Summary of Changes April June 2016 4

CaliforniaChoice® EXCITING NEWS and SUMMARY OF CHANGES Groups Renewing 4/1/16 - 6/1/16 TABLE OF CONTENTS EXCITING N...

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CaliforniaChoice®

EXCITING NEWS and

SUMMARY OF CHANGES Groups Renewing 4/1/16 - 6/1/16

TABLE OF CONTENTS

EXCITING NEWS •  CaliforniaChoice® Welcomes Two

New Ancillary Carriers.............................................................1

• New Aetna Plan....................................................................... 1 • New Health Net Plans............................................................. 2 • CaliforniaChoice Welcomes Sutter Health Plus................... 3-5 • New UnitedHealthcare Plan................................................... 6 • New Anthem Blue Cross Plans.............................................. 7 • New Option from Sharp Health Plan.................................... 8

SUMMARY OF CHANGES • General Administrative Changes........................................... 9-10 • Aetna........................................................................................ 10-11 • Anthem Blue Cross................................................................. 11-18 • Health Net................................................................................ 19 • Kaiser Permanente.................................................................. 20-25 • Sharp Health Plan ................................................................... 26-27 • UnitedHealthcare ................................................................... 27-32

• Western Health Advantage.................................................... 33-39 For more information on changes, please contact our Customer Service Center at 800.558.8003 Monday - Friday 8:00 a.m. to 5:00 p.m.

800.558.8003

www.calchoice.com

EXCITING NEWS

Groups Renewing 4/1/16 - 6/1/16 Beginning September 23, 2012, health care reform requires that employees have access to Summary of Benefits and Coverage (SBC) documents for the plans made available to them. SBCs can be found at www.calchoice.com/documents/. To request a printed copy, please contact our Customer Service Department at (800) 558-8003. Thank you for renewing your benefits with CaliforniaChoice®. As you go through your renewal, please be aware of the additions and/or changes below.

CaliforniaChoice Welcomes Two New Ancillary Carriers Dentegra® Smile Club and VSP have come to CaliforniaChoice! Effective 4/1/2016 groups will have the option to offer these new carriers to their employees. Dentegra Smile Club will be offering a discount dental plan and VSP will be offering a Voluntary Vision plan.

Aetna Adds a New HMO Option Aetna is adding a new HMO option, Bronze HMO B, for 2016. It includes the Basic HMO Network. Plan highlights appear below. At renewal, if you’ve chosen the Bronze tier, your employees will have access to Aetna’s new Bronze HMO B plan. Medical Benefits Participating Health Plans Network Name Calendar Year Deductible Dr. Office Visits (PCP)

Bronze HMO B Aetna Basic HMO $5,500 / $11,000 (combined Med/Pediatric dental ded) (applies to Max OOP) $50 Copay (ded waived)

Hospital Services – In-Patient

50%

In-Patient Physician Fees

50%

Emergency Room (copay waived if admitted)

50%

Rx Benefits – Generic

$35 Copay (ded waived)

Rx Benefits – Formulary Brand

$250 Ded - $75 Copay

Out-of-Pocket Max Ind/Fam

$6,600 / $13,200

Hospital Services – Out-Patient Surgical Facility

50%

Ambulance Services (per trip)

$150 Copay

Infertility Evaluation and Treatment

Covered

For a complete listing of all benefits, limits, and exclusions, please see the Evidence of Coverage or Certificate of Insurance.

800.558.8003

www.calchoice.com

1

EXCITING NEWS

Groups Renewing 4/1/16 - 6/1/16 Health Net Adds Three New HSP Options Health Net is adding three new Healthcare Service Plan (HSP) options for 2016. The new Gold HSP A, Silver HSP A, and Bronze HSP A all include the PureCare Network and 50% coverage for most services. Below are plan highlights. At renewal, your employees will have access to the tier (or tiers) you select for your group. Your employees’ Enrollment Worksheets will reflect your group’s selected tier(s). Medical Benefits

Gold HSP A

Silver HSP A

Bronze HSP A

Participating Health Plans

Health Net

Health Net

Health Net

Network Name

PureCare

PureCare

PureCare

$500 / $1,000 (applies to Max OOP)

$1,750 / $3,500 (applies to Max OOP)

$4,000 / $8,000 (combined Med/Rx ded) (applies to Max OOP)

$3 Copay

$30 Copay

$45 Copay

Hospital Services – In-Patient

50%

50%

50%

In-Patient Physician Fees

50%

50%

50%

Emergency Room (copay waived if admitted)

50%

50%

50%

Calendar Year Deductible Dr. Office Visits (PCP)

Rx Benefits – Generic

$5 Copay (overall ded waived) $10 Copay (overall ded waived)

$15 Copay (ded waived)

Rx Benefits – Formulary Brand $30 Copay (overall ded waived) $30 Copay (overall ded waived)

$45 Copay (combined Med/Rx ded)

Out-of-Pocket Max Ind/Fam

$6,850 / $13,700

$6,850 / $13,700

$6,850 / $13,700

Hospital Services – Out-Patient Surgical Facility

50%

50%

50%

Ambulance Services (per trip)

50%

50%

50%

Covered

Covered

Covered

Infertility Evaluation and Treatment

For a complete listing of all benefits, limits, and exclusions, please see the Evidence of Coverage or Certificate of Insurance.

800.558.8003 2

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EXCITING NEWS

Groups Renewing 4/1/16 - 6/1/16 CaliforniaChoice® Welcomes Sutter Health Plus CaliforniaChoice will offer Sutter Health Plus to groups effective 12/1/2015 or later; this gives eligible groups 11 new plan options (including three HSA-Qualified plans). Plan options are shown below. At renewal, your employees will have access to the plan(s) in the tier (or tiers) you select for your group. Your employees’ Enrollment Worksheets will reflect your selected tier(s). Medical Benefits

Platinum HMO A

Platinum HMO C

Participating Health Plans

Sutter Health Plus

Sutter Health Plus

Full

Full

None

None

$20 Copay

$20 Copay

$250 Copay per day – 5 days max

90%

In-Patient Physician Fees

$40 Copay

90%

Emergency Room (copay waived if admitted)

$150 Copay

$150 Copay

$5 Copay

$5 Copay

Rx Benefits – Formulary Brand

$15 Copay

$15 Copay

Out-of-Pocket Max Ind/Fam

$4,000 / $8,000

$4,000 / $8,000

Hospital Services – Out-Patient Surgical Facility

$250 Copay

90%

Ambulance Services (per trip)

$150 Copay

$150 Copay

Infertility Evaluation and Treatment

Not Covered

Not Covered

Network Name Calendar Year Deductible Dr. Office Visits (PCP) Hospital Services – In-Patient

Rx Benefits – Generic

For a complete listing of all benefits, limits, and exclusions, please see the Evidence of Coverage or Certificate of Insurance. 

(continued)

800.558.8003

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3

EXCITING NEWS

Groups Renewing 4/1/16 - 6/1/16 CaliforniaChoice® Welcomes Sutter Health Plus (continued) Medical Benefits Participating Health Plans Network Name

Gold HMO A

Gold HMO B

Gold HMO C

Sutter Health Plus

Sutter Health Plus

Sutter Health Plus

Full

Full

Full

$1,500 / $3,000 (applies to Max OOP)

None

None

$30 Copay

$35 Copay

$35 Copay

Hospital Services – In-Patient

80%

$600 Copay per day – 5 days max

80%

In-Patient Physician Fees

80%

$55 Copay

80%

$150 Copay

$250 Copay

$250 Copay

Rx Benefits – Generic

$5 Copay (overall ded waived)

$15 Copay

$15 Copay

Rx Benefits – Formulary Brand

$15 Copay (overall ded waived)

$50 Copay

$50 Copay

Out-of-Pocket Max Ind/Fam

$2,500 / $5,000

$6,200 / $12,400

$6,200 / $12,400

Hospital Services – Out-Patient Surgical Facility

80%

$600 Copay

80%

Ambulance Services (per trip)

$150 Copay

$250 Copay

$250 Copay

Infertility Evaluation and Treatment

Not Covered

Not Covered

Not Covered

Medical Benefits

Silver HMO A

Silver HMO B

Silver HMO C

Sutter Health Plus

Sutter Health Plus

Sutter Health Plus

Full

Full

Full

$1,500 / $3,000 (applies to Max OOP)

$1,500 / $3,000 (applies to Max OOP)

$2,600 / $4,000 (combined Med/Rx ded) (applies to Max OOP)

$45 Copay (ded waived)

$45 Copay (ded waived)

$35 Copay

Hospital Services – In-Patient

80%

80%

80%

In-Patient Physician Fees

80%

80%

80%

$250 Copay

$250 Copay

80%

$15 Copay (ded waived)

$15 Copay (ded waived)

Rx Benefits – Formulary Brand

$250 / $500 Ded – $55 Copay

$250 / $500 Ded – $55 Copay

$10 Copay (combined Med/RX ded) $20 Copay (combined Med/RX ded)

Out-of-Pocket Max Ind/Fam

$6,500 / $13,000

$6,500 / $13,000

$4,500 / $9,000

Hospital Services – Out-Patient Surgical Facility

80% (ded waived)

80% (ded waived)

80%

Ambulance Services (per trip)

$250 Copay

$250 Copay

80%

Infertility Evaluation and Treatment

Not Covered

Not Covered

Not Covered

Calendar Year Deductible Dr. Office Visits (PCP)

Emergency Room (copay waived if admitted)

HSA Qualified

Participating Health Plans Network Name Calendar Year Deductible Dr. Office Visits (PCP)

Emergency Room (copay waived if admitted) Rx Benefits – Generic

For a complete listing of all benefits, limits, and exclusions, please see the Evidence of Coverage or Certificate of Insurance. 

800.558.8003 4

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(continued)

EXCITING NEWS

Groups Renewing 4/1/16 - 6/1/16 CaliforniaChoice® Welcomes Sutter Health Plus (continued) HSA Qualified

HSA Qualified

Medical Benefits

Silver HMO D

Bronze HMO A

Bronze HMO B

Sutter Health Plus

Sutter Health Plus

Sutter Health Plus

Full

Full

Full

$2,600 / $4,000 (combined Med/Rx ded) (applies to Max OOP)

$6,000 / $12,000 (applies to Max OOP)

$4,500 / $9,000 (combined Med/Rx ded) (applies to Max OOP)

Dr. Office Visits (PCP)

80%

$70 Copay

60%

Hospital Services – In-Patient

80%

100%

60%

In-Patient Physician Fees

80%

100%

60%

Emergency Room (copay waived if admitted)

80%

100%

60%

Participating Health Plans Network Name Calendar Year Deductible

$500 / $1,000 Ded – 100% (up to $500 per prescription) $500 / $1,000 Ded – 100% (up to $500 per prescription)

Rx Benefits – Generic

80% (combined Med/Rx ded)

Rx Benefits – Formulary Brand

80% (combined Med/Rx ded)

Out-of-Pocket Max Ind/Fam

$6,250 / $12,500

$6,500 / $13,000

$6,500 / $13,000

Hospital Services – Out-Patient Surgical Facility

80%

100%

60%

Ambulance Services (per trip)

80%

100%

60%

Not Covered

Not Covered

Not Covered

Infertility Evaluation and Treatment

60% (combined Med/Rx ded) 60% (combined Med/Rx ded)

For a complete listing of all benefits, limits, and exclusions, please see the Evidence of Coverage or Certificate of Insurance.

800.558.8003

www.calchoice.com

5

EXCITING NEWS

Groups Renewing 4/1/16 - 6/1/16 UnitedHealthcare Adds a New HMO Option As part of UnitedHealthcare’s commitment to delivering the right benefits solution for businesses, the company has added a new Silver HMO option for CaliforniaChoice groups with new or renewed coverage effective 10/1/2015 or later. Highlights of the new plan are shown below. At renewal, your employees will have access to the plan(s) in the tier (or tiers) you select for your group. Your employees’ Enrollment Worksheets will reflect your selected tier(s). Medical Benefits Participating Health Plans Network Name Calendar Year Deductible Dr. Office Visits (PCP)

Silver HMO D UnitedHealthcare Focus $2,000 / $4,000 (applies to Max OOP) $45 Copay (ded waived)

Hospital Services – In-Patient

60%

In-Patient Physician Fees

60%

Emergency Room (copay waived if admitted)

$400 Copay (ded waived)

Rx Benefits – Generic

$20 Copay (overall ded waived)

Rx Benefits – Formulary Brand

$50 Copay (overall ded waived)

Out-of-Pocket Max Ind/Fam

$6,500 / $13,000

Hospital Services – Out-Patient Surgical Facility

60%

Ambulance Services (per trip)

$100 Copay (ded waived)

Infertility Evaluation and Treatment

Covered

For a complete listing of all benefits, limits, and exclusions, please see the Evidence of Coverage or Certificate of Insurance.

800.558.8003 6

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EXCITING NEWS

Groups Renewing 4/1/16 - 6/1/16 Anthem Blue Cross Adds Two New HSA-Qualified EPO Options Anthem Blue Cross has added two new Exclusive Provider Organization (EPO) plan options. The new Gold EPO and Bronze EPO plans are Health Savings Account-Qualified and give Anthem members access to the Small Group Prudent Buyer network. Highlights of each plan are shown below. At renewal, your employees will have access to the plan(s) in the tier (or tiers) you select for your group. Your employees’ Enrollment Worksheets will reflect your selected tier(s). HSA Qualified

Medical Benefits Participating Health Plans Network Name Calendar Year Deductible

HSA Qualified

Gold EPO A

Bronze EPO B

Anthem Blue Cross

Anthem Blue Cross

Prudent Buyer – Small Group

Prudent Buyer – Small Group

$2,600 / $5,200 (combined $5,000 / $10,000 (combined Med/Rx/Pediatric dental ded) Med/Rx/Pediatric dental ded) (applies to Max OOP) (applies to Max OOP)

Dr. Office Visits (PCP)

80%

80%

Hospital Services – In-Patient

80%

80%

In-Patient Physician Fees

80%

80%

Emergency Room (copay waived if admitted)

80%

80%

Rx Benefits – Generic

80% (combined Med/Rx/ Pediatric dental ded)

80% (combined Med/Rx/ Pediatric dental ded)

Rx Benefits – Formulary Brand

80% (combined Med/Rx/ Pediatric dental ded)

80% (combined Med/Rx/ Pediatric dental ded)

Out-of-Pocket Max Ind/Fam

$5,000 / $10,000

$6,500 / $13,000

Hospital Services – Out-Patient Surgical Facility

80%

80%

Ambulance Services (per trip)

80%

80%

Not Covered

Not Covered

Infertility Evaluation and Treatment

For a complete listing of all benefits, limits, and exclusions, please see the Evidence of Coverage or Certificate of Insurance.

800.558.8003

www.calchoice.com

7

EXCITING NEWS

Groups Renewing 4/1/16 - 6/1/16 Sharp Health Plan Adds a New HSA-Qualified Option Sharp Health Plan, the largest commercial health plan in San Diego, has added a new Bronze HMO plan. The Health Savings Account-Qualified plan gives members access to Sharp’s Premier network of health care providers. Highlights of the plan are shown below. At renewal, if you’ve chosen the Bronze tier for your group, your employees will have access to Sharp’s new Bronze HMO plan. HSA Qualified

Medical Benefits Participating Health Plans Network Name Calendar Year Deductible

Bronze HMO C Sharp Premier $4,500 / $9,000 (combined Med/Rx ded) (applies to Max OOP)

Dr. Office Visits (PCP)

60%

Hospital Services – In-Patient

60%

In-Patient Physician Fees

60%

Emergency Room (copay waived if admitted)

60%

Rx Benefits – Generic

60% (combined Med/Rx ded)

Rx Benefits – Formulary Brand

60% (combined Med/Rx ded)

Out-of-Pocket Max Ind/Fam

$6,250 / $12,500

Hospital Services – Out-Patient Surgical Facility

60%

Ambulance Services (per trip)

60%

Infertility Evaluation and Treatment

Covered

For a complete listing of all benefits, limits, and exclusions, please see the Evidence of Coverage or Certificate of Insurance.

800.558.8003 8

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SUMMARY OF CHANGES Groups Renewing 4/1/16 - 6/1/16

PLEASE DISTRIBUTE TO ALL EMPLOYEES Below is an overview of changes and updates that will take effect at Renewal. For a complete listing of all benefits, limits and exclusions, please see the Evidence of Coverage or Certificate of Insurance.

General Administrative Changes – Affordable Care Act Impactors Effective April 13, 2016, the Ameritas EPO 3000 and EPO 3500 plans will have a name change to PPO 3000 and PPO 3500 and are now in the Ameritas PPO network. Effective April 1, 2016, the First Dental Health free dental plan will no longer be available as an option in the CaliforniaChoice® Program. Effective January 1, 2016, the following Plans will no longer be available as an option in the CaliforniaChoice Program: • Anthem Blue Cross – Gold HMO B • Health Net – All PPO plans • Kaiser Permanente – Silver HMO A and Bronze HMO A To comply with the Affordable Care Act (ACA), effective January 1, 2016, there will be changes that may impact small groups and their employees in 2016. As you go through your renewal, please be aware of the IMPORTANT changes below. • Group Size: The group size for small group is now 1-100 based on full-time equivalent (FTE) calculation • All plans calendar year deductibles and out-of-pocket maximums are now embedded Effective October 1, 2015, UnitedHealthcare Bronze HMO C plan will no longer be available as an option in the CaliforniaChoice Program. Aetna – New ID Cards for Current Members Effective July 1, 2015, all CaliforniaChoice members currently enrolled in Aetna will be mailed a new member ID card with a new medical identification (ID) number, as they come up for renewal. Current member ID cards will no longer be active or accepted by their Primary Care Physicians and should be discarded. If any members do not receive their new Aetna member ID card by their renewal date, please have them contact CaliforniaChoice Customer Service at 800-558-8003 Monday - Friday, from 8:00 a.m. - 5:00 p.m.

800.558.8003

www.calchoice.com

9

SUMMARY OF CHANGES Groups Renewing 4/1/16 - 6/1/16

New HSA Contribution Amounts for 2016 Now you can contribute up to $3,350 for individual coverage and $6,750 for family coverage.

Aetna Aetna Platinum HMO A • The In-Patient Physician Fees and Out-Patient Physician Fees benefits have changed from “100%” to “$40 Copay“ • The Specialty prescription benefit has changed from “90%” to “90% (up to $250 per prescription)”

• The Acupuncture benefit has changed from “$15 Copay (12 visits max per year)” to “$20 Copay”

Aetna Gold HMO A • The out-of-pocket maximum for individual/family has changed from “5,000/$10,000” to “$6,000/$12,000“ • The Acupuncture benefit has changed from “$15 Copay (12 visits max per year)” to “$15 Copay”

Aetna Gold HMO B • The out-of-pocket maximum for individual/family has changed from “5,500/$11,000” to “$6,000/$12,000“ • The Generic prescription benefit has changed from “$10 Copay (ded waived)” to “$20 Copay (ded waived)” • The Non-Formulary Brand prescription benefit has changed from “$250 Ded $100 Copay” to “$250 Ded - $70 Copay“

• The Acupuncture benefit has changed from “$15 Copay (12 visits max per year)” to “$15 Copay”

• The X-Ray benefit has changed from “$60 Copay” to “$30 Copay” Aetna Silver HMO A and HMO B • The Acupuncture benefit has changed from “$15 Copay (ded waived; 12 visits max per year) to “$15 Copay (ded waived)” • The Non-Formulary Brand prescription benefit has changed from “$100 Copay (overall ded waived)” to “$70 Copay (overall ded waived)”

Aetna Bronze HMO A • The Acupuncture benefit has changed from “$15 Copay (ded waived; 12 visits max per year)” to “$15 Copay (ded waived)”

800.558.8003 10

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SUMMARY OF CHANGES Groups Renewing 4/1/16 - 6/1/16

Aetna – Continued • The Durable Medical Equipment benefit has changed from “50%” to “$100 Copay”

Anthem Blue Cross Anthem Blue Cross All HMO and EPO Plans • The Adult Vision benefit has changed from “Not Covered” to “$20 Copay”

Anthem Blue Cross All PPO Plans • The Adult Vision (IN) benefit has changed from “Not Covered” to “$20 Copay”

Anthem Blue Cross Platinum HMO A • The following benefits have changed from “10 Copay” to “$20 Copay”:

o Doctor Office Visit (PCP) o Acupuncture o Out-Patient Mental Health o Infertility Evaluation and Treatment o Physical, Occupational, Speech Therapy o Rehabilitative & Habilitative Services and Devices • The following benefits have changed from “$10 Copay” to “$40 Copay”:



o Specialist Visit (SPC) o 2nd Surgical Opinion o Chemotherapy o Hemodialysis and Peritoneal Dialysis • The following benefits have changed from “$450 Copay per day – 4 days max” to “$500 Copay per day – 4 days max”:



o In-Patient Hospital Services o In-Patient Mental Health o In-Patient Drug/Substance Abuse (Detox Only) • The Emergency Room benefit has changed from “$150 Copay (waived if admitted)” to “$200 Copay (waived if admitted)” • The Brand Name deductible has changed from “None” to “$300/$600” • The Generic prescription benefit has changed from “$5 Copay” to “$15 Copay (ded waived)” (continued)

800.558.8003

www.calchoice.com

11

SUMMARY OF CHANGES Groups Renewing 4/1/16 - 6/1/16

Anthem Blue Cross – Continued • The Formulary Brand prescription benefit has changed from “$30 Copay” to ”$300/$600 Ded - $40 Copay” • The Non-Formulary Brand prescription benefit has changed from “$60 Copay” to ”$300/$600 Ded - $80 Copay” • The Chiropractic benefit has changed from “$10 Copay, 20 visits max per year” to “$20 Copay, 20 visits max per year” • The out-of-pocket maximum for individual/family has changed from “$2,500/$5,000” to “$4,500/$9,000” • The Out-Patient Surgical Facility and Ambulatory Surgical Center benefits have changed from “$150 Copay” to “$250 Copay” • The Home Health Care benefit has changed from “$10 Copay, 100 visits max per year” to “$20 Copay, 100 visits max per year” • The Ambulance Services and Durable Medical Equipment benefits have changed from “90%” to “80%” • The Urgent Care benefit has changed from “$10 Copay” to “$75 Copay” • The Specialist Visit and 2nd Surgical Opinion benefits have changed from “$70 Copay (ded waived)” to “$75 Copay (ded waived)” • The Laboratory and X-Ray benefits have changed from “100% (ded waived)” to “$25 Copay (ded waived)”

Anthem Blue Cross Gold HMO A

• The following benefits have changed from “$35 Copay” to “$50 Copay”: o Doctor Office Visit (PCP) o Acupuncture o Out-Patient Mental Health o Infertility Evaluation and Treatment o Physical, Occupational, Speech Therapy o Rehabilitative & Habilitative Services and Devices • The following benefits have changed from “$60 Copay” to “$100 Copay”:



o Specialist Visit (SPC) o 2nd Surgical Opinion o Chemotherapy o Urgent Care (continued)

800.558.8003 12

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SUMMARY OF CHANGES Groups Renewing 4/1/16 - 6/1/16

Anthem Blue Cross – Continued • The MRI, CT and PET Scans benefit has changed from “$150 Copay per test” to “$100 Copay per test” • The Emergency Room benefit has changed from “$200 Copay (waived if admitted)” to “$350 Copay (waived if admitted)” • The Brand Name prescription deductible has changed from “$300/$600” to “$250/$500” • The Formulary Brand prescription benefit has changed from “$300/$600 Ded $35 Copay” to “$250/$500 Ded - $50 Copay” • The Non-Formulary Brand prescription benefit has changed from “$300/$600 Ded - $70 Copay” to “$250/$500 Ded - $90 Copay” • The Specialty prescription benefit has changed from “$300/$600 Ded – 70% (up to 500 per prescription)” to “$250/$500 Ded – 75% (up to $250 per prescription)” • The Chiropractic benefit has changed from “$35 Copay, 20 visits max per year” to “$50 Copay, 20 visits max per year” • The out-of-pocket maximum for individual/family has changed from “$6,350/$12,700” to “$6,850/$13,700” • The Out-Patient Surgical Facility and Ambulatory Surgical Center benefits have changed from “$250 Copay” to “$500 Copay” • The Home Health Care benefit has changed from “$35 Copay, 100 visits max per year” to “$50 Copay, 100 visits max per year” • The Ambulance Services and Durable Medical Equipment benefits have changed from “80%” to “70%” • The Hemodialysis and Peritoneal Dialysis benefit has changed from “$60 Copay” to “$50 Copay”

Anthem Blue Cross Silver HMO A • The following benefits have changed from “70%” to “60%”:

o o o o o o o

In-Patient Hospital Services In-Patient Mental Health In-Patient Drug/Substance Abuse (Detox Only) Out-Patient Surgical Facility Ambulatory Surgical Center Ambulance Services Durable Medical Equipment

(continued)

800.558.8003

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13

SUMMARY OF CHANGES Groups Renewing 4/1/16 - 6/1/16

Anthem Blue Cross – Continued • The MRI, CT and PET Scans benefit has changed from “$150 Copay per test (ded waived)” to “$250 Copay per test (ded waived)” • The Emergency Room benefit has changed from “$200 Copay – 70% (waived if admitted)” to “$300 Copay (waived if admitted)” • The Formulary Brand prescription benefit has changed from “$250/$500 Ded $35 Copay” to “$250/$500 Ded – $50 Copay” • The Non-Formulary Brand prescription benefit has changed from “$250/$500 Ded - $70 Copay” to “$250/$500 Ded – $90 Copay” • The Specialty prescription benefit has changed from “$250/$500 Ded – 70% (up to 500 per prescription)” to “$250/$500 Ded – 75% (up to $250 per prescription)” • The out-of-pocket maximum for individual/family has changed from “$6,600/$13,200” to “$6,850/$13,700” • The Skilled Nursing benefit has changed from “70%, 100 days max per year” to “60%, 100 days max per year” • The Chemotherapy and Hemodialysis and Peritoneal Dialysis benefits have changed from “70% (ded waived)” to “60% (ded waived)” • The Urgent Care benefit has changed from “$70 Copay (ded waived)” to “$100 Copay (ded waived)” • The Specialist Visit and 2nd Surgical Opinion benefits have changed from “$70 Copay (ded waived)” to “$75 Copay (ded waived)” • The Laboratory and X-Ray benefits have changed from “100% (ded waived)” to “$25 Copay (ded waived)”

Anthem Blue Cross Silver EPO A • The following benefits have changed from “$750 Copay – 70%” to “$750 Copay”:

o In-Patient Hospital Services o In-Patient Mental Health o In-Patient Drug/Substance Abuse (Detox Only) • The Emergency Room benefit has changed from “$250 Copay – 70% (waived if admitted)” to “$300 Copay (waived if admitted)” • The Formulary Brand prescription benefit has changed from “$35 Copay (overall ded waived)” to “$40 Copay (overall ded waived)” (continued)

800.558.8003 14

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SUMMARY OF CHANGES Groups Renewing 4/1/16 - 6/1/16

Anthem Blue Cross – Continued • The Non-Formulary Brand prescription benefit has changed from “$70 Copay (overall ded waived)” to “$80 Copay (overall ded waived)” • The Out-Patient Surgical Facility and Ambulatory Surgical Center benefits have changed from “$250 Copay – 70%” to “$300 Copay” • The Skilled Nursing benefit has changed from “$750 Copay – 70%, 100 days max per year” to “$750 Copay, 100 days max per year”

Anthem Blue Cross Bronze EPO A • The following benefits have changed from “$1,000 Copay – 60%” to “$1,000 Copay”

o In- Patient Hospital Services o In-Patient Mental Health o In-Patient Drug/Substance Abuse (Detox Only) • The Emergency Room benefit has changed from “$400 Copay – 60% (waived if admitted)” to “$400 Copay (waived if admitted)” • The out-of-pocket maximum for individual/family has changed from “$6,350/$12,700” to “$6,850/$13,700” • The Out-Patient Surgical Facility and Ambulatory Surgical Center benefits have changed from “$500 Copay – 60%” to “$500 Copay” • The Skilled Nursing benefit has changed from “$1,000 Copay – 60%, 100 days max per year” to “$1,000 Copay, 100 days max per year”

Anthem Blue Cross Gold PPO A • The Chemotherapy benefit (OON) has changed from “80%” to “50%” • The Formulary Brand prescription benefit (IN) has changed from “$35 Copay” to “$40 Copay” • The Non-Formulary prescription benefit (IN) has changed from “$70 Copay” to “$80 Copay” • The Specialty prescription benefit (IN) has changed from “70% (up to $500 per prescription)” to “75% (up to $250 per prescription)” • The out-of-pocket maximum for individual/family has changed from “$3,500/$7,000” to “$4,000/$8,000” for (IN) and from “$7,000/$14,000” to “$8,000/$16,000” for (OON) • The Ambulatory Surgical Center benefit (IN) has changed from “80%” to “Tier 1: 80%; Tier 2: $250 Copay – 80%” (continued)

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SUMMARY OF CHANGES Groups Renewing 4/1/16 - 6/1/16

Anthem Blue Cross – Continued Anthem Blue Cross Gold PPO B • The Chemotherapy benefit (OON) has changed from “80%” to “50%” • The Generic prescription benefit (IN) has changed from “$15 Copay (ded waived)” to “$10 Copay (ded waived)” • The Specialty prescription benefit (IN) has changed from “$250/$500 Ded – 70% (up to $500 per prescription)” to “$250/$500 Ded – 75% (up to $250 per prescription)” • The out-of-pocket maximum for individual/family has changed from “$3,500/$7,000” to “$4,000/$8,000” for (IN) and from “$7,000/$14,000” to “$8,000/$16,000” for (OON) • The Urgent Care benefit (IN) has changed from “$50 Copay (ded waived)” to “$100 Copay (ded waived)”

Anthem Blue Cross Gold PPO C • The Chemotherapy benefit (OON) has changed from “80%” to “50%”



• The following benefits (IN) have changed from “$20 Copay (first 3 visits) – 80%” to “$25 Copay (first 3 visits) – 80%”: o Doctor Office Visit (PCP) o Specialist Visit (SPC) o Acupuncture o Out-Patient Mental Health o Infertility Evaluation and Treatment o Physical, Occupational, Speech Therapy o Rehabilitative & Habilitative Services and Devices • The following benefits (IN) have changed from “$500 Copay – 80%” to “$500 Copay”:



o In- Patient Hospital Services o In-Patient Mental Health o In-Patient Drug/Substance Abuse (Detox Only) • The Skilled Nursing benefit has changed from “$500 Copay – 80%, 100 days max per year” to “$500 Copay, 100 days max per year” • The Emergency Room benefit (both IN & OON) has changed from “$200 Copay – 80% (waived if admitted)” to “$250 Copay (waived if admitted)” (continued)

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SUMMARY OF CHANGES Groups Renewing 4/1/16 - 6/1/16

Anthem Blue Cross – Continued • The Formulary Brand prescription benefit (IN) has changed from “$35 Copay” to “$40 Copay” • The Non-Formulary prescription benefit (IN) has changed from “$70 Copay” to “$80 Copay” • The Specialty prescription benefit (IN) has changed from “70% (up to $500 per prescription)” to “75% (up to $250 per prescription)” • The Chiropractic benefit (IN) has changed from “$20 Copay (first 3 visits) – 80%, 20 visits max per year” to “$25 Copay (first 3 visits) – 80%, 20 visits max per year” • The out-of-pocket maximum for individual/family has changed from “$3,000/$6,000” to “$4,000/$8,000” for (IN) and from “$6,000/$12,000” to “$8,000/$16,000” for (OON) • The 2nd Surgical Opinion benefit (IN) has changed from “$20 Copay (ded waived)” to “$25 Copay (first 3 visits) – 80%” • The Out-Patient Surgical Facility and Ambulatory Surgical Center benefits (IN) have change from “$250 Copay – 80%” to “$250 Copay”

Anthem Blue Cross Gold PPO D • The Chemotherapy benefit (OON) has changed from “80%” to “50%” • The Formulary Brand prescription benefit (IN) has changed from “$250/$500 Ded – $35 Copay” to “$250/$500 Ded – $40 Copay” • The Non-Formulary prescription benefit (IN) has changed from “$250/$500 Ded – $70 Copay” to “$250/$500 Ded – $80 Copay” • The Urgent Care benefit (IN) has changed from “$40 Copay (ded waived)” to “$100 Copay (ded waived)”

Anthem Blue Cross Silver PPO A • The Chemotherapy benefit (OON) has changed from “60%” to “50%” • The Formulary Brand prescription benefit (IN) has changed from “$250/$500 Ded – $35 Copay” to “$250/$500 Ded – $40 Copay” • The Non-Formulary Brand prescription benefit (IN) has changed from “$250/$500 Ded – $70 Copay” to “$250/$500 Ded – $80 Copay” • The Specialty prescription benefit (IN) has changed from “$250/$500 Ded – 70% (up to $500 per prescription)” to “$250/$500 Ded – 70% (up to $250 per prescription)” (continued)

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SUMMARY OF CHANGES Groups Renewing 4/1/16 - 6/1/16

Anthem Blue Cross – Continued Anthem Blue Cross Silver PPO B • The Chemotherapy benefit (OON) has changed from “70%” to “50%” • The following benefits (IN) have changed from “$500 Copay – 70%” to “$500 Copay”:

o In-Patient Hospital Services o In-Patient Mental Health o In-Patient Drug/Substance Abuse (Detox Only) • The Emegency Room benefit (both IN & OON) has changed from “$250 Copay – 70% (waived if admitted)” to “$300 Copay (waived if admitted)” • The Formulary Brand prescription benefit (IN) has changed from “$250/$500 Ded - $35 Copay” to “$250/$500 Ded - $40 Copay” • The Non-Formulary Brand prescription benefit (IN) has changed from “$250/$500 Ded - $70 Copay” to “$250/$500 Ded - $80 Copay” • The Specialty prescription benefit (IN) has changed from “$250/$500 Ded – 70% (up to $500 per prescription)” to “$250/$500 Ded – 70% (up to $250 per prescription)” • The out-of-pocket maximum for individual/family has changed from “$4,250/$8,500” to “$5,500/$11,000” for (IN) and from “$8,500/$17,000” to “$11,000/$22,000” for (OON) • The Out-Patient Surgical Facility and Ambulatory Surgical Center benefits (IN) have changed from “$250 Copay -70%” to “$300 Copay” • The Skilled Nursing benefit (IN) has changed from “$500 Copay – 70%, 100 days max per year” to “$500 Copay, 100 days max per year”

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SUMMARY OF CHANGES Groups Renewing 4/1/16 - 6/1/16

Health Net Health Net All Plans • The Pediatric Dental Office Visit benefit has changed from “$20 Copay” to “100%” • The Pediatric Dental Basic Services benefit has changed from “$95 Copay” to “$25 Copay” • The Pediatric Dental Major Services benefit has changed from “$365 Copay” to “$300 Copay”

Health Net Platinum HMO A • The Elective Abortion benefit has changed from “$150 Copay” to “100%” • The Out-Patient Physician Fees benefit has changed from “$20 Copay” to “100%”

Health Net Gold HMO’s • The MRI, CT and PET Scan benefit has changed from “$100 Copay per procedure” to “$150 Copay per procedure” • The out-of-pocket maximum for individual/family has changed from “$4,500/$9,000” to “$5,500/$11,000” • The Out-Patient Physician Fees benefit has changed from “$40 Copay” to “100%” • The Acupuncture benefit has changed from “$40 Copay” to “$10 Copay”

Health Net Gold HMO A • The Laboratory and X-Ray benefits have changed from “$25 Copay” to “$40 Copay” • The following benefits have changed from “$500 Copay per day – 4 days max” to “$600 Copay per day – 4 days max”:

o o o o

In-Patient Hospital Services Skilled Nursing In-Patient Mental Health In-Patient Drug/Substance Abuse (Detox Only)

• The Out-Patient Surgery Facility and Ambulatory Surgical Center benefits have changed from “$500 Copay” to “$600 Copay”

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SUMMARY OF CHANGES Groups Renewing 4/1/16 - 6/1/16

Kaiser Permanente Kaiser Permanente Platinum HMO A • The following benefits have changed from “$20 Copay” to “$10 Copay”:

o o o o o

Doctor Office Visit (PCP) Out-Patient Mental Health Physical, Occupational, Speech Therapy Rehabilitative & Habilitative Services and Devices Urgent Care

• The following benefits have changed from “$40 Copay” to “$10 Copay”:

o Specialist Visit (SPC) o Acupuncture o 2nd Surgical Opinion o Chronic Disease Management

• The following benefits have changed from “$250 Copay per day – 5 days max “ to “$300 Copay per day – 5 days max”:

o In-Patient Hospital Services o In-Patient Mental Health o In-Patient Drug/Substance Abuse (Detox Only)

• The Emergency Room benefit has changed from “$150 Copay (waived if admitted)” to “$200 Copay (waived if admitted)” • The Specialty prescription benefit has changed from “90% (with physician approval)” to “90% (up to $250 per prescription; with physician approval)” • The Out-Patient Surgical Facility and Ambulatory Surgical Center benefits have changed from “$250 Copay” to “$300 Copay” • The Ambulance Services benefit has changed from “$150 Copay” to “$200 Copay”

Kaiser Permanente Gold HMO A • The following benefits have changed from “$30 Copay (ded waived)” to “$25 Copay (ded waived)”:

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o o o o o o

Doctor Office Visit (PCP) Specialist Visit (SPC) Out-Patient Mental Health Physical, Occupational, Speech Therapy Rehabilitative & Habilitative Services and Devices Urgent Care

(continued)

SUMMARY OF CHANGES Groups Renewing 4/1/16 - 6/1/16

Kaiser Permanente – Continued • The Laboratory and X-Ray benefits have changed from “$20 Copay (ded waived)” to “$25 Copay (ded waived)” • The MRI, CT and PET Scan benefit has changed from “$250 Copay per procedure (ded waived)” to “$150 Copay per procedure (ded waived)” • The Specialty prescription benefit has changed from “80% (with physician approval)” to “80% (up to $250 per prescription; with physician approval)” • The out-of-pocket maximum for individual/family has changed from “$6,250/$12,500” to “$6,000/$12,000” • The Skilled Nursing benefit has changed from “$250 Copay per day – 5 days max, 100 days max per benefit period” to “$300 Copay per day – 5 days max, 100 days max per benefit period” • The 2nd Surgical Opinion and Chronic Disease Management benefits have changed from “$30 Copay” to “$25 Copay”

Kaiser Permanente Gold HMO B • The following benefits have changed from “$50 Copay” to “$30 Copay”:

o Specialist Visit (SPC) o Acupuncture o 2nd Surgical Opinion

• The Specialty prescription benefit has changed from “80% (with physician approval)” to “80% (up to $250 per prescription; with physician approval)” • The out-of-pocket maximum for individual/family has changed from “$6,250/$12,500” to “$6,000/$12,000” • The Laboratory benefit has changed from “$30 Copay” to “$40 Copay”

Kaiser Permanente Silver HMO B • The Laboratory benefit has changed from “$30 Copay (ded waived)” to “$50 Copay (ded waived)” • The X-Ray benefit has changed from “$40 Copay (ded waived)” to “$60 Copay (ded waived)” • The MRI, CT and PET Scan benefit has changed from “70% per procedure” to “$250 Copay per procedure” • The Brand Name prescription deductible has changed from “None” to “$100”

(continued)

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SUMMARY OF CHANGES Groups Renewing 4/1/16 - 6/1/16

Kaiser Permanente – Continued • The Generic prescription benefit has changed from “$25 Copay (overall ded waived)” to “$20 Copay (ded waived)” • The Specialty prescription benefit has changed from “80% (overall ded waived; with physician approval)” to “$100 Ded - 80% (up to $250 per prescription; with physician approval)” • The out-of-pocket maximum for individual/family has changed from “$6,250/$12,500” to “$6,500/$13,000”

Kaiser Permanente Silver HMO C • The following benefits have changed from “$45 Copay (ded waived)” to “$50 Copay (ded waived)”:

o o o o o

Doctor Office Visit (PCP) Out-Patient Mental Health Physical, Occupational, Speech Therapy Rehabilitative & Habilitative Services and Devices Urgent Care

• The following benefits have changed from “$65 Copay (ded waived)” to “$50 Copay (ded waived)”:

o Specialist Visit (SPC) o X-Ray o Acupuncture

• The Laboratory benefit has changed from “$45 Copay (ded waived)” to “$30 Copay (ded waived)” • The calendar year deductible now applies to the MRI, CT and PET Scan, Out-Patient Surgical Facility and Ambulatory Surgical Center benefits • The Brand Name prescription deductible benefit has changed from “$500” to “None” • The Generic prescription benefit has changed from “$15 Copay (ded waived)” to “$20 Copay (overall ded waived)” • The Specialty prescription benefit has changed from “$500 Ded – 80% (with physician approval)” to “80% (up to $250 per prescription; overall ded waived; with physician approval)”

(continued)

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SUMMARY OF CHANGES Groups Renewing 4/1/16 - 6/1/16

Kaiser Permanente – Continued • The out-of-pocket maximum for individual/family has changed from “$6,250/$12,500” to “$6,500/$13,000”

Kaiser Permanente Bronze HMO B • The Specialist Visit (SPC) benefit has changed from “$70 Copay” to “$60 Copay”

o  Deductible is waived for first three visits (combined for primary care, specialist, urgent care and individual mental/behavioral health and substance use disorder services)

• The following benefits have changed from “70%” to “60%”:

o Laboratory o X-Ray o In-Patient Hospital Services o In-Patient Physician Fees o In-Patient Mental Health o In-Patient Drug/Substance Abuse (Detox Only) o Out-Patient Surgical Facility o Out-Patient Physician Fees o Ambulatory Surgical Center o Durable Medical Equipment

• The MRI, CT and PET Scan benefit has changed from “70% per procedure” to “60% per procedure” • The Emergency Room benefit has changed from “$300 Copay (waived if admitted)” to “60%” • The Brand Name prescription deductible benefit has changed from “None” to “$1,000” • The Generic prescription benefit has changed from “$15 Copay” to “$1,000 Ded - $20 Copay” • The Specialty prescription benefit has changed from “70% (with physician approval)” to “$1,000 Ded - 80% (up to $250 per prescription; with physician approval)” • The Acupuncture benefit has changed from “$70 Copay” to “$90 Copay” • The out-of-pocket maximum for individual/family has changed from “$6,250/$12,500” to “$6,500/$13,000” (continued)

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SUMMARY OF CHANGES Groups Renewing 4/1/16 - 6/1/16

Kaiser Permanente – Continued • The Skilled Nursing benefit has changed from “70%, 100 days max per benefit period” to “60%, 100 days max per benefit period” • The Ambulance Services benefit has changed from “$300 Copay” to “60%”

Kaiser Permanente Bronze HMO C • The following benefits have changed from “60%” to “75%”

o Doctor Office Visit (PCP) o Specialist Visit (SPC) o Laboratory o X-Ray o In-Patient Hospital Services o In-Patient Physician Fees o In-Patient Mental Health o In-Patient Drug/Substance Abuse (Detox Only) o Emergency Room o Acupuncture o 2nd Surgical Opinion o Out-Patient Surgical Facility o Out-Patient Physician Fees o Ambulatory Surgical Center o Out-Patient Mental Health o Ambulance Services o Chronic Disease Management o Physical, Occupational, Speech Therapy o Rehabilitative & Habilitative Services and Devices o Urgent Care o Durable Medical Equipment

• The MRI, CT and PET Scan benefit has changed from “60% per procedure” to “75% per procedure” • The out-of-pocket maximum for individual/family has changed from “$6,250/$12,500” to “$6,500/$13,000”

(continued)

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SUMMARY OF CHANGES Groups Renewing 4/1/16 - 6/1/16

Kaiser Permanente – Continued • The Skilled Nursing benefit has changed from “60%, 100 days max per benefit period” to “75%, 100 days max per benefit period” • The Brand Name prescription deductible has changed from “None” to “Combined with Medical” • The Generic prescription benefit has changed from “60%” to “75% (combined Med/Rx ded)” • The Formulary Brand and Non-Formulary Brand prescription benefits have changed from “60% (with physician approval)” to “75% (combined Med/Rx ded; with physician approval)” • The Specialty prescription benefit has changed from “60% (with physician approval)” to “75% (up to $250 per prescription; combined Med/Rx ded; with physician approval)”

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SUMMARY OF CHANGES Groups Renewing 4/1/16 - 6/1/16

Sharp Health Plan Sharp Health Plan All Plans • The Infertility Evaluation and Treatment benefit has changed from “50%” to “Not Covered” • The Infertility Drugs benefit has changed from “See Plan Specific EOC” to “Not Covered”

Sharp Health Plan Platinum HMO A • The Ambulance Services benefit has changed form “$100 Copay” to “$150 Copay”

Sharp Health Plan Gold HMO A • The out-of-pocket maximum for individual/family has changed from “$6,350/$12,700” to “$6,500/$13,000” • The following benefits have changed from “$45 Copay” to “$50 Copay”:

o Specialist Visit (SPC) o Acupuncture o Physical, Occupational, Speech Therapy o Rehabilitative & Habilitative Services and Devices o Urgent Care o Prenatal and Postpartum Office Visit o Prosthetics and Orthotics (DME) o Out-Patient Mental Health o Out-Patient Drug/Substance Abuse o 2nd Surgical Opinion o Chemotherapy

• The Home Health Care benefit has changed from “$45 Copay, 100 visits max per year” to “$50 Copay, 100 visits max per year”

Sharp Health Plan Gold HMO B • The Ambulance Services benefit has changed form “$150 Copay” to “$200 Copay”

Sharp Health Plan Bronze HMO A • The calendar year deductible has changed from “$2,000/$4,000 (combined Med/Rx ded; applies to Max OOP) to “$2,650/$5,300 (combined Med/Rx ded; applies to Max OOP)” • The out-of-pocket maximum for individual/family has changed from “$6,350/$12,700” to “$6,500/$13,000” (continued)

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SUMMARY OF CHANGES Groups Renewing 4/1/16 - 6/1/16

Sharp Health Plan – Continued • The Ambulance Services benefit has changed form “$350 Copay” to “$500 Copay”

Sharp Health Plan Bronze HMO B • The calendar year deductible has changed from “$3,750/$7,500 (combined Med/Rx ded; applies to Max OOP) to “$3,850/$7,700 (combined Med/Rx ded; applies to Max OOP)” • The out-of-pocket maximum for individual/family has changed from “$6,350/$12,700” to “$6,500/$13,000”

UnitedHealthcare United Healthcare Platinum HMO’s and Gold HMO’s • The Pediatric Vision Contact Lenses and Frames benefits have changed from “90%” to “70%”

UnitedHealthcare Platinum HMO’s • The Laboratory and X-Ray benefits have changed from “$15 Copay” to “$5 Copay”

• The MRI, CT and PET Scan benefit has changed from “$50 Copay per procedure” to “$100 Copay per procedure”

• The following benefits have changed from “$250 Copay per day – 4 days max” to “70%”



o In-Patient Hospital Services o In-Patient Mental Health o In-Patient Drug/Substance Abuse (Detox Only)

• The out-of-pocket maximum for individual/family has changed from “$4,000/$8,000” to “$3,000/$6,000”

• The Out-Patient Surgical Facility and Ambulatory Surgical Center benefits have changed from “$150 Copay “ to “70%”

• The Skilled Nursing benefit has changed from “$250 Copay per day – 4 days max, 100 days max per benefit period” to “70%, 100 days max per benefit period”

UnitedHealthcare Gold HMO’s • The In-Patient Hospital Services has changed from “$1,000 Copay per day – 4 days max” to “70%”

• The In-Patient Mental Health and In-Patient Drug/Substance Abuse (Detox Only) benefits have changed from “$500 Copay per day – 4 days max” to “70%”

(continued)

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SUMMARY OF CHANGES Groups Renewing 4/1/16 - 6/1/16

UnitedHealthcare – Continued • The out-of-pocket maximum for individual/family has changed from “$6,350/$12,700” to “$5,000/$10,000”

• The Out-Patient Surgical Facility and Ambulatory Surgical Center benefits have changed from “$500 Copay” to “70%”

• The Out-Patient Physician Fees benefit has changed from “100%” to “70%” • The Skilled Nursing benefit has changed from $300 Copay per day, 100 days max per benefit period” to “70%, 100 days max per benefit period”

UnitedHealthcare Silver HMO A and HMO B • The calendar year deductible has changed from “$1,750/$3,500 (applies to Max OOP)” to “$2,000/$4,000 (applies to Max OOP)”

• The following benefits have changed from “$30 Copay (ded waived)” to “$45 Copay (ded waived)”:



o Doctor Office Visit (PCP) o Physical, Occupational, Speech Therapy o Rehabilitative & Habilitative Services and Devices

• The Specialist Visit (SPC) and 2nd Surgical Opinion benefits have changed from “$50 Copay (ded waived)” to “$65 Copay (ded waived)”

• The following benefits have changed from “75%” to “60%”:

o o o o o

In-Patient Hospital Services In-Patient Mental Health In-Patient Drug/Substance Abuse (Detox Only) Out-Patient Surgical Facility Ambulatory Surgical Center

• The In-Patient Physician Fees benefit has changed from “75% (ded waived)” to “60%”

• The Emergency Room benefit has changed from “$300 Copay (ded waived; waived if admitted)” to “$400 Copay (ded waived; waived if admitted)”

• The Brand Name prescription deductible has changed from “$250/$500” to “None”

• The Generic prescription benefit has changed from “$15 Copay (ded waived)” to “$20 Copay (overall ded waived)”

• The Formulary Brand prescription benefit has changed from “$250/$500 Ded $35 Copay” to “$50 Copay (overall ded waived)”

(continued)

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SUMMARY OF CHANGES Groups Renewing 4/1/16 - 6/1/16

UnitedHealthcare – Continued • The Non-Formulary Brand prescription benefit has changed from “$250/$500 Ded $70 Copay” to “$100 Copay (overall ded waived)”

• The out-of-pocket maximum for individual/family has changed from “$6,250/$12,500” to “$6,500/$13,000”

• The Out-Patient Physician Fees benefit has changed from “75% (ded waived)” to “60% (ded waived)”

• The Home Health Care benefit has changed from “$30 Copay (ded waived),

100 visits max per year” to “$45 Copay (ded waived), 100 visits max per year”

• The Skilled Nursing benefit has changed from “75%, 100 days max per benefit period” to “60%, 100 days max per benefit period”

• The Urgent Care benefit has changed from “$75 Copay (ded waived)” to “$100 Copay (ded waived)”

• The Pediatric Vision Contact Lenses and Frames benefits have changed from “75% (ded waived)” to “60% (ded waived)”

UnitedHealthcare Silver HMO C • The following benefits have changed from “80%” to “75%”:

o Doctor Office Visit (PCP) o Specialist Visit (SPC) o Laboratory o X-Ray o MRI, CT and PET Scan o In-Patient Hospital Services o In-Patient Physician Fees o In Patient Mental Health o In-Patient Drug/Substance Abuse (Detox Only) o Emergency Room o Acupuncture o 2nd Surgical Opinion o Out-Patient Surgical Facility o Out-Patient Mental Health o Out-Patient Physician Fees o Ambulatory Surgical Center o Ambulance Services (continued)

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SUMMARY OF CHANGES Groups Renewing 4/1/16 - 6/1/16

UnitedHealthcare – Continued

o Chemotherapy o Physical, Occupational, Speech Therapy o Rehabilitative & Habilitative Services and Devices o Urgent Care o Hemodialysis and Peritoneal Dialysis o Durable Medical Equipment

• The Generic prescription benefit has changed from “$15 Copay (combined Med/Rx ded)” to “$20 Copay (combined Med/Rx ded)”

• The Formulary Brand prescription benefit has changed from “$35 Copay (combined Med/Rx ded)” to “$50 Copay (combined Med/Rx ded)”

• The Non-Formulary Brand prescription benefit has changed from “$70 Copay (combined Med/Rx ded)” to “$100 Copay (combined Med/Rx ded)”

• The out-of-pocket maximum for individual/family has changed from “$5,000/$10,000” to “$6,500/$6,850”

• The Home Health Care benefit has changed from “80%, 100 visits max per year” to “75%, 100 visits max per year”

• The Skilled Nursing benefit has changed from “80%, 100 days max per benefit period” to “75%, 100 days max per benefit period”

• The Pediatric Vision Contact Lenses and Frames benefits have changed from “80%” to “75%”

UnitedHealthcare Bronze HMO A • The calendar year deductible has changed from “$4,500/$9,000 (applies to Max OOP)” to “$6,600/$13,200 (applies to Max OOP)”

• The following benefits have changed from “$50 Copay (ded waived)” to “$55 Copay (ded waived)”:



o Doctor Office Visit (PCP) o Physical, Occupational, Speech Therapy o Rehabilitative & Habilitative Services and Devices

• The Specialist Visit (SPC) and 2nd Surgical Opinion benefits have changed from “$75 Copay (ded waived)” to “$85 Copay (ded waived)”

• The MRI, CT and PET Scan benefit has changed from “$200 Copay per procedure (ded waived)” to “$250 Copay per procedure (ded waived)”

(continued)

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SUMMARY OF CHANGES Groups Renewing 4/1/16 - 6/1/16

UnitedHealthcare – Continued • The following benefits have changed from “70%” to “100%”: o In-Patient Hospital Services o In-Patient Physician Fees o In-Patient Mental Health o In-Patient Drug/Substance Abuse (Detox Only) o Out-Patient Surgical Facility o Out-Patient Physician Fees o Ambulatory Surgical Center • The Emergency Room benefit has changed from “$300 Copay (ded waived; waived if admitted)” to “100%”

• The Brand Name prescription deductible has changed from “$250/$750” to “$250/$500”

• The Generic prescription benefit has changed from $20 Copay (ded waived)” to “$25 Copay (ded waived)”

• The Non-Formulary Brand prescription benefit has changed from “$250/$750 Ded $100 Copay” to “$250/$500 Ded - $125 Copay”

• The Specialty prescription benefit has changed from “$250/$750 Ded – 75% (up to $300 per prescription)” to “$250/$500 Ded – 50% (up to $300 per prescription)”

• The out-of-pocket maximum for individual/family has changed from “$6,250/$12,500” to “$6,850/$13,700”

• The Skilled Nursing benefit has changed from “70%, 100 days max per benefit period” to “100%, 100 days max per benefit period”

• The Urgent Care benefit has changed from “$100 Copay (ded waived)” to “$150 Copay (ded waived)”

• The Pediatric Vision Contact Lenses and Frames benefits have changed from “70% (ded waived)” to “100% (ded waived)”

UnitedHealthcare Bronze HMO B • The calendar year deductible has changed from “$3,500/$7,000 (combined Med/Rx ded; applies to Max OOP” to “$4,500/$9,000 (combined Med/Rx ded; applies to Max OOP”

(continued)

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SUMMARY OF CHANGES Groups Renewing 4/1/16 - 6/1/16

UnitedHealthcare – Continued • The following benefits have changed from “80%” to “60%”:

o Doctor Office Visit (PCP) o Specialist Visit (SPC) o Laboratory o X-Ray o MRI, CT and PET Scan o In-Patient Hospital Services o In-Patient Physician Fees o In-Patient Mental Health o In-Patient Drug/Substance Abuse (Detox Only) o Emergency Room o Acupuncture o 2nd Surgical Opinion o Out-Patient Surgical Facility o Out-Patient Physician Fees o Out-Patient Mental Health o Ambulatory Surgical Center o Ambulance Services o Chemotherapy o Physical, Occupational, Speech Therapy o Rehabilitative & Habilitative Services and Devices o Hemodialysis and Peritoneal Dialysis o Urgent Care o Durable Medical Equipment o Pediatric Vision Contact Lenses o Pediatric Vision Frames

• The out-of-pocket maximum for individual/family has changed from “$6,250/$12,500” to “$6,500/$13,000”

• The Home Health Care benefit has changed from “80%, 100 visits max per year” to “60%, 100 visits max per year”

• The Skilled Nursing benefit has changed from “80%, 100 days max per benefit period” to “60%, 100 days max per benefit period”

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SUMMARY OF CHANGES Groups Renewing 4/1/16 - 6/1/16

Western Health Advantage Western Health Advantage Platinum HMO B, Gold HMO B, Silver HMO A, HMO B and HMO C and Bronze HMO A, HMO B, HMO C and HMO D • The Pediatric Dental Office Visit benefit has changed from “$20 Copay” to “100%”

Western Health Advantage Platinum HMO A • The Out-Patient Physician Fees benefit has changed from “$25 Copay” to “100%” • The Hearing Examination benefit has changed from “$25 Copay” to “100%” • The Emergency Room benefit has changed from “$100 Copay (waived if admitted)” to “$150 Copay (waived if admitted)” • The Specialty prescription benefit has changed from “80% (up to $100 per prescription)“ to “80% (up to $250 per 30 day supply)”

Western Health Advantage Platinum HMO B • The In-Patient Physician Fees and Out-Patient Physician Fees benefits have changed from “100%” to “$40 Copay” • The following benefits have changed from “100%” to “90%”:

o Dialysis



o Infusion Therapy



o Chemotherapy

• The Specialty prescription benefit has changed from “90%” to “90% (up to $250 per 30 day supply)”

Western Health Advantage Gold HMO A • The Out-Patient Physician Fees benefit has changed from “$40 Copay” to “100%” • The Hearing Examination benefit has changed from “$40 Copay” to “100%” • The following benefits have changed from “$500 Copay per day” to “$600 Copay per day”:



o In-Patient Hospital Services



o In-Patient Mental Health



o In-Patient Drug/Substance Abuse (Detox Only)



o In-Patient Rehabilitation (continued)

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SUMMARY OF CHANGES Groups Renewing 4/1/16 - 6/1/16

Western Health Advantage – Continued • The In-Patient Mental Health and In-Patient Drug/Substance Abuse at a

residential treatment center benefits have changed from “$250 Copay per day” to “$300 Copay per day”

• The Skilled Nursing benefit has changed from “$500 Copay per day, 100 days max per benefit period” to “$600 Copay per day, 100 days max per benefit period”

• The Specialty prescription benefit has changed from “80% (up to $100 per prescription)” to “80% (up to $250 per 30 day supply)”

Western Health Advantage Gold HMO B • The out-of-pocket maximum for individual/family has changed from “$6,250/$12,500” to “$6,200/$12,400” • The following benefits have changed from “$30 Copay” to “$35 Copay”:

o Doctor Office Visit (PCP)



o Laboratory



o Orthotics and Prosthetics



o Out-Patient Mental Health



o Physical, Occupational, Speech Therapy



o Rehabilitative & Habilitative Services and Devices

• The Specialist Visit (SPC) and 2nd Surgical Opinion benefits have changed from “$50 Copay” to “$55 Copay” • The In-Patient Physician Fees and Out-Patient Physician Fees benefits have changed from “100%” to “$55 Copay” • The following benefits have changed from “100%” to “80%”:

o Dialysis



o Infusion Therapy



o Chemotherapy

• The Specialty prescription benefit has changed from “80%” to “80% (up to $250 per 30 day supply)” • The Home Health Care benefit has changed from “$30 Copay, 100 visits max per year” to “$35 Copay, 100 visits max per year”

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SUMMARY OF CHANGES Groups Renewing 4/1/16 - 6/1/16

Western Health Advantage – Continued Western Health Advantage Silver HMO A • The MRI, CT and PET Scan benefit has changed from “$250 Copay (ded waived)” to “$275 Copay (ded waived)”

• The calendar year deductible has changed from “$2,000/$4,000 (applies to Max OOP)” to “$1,750/$3,500 (applies to Max OOP)”

• The Brand Name prescription deductible has changed from “None” to “$250/$500”

• The Hearing Examination benefit has changed from “$50 Copay” to “100%” • The Generic prescription benefit has changed from “$20 Copay (overall ded waived)” to “$25 Copay (ded waived)”

• The Formulary Brand prescription benefit has changed from “$40 Copay (overall ded waived)” to “$250/$500 Ded - $50 Copay”

• The Non-Formulary Brand prescription benefit has changed from “$60 Copay (overall ded waived)” to “$250/$500 Ded - $75 Copay”

• The Specialty prescription benefit has changed from “80% (up to $100 per

prescription)” to ”$250/$500 Ded - 80% (up to $250 per 30 day supply)”

• The Out-Patient Physician Fees has changed from “$50 Copay” to “100% (ded waived)”

• The calendar year deductible no longer applies to the following benefits:

o

Pediatric Vision Exam



o

Pediatric Vision Contacts



o

Pediatric Vision Frames

Western Health Advantage Silver HMO B • The Brand Name prescription deductible has changed from “$500/$1,000” to “$250/$500” • The out-of-pocket maximum for individual/family has changed from “$6,250/$12,500” to “$6,500/$13,000” • The Specialist Visit (SPC) and 2nd Surgical Opinion benefits have changed from “$65 Copay (ded waived)” to “$70 Copay (ded waived)” • The Laboratory benefit has changed from “$45 Copay (ded waived)” to “$35 Copay (ded waived)” (continued)

800.558.8003

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SUMMARY OF CHANGES Groups Renewing 4/1/16 - 6/1/16

Western Health Advantage – Continued • The Formulary Brand prescription and Diabetes Self-Injectable benefits have changed from “$500/$1,000 Ded - $50 Copay” to “$250/$500 Ded - $55 Copay” • The Non-Formulary Brand prescription benefit has changed from “$500/$1,000 Ded - $70 Copay” to “$250/$500 Ded - $75 Copay” • The Specialty prescription benefit has changed from “$500/$1,000 Ded – 80%” to “$250/$500 Ded – 80% (up to $250 per 30 day supply)”

Western Health Advantage Silver HMO C • The calendar year deductible has changed from “$1,500/$3,000 (combined Med/Rx ded; applies to Max OOP)” to “$2,600/$4,000 (combined Med/Rx ded; applies to Max OOP”

Western Health Advantage Bronze HMO A • The Specialty prescription benefit has changed from “70% (up to $100 per prescription) “ to “60%”

• The calendar year deductible has changed from “$3,500/$7,000 (applies to Max OOP)” to “$4,000/$8,000 (applies to Max OOP)”

• The Hearing Examination benefit has changed from “70%” to “100%” • The following benefits have changed from “70%” to “60%”:

o Doctor Office Visit (PCP)



o Specialist Visit (SPC)



o In-Patient Hospital Services



o In-Patient Physician Fees



o In-Patient Mental Health



o In-Patient Drug/Substance Abuse (Detox Only)



o In-Patient Rehabilitation



o Out-Patient Surgery Facility



o Out-Patient Physician Fees



o Out-Patient Mental Health



o Ambulatory Surgical Center



o Dialysis



o Infusion Therapy



o Chemotherapy

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(continued)

SUMMARY OF CHANGES Groups Renewing 4/1/16 - 6/1/16

Western Health Advantage – Continued

o Laboratory



o X-Ray



o MRI, CT and PET Scan



o Therapeutic Injections



o Emergency Room



o Ambulance Services



o Generic prescription



o Formulary Brand prescription



o Non-Formulary Brand prescription



o Durable Medical Equipment



o Physical, Occupational, Speech Therapy



o Rehabilitative & Habilitative Services and Devices



o Urgent Care



o 2nd Surgical Opinion



o Diabetes Self-Injectable

• The Home Health Care benefit has changed from “70%, 100 visits max per year” to “60%, 100 visits max per year”

• The Skilled Nursing benefit has changed from “70%, 100 days max per benefit period” to “60%, 100 days max per benefit period”

Western Health Advantage Bronze HMO B • The calendar year deductible has changed from “$5,000/$10,000 (combined Med/ Rx ded; applies to Max OOP)” to “$6,000/$12,000 (applies to Max OOP)” • The Brand Name prescription deductible has changed from “Combined with Medical” to “$500/$1,000” • The out-of-pocket maximum for individual/family had changed from “$6,250/$12,500” to “$6,500/$13,000” • The following benefits have changed from “$60 Copay” to “$70 Copay”:

o Doctor Office Visit (PCP)



o Out-Patient Mental Health (continued)

800.558.8003

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SUMMARY OF CHANGES Groups Renewing 4/1/16 - 6/1/16

Western Health Advantage – Continued • The Specialist Visit (SPC) and 2nd Surgical Opinion benefits have changed from “$70 Copay” to “$90 Copay”

o Deductible is waived for first three non-preventive visits

• The following benefits have changed from “70%” to “100%”:

o Out-Patient Surgical Facility



o Out-Patient Physician Fees



o Ambulatory Surgical Center



o Dialysis



o Infusion Therapy



o Chemotherapy



o X-Ray



o MRI, CT and PET Scan



o In-Patient Hospital Services



o In-Patient Physician Fee



o In-Patient Mental Health



o In-Patient Drug/Substance Abuse (Detox Only)



o In-Patient Rehabilitation



o Durable Medical Equipment

• The Laboratory benefit has changed from “70%” to “$40 Copay (ded waived)” • The calendar year deductible now applies to the Urgent Care benefit • The Emergency Room benefit has changed from “$300 Copay (waived if admitted)” to “100%” • The Ambulance Services benefit has changed from “$300 Copay” to “100%” • The Generic prescription benefit has changed from “$15 Copay (combined Med/Rx ded)” to “$500/$1,000 Ded – 100% (up to $500 per prescription)” • The Formulary Brand prescription and Diabetes Self-Injectable benefits have changed from “$50 Copay (combined Med/Rx ded)” to “$500/$1,000 Ded – 100% (up to $500 per prescription)”

(continued)

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SUMMARY OF CHANGES Groups Renewing 4/1/16 - 6/1/16

Western Health Advantage – Continued • The Non-Formulary Brand prescription benefit has changed from “$75 Copay (combined Med/Rx ded)” to “$500/$1,000 Ded – 100% (up to $500 per prescription)” • The Specialty prescription benefit has changed from “70% (combined Med/Rx ded)” to “$500/$1,000 Ded – 100% (up to $500 per prescription)” • The Orthotics and Prosthetics benefit has changed from “$60 Copay” to “$70 Copay” • The Home Health Care benefit has changed from “70%, 100 visits max per year” to “100%, 100 visits max per year” • The Skilled Nursing benefit has changed from “70%, 100 days max per benefit period” to “100%, 100 days max per benefit period” • The Physical, Occupational, Speech Therapy and Rehabilitative & Habilitative Services and Devices benefits have changed from “$60 Copay” to “$70 Copay (ded waived)” • The calendar year deductible is now waived for the first three non-preventive care visits for the Acupuncture benefit

Western Health Advantage Bronze HMO C • The calendar year deductible has changed from “$5,500/$11,000 (combined Med/ Rx ded; applies to Max OOP)” to “$6,000/$12,000 (combined Med/Rx ded; applies to Max OOP)” • The out-of-pocket maximum for individual/family has changed from “$5,500/$11,000” to “$6,000/$12,000” • The Chiropractic benefit is no longer covered • The calendar year deductible no longer applies to the following benefits:

o Pediatric Vision Exam



o Pediatric Vision Contacts



o Pediatric Vision Frames

Western Health Advantage Bronze HMO D • The out-of-pocket maximum for individual/family has changed from “$6,250/$12,500” to “$6,500/$13,000”

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