City of Baltimore 2017 Active Employee Benefits Booklet

Rajesh Gulhar, Chief, Employee Benefits Division

Mary H. Talley Director & Chief Human Capital Officer

Note: This Comparison Is To Be Used As A Guide Only. Actual Benefits Will Be Governed by The Terms and conditions of the Master Contract.

Revised 9/26/2016

October 2016

Table of Contents Section Contents

Page

Cover Page Table of Contents Section 1

Section 2

Section 3

Section 4

Important Information Important Information About 2017 Benefits Medicare Information for Active Employees Flexible Spending Account Family Status Change Waiver Credit Alex Wellness Information Premium Deductions Weekly Medical Premium Bi-Weekly Medical Premium 21-Pay Medical Premium Prescription Premiums Dental Premiums Benefits Information Prescription Drug Co-Pay Information CareFirst Select Vision Schedule of Benefits Delta Dental HMO Benefits Information Delta Dental PPO Benefits Information Life Insurance Information Medical Plan Comparison Aetna PPO UnitedHealthcare POS CareFirst PPN HMO Plan Comparisons (Aetna, UnitedHealthcare, Kaiser) Contact Information

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4-5 6 7 8 9 10 11 13 14 15 16 17 19 20 21-22 23 24 26-28 29-31 32-36 37-40 41

Section 1 Important Information

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Information About Your 2017 Benefits Please read the information provided in this Comparison Chart Administrative Notices Duplicate Coverage Information

If you and your spouse/partner are both a City employee/retiree, you both cannot enroll each other or the same eligible dependents on your City medical, dental, vision and prescription plans during any coverage period. You will be notified to adjust duplicate coverage, if applicable.

Summary Benefits and Coverage (SBC)

The Patient Protection and Affordable Care Act (PPACA) requires health plans and health insurance issuers to provide a Summary of Benefits and Coverage (SBC) to applicants and enrollees. The SBC is a concise document providing simple and consistent information about health plan benefits and coverage. Its purpose is to help health plan consumers better understand the coverage they have and to help them make easy comparisons of different options when shopping for new coverage. The City of Baltimore will post this document on its enrollment website: www.baltimorecity.essbenefits.com under its own drop down menu labeled Summary of Benefits and Coverage.

Medicare Secondary Payer (MSP) Mandatory Reporting

Under the Medicare Secondary Payer (MSP) Mandatory Reporting Provision and the Affordable Care Act (ACA) Individual Shared Responsibility Reporting provision, the federal law requires the mandatory collection and reporting of social security numbers of all covered participants, including employees, retirees and their dependents through employer group health plans. Noncompliance may be subject to a $50 penalty imposed by the IRS under Section 6723 of the Internal Revenue Code.

Important Medicare Information

Disability Retirees as Determined by Social Security

The City requires all its members (including you and your dependents) to enroll in Medicare Part B at the time you become eligible for Medicare Part A. Once enrolled in Medicare part B, you must remain enrolled in order to continue receiving the maximum possible benefit from the City's supplemental medical plan. The CareFirst Medicare Supplemental offered by the City, will cover only 80% of your health claims not covered by Medicare up to the maximum Medicare Allowed Amount, you will be responsible for any balance due. When you (or spouse/child) become disabled as determined by the SSA, you must apply for Medicare Part B through SSA at the time you become eligible for Medicare Part A and provide Employee Benefits with your Medicare information immediately. If you decline your Medicare Part B, you will be responsible for all Medicare Part B (Medical) claims that would ordinarily be covered by Medicare B. The CareFirst Medicare Supplemental offered by the City, will cover only 80% of your health claims not covered by Medicare up to the maximum Medicare Allowed Amount, you will be responsible for any balance due.

Change of Address

You must notify your agency about your change of address, in writing.

Enrollment Website

www.baltimorecity.essbenefits.com

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Information About Your 2017 Benefits Plan Information United Healthcare Choice (HMO) Plan

The UnitedHealthcare Choice (HMO). - PCP (Primary Care Physician) selection not required - Referrals will no longer be required - Nationwide network access

The Open Access Aetna Select (HMO). - PCP (Primary Care Physician) selection not required Aetna Open Access HMO Plan - Referrals will no longer be required - Nationwide network access

ID Cards

New ID cards will be mailed to members who change medical plans, enroll in medical and or the FSA plans during open enrollment.

Jelly Vision - Alex is back!

JellyVision is back for the 2017 Open Enrollment period as well as Ongoing Enrollment starting October 21, 2016. Active employees and retirees without Medicare will have an opportunity to interact online with Alex the virtual benefits counselor. You can find Alex on the City's health Benefits Enrollment System under the Main Menu. Alex will help you make smarter healthcare decisions that may save you time and money by answering a series of health related questions.

FSA plans and Waiver Credits

Reminder; the Waiver Credit, Healthcare FSA and the Dependent Care FSA plans do not roll over, they end on December 31st each year. You must re-enroll each year during Open Enrollment.

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Employee Benefits Division 201 E. Baltimore Street, Suite 500, Baltimore, MD 21202

IMPORTANT MEDICARE INFORMATION Actively Employed with the City of Baltimore (COB) At Age 65 & Older

What should I do if I am still actively employed and enrolled in health benefits with the City of Baltimore when I turn age 65? If you are still employed and enrolled in health benefits with the City of Baltimore (COB) as an active full-time employee when you (or your spouse) turn age 65, you should contact Social Security Administration (SSA) three months before you (or your spouse) turn age 65 to enroll in Medicare Part A and Part B. However, if you decide to remain employed as an active full-time employee with COB beyond age 65 and you (and your spouse) remain enrolled in COB group health benefits, you (or your spouse) may consider delaying your enrollment in Medicare Part B through SSA without a late-enrollment penalty. Your (and spouse’s) health plan coverage will remain primary until your employment or coverage ends, whichever occurs first. Three months before and 8 months after your current employment or group health plan coverage ends with the COB, whichever happens first, you must visit your local Social Security office to enroll in Medicare Part B during the Special Enrollment Period, which runs for 8 months from the date your employment and/or group health plan coverage ends. Prior to your Special Enrollment Period, you should obtain a Request For Employment Information form from SSA to be completed by the Employee Benefits Division. If you are an employee of BCPSS, this form must be completed by the BCPSS - Office of Benefits Management. This form verifies your employment and health benefits status with the Baltimore City or BCPSS at the time your employment ends. Return the completed form to your Social Security office in order to waive the late-enrollment penalty for enrollment in Medicare Part B. Note: If you wait until after you retire (within the 8-month special enrollment period) to enroll in Medicare Part B, your Medicare Part B start date will be delayed causing a lapse in coverage and out of pocket expenses.

Who do I contact if I have any questions? If you have any questions regarding your Baltimore City medical plan coverage, please contact our office at 410-396-5830/TTY 711 (Maryland). Baltimore City retirees should select option 2 and BCPSS retirees should select option 3, and then choose option 1 to speak to a customer service representative. If you have any questions regarding the Baltimore City Medicare Part D Rx Plan, please call 410-396-1780. If you have any questions regarding Medicare enrollment in Part A and Part B, please contact the Social Security Administration at 1-800-772-1213. If you have any questions regarding Medicare benefits, please call 1-800633-4227. 7

Flexible Spending Accounts (FSA) The City of Baltimore gives you the opportunity to save taxes on your eligible health and dependent care expenses by participating in one or both flexible spending accounts (FSAs):  Health Care Flexible Spending Account (FSA)  Dependent Care Flexible Spending Account (FSA) Participation in both types of flexible spending accounts is completely voluntary and currently administered by, Vantagen Baker Tilly. If you choose to enroll, simply decide how much to contribute each year to one or both accounts. Contributions to your account(s) are deducted from your paycheck before federal, state* income and Social Security taxes are withheld. This reduces your taxes and saves you money. When you have an eligible expense, you submit a claim for reimbursement to the City’s FSA Administrator, Vantagen. FSA Eligibility You can use your Health Care FSA to be reimbursed for eligible health care expenses incurred by you, your spouse, your qualifying child, or your qualifying relative. You may use your Dependent Care FSA to be reimbursed for eligible dependent care expenses for your child (under age 13) or other qualifying individual. Please see the Flexible Spending Account FAQs at www.myflexdollars.com for more information. You will need to register the first time you use the site Enrolling in an FSA If you are a new hire, you may enroll in one or both of the FSAs. Your FSA participation becomes effective with your first payroll deduction, as long as you enroll online within 45 days from your date of hire. Once enrolled, you may not change your election mid-year unless you have a Qualified Life Event (QLE), such as marriage or the birth of a child. (See the “General Information” section of the City’s Benefits Guide for more information on Qualified Life Events). Each year during the annual benefits Open Enrollment period, you may choose to enroll or re-enroll in one or both of the FSAs. Your participation starts on the January 1 following your enrollment. You must re-enroll each year during Open Enrollment if you wish to participate in one or both FSAs the following plan year. Your enrollment does not automatically carry over from year to year. If you do not actively enroll in an FSA during Open Enrollment, you will not participate in that FSA for the following year. Estimating Your Expenses If you are enrolling during the annual Open Enrollment period, your election will be in force for the full plan year (January 1 – December 31). Therefore, you should estimate your eligible expenses for the full twelve months. However, if you are a new hire, you should estimate only those expenses you will incur from the effective date of your enrollment to the end of the year, December 31. Estimate carefully to avoid forfeiting any money left in these FSA accounts. For more information about the FSA plans please visit the enrollment website at https://www.baltimorecity.essbenefits.com , located under “plan Information”. To receive information on the eligible health care expenses, and dependent care expenses, please call Vantagen at 1-800-307-0230. You may also visit www.myflexdollars.com .

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Waiver Credit You have the option of opting out of certain City of Baltimore health benefits and electing the waiver credit. The City of Baltimore determines which waiver credit applies to you, based on your union affiliation. The Waiver Credit amount is provided in increments over the course of the full plan year if enrolling during Open Enrollment or based on the number of pay periods left in the year for a new employee. New employees have 45 days from their date of hire to enroll online for the waiver credit. If, after waiving coverage with the City of Baltimore, you (the employee) lose coverage due to divorce, loss of employment, or the death of your spouse or other person who is the source of coverage, you may enroll in health benefits through the City within 60 days of the qualifying life event. In this case, you will relinquish the waiver payment. $2,500 Waiver Credit AFSCME Local 558, 44, and 2202 If you are represented by the AFSCME Local 558, 44, or 2202 union, you may elect the $2,500 waiver credit. To receive the waiver credit, you must enroll online within 45 days of hire or during the Open Enrollment period each year. When you make this election, you are waiving medical, dental, prescription drug, and vision coverage with the understanding that you cannot enroll in any of these plans, as the policyholder or as a dependent, through the City of Baltimore for that plan year. You must re-enroll each year. $650 Waiver Credit (waives Medical only) CUB, MAPS, and Police If you are represented by the CUB, MAPS, or Police union, you may elect the $650 waiver credit. To receive this waiver credit you must enroll online within 45 days of hire or during the Open Enrollment period each year. If you waive medical coverage, you may still elect dental, prescription drug, and vision coverage. However, you may not elect dental, prescription drug, and vision coverage as the policyholder if you are already enrolled as a dependent under the City plans for that plan year. You must re-enroll each year. $650 Waiver Credit (waives Medical and Prescription Drug) Firefighters and Fire Officers If you are a firefighter or fire officer, you may elect the $650 waiver credit. To receive this waiver credit, you must enroll online within 45 days of hire or during the Open Enrollment period each year. If you waive medical and prescription drug coverage, you may still elect dental and vision coverage. However, you may not elect dental and vision coverage as the policyholder if you are already enrolled as a dependent under the City plans for that plan year. You must re-enroll each year. Each year during the annual benefits Open Enrollment period, you may choose to enroll or re-enroll in the waiver credit. Your participation starts on the January 1 following your enrollment. You must re-enroll each year during Open Enrollment if you wish to receive the waiver credit the following plan year. Your enrollment does not automatically carry over from year to year. If you do not actively enroll in the waiver credit during Open Enrollment, you will not receive the increments for the following benefit year. For more information about the Waiver credit plans please visit the enrollment website at https://www.baltimorecity.essbenefits.com and view the Benefit Guide located under “plan Information”.

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Wellness Programs for Active Employees Wellness Programs for Active Employees

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Section 2 Premium Deductions

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Medical Premium 2017 Weekly Medical & Rx Plan Rates for Active Employees CareFirst Preferred Provider Network (PPN) High Option Medical Plan Coverage Total City Level Cost Cost Participant Only $ 158.63 $ 114.78 Participant + Child $ 307.89 $ 222.78 Participant + Spouse $ 354.71 $ 256.65 Participant + Family $ 385.01 $ 278.58

Standard Option Medical Plan Coverage Total City Level Cost Cost Participant Only $ 143.47 $ 114.78 Participant + Child $ 278.48 $ 222.78 Participant + Spouse $ 320.82 $ 256.66 Participant + Family $ 348.23 $ 278.58

Employee Cost $ 43.85 $ 85.11 $ 98.06 $ 106.43

Employee Cost $ 28.69 $ 55.70 $ 64.16 $ 69.65

UnitedHealthcare Point of Service (POS) High Option Medical Plan Coverage Total City Level Cost Cost Participant Only $ 140.77 $ 99.15 Participant + Child $ 267.45 $ 188.44 Participant + Spouse $ 295.63 $ 208.30 Participant + Family $ 422.30 $ 297.55

Standard Option Medical Plan Coverage Total City Level Cost Cost Participant Only $ 123.93 $ 99.14 Participant + Child $ 235.56 $ 188.45 Participant + Spouse $ 260.37 $ 208.30 Participant + Family $ 371.94 $ 297.55

Employee Cost $ 41.62 $ 79.01 $ 87.33 $ 124.75

Employee Cost $ 24.79 $ 47.11 $ 52.07 $ 74.39

Aetna Choice POS II High Option Medical Plan Coverage Total City Level Cost Cost Participant Only $ 117.44 $ 82.09 Participant + Child $ 253.84 $ 177.80 Participant + Spouse $ 279.94 $ 196.97 Participant + Family $ 388.97 $ 272.65

Standard Option Medical Plan Coverage Total City Level Cost Cost Participant Only $ 102.60 $ 82.08 Participant + Child $ 222.25 $ 177.80 Participant + Spouse $ 246.22 $ 196.98 Participant + Family $ 340.80 $ 272.64

Employee Cost $ 35.35 $ 76.04 $ 82.97 $ 116.32

UnitedHealthcare Choice (HMO)

Kaiser Permanente HMO

Optimum Choice HMO Plan Coverage Total City Employee Level Cost Cost Cost Participant Only 114.35 102.92 11.43 Participant + Child 217.26 195.53 21.73 Participant + Spouse 240.13 216.12 24.01 Participant + Family 343.04 308.74 34.30

Kaiser Permanente Coverage Total Level Cost Participant Only $ 101.78 Participant + Child $ 193.39 Participant + Spouse $ 213.75 Participant + Family $ 305.35

Open Access Aetna Select (HMO) Coverage Level Participant Only Participant + Child Participant + Spouse Participant + Family

Aetna HMO Plan Total City Cost Cost $ 105.17 $ 94.65 $ 212.33 $ 191.10 $ 232.94 $ 209.65 $ 254.13 $ 228.72

Employee Cost $ 20.52 $ 44.45 $ 49.24 $ 68.16

HMO Plan City Cost $ 91.60 $ 174.05 $ 192.38 $ 274.81

Employee Cost $ 10.18 $ 19.34 $ 21.37 $ 30.54

Bundled Medical & Rx Election Chart Bundled Medical & Rx Election Chart Rx coverage is bundled with Medical plan election, but with a separate payroll deduction.

Employee Cost $ 10.52 $ 21.23 $ 23.29 $ 25.41

High Option Medical Plans => High Option Rx Plan Standard Option Medical Plans => Standard Option Rx Plan HMO Medical Plans => High Option Rx Plan

Express Scripts (High & Standard Options) Express Scripts High Option Rx Plan Coverage Total City Employee Level Cost Cost Cost Participant Only $ 28.95 $ 22.16 $ 6.79 Participant + Child $ 56.20 $ 43.02 $ 13.18 Participant + Spouse $ 64.75 $ 49.56 $ 15.19 Participant + Family $ 70.27 $ 53.79 $ 16.48

Express Scripts Standard Option Rx Plan Coverage Total City Employee Level Cost Cost Cost Participant Only $ 27.70 $ 22.16 $ 5.54 Participant + Child $ 53.77 $ 43.02 $ 10.75 Participant + Spouse $ 61.95 $ 49.56 $ 12.39 Participant + Family $ 67.24 $ 53.79 $ 13.45

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Medical Premium 2017 Biweekly Medical & Rx Plan Rates for Active Employees CareFirst Preferred Provider Network (PPN) High Option Medical Plan Coverage Total City Level Cost Cost Participant Only $ 317.26 $ 229.56 Participant + Child $ 615.78 $ 445.56 Participant + Spouse $ 709.42 $ 513.31 Participant + Family $ 770.03 $ 557.16

Standard Option Medical Plan Coverage Total City Level Cost Cost Participant Only $ 286.94 $ 229.55 Participant + Child $ 556.95 $ 445.56 Participant + Spouse $ 641.63 $ 513.30 Participant + Family $ 696.45 $ 557.16

Employee Cost $ 87.70 $ 170.22 $ 196.11 $ 212.87

Employee Cost $ 57.39 $ 111.39 $ 128.33 $ 139.29

UnitedHealthcare Point of Service (POS) High Option Medical Plan Coverage Total City Level Cost Cost Participant Only $ 281.54 $ 198.30 Participant + Child $ 534.90 $ 376.89 Participant + Spouse $ 591.25 $ 416.58 Participant + Family $ 844.61 $ 595.10

Standard Option Medical Plan Coverage Total City Level Cost Cost Participant Only $ 247.87 $ 198.30 Participant + Child $ 471.11 $ 376.89 Participant + Spouse $ 520.73 $ 416.58 Participant + Family $ 743.88 $ 595.10

Employee Cost $ 83.24 $ 158.01 $ 174.67 $ 249.51

Employee Cost $ 49.57 $ 94.22 $ 104.15 $ 148.78

Aetna Choice POS II High Option Medical Plan Coverage Total City Level Cost Cost Participant Only $ 234.87 $ 164.16 Participant + Child $ 507.68 $ 355.61 Participant + Spouse $ 559.88 $ 393.94 Participant + Family $ 777.93 $ 545.29

Standard Option Medical Plan Coverage Total City Level Cost Cost Participant Only $ 205.20 $ 164.16 Participant + Child $ 444.51 $ 355.61 Participant + Spouse $ 492.43 $ 393.94 Participant + Family $ 681.61 $ 545.29

Employee Cost $ 70.71 $ 152.07 $ 165.94 $ 232.64

UnitedHealthcare Choice (HMO)

Kaiser Permanente HMO

Optimum Choice HMO Plan Coverage Total City Employee Level Cost Cost Cost Participant Only 228.69 205.82 22.87 Participant + Child 434.52 391.07 43.45 Participant + Spouse 480.26 432.23 48.03 Participant + Family 686.08 617.47 68.61

Open Access Aetna Select (HMO) Coverage Level Participant Only Participant + Child Participant + Spouse Participant + Family

Aetna HMO Plan Total City Cost Cost $ 210.34 $ 189.31 $ 424.65 $ 382.18 $ 465.88 $ 419.29 $ 508.26 $ 457.44

Employee Cost $ 41.04 $ 88.90 $ 98.49 $ 136.32

Kaiser Permanente Coverage Total Level Cost Participant Only $ 203.57 Participant + Child $ 386.78 Participant + Spouse $ 427.49 Participant + Family $ 610.70

HMO Plan City Cost $ 183.21 $ 348.10 $ 384.74 $ 549.63

Employee Cost $ 20.36 $ 38.68 $ 42.75 $ 61.07

Bundled Medical & Rx Election Chart Bundled Medical & Rx Election Chart Rx coverage is bundled with Medical plan election, but with a separate payroll deduction.

Employee Cost $ 21.03 $ 42.47 $ 46.59 $ 50.82

High Option Medical Plans => High Option Rx Plan Standard Option Medical Plans => Standard Option Rx Plan HMO Medical Plans => High Option Rx Plan

Express Scripts (High & Standard Options) Express Scripts High Option Rx Plan Coverage Total City Employee Level Cost Cost Cost Participant Only $ 57.91 $ 44.33 $ 13.58 Participant + Child $ 112.40 $ 86.04 $ 26.36 Participant + Spouse $ 129.49 $ 99.12 $ 30.37 Participant + Family $ 140.54 $ 107.58 $ 32.96

Express Scripts Standard Option Rx Plan Coverage Total City Employee Level Cost Cost Cost Participant Only $ 55.41 $ 44.33 $ 11.08 Participant + Child $ 107.54 $ 86.03 $ 21.51 Participant + Spouse $ 123.90 $ 99.12 $ 24.78 Participant + Family $ 134.47 $ 107.58 $ 26.89

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Medical Premium 2017 21-Pay Medical & Rx Plan Rates for Active Employees CareFirst Preferred Provider Network (PPN) High Option Medical Plan Total City Cost Cost Participant Only $ 392.79 $ 284.21 Participant + Child $ 762.40 $ 551.65 Participant + Spouse $ 878.33 $ 635.52 Participant + Family $ 953.37 $ 689.82 Coverage Level

Standard Option Medical Plan Coverage Total City Level Cost Cost Participant Only $ 355.26 $ 284.21 Participant + Child $ 689.56 $ 551.65 Participant + Spouse $ 794.40 $ 635.52 Participant + Family $ 862.27 $ 689.81

Employee Cost $ 108.58 $ 210.75 $ 242.81 $ 263.55

Employee Cost $ 71.05 $ 137.91 $ 158.88 $ 172.46

UnitedHealthcare Point of Service (POS) High Option Medical Plan Coverage Total City Level Cost Cost Participant Only $ 348.57 $ 245.51 Participant + Child $ 662.26 $ 466.63 Participant + Spouse $ 732.03 $ 515.77 Participant + Family $ 1,045.70 $ 736.79

Standard Option Medical Plan Coverage Total City Level Cost Cost Participant Only $ 306.89 $ 245.51 Participant + Child $ 583.28 $ 466.62 Participant + Spouse $ 644.71 $ 515.77 Participant + Family $ 920.99 $ 736.79

Employee Cost $ 103.06 $ 195.63 $ 216.26 $ 308.91

Employee Cost $ 61.38 $ 116.66 $ 128.94 $ 184.20

Aetna Choice POS II High Option Medical Plan Coverage Total City Level Cost Cost Participant Only $ 290.79 $ 203.25 Participant + Child $ 628.55 $ 440.27 Participant + Spouse $ 693.19 $ 487.74 Participant + Family $ 963.15 $ 675.12

Standard Option Medical Plan Coverage Total City Level Cost Cost Participant Only $ 254.06 $ 203.25 Participant + Child $ 550.34 $ 440.27 Participant + Spouse $ 609.68 $ 487.74 Participant + Family $ 843.90 $ 675.12

Employee Cost $ 87.54 $ 188.28 $ 205.45 $ 288.03

UnitedHealthcare Choice (HMO)

Kaiser Permanente HMO

Optimum Choice HMO Plan Coverage Total City Employee Level Cost Cost Cost Participant Only 283.14 254.83 28.31 Participant + Child 537.98 484.18 53.80 Participant + Spouse 594.61 535.15 59.46 Participant + Family 849.43 764.49 84.94

Open Access Aetna Select (HMO) Coverage Level Participant Only Participant + Child Participant + Spouse Participant + Family

Aetna HMO Plan Total City Cost Cost $ 260.42 $ 234.38 $ 525.76 $ 473.18 $ 576.81 $ 519.13 $ 629.27 $ 566.34

Employee Cost $ 50.81 $ 110.07 $ 121.94 $ 168.78

Kaiser Permanente Coverage Total Level Cost Participant Only $ 252.03 Participant + Child $ 478.87 Participant + Spouse $ 529.27 Participant + Family $ 756.11

HMO Plan City Cost $ 226.82 $ 430.98 $ 476.34 $ 680.50

Employee Cost $ 25.21 $ 47.89 $ 52.93 $ 75.61

Bundled Medical & Rx Election Chart Bundled Medical & Rx Election Chart Rx coverage is bundled with Medical plan election, but with a separate payroll deduction.

Employee Cost $ 26.04 $ 52.58 $ 57.68 $ 62.93

High Option Medical Plans => High Option Rx Plan Standard Option Medical Plans => Standard Option Rx Plan HMO Medical Plans => High Option Rx Plan

Express Scripts (High & Standard Options) Express Scripts High Option Rx Plan Coverage Total City Employee Level Cost Cost Cost Participant Only $ 71.70 $ 54.88 $ 16.82 Participant + Child $ 139.16 $ 106.52 $ 32.64 Participant + Spouse $ 160.33 $ 122.72 $ 37.61 Participant + Family $ 174.01 $ 133.20 $ 40.81

Express Scripts Standard Option Rx Plan Coverage Total City Employee Level Cost Cost Cost Participant Only $ 68.60 $ 54.88 $ 13.72 Participant + Child $ 133.15 $ 106.52 $ 26.63 Participant + Spouse $ 153.40 $ 122.72 $ 30.68 Participant + Family $ 166.49 $ 133.19 $ 33.30

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2017 Prescription Drug Premium

Weekly Prescription Premiums Express Scripts (High & Standard Options) Express Scripts High Option Rx Plan Coverage Total City Employee Level Cost Cost Cost Participant Only $ 28.95 $ 22.16 $ 6.79 Participant + Child $ 56.20 $ 43.02 $ 13.18 Participant + Spouse $ 64.75 $ 49.56 $ 15.19 Participant + Family $ 70.27 $ 53.79 $ 16.48

Express Scripts Standard Option Rx Plan Coverage Total City Employee Level Cost Cost Cost Participant Only $ 27.70 $ 22.16 $ 5.54 Participant + Child $ 53.77 $ 43.02 $ 10.75 Participant + Spouse $ 61.95 $ 49.56 $ 12.39 Participant + Family $ 67.24 $ 53.79 $ 13.45

Bi-Weekly Prescription Premiums Express Scripts (High & Standard Options) Express Scripts High Option Rx Plan Coverage Total City Employee Level Cost Cost Cost Participant Only $ 57.91 $ 44.33 $ 13.58 Participant + Child $ 112.40 $ 86.04 $ 26.36 Participant + Spouse $ 129.49 $ 99.12 $ 30.37 Participant + Family $ 140.54 $ 107.58 $ 32.96

Express Scripts Standard Option Rx Plan Coverage Total City Employee Level Cost Cost Cost Participant Only $ 55.41 $ 44.33 $ 11.08 Participant + Child $ 107.54 $ 86.03 $ 21.51 Participant + Spouse $ 123.90 $ 99.12 $ 24.78 Participant + Family $ 134.47 $ 107.58 $ 26.89

21-Pay Prescription Premiums Express Scripts (High & Standard Options) Express Scripts High Option Rx Plan Coverage Total City Employee Level Cost Cost Cost Participant Only $ 71.70 $ 54.88 $ 16.82 Participant + Child $ 139.16 $ 106.52 $ 32.64 Participant + Spouse $ 160.33 $ 122.72 $ 37.61 Participant + Family $ 174.01 $ 133.20 $ 40.81

Express Scripts Standard Option Rx Plan Coverage Total City Employee Level Cost Cost Cost Participant Only $ 68.60 $ 54.88 $ 13.72 Participant + Child $ 133.15 $ 106.52 $ 26.63 Participant + Spouse $ 153.40 $ 122.72 $ 30.68 Participant + Family $ 166.49 $ 133.19 $ 33.30

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Dental Premium

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Section 3 Benefit Information (Rx, Vision, Dental & Life Insurance)

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2017 Prescription Drug Copays High Option Prescription Drug Plan Formulary (Preferred Brand) MAPS/Unrepresented $15 $30 $20 $40 Represented $10 $20 $15 $25

Generic Retail (30 Day Supply) Mail Order (90 Day Supply) Retail (30 Day Supply) Mail Order (90 Day Supply)

Non-Formulary (Non-Preferred Brand) $40 $60 $30 $35

Standard Option Prescription Drug Plan Formulary (Preferred Brand) $30 $60

Generic Retail (30 Day Supply) Mail Order (90 Day Supply)

$5 $10

Non-Formulary (Non-Preferred Brand) $50 $100

The Standard Prescription Drug Plan requires that all plan participants meet a $50.00 deductible, per member, per calendar year. A deductible is the amount of covered expenses you must pay before your insurance plan will pay benefits.

Prescription Out of Pocket Maximums Medical Plan Enrollment

2017 Medical Out-of-Pocket Maximums

2017 Rx Out-of-Pocket Maximums

In-Network Out-of-Network NOTE: Based on medical Family/Individual Family/Individual plan enrollment Active PPO Plans High Option $1,000/$2,000 None $5,500/$9,600 Standard Option $44,999 $1,500/$3,000 $3,000/$6,000 $5,100/$10,200 Active HMO Plans Kaiser $1,100/$3,600 $5,500/$9,600 UnitedHealthcare $1,100/$3,600 $5,500/$9,600 Aetna $1,100/$2,200 $5,500/$9,600

2017 Total Out-of-Pocket Maximums (Combined Medical & Rx) $6,500/$11,200 $6,100/$12,200 $6,600/$13,200 $6,600/$13,200 $6,600/$13,200 $6,600/$11,800

Out-of-Pocket Maximum Definition: The yearly out-of-pocket maximum is the highest or total amount your health plan requires you to pay towards the cost of your health care. Once you have met your out-of-pocket maximums you will not be required to pay towards the cost of services, you will still be required to pay your premiums. Out-of-Pocket expenses are what you pay for health-related services above and beyond your monthly premium, including: annual deductible, coinsurance and copayments.

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CareFirst Select Vision‐ Schedule of Benefits If you go to a .... Participating Provider Non‐Participating Provider Covered Service (Note: Plan allows one pair of glasses or contacts, per member, in a 24 month period.) Vision Exam Glasses s

Plan Pays 100% of Allowed Benefit. Single Vision Bifocal Trifocal Double Bifocal Cataract (Aphakic)

Plan pays up to: $41.50 $67.00 $89.50 $100.50 $156.50

Plan Pays 100% of allowed Benefit; you pay the balance. Plan pays up to: Single Vision $41.50 Bifocal $67.00 Trifocal $89.50 Double Bifocal $100.50 Cataract (Aphakic) $156.50

Frames Per (If you select more expensive frames then you pay the Play pays up to $29.50; you pay the balance. Pair Contact Covered only if medically necessary or instead of glasses Lenses** Medically Required* Plan pays up to $221; you pay the balance. Plan pays up to $221. Not Medically Required. Single Vision.**

Plan pays up to $71.

Plan pays up to $71; you pay the balance.

Not Medically Required. Bifocal **

Plan pays up to $96.50.

Plan pays up to $96.50; you pay the balance.

* Following cataract surgery or when visual acuity of at least 20/70 in the better eye is possible with the use of contact lenses. ** In place of glasses (frames and lenses)

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You Pay: Balance Balance Balance Balance Balance

DeltaCare USA: Dental HMO

COPAYMENTS FOR COMMON DENTAL SERVICES CODE

DESCRIPTION OF SERVICE

ENROLLEE PAYS

D0100-D0999 I. Diagnostic D0120

Periodic oral evaluation – established patient

$5.00

D0140

Limited oral evaluation - problem focused Comprehensive oral evaluation - new or established patient

$5.00

D0210

Intraoral - complete series of radiographic images

$25.00

D0220

Intraoral - periapical first radiographic image

$4.00

D0230

Intraoral - periapical each additional radiographic image

$3.00

D0272

Bitewings - two radiographic images

$5.00

D0274

Bitewings - four radiographic images

$5.00

D0330

Panoramic radiographic image

$20.00

CODE

DESCRIPTION OF SERVICE

D0150

$5.00

ENROLLEE PAYS

D1000-D0999 II. Preventive D1110

Prophylaxis - adult

$10.00

D1120

Prophylaxis - child Topical application of fluoride (prophylaxis excluded) through age 18

$10.00

D1351

Sealant - per tooth

$5.00

CODE

DESCRIPTION OF SERVICE

D1208

$5.00

ENROLLEE PAYS

D2000-D2999 III. Restorative D2140

Amalgam - one surface, primary or permanent

$28.00

D2150

Amalgam - two surfaces, primary or permanent

$35.00

D2160

Amalgam - three surfaces, primary or permanent Amalgam - four or more surfaces, primary or permanent

$45.00

D2330

Resin-based composite - one surface, anterior

$35.00

D2331

Resin-based composite - two surfaces, anterior

$45.00

D2332

Resin-based composite - three surfaces, anterior Resin-based composite - four or more surfaces or involving incisal angle (anterior)

$55.00

D2391

Resin-based composite - one surface, posterior

$40.00

D2392

Resin-based composite - two surfaces, posterior

D2750

Crown - porcelain fused to high noble metal

$390.00

D2752

Crown - porcelain fused to noble metal

$380.00

D2790

Crown - full cast high noble metal

$390.00

D2792

Crown - full cast noble metal

$380.00

D2920

Recement crown

$25.00

D2950

Core buildup, including any pins

$60.00

D2954

Prefabricated post and core in addition to crown

$70.00

D2161

D2335

22

$55.00

$80.00

$50.00

CODE

DESCRIPTION OF SERVICE

ENROLLEE PAYS

D3000-D3999 IV. Endodontics D3310 D3320

Endodontic therapy, anterior tooth (excluding final restoration) Endodontic therapy, bicuspid tooth (excluding final restoration)

D3330

Endodontic therapy, molar (excluding final restoration)

CODE

DESCRIPTION OF SERVICE

$200.00 $300.00 $425.00 ENROLLEE PAYS

D4000-D4999 V. Periodontics D4341 D4910 D7140

Periodontal scaling and root planing - four or more teeth per quadrant Periodontal maintenance Extraction, erupted tooth or exposed root (elevation and/or forceps removal)

D7210

Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated

CODE

DESCRIPTION OF SERVICE

$60.00 $50.00 $35.00 $60.00

ENROLLEE PAYS

D7000-D7999 VI. Oral and Maxillofacial Surgery D7230

Removal of impacted tooth - partially bony

$110.00

D7240

Removal of impacted tooth - completely bony Palliative (emergency) treatment of dental pain - minor procedure

$150.00

D9110 D9230

Deep sedation/general anesthesia - first 30 minutes

$10.00 $88.00

NOTE: THIS IS ONLY A BRIEF SUMMARY OF THE PLAN. The Group Dental Service Contract must be consulted to determine the exact terms and conditions of coverage. An Evidence of Coverage will be sent to you upon enrollment.

23

Delta Dental PPO

24

Minnesota Life: Basic & Optional Life/AD&D Coverage

Minnesota Life Beneficiary Maintenance System

25

Section 4 Medical Plan Comparison

Comparing Medical Plan Benefits The following charts are a summary of generally available benefits and do not guarantee coverage. Check each carrier’s website to find out if your providers and the facilities in which your providers work are included in the various plan networks. To ensure coverage under your plan, contact the plan before receiving services or treatment to obtain more information on coverage limitations, exclusions, determinations of medical necessity, and preauthorization requirements.

26

Aetna PPO 2017 Active Benefit Plan Comparison Charts *All Out of Network benefits paid at Allowed Amount. Allowed Benefit is 50% of R & C ** any out-of-network provider can balance bill the difference between allowed amount and billed amount

Standard Option Plan In-Network Out-of-Network**

In-Network

High Option Plan Out-of-Network**

Dependent Eligibility: Dependent children, until the end of the calendar year they reach age 26, regardless of student or marital status. Are Referrals Required? No No No No $250 per individual $500 per individual Deductible None None $500 per family $1000 per family

Out-of-Pocket Maximum (Based on annual salary)

Employee Salary < $45,000: $1,000 per individual/$2,000 per family Employee Salary > $44,999: $1,500 per individual/$3,000 per family

Lifetime Maximum Benefit Unlimited Routine & Preventive Services Routine Office Visit 100% (Annual physical) Well Baby/Child Care (Age & frequency schedule 100% apply) Routine GYN Examination (Limit-one per year)

100%

Screenings: Mammography, Colorectal & 100% Allowed Benefit Prostate Physician Office Visits (Non-Routine)

Employee Salary < $45,000: $2,000 per individual/$4,000 per family $1,000 per individual Employee Salary > $44,999: $2,000 per family $3,000 per individual/$6,000 per family

None

Unlimited

Unlimited

Unlimited

100% allowed benefit*

covered in full

100% allowed benefit*

100% allowed benefit*

covered in full

100% allowed benefit*

100% allowed benefit*

covered in full

100% allowed benefit*

100% Allowed Benefit

100% Allowed Benefit

80% Allowed Benefit

Physician's Office Visit (Sickness)

$25 copay

80%

$5 copay per visit

$5 copay per visit; 100 % allowed benefit*

Specialist Office Visit

$40 copay

80%

$5 copay per visit

$5 copay per visit; 100 % allowed benefit*

Hearing Exams

90%

70%

$5 copay per visit

$5 copay per visit; 100 % allowed benefit*

Emergency Room and Urgent Care Services Ambulance Service (based on medical necessity)

90%

90%

covered in full

100% allowed benefit*

Emergency Room (copay waived if admitted)

90%

90%

$50 copay

$50 copay

Urgent Care

$25 Copay, 90%

$25 Copay, 90%

$5 copay per visit

$5 copay per visit

27

Aetna PPO 2017 Active Benefit Plan Comparison Charts *All Out of Network benefits paid at Allowed Amount. Allowed Benefit is 50% of R & C ** any out-of-network provider can balance bill the difference between allowed amount and billed amount

Standard Option Plan In-Network Out-of-Network** Hospital Inpatient Services Anesthesia Hospital Services, including Room, Board & General Nursing Services Organ Transplant (Pre-Auth Required) Diagnostic Lab Work & Xrays Acute Inpatient Rehab Outpatient Services Medical Surgical Physician Services Physical, Speech & Occupational Therapy

In-Network

High Option Plan Out-of-Network**

90%

70%

covered in full

100% allowed benefit*

90%

70%

covered in full

100% allowed benefit*

90%

70%

Covered in full

no coverage

90%

70%

covered in full

100% allowed benefit*

90%

70%

covered in full

100% allowed benefit*

90%

70%

covered in full

100% allowed benefit*

90% (Combined 60 visits per year)

70% (Combined 60 visits per year)

covered in full

100% allowed benefit*

Chemotherapy & Radiation

90%

70%

$5 copay per visit

Renal Dialysis Diagnostic Lab Work & X-rays

90%

70%

covered in full

$5 copay per visit, 100% allowed benefit* 100% allowed benefit *

90%

70%

covered in full

100% allowed benefit*

Cardiac Rehab

$40 copay per visit

70%

$5 copay per visit

Outpatient Surgery

90%

70%

Physical, Speech & Occupational Therapy

90% (Combined 60 visits per year)

70% (Combined 60 visits per year)

Pre-Admission Testing

90%

70%

Allergy Testing

90%

70%

Allergy Serum

90%, Call Aetna for plan details

70%, Call Aetna for plan details

Maternity Pre/Post-Natal Covered in Full (Physician Services) Fertility Testing & Family Planning

80%

$5 copay per visit, 100% allowed benefit* covered in full 100% allowed benefit* $5 copay per visit, 100% $5 copay per visit allowed benefit* Call Call Plan for Visit limits Plan for Visit limits covered in full 100% allowed benefit* $5 copay per visit, 100% $5 copay per visit allowed benefit * $5 copay per visit, 100% $5 copay per visit allowed benefit* covered in full

100% allowed benefit*

Fertility Testing & Family Planning

100% allowed benefit* Member cost sharing Member cost sharing based on Member cost sharing based on member cost sharing based on type of service type of service performed and type of service performed and based on type of service performed and place of place of service where rendered place of service where rendered performed and place of service where rendered service where rendered

In-Vitro Fertilization

90%; $100,000 Maximum lifetime benefit; up to 3 attempts per live birth combined with ART, AI and AO

70%; $100,000 Maximum lifetime benefit; up to 3 attempts per live birth combined with Art, AI and AO

28

Covered in full; $100,000 Maximum lifetime benefit; up to 3 attempts per live birth combined with ART, AI & AO

100% allowed benefit* covered in full; $100,000 Maximum lifetime benefit; up to 3 attempts per live birth combined with Art, AI & AO

Aetna PPO 2017 Active Benefit Plan Comparison Charts *All Out of Network benefits paid at Allowed Amount. Allowed Benefit is 50% of R & C ** any out-of-network provider can balance bill the difference between allowed amount and billed amount

Standard Option Plan In-Network Out-of-Network** Mental Health & Substance Abuse Benefits Inpatient Mental Health & 90% Alcohol & Substance Abuse Outpatient Mental Health & $25 copay Alcohol & Substance Abuse Miscellaneous Supplies & Services Nutrition Counseling

90%

Diabetic Supplies

90%

Durable Medical Equipment Private duty nursing (pre-auth required) Hospice Care Prosthetic Devices

90%

In-Network

High Option Plan Out-of-Network**

70%

covered in full

100% allowed benefit*

80%

$5 copay per visit

$5 copay per visit 100% allowed benefit*

70%

$5 copay per visit,

70% Insulin & Syringes Covered by Rx Plan 70%

covered in full

$5 copay per visit, 100% allowed benefit* 100% allowed benefit*

covered in full

100% allowed benefit*

90%

70%

covered in full

100% allowed benefit *

90% 90%

70% 70%

covered in full covered in full

100% allowed benefit * 100% allowed benefit *

29

UnitedHealthcare POS 2017 Active Benefit Plan Comparison Charts *Allowed Benefit is 50% of R & C ** any out-of-network provider can balance bill the difference between allowed amount & billed amount Standard Option Plan In-Network Out-of-Network**

In-Network

High Option Out-of-Network**

Dependent Eligibility: Dependent children, until the end of the calendar year they reach age 26, regardless of student or marital status. Are Referrals Required?

No

No

No

No

Deductible

$250 per individual $500 per family

$500 per individual $1000 per family

None

None

Out-of-Pocket Maximum (Based on annual salary)

Employee Salary < $45,000: $1,000 per individual/$2,000 per family Employee Salary > $44,999: $1,500 per individual/$3,000 per family

Employee Salary < $45,000: $2,000 per individual/$4,000 $1,000 per per family individual Employee Salary > $44,999: $2,000 per family $3,000 per individual/$6,000 per family

None

Plan Lifetime Maximum Benefit

Unlimited

Unlimited

Unlimited

Unlimited

Routine & Preventive Services Routine Office Visit (Annual physical)

100%

100%

Covered in full

$5 copay per visit, 100% allowed Benefit*

Well Baby/Child Care

100%

100%

Covered in full

$5 copay per visit; 100% allowed Benefit*

Routine GYN Examination

100%

100%

Covered in full

$5 copay per visit, 100% allowed Benefit*

Screenings: Mammography, Colorectal & Prostate

100% Allowed Benefit

100% Allowed Benefit

Covered in full

100% allowed Beneft*

Physician Office Visits (Non-Routine) Physician's Office Visit (Sickness)

$25 copay per visit

80%

$5 copay per visit

$5 copay per visit, 100% allowed Benefit*

Specialist Office Visit

$40 copay per visit

80%

$5 copay per visit

$5 copay per visit, 100% allowed Benefit*

Hearing Exams

90%

70%

$5 copay per visit

$5 copay per visit 100% allowed benefit*

Emergency Room and Urgent Care Services Ambulance Service (based on medical necessity)

90%

90%

Covered in full for 100 % allowed benefit emergency only for emergency only

Emergency Room (copay waived if admitted)

90%

90%

$50 copay

$50 copay

Urgent Care

$25 Copay, 90%

$25 Copay, 90%

$5 copay per visit

$5 copay per visit, 100% allowed Benefit*

30

UnitedHealthcare POS 2017 Active Benefit Plan Comparison Charts *Allowed Benefit is 50% of R & C ** any out-of-network provider can balance bill the difference between allowed amount & billed amount Standard Option Plan High Option In-Network Out-of-Network** In-Network Out-of-Network**

Hospital Inpatient Services Anesthesia

90%

70%

covered in full

100% allowed benefit*

Hospital Services, including Room, Board & General Nursing Services

90%

70%

covered in full

100% allowed benefit*

Diagnostic Lab Work & X-rays

90%

70%

covered in full

100% allowed benefit*

90%

70%

covered in full

100% allowed benefit*

90%

70%

covered in full

100% allowed benefit*

Organ Transplant (Pre-Authorization Required)

90% for non-experimental transplants

70%

Acute Inpatient Rehab

90%

70%

covered in full for nonexperimental 100% allowed benefit* transplants covered in full covered in full

Cardiac Rehab

90%

70%

$5 copay per visit

$5 copay per visit, 100% allowed benefit*

Chemotherapy & Radiation

90%

70%

$5 copay per visit

$5 copay per visit, 100% allowed benefit*

Renal Dialysis

90%

70%

covered in full

100% allowed benefit*

Diagnostic Lab Work & X-rays

90%

70%

covered in full

100% allowed benefit*

Outpatient Surgery

90%

70%

covered in full

100% allowed benefit*

Physical, Speech & Occupational Therapy 90% (60 visits combined per therapy/type per year)

70%

$5 copay per visit;

$5 copay per visit; 100% allowed benefit*

Medical Surgical Physician Services Physical, Speech & Occupational Therapy

Outpatient Services

Outpatient Services Pre-Admission Testing

90%

70%

$5 copay per visit, $5 copay per visit, testing covered in full 100% allowed benefit*

Allergy Testing

90%

70%

$5 copay per visit

$5 copay per visit; 100% allowed benefit*

Allergy Serum

90%

70%

Covered in Full

100% allowed benefit*

31

UnitedHealthcare POS 2017 Active Benefit Plan Comparison Charts *Allowed Benefit is 50% of R & C ** any out-of-network provider can balance bill the difference between allowed amount & billed amount Standard Option Plan High Option In-Network Out-of-Network** In-Network Out-of-Network**

Maternity Pre and Post-Natal (Physician Services)

100%

80%

Covered in Full

70%

$5 copay per visit

$5 copay for initial visit to determine pregnancy, then 100% allowed benefit*

Fertility Testing & Family Planning Fertility Testing & Family Planning

90%

In-Vitro Fertilization

90 % allowable charges; 70% allowed benefit*; 100 % allowable $100,000 maximum lifetime $100,000 maximum lifetime charges; $100,000

$5 copay per visit; 100% allowed benefit* 100% allowed benefit*; $100,000

Mental Health & Substance Abuse Benefits Inpatient Alcohol & Substance Abuse/Mental Health

90%

Outpatient Alcohol & Substance $25 copay per visit Abuse/Mental Health

70%

covered in full

100% allowed benefit*

80% after deductible

$5 copay per visit

$5 copay per visit; 100% allowed benefit*

70%

$5 copay per visit covered in full , including lancets, tests strips and glucometers

Miscellaneous Supplies & Services Nutrition Counseling Diabetic Supplies

90% 90%

70%

$5 copay per visit 100% allowed benefit, including lancets, test strips & glucometers

Insulin & Syringes Covered by Rx Plan Durable Medical Equipment (pre-authorization required)

90%

70% (pre-authorization required for over $1,000)

Private duty nursing (pre-authorization required)

Contact plan for details

Contact plan for details

Hospice Care (pre-authorization required)

90%

70%

Prosthetic Devices (Such as artificial limbs) (pre-authorization required)

90%

70% (pre-authorization required for over $1,000)

32

covered in full;

100% allowed benefit; (pre-authorization required for over $1,000)

covered in full for skilled care based on 100% allowed benefit* medical necessity 100% allowed covered in full; benefit*; 100% allowed benefit* after prior plan approval (precovered in full authorization required for over $1,000)

CareFirst PPN 2017 Active Benefit Plan Comparison Charts ** Any Out-of-Network Provider can balance bill the difference between the allowed amount and the billed amount. Standard Option Plan High Option Plan In-Network Out-of-Network** In-Network Out-of-Network** Dependent Eligibility: Dependent children, until the end of the calendar year they reach age 26, regardless of student or marital status. Are Referrals Required? No No No No Deductible

$250 per individual $500 per family

$500 per individual $1,000 per family

Out-of-Pocket Maximum (Based on annual salary)

Employee Salary < $45,000: $1,000 individual/$2,000 family Employee Salary > $44,999: $1,500 individual/$3,000 family

Employee Salary < $45,000: $2,000 individual/$4,000 family Employee Salary > $44,999: $3,000 individual/$6,000 family

$1,000 per individual N/A $2,000 per family

Unlimited

Unlimited

100% Allowed Benefit

100% Allowed Benefit 80% of Allowed Benefit

Plan Lifetime Maximum Unlimited Benefit Routine & Preventive Services Routine Office Visit (Annual 100% Allowed Benefit physical)

Unlimited

Well Baby/Child Care

100% Allowed Benefit

100% Allowed Benefit

100% Allowed Benefit 80% Allowed Benefit

Routine GYN Examination (Limit-one per year)

100% Allowed Benefit

100% Allowed Benefit

100% Allowed Benefit 80% allowed benefit

Screenings: Mammography, Colorectal & 100% Allowed Benefit Prostate

100% Allowed Benefit

100% Allowed Benefit 80% Allowed Benefit

80% Allowed Benefit

$20 copay per visit 80% allowed benefit 100% allowed benefit

Physician Office Visits (Not-Routine) Physician's Office Visit (Sickness) $25 Copay (Maps & Unrepresented) Physician's Office Visit (Sickness) (Represented)

$25 Copay

80% Allowed Benefit

$10 copay per visit 80% allowed benefit 100% allowed benefit

Specialist Office Visit (Maps & Unrepresented)

$40 Copay

80% Allowed Benefit

$25 copay per visit 80% allowed benefit 100% allowed benefit

Specialist Office Visit (Represented)

$40 Copay

80% Allowed Benefit

$15 copay per visit 80% allowed benefit 100% allowed benefit

70% Allowed Benefit

100% allowed benefit 80% allowed benefit with medical with medical diagnosis diagnosis

Ambulance Service (Based on medical necessity) 90% Allowed Benefit (Ground Only)

90% Allowed Benefit

major medical subject to deductible and coinsurance if applicable

major medical subject to deductible and coinsurance if applicable

Emergency Room (copay waived if admitted)

90% Allowed Benefit

90% Allowed Benefit

$50 copay

$50 copay

Urgent Care

$25 Copay, 90% Allowed Benefit

$25 Copay, 90% Allowed Benefit

$10 copay per visit;

100% of allowed benefit

Hearing Exams- one exam every 36 months (routine 90% Allowed Benefit exams excluded) Emergency Room and Urgent Care Services

33

Organ Transplant 90% Allowed Benefit (Pre-Authorization Required)

70% Allowed Benefit 100% allowed benefit 100% allowed benefit ($30,000 per transplant max)

Acute Inpatient Rehab

Not a covered benefit

Not a covered benefit

Not a covered benefit Not a covered benefit

CareFirst PPN 2017 Active Benefit Plan Comparison Charts ** Any Out-of-Network Provider can balance bill the difference between the allowed amount and the billed amount. Standard Option Plan In-Network Out-of-Network**

High Option Plan In-Network Out-of-Network**

Hospital Inpatient Services Anesthesia

90% Allowed Benefit

70% Allowed Benefit

100% allowed benefit 80% allowed benefit

Maps & Unrepresented Hospital Services, including 90% Allowed Benefit Room, Board & General Nursing Services

70% Allowed Benefit

Represented Hospital Services, including Room, Board & General Nursing Services pre-authorization required

90% Allowed Benefit

70% Allowed Benefit

90% Allowed Benefit

70% Allowed Benefit

100% allowed benefit 80% allowed benefit

90% Allowed Benefit

70% Allowed Benefit

100% allowed benefit 80% allowed benefit

Medical Surgical Physician Services Physical, Speech & Occupational Therapy

$100 deductible per 100% allowed benefit admission, then plan preauthorization pays 70% up to $1,500 required out of pocket $100 deductible per admission, then plan pays 80% up to $1,500 100% allowed benefit out of pocket maximum per admission, then 100%

Organ Transplant 90% Allowed Benefit (Pre-Authorization Required)

70% Allowed Benefit 100% allowed benefit 100% allowed benefit ($30,000 per transplant max)

Acute Inpatient Rehab

Not a covered benefit

Not a covered benefit

Not a covered benefit Not a covered benefit

Cardiac Rehab

90% Allowed Benefit

70% Allowed Benefit

100% Allowed Benefit 80% Allowed Benefit

Chemotherapy & Radiation

90% Allowed Benefit

70% Allowed Benefit

100% allowed benefit 80% allowed benefit

Renal Dialysis

90% Allowed Benefit

70% Allowed Benefit

100% allowed benefit 80% allowed benefit

Diagnostic Lab Work & Xrays

90% Allowed Benefit

70% Allowed Benefit

100% allowed benefit 80% allowed benefit

Outpatient Surgery

90% Allowed Benefit

70% Allowed Benefit

100% allowed benefit 80% allowed benefit

70% Allowed Benefit - limit 60 visits combined

100% allowed benefit 80% allowed benefit precertification precertification required after 10th required after 10th lifetime visit - limited lifetime visit - limited to 100 combined to 100 combined visits visits per calendar per calendar year year

Outpatient Services

Physical, Speech & Occupational Therapy (Maps & Unrepresented)

90% Allowed Benefit - limit 60 visits combined

34

CareFirst PPN 2017 Active Benefit Plan Comparison Charts ** Any Out-of-Network Provider can balance bill the difference between the allowed amount and the billed amount. Standard Option Plan High Option Plan In-Network Out-of-Network** In-Network Out-of-Network** Outpatient Services Continued facility $10 copay; 80% allowed benefit office 100% allowed for 100 visits per benefit calendar year for Physical, Speech & precertification physical, speech and 90% Allowed Benefit - limit 70% Allowed Benefit - limit 60 Occupational Therapy required after 10th occupational 60 visits combined visits combined (Represented) lifetime visit - limited therapies combined. to 100 combined Pre-certification visits per calendar required after first 10 year visits. Pre-Admission Testing

90% Allowed Benefit

70% Allowed Benefit

100% allowed benefit 80% allowed benefit

Allergy Testing

90% Allowed Benefit

70% Allowed Benefit

100% allowed benefit 80% allowed benefit

Allergy Serum ($200 Annual Maximum)

90% after Deductible up to annual maximum

70% allowed benefit up to annual maximum

100% allowed benefit 80% allowed benefit up to annual up to annual maximum maximum

80% Allowed Benefit

100% allowed benefit 80% allowed benefit

70% Allowed Benefit

100% allowed benefit 80% allowed benefit

Maternity Pre & Post-Natal (Physician covered in full Services) Fertility Testing & Family Planning Fertility Testing & Family 90% Allowed Benefit Planning

In-Vitro Fertilization 90% Allowed Benefit 70% Allowed Benefit (Pre-Authorization Required) $100,000 lifetime maximum $100,000 lifetime maximum

100% allowed benefit; $12,000 maximum lifetime.

80% allowed benefit; $12,000 maximum lifetime

Inpatient Mental Health & Substance Abuse-Benefits Provided by Beacon Health Options Inpatient Alcohol & Substance Abuse/Mental Health 90% Allowed Benefit (Maps & Unrepresented) Pre-Authorization Required

70% Allowed Benefit

Inpatient Alcohol & Substance Abuse/Mental 90% Allowed Benefit Health (Represented) Pre-Authorization Required

70% Allowed Benefit

35

$100 deductible per admission, then plan pays 70% up to $1,500 100% allowed benefit out of pocket maximum per admission, then 100% allowed benefit. $100 deductible per admission, then plan 100% allowed benefit pays 80% up to $1,500 out of pocket maximum per

CareFirst PPN 2017 Active Benefit Plan Comparison Charts ** Any Out-of-Network Provider can balance bill the difference between the allowed amount and the billed amount. Standard Option Plan High Option Plan In-Network Out-of-Network** In-Network Out-of-Network** Inpatient Mental Health & Substance Abuse- Benefits Provided by Beacon Health Option $100 deductible per Inpatient Alcohol & admission, then plan Substance Abuse/Mental pays 70% up to $1,500 Health 90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit out of pocket (Maps & Unrepresented) maximum per Pre-Authorization Required admission, then 100% allowed benefit. $100 deductible per admission, then plan Inpatient Alcohol & pays 80% up to $1,500 Substance Abuse/Mental 90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit out of pocket Health (Represented) maximum per Pre-Authorization Required admission, then 100% allowed benefit. Outpatient Mental Health & Substance Abuse- Benefits Provided by Beacon Health Option Outpatient Mental Health/Alcohol & Substance $25 Copay 80% Allowed Benefit Abuse (Maps & Unrepresented) Outpatient Mental Health/Alcohol & Substance $25 Copay 80% Allowed Benefit Abuse (Represented) Miscellaneous Supplies & Services $25 primary/$40 specialist Nutrition Counseling copay then 100% allowed 70% benefit. Diabetic Supplies

90% Allowed Benefit

70% Allowed Benefit

$20 copay per visit; 80% allowed benefit. 100% allowed benefit. $10 copay per visit; 80% allowed benefit. 100% allowed benefit. Covered same as any 80% allowed benefit, office visit- based on for specific diagnosis diagnosis. only 100% allowed benefit, 100% allowed benefit, includes lancets test includes lancets, test strips & glucometers strips & glucometers

Insulin & Syringes Covered by Rx Plan Durable Medical Equipment

See major medical benefit based on medical necessity; See major medical benefit

See major medical benefit based on medical necessity; See major medical benefit

90% Allowed Benefit

70% Allowed Benefit

Private duty nursing (Pre-Authorization required) 90% Allowed Benefit Outpatient Only

70% Allowed Benefit

Hospice Care

90% Allowed Benefit

70% Allowed Benefit

100% allowed benefit 100% allowed benefit

Prosthetic Devices (IE: as artificial limbs)

90% Allowed Benefit

70% Allowed Benefit

100% allowed benefit 80% allowed benefit

36

CareFirst PPN 2017 Active Benefit Plan Comparison Charts ** Any Out-of-Network Provider can balance bill the difference between the allowed amount and the billed amount. Standard Option Plan High Option Plan In-Network Out-of-Network** In-Network Out-of-Network** Major Medical- Applies to CareFirst Plans Only Major medical Major medical Major Medical Annual expenses only - $250 expenses only - $250 Deductible NA NA deductible per person deductible per person (Maps & Unrepresented) per year per year major medical major medical Major Medical Annual expenses only; $200 expenses only; $200 NA NA Deductible (Represented) deductible per person deductible per person per year per policy year Deductible then 100% Major Medical Yearly Out-OfDeductible then 100% first $30,000, then Pocket Maximum NA NA first $30,000, the 50% 50% of allowed (Maps & Unrepresented) of allowed benefit benefit Major Medical Yearly Out-OfDeductible then 80% Deductible then 80% of Pocket Maximum NA NA of allowed benefit allowed benefit (Represented)

37

HMO Plans 2017 Active Benefit Plan Comparison Charts NOTE: Out-of-Network Services are not covered under HMO unless an emergency UnitedHealthcare Choice HMO

Kaiser HMO

Open Access Aetna Select (HMO)

Dependent Eligibility: Dependent children, until the end of the calendar year they reach age 26, regardless of student or marital status. Are Referrals Required?

Yes

No

No

Out- Of- Pocket Maximum

$3,500 per individual; $9,400 per family

$1,100 per Individual; $3,600 per family

$1,100 per individual; $2,200 per family

Plan Lifetime Maximum Benefit

Unlimited

Unlimited

Unlimited

Physician's Office Visit (Annual Physical)

Covered in full

Covered in full

Covered in full

Well Baby/Child Care

Covered in full

Covered in full

Covered in full

Routine GYN Examination

Covered in full

Covered in full

Covered in full

Immunizations Screenings: Mammography, Colorectal & Prostate

Covered in full Covered in full - call plan for details

Covered in full Covered in full Covered in full - call plan Covered in full - call plan for details for details

Specialist Office Visit

$5 copay per visit

$5 copay per visit

$5 copay per visit

Hearing Exams

$5 copay per visit

$5 copay per visit

$5 copay per visit

Covered in full for emergency only

Covered in full for emergency only

Covered in full for emergency only

$50 copay

$50 copay

$50 copay

$5 copay per visit

$5 copay per visit

$5 copay per visit

Routine & Preventive Services

Physician Office Visit (Non-Routine)

Emergency Room and Urgent Care Services Ambulance Service (Based on medical necessity) Emergency Room (Waived if admitted) Urgent Care

38

HMO Plans 2017 Active Benefit Plan Comparison Charts NOTE: Out-of-Network Services are not covered under HMO unless an emergency UnitedHealthcare Choice HMO

Kaiser HMO

Open Access Aetna Select (HMO)

Hospital Inpatient Services Anesthesia Hospital Services Including Room, Board & General Nursing Services Diagnostic Lab Work & X-rays

Covered in full

Covered in full

Covered in full

Covered in full

Covered in full

Covered in full

Covered in full

Covered in full

Covered in full

Medical Surgical Physician Services Covered in full

Covered in full

Covered in full

Physical, Speech & Occupational Therapy

Covered in full

Covered in full

Covered in full

Organ Transplant Pre-Authorization Required

Covered in full for non-experimental transplants

Covered in full for non-experimental transplants

Covered in full for non-experimental transplants

Acute In-Patient Rehab

Covered in full

Covered in full

Covered in full

Cardiac Rehab

$5 copay per visit

$5 copay per visit

$5 copay per visit

Chemotherapy & Radiation

$5 copay per visit

$5 copay per visit

$5 copay per visit

Renal Dialysis

$5 copay per visit

covered in full

covered in full

Diagnostic Lab Work & X-rays Outpatient Surgery

covered in full $5 copay per visit

covered in full covered in full

covered in full covered in full

Physical, Speech & Occupational Therapy

$5 copay per visit call plan $5 copay per visit 90 visits $5 copay per visit for visit limits per therapy type per year Call plan for visit limits

Pre-Admission Testing

$5 copay per visit

covered in full

covered in full

Allergy Testing

$5 copay per visit

$5 copay per visit

$5 copay per visit

Allergy Serum

covered in full

covered in full

$5 copay per visit

Outpatient Services

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HMO Plans 2017 Active Benefit Plan Comparison Charts NOTE: Out-of-Network Services are not covered under HMO unless an emergency UnitedHealthcare Choice HMO

Kaiser HMO

Open Access Aetna Select (HMO)

Maternity Pre and Post-Natal (Physician Services)

Covered in full

Covered in full

Covered in full

Delivery (Inpatient)

covered in full

covered in full

covered in full

Newborn Care (Inpatient)

covered in full

covered in full

covered in full

Fertility Testing & Family Planning

$5 copay per visit for family planning. Fertility testing office visit and any other fertility services covered at 50%

$5 copay per visit for family planning and fertility testing; other fertility services 50%

Member cost sharing based on type of service performed and place of service where rendered

In-Vitro Fertilization

50% of allowable charges; $100,000 maximum lifetime benefit for up to 3 attempts per live birth

50% of allowable charges; $100,000 maximum Call plan for specific lifetime benefit for up to state mandated benefits 3 attempts per live birth

Fertility Testing & Family Planning

Mental Health & Substance Abuse Benefits Inpatient Mental Health/Alcohol & Substance covered in full Abuse

covered in full

covered in full; pre-authorization required

Outpatient Mental Health/Alcohol & Substance $5 copay per visit Abuse

$5 copay per visit

$5 copay per visit

$5 copay per visit

$5 copay per visit

$5 copay per visit

Covered in full

Lancets & test strips, generic covered by a $5 copay and brand covered by a $20 copay at pharmacy. Diabetic Supplies covered in full $5 copay through DME benefit. Glucometers covered in full with preauthorization.

Miscellaneous Supplies & Services Nutrition & Health Education

Diabetic Supplies

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HMO Plans 2017 Active Benefit Plan Comparison Charts NOTE: Out-of-Network Services are not covered under HMO unless an emergency UnitedHealthcare Open Access Aetna Kaiser HMO Choice HMO Select (HMO) Insulin & Syringes Covered by Rx plan Durable Medical Equipment Preauthorization required Private Duty Nursing Preauthorization required Hospice Care Prosthetic Devices Such As Artificial Limbs) preauthorization required

Covered in full

Covered in full

Covered in full

Covered in full

Not covered

Not covered

Covered in full

Covered in full

Covered in full

Covered in full

Covered in full

Covered in full

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Contact Phone Numbers & websites Provider

Phone Number

Website

CareFirst PPN UnitedHealthcare HMO & PPO Plans Aetna HMO & PPO Plans Kaiser Permanente HMO Beacon Health Options (CareFirst Members Express Scripts Prescription Plan CareFirst Select Vision Minnesota Life (Claims) Minnesota Life (Beneficiary System) Vantagen Flexible Spending Accounts Dental Dental PPO DeltaCare USA (Dental HMO) ADP COBRA

1-800-535-2292 1-877-462-5027 1-800-900-7562 1-866-248-0715 1-866-468-5633 1-800-354-8123 1-800-535-2292 1-888-658-0193 1-877-494-1754 1-800-307-0230 1-800-471-7081 1-855-830-6581 1-800-526-2750

www.carefirst.com

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www.myuhc.com www.aetna.com www.kaiserpermanente.org www.achievesolutions.net/baltimore www.express-scripts.com www.carefirst.com www.lifebenefits.com/baltimorecity www.lifebenefits.com/baltimorecity www.myflexdollars.com www.deltadentalins.com/city-of-baltimore www.deltadentalins.com/city-of-baltimore www.benedirect.adp.com

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