible

$250

$20

$60

$80

10%*

$0

Steward 2000 Silver

0%

$2,000/$4,000

$6,850/$13,700

$40

$65

$250

$250

$30

$75

$100

10%*

$0

HMO Saver Plans

HMO Select Plans

HMO Steward Plans

Deductible Deductible $250

Deductible

*Plan has 10% coinsurance on the fourth tier with a max cost of $250 per fill. **These plans feature the generic preferred program formulary. If a brand name drug has a generic equivalent, and a member requests a fill for a brand name drug, the member must pay the difference in cost between the generic copay and cost of the brand name drug. ***Plan has 10% coinsurance on the fourth tier with a max cost of $350 per fill. These charts provide benefit highlights for general comparison purposes only. There are also services that the plans do not cover. Please see a Summary of Benefits and Coverage for more information or refer to your Member Benefit Document for complete information.

11/15

2016 Massachusetts Small Group Plan Design Comparison Plan Year or Calendar Year Available for All Plans Plan Name

Coinsurance

Deductible Ind/Fam

Combined Medical/RX/ Pedi Dental OOPM

PCP

Specialist

High-Tech Imaging

In: $0 Out: $500/$1,000

In: $3,500/$7,000 Out: $7,000/$14,000

$30

$30

$100

In: 0% In: 0 In: $2,000/$4,000 Out: 20% Out: $750/$1,500 Out: $4,000/$8,000

$25

$25

$150

In: $6,850/$13,700 Out: $13,700/$27,400

$35

$35

$250

$250

PPO Copay Plans PPO Value 250 In: 0% Platinum Out: 20% PPO Basic 25 Platinum

­­­

Inpatient Services

Outpatient Services

ER

RX Tier 1

RX Tier 2

RX Tier 3

RX Tier 4

RX Deductible Ind/Fam

$250

$250

$150

$15

$30

$50

$75

$0

$500

$500

$150

$20

$40

$60

$100

$0

Deductible

$250

$250

$25

$55

$70

$100

$0

Deductible

$250

$250

$20

$55

$70

$100

$0

IN-NETWORK

PPO Deductible Plans

IN-NETWORK

Advantage PPO 500 Gold

In: 0% Out: 20%

Advantage PPO 1000 Gold

In: 0% In: $1,000/$2,000 Out: 20% Out: $2,000/$4,000

In: $6,500/$13,000 Out: $13,000/$26,000

$35

$35

Advantage PPO 1500 Gold

In: 0% In: $1,500/$3,000 Out: 20% Out: $3,000/$6,000

In: $6,500/$13,000 Out: $13,000/$26,000

$35

$35

Deductible Deductible

Deductible

$250

$20

$55

$70

$100

$0

Advantage PPO 2000 Gold

In: 0% Out: 20%

In: $2,000/$4,000 Out: $4,000/$8,000

In: $4,500/$9,000 Out: $9,000/$18,000

$35

$35

Deductible Deductible

Deductible

Deductible

$20

$40

$60

$100

$0

New Plan Advantage PPO 2500 Silver

In: 0% Out: 20%

In: $2,500/$5,000 Out: $5,000/$10,000

In: $6,500/$13,000 Out: $13,000/$26,000

$45

$45

$250

Deductible

$250

Deductible

$25

$70

$100

10%*

$0

Advantage PPO 3000 Silver

In: 0% Out: 20%

In: $3,000/$6,000 Out: $6,000/$12,000

In: $6,850/$13,700 Out: $13,700/$27,400

$50

$50

$250

Deductible

$250

Deductible

$30

$75

$100

10%*

$0

In: $500/$1,000 Out: $1,000/$2,000

PPO Low Option / Coinsurance Plans

IN-NETWORK

Advantage PPO 2000 (80%) Silver**

In: 20% Out: 40%

In: $2,000/$4,000 Out: $4,000/$8,000

In: $6,850/$13,700 Out: $13,700/$27,400

$40

$40

Deductible Deductible then 20% then 20%

Deductible then 20%

Deductible then 20%

$25

$75

$100

10%*

$0

Advantage PPO 2000 (65%) Silver**

In: 35% Out: 55%

In: $2,000/$4,000 Out: $4,000/$8,000

In: $6,850/$13,700 Out: $13,700/$27,400

$40

$40

Deductible Deductible then 35% then 35%

Deductible then 35%

Deductible then 35%

$25

$75

$100

10%***

$0

*Plan has 10% coinsurance on the fourth tier with a max cost of $250 per fill. **These plans feature the generic preferred program formulary. If a brand name drug has a generic equivalent, and a member requests a fill for a brand name drug, the member must pay the difference in cost between the generic copay and cost of the brand name drug. ***Plan has 10% coinsurance on the fourth tier with a max cost of $350 per fill. These charts provide benefit highlights for general comparison purposes only. There are also services that the plans do not cover. Please see a Summary of Benefits and Coverage for more information or refer to your Member Benefit Document for complete information.

11/15

2016 Massachusetts Small Group Plan Design Comparison Plan Year or Calendar Year Available for All Plans Plan Name

Coinsurance

PPO Saver Plans

Deductible Ind/Fam

Combined Medical/RX/ Pedi Dental OOPM

PCP

Specialist

­­­

High-Tech Imaging

Inpatient Services

Outpatient Services

ER

RX Tier 1

RX Tier 2

RX Tier 3

RX Tier 4

RX Deductible Ind/Fam

IN-NETWORK

Advantage PPO 1500 Saver Gold

In: 0% In: $1,500/$3,000 In: $6,550/$13,100 Deductible Deductible Deductible Deductible Out: 20% Out: Out: $3,000/$6,000 $13,100/$26,200

Deductible

Deductible

$20

$75

$100

$125

$1,500/ $3,000

New Plan Advantage PPO 2000 (90%) Saver Silver

In: 10% Out: 30%

In: $2,000/$4,000 Out: $4,000/$8,000

In: $6,550/$13,100 Deductible Deductible Deductible Deductible Out: then 10% then 10% then 10% then 10% $13,100/$26,200

Deductible then 10%

Deductible then 10%

$20

$75

$100

$125

$2,000/ $4,000

Advantage PPO 2500 Saver Silver

In: 0% Out: 20%

In: $2,500/$5,000 Out: $5,000/$10,000

In: $6,550/$13,100 Deductible Deductible Deductible Deductible Out: $13,100/$26,200

Deductible

Deductible

$20

$75

$100

$125

$2,000/ $4,000

New Plan Advantage PPO 3000 Saver Silver

In: 0% Out: 20%

In: $3,000/$6,000 Out: $6,000/$12,000

In: $6,550/$13,100 Deductible Deductible Deductible Deductible Out: $13,100/$26,200

Deductible

Deductible

$25

$75

$100

$125

$3,000/ $6,000

New Plan Advantage PPO 4500 (70%) Saver Bronze

In: 30% Out: 50%

In: $4,500/$9,000 Out: $9,000/$18,000

In: $6,550/$13,100 Deductible Deductible Deductible Deductible Out: then 30% then 30% then 30% then 30% $13,100/$26,200

Deductible then 30%

Deductible then 30%

30%

30%

30%

30%

$4,500/ $9,000

$500

$150

$15

$30

$50

N/A

$0

N/A

$100/$200 (Tiers 2 + 3)

Health Connector Plans Premier Platinum

0%

0

$2,000/$4,000

$25

$40

$150

$500

Premier Gold 400 with Coinsurance

30%

$400/$800

$3,000/$6,000

$20

$35

Deductible Deductible then 30% then 30%

Deductible then 30%

Deductible then 30%

$15

Premier Gold 1000

0%

$1,000/$2,000

$5,000/$10,000

$30

$45

Deductible Deductible then $200 then $500

Deductible then $250

Deductible then $150

$20

$30

$50

N/A

$0

Premier Silver 2000

0%

$2,000/$4,000

$6,850/$13,700

$30

$50

Deductible Deductible then $500 then $1000

Deductible then $750

Deductible then $500

$20

$50

$75

N/A

$0

Premier Bronze Saver 3300

30%

$3,300/$6,600

$6,550/$13,100

Deductible Deductible Deductible Deductible then $40 then $65 then $750 then $1000

Deductible then $1000

Deductible then $750

N/A

$3,300/ $6,600

Deductible Deductible then 30% then 30%

Deductible Deductible Deductible then $25 then $75 then $100

*Plan has 10% coinsurance on the fourth tier with a max cost of $250 per fill. **These plans feature the generic preferred program formulary. If a brand name drug has a generic equivalent, and a member requests a fill for a brand name drug, the member must pay the difference in cost between the generic copay and cost of the brand name drug. ***Plan has 10% coinsurance on the fourth tier with a max cost of $350 per fill. These charts provide benefit highlights for general comparison purposes only. There are also services that the plans do not cover. Please see a Summary of Benefits and Coverage for more information or refer to your Member Benefit Document for complete information. ALL PREMIER PLANS FEATURE THE MANDATORY MAIL ORDER REQUIREMENT FOR MAINTENANCE MEDICATIONS.

11/15

2016 Massachusetts Small Group Plan Design Comparison Plan Year or Calendar Year Available for All Plans Office Visit Copay

Tier PCP

Specialist

Day Surgery Center

ER Copay

Inpatient Hospital Copay

Freestanding Outpatient Surgery Center

Hospital

High-Tech Imaging

Freestanding Imaging Center

Hospital or Other Provider

Diagnostic Tests

Any Non Hospital Provider

Member Coinsurance

Medical Deductible Individual/ Family

Deductible then covered in full

N/A

$250/ $500

Deductible then covered in full

N/A

$1,000/ $2,000

Outpatient Hospital

Combined Annual Out-of-Pocket Maximum Includes Medical, Pharmacy, and Pediatric Dental (Individual/Family)

Pharmacy Retail Copays

$6,600/ $13,200

$20/$40/ $60/$80

$6,600/ $13,200

$15/$30/ $50/$75

YOUR CHOICE HMO — A Tiered Provider Network Option Your Choice HMO 3-Tier Option 9 - GOLD

Tier 1

$25

$50

$200

Deductible then $500

Tier 2

$35

$60

$200

Deductible then $750

Tier 3

$45

$75

$200

Deductible then $1,000

Deductible then $500

Tier 1 Deductible then $500

Deductible then $750

Deductible then $150

Tier 1 Deductible then $150

Deductible then $350

Covered in full

Deductible then $1,000

Deductible then $750

Deductible then covered in full

N/A

$2,000/ $4,000

Deductible then covered in full

Deductible then $100

Deductible then covered in full

N/A

$500/ $1,000

Deductible then covered in full

N/A

$1,000/ $2,000

Deductible then covered in full

N/A

$2,000/ $4,000

Your Choice HMO 3-Tier Option 10 - GOLD

Tier 1

$25

$50

$200

Deductible then covered in full

Tier 2

$35

$60

$200

Deductible then covered in full

$200

Deductible then covered in full

Tier 3

$50

$75

Tier 1 Deductible then covered in full

Deductible then covered in full Deductible then covered in full

Tier 1 Deductible then $100

Deductible then $350

Deductible then $750

Covered in full

* Mail Order Pharmacy: 90-day supply is available at the 60-day supply copayment for Tier 1 and Tier 2 medications. Tier 3 medications require the 90-day supply copayment and Tier 4 is NA for mail order. Pricing relativity as compared to Advantage HMO 1000 as the baseline measurement. Information is provided for illustrative purposes only; actual quotes may vary. This information is subject to change without notice. This chart provides benefit highlights for general comparison purposes only. There are also services that the plans do not cover. Please see a Summary of Benefits for more information or refer to your Evidence of Coverage for complete information. All plans come with Altus pediatric dental coverage. To request a plan without pediatric dental coverage please contact your sales executive or account manager. All mail order values reflect a 90 day supply.

11/15

2016 Massachusetts Small Group Plan Design Comparison Plan Year or Calendar Year Available for All Plans Office Visit Copay

Tier PCP

Specialist

Day Surgery Center

ER Copay

Inpatient Hospital Copay

Freestanding Outpatient Surgery Center

Hospital

High-Tech Imaging

Freestanding Imaging Center

Hospital or Other Provider

Diagnostic Tests

Any Non Hospital Provider

Outpatient Hospital

Member Coinsurance

Medical Deductible Individual/ Family

Combined Annual Out-of-Pocket Maximum Includes Medical, Pharmacy, and Pediatric Dental (Individual/Family)

Pharmacy Retail Copays

$750/ $1,500

$6,600/ $13,200

$15/$30/ $50/$75

$1,000/ $2,000

$5,850/ $11,700

$15/$30/ $50/$75

YOUR CHOICE HMO — A Tiered Provider Network Option Your Choice HMO 2-Tier Option 8 - GOLD

Tier 1

Tier 2

$25

$50

$50

$75

$200

$200

Deductible then $500

Deductible then $1,000

Deductible then $500 Deductible then $500

Deductible then $1,000

Deductible then covered in full

N/A

Deductible then $450

Deductible then covered in full

N/A

Deductible then covered in full

Deductible then covered in full

N/A

Deductible then covered in full

N/A

Deductible then $200 Deductible then $200

Covered in full

Your Choice HMO 2-Tier Option 9 - GOLD

Tier 1

Tier 2

$25

$50

$50

$75

$150

$150

Deductible then covered in full Deductible then $1,000

Deductible then covered in full

Deductible then covered in full Deductible then $1,000

Deductible then covered in full

Deductible then $450

Covered in full

* Mail Order Pharmacy: 90-day supply is available at the 60-day supply copayment for Tier 1 and Tier 2 medications. Tier 3 medications require the 90-day supply copayment and Tier 4 is NA for mail order. Pricing relativity as compared to Advantage HMO 1000 as the baseline measurement. Information is provided for illustrative purposes only; actual quotes may vary. This information is subject to change without notice. This chart provides benefit highlights for general comparison purposes only. There are also services that the plans do not cover. Please see a Summary of Benefits for more information or refer to your Evidence of Coverage for complete information. All plans come with Altus pediatric dental coverage. To request a plan without pediatric dental coverage please contact your sales executive or account manager. All mail order values reflect a 90 day supply.

11/15