Connecticut Small Group Benefit Designs. January 1, 2018 through March 31, 2018

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Amie Walsh
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1 Connecticut Small Group Benefit Designs January 1, 2018 through March 31, 2018

2 HMO Copay 25/35 Platinum MD RX Best Buy HMO Hospital 2000 MD RX Best Buy HMO 2000 with Coinsurance MD RX Best Buy HMO 5000 with Coinsurance MD RX HMO Conv Care/ Inpatient/ Day Urgent Care Surgery $25/$35 None/None $2,000/$4,000 None $150 Conv: $25 IP: $500 Labs: CIF $75, $375 /Year $25 $25/$35 $2,000/$4,000 $4,700/$9,400 None $200 $25/$35 $2,000/$4,000 $4,500/$9,000 $40/$50 $5,000/$10,000 $7,100/$14,200 Urg: $75 Day: $250 X-Rays: CIF Conv: $25 IP: CIF Labs: $10 $75, $375 /Year PT/OT: $25 Urg: $75 Day: CIF X-Rays: $35 ST: $35 Conv: $25 IP: Labs: Urg: $75 Day: X-Rays: Conv: $40 IP: Labs: Urg: $75 Day: X-Rays: Best Buy HSA HMO 3000 MD RX HSA HMO $3,000/$6,000 $6,400/$12,800 None $35/$50 $200 Conv Care/ Urgent Care Conv: $35 Inpatient/ Day Surgery IP: $500, $2,000 /Admit Urg: $75 Day: $500 $10 $40 $75 PT/OT: Ded then $30 ST: $50 EOC apply. Page 2 of 8

3 PPO Copay 25/35 Platinum MD RX Best Buy PPO Hospital 1200 Platinum MD RX Best Buy PPO 1500 MD RX Best Buy PPO 1500 with Coinsurance MD RX Best Buy PPO 3500 MD RX Best Buy PPO 3500 with Coinsurance MD RX Best Buy PPO 3 Free 3300 MD RX Conv Care/ Inpatient/ Day Urgent Care Surgery $25/$35 IN: None/None IN: $2,000/$4,000 IN: None $150 Conv: $25 IP: $500 Labs: CIF $75, $375 /Year $25 $2,000/$4,000 $4,000/$8,000 $20/$40 IN: $1,200/$2,400 IN: $3,250/$6,500 IN: None $150 Conv: $20 IP: CIF Labs: $10 $75, $375 /Year PT/OT: $20 Urg: $75 Day: CIF X-Rays: $40 ST: $40 $2,400/$4,800 $6,500/$13,000 $25/$40 IN: $1,500/$3,000 IN: $4,500/$9,000 IN: None $200 Conv: $25 IP: $500, $1,500 /Admit $10 $75, $375 /Year PT/OT: $25 Urg: $75 Day: $500 ST: $40 $3,000/$6,000 $9,000/$18,000 $40 $25/$40 IN: $1,500/$3,000 IN: $4,500/$9,000 IN: Conv: $25 IP: PT/OT: $25 Urg: $75 Day: ST: $40 $3,000/$6,000 $9,000/$18,000 $40/$50 IN: $3,500/$7,000 IN: $6,900/$13,800 IN: None $200 Conv: $40 IP: $500, $2,000 /Admit $10 $75, $375 /Year PT/OT: $30 Urg: $75 Day: $500 $7,000/$14,000 $13,800/$27,600 $40 $35/$50 IN: $3,500/$7,000 IN: $6,900/$13,800 IN: Conv: $35 IP: PT/OT: $30 3 visits CIF, then Ded then Urg: $75 Day: $7,000/$14,000 $13,800/$27,600 IN: $3,300/$6,600 IN: $6,950/$13,900 IN: IP: $9,900/$19,800 $20,850/$41,700 PPO Urg: $75 Day: $250 X-Rays: CIF Conv: 3 visits CIF, then Urg: Day: EOC apply. Page 3 of 8

4 Best Buy PPO Hospital CB MD RX Best Buy PPO Hospital CB MD RX Best Buy PPO CB MD RX Best Buy PPO CB MD RX Conv Care/ Inpatient/ Day Urgent Care Surgery $30/$45 IN: $1,500/$3,000 IN: $3,700/$7,400 IN: None $200 Conv: $30 IP: $500, $1,500 /Admit Labs: $10 Hosp: PT/OT: $30 $75 /Fre: $75, $375 /Year Urg: $75 Day: Hosp: X-Rays: $40 ST: $45 $3,000/$6,000 $7,400/$14,800 $500 $25/$50 IN: $2,500/$5,000 IN: $5,500/$11,000 IN:, $350 Per Visit Conv: $25 IP: Labs: $10 PT/OT: $25 $5,000/$10,000 $11,000/$22,000 PPO - CB $40/$50 IN: $3,250/$6,500 IN: $7,350/$14,700 IN: Urg:, $175 Per Visit Day: X-Rays: $40 Conv: $40 IP: Hosp: /Fre: $75, $375 /Year PT/OT: $30 Urg: Day: Hosp: $6,500/$13,000 $14,700/$29,400 $40/$50 IN: $3,750/$7,500 IN: $7,350/$14,700 IN: Conv: $40 IP: Labs: $10 PT/OT: $30 Urg: Day: $7,500/$15,000 $14,700/$29,400 Best Buy PPO CB $35/$50 IN: $4,000/$8,000 IN: $7,150/$14,300 IN: Conv: $35 IP: MD RX $8,000/$16,000 $14,300/$28,600 Urg: Day: EOC apply. Page 4 of 8

5 Best Buy HSA PPO /70 Coins IN: $2,700/$5,400 IN: $5,700/$11,400 IN: HSA PPO ER Conv Care/ Urgent Care Conv: Inpatient/ Day Surgery IP: IN: MD RX $5,400/$10,800 $11,400/$22,800 Urg: Day: Best Buy HSA PPO 2700 $25/$35 IN: $2,700/$5,400 IN: $5,400/$10,800 IN: Conv: $25 IP: $10 PT/OT: Ded then $25 MD RX Urg: $75 Day: ST: $35 $35 $5,400/$10,800 $10,800/$21,600 EOC apply. Page 5 of 8

6 Best Buy HSA PPO CB HSA PPO - CB IN: $2,800/$5,600 IN: $4,500/$9,000 IN: Conv Care/ Urgent Care Conv: Inpatient/ Day Surgery IP: MD RX Best Buy HSA PPO CB $5,600/$11,200 $9,000/$18,000 IN: $3,500/$7,000 IN: $5,500/$11,000 IN: Urg: Conv: Day: IP: MD RX $7,000/$14,000 $11,000/$22,000 Urg: Day: EOC apply. Page 6 of 8

7 RX Cost Share Massachusetts Minimum Creditable Coverage (MA CC): All of the HSA-qualified Small Group plans Plans except Retail those Rxlisted below meet the All Plans All non-hsa medical plans Non-HSA have the qualified following Plans pharmacy Retail benefits Rx RetailPlatinum & Plans Mail& Bronze Plans Massachusetts Minimum Creditable Coverage (MA CC) Standards. Tier 1: $5(2x max on Mail Order Rx) Tier (2x 1: max $10on Mail Order Rx) The following (2x max plans on must Mail be Order submitted Rx) via the MA CC application process. Tier 2: ($50/script max) Tier 2: ($100/script max) Tier 1: $5 Tier 1: $5 Tier 1: $5* Tier 3: ($250/script max) Tier 3: ($500/script max) BB HMO 5000 with Coins (MD4521) BB PPO Hosp CB (MD4535) Tier 2: ($50/script max) Tier 2: ($50/script max) Tier 2: ($50/script max)* Tier 4: ($750/script max) Tier 4: ($1,500/script max) BB PPO 3 Free 3300 (MD4525) BB PPO CB (MD4536) Tier 3: ( $250/script max) Tier 3: ( $250/script max)* Tier 3: Ded BB PPO then 3500 ( - with $250/script Coins (MD4534) max)* BB PPO CB (MD4545) All HSA Tier medical 4: ($500/script plans have the following max) pharmacy Tier 4: ($750/script benefits max)* Tier 4: ($750/script max)* *MD 4534 has Ded on T3 & T4 Rx *Preventive Rx not subject to deductible Retail Mail Medicare Creditable Coverage (MCC): Deductible then* Deductible then* All of the Small Tier Massachusetts 1: $5 Minimum Creditable Tier Coverage 1: $10 (MA CC): Tier All 2: of the ($50/script Small Group max) plans except those Tier 2: listed ($100/script below meet max) the Tier Massachusetts 3: ($250/script Minimum max) Creditable Coverage Tier 3: (MA ($500/script CC) Standards. max) Medicare Creditable Coverage (MCC): All plans pass Medicare Creditable Coverage BB PPO 3500 /MD / RX Tier The 4: following ($750/script plans max) must be submitted Tier via 4: the MA ($1,500/script CC application max) process. BB PPO Hosp 3500 / MD / RX BB PPO Hosp CB / MD / RX BB HMO 5000 with Coins (MD4521) BB PPO Hosp CB (MD4535) HSA-qualified Medical Plans: BB PPO CB / MD / RX BB PPO 3 Free 3300 (MD4525) BB PPO CB (MD4536) All have embedded deductibles and out-of-pocket maximums BB PPO with Coins (MD4534) BB PPO CB (MD4545) Business Rules HSA-qualified Medical Plans: All Open All have embedded deductibles and out-of-pocket maximums Access This HMO document does Business not Rules All HMO plans are offered by Harvard Pilgrim Health Care of Connecticut Inc. and all PPO plans are offered by HPHC Insurance Company, an affiliate of Harvard Pilgrim Health Care. Rates HPHC quoted are valid for 12 months with coverage starting from requested effective dates. requires HPHC requires groups of 1-4 employees who are eligible for health benefits to have a minimum of 100% participation in our product(s), groups of 1-4 and for all other small groups minimum of 65% participation in our product(s), except during the Small Group Special Open Enrollment Period. employees Employees who waive coverage due to spousal or dependent coverage, employees covered by Medicare, Medicaid, or a Military Program, or covered under another plan by a who are second employer are excluded from the participation calculations. We require employer rate contributions to be at least of the employee-only rate of the lowest plan offered. HMO If a plans subscriber enrolls with a dependent who is over the age of 26 and is disabled, the dependent will require approval from Harvard Pilgrim before obtaining coverage. are We only require employer rate contributions to be at least of the employee-only rate of the lowest plan offered. available to Harvard HMO plans are only available to employees who reside in HPHC's HMO service area at least nine months of the year. Pilgrim This requirement does not apply to a dependent child who lives outside of the Harvard Pilgrim Enrollment Area. reserves the For For each each new new health plan sale or annual renewal, employers must disclose to HPHC all out-of-state office locations and the state residency for each enrolled member under the plan. health Bariatric plan Surgery is not covered on all 2018 small group plans EOC apply. Page 7 of 8

f 2018 Medical Plan 2018 MD# 2017 Plan Version(s) Copay Plans HMO Copay 25/35 MD0000004520 HMO Copay 25/35 (MD4204) PPO Copay 25/35 MD0000004219 PPO Copay 25/35 (MD4205) Hospital Plans Best Buy HMO

8 f 2018 Medical Plan 2018 MD# 2017 Plan Version(s) Copay Plans HMO Copay 25/35 MD HMO Copay 25/35 (MD4204) PPO Copay 25/35 MD PPO Copay 25/35 (MD4205) Hospital Plans Best Buy HMO Hospital 2000 MD BB HMO Hospital 2000 (MD4212) New! Best Buy PPO Hospital 1200 MD Best Buy PPO Hospital CB MD BB PPO Hospital 1500-CB (MD4224) Best Buy PPO Hospital CB MD BB PPO Hospital 2000 (MD4209) / BB PPO Hospital 2000-CB (MD4225) Coinsurance & 3 Free Plans New! Best Buy HMO 2000 w/coinsurance MD New! Best Buy HMO 5000 w/coinsurance MD BB HMO Hospital 4000 (MD4211) New! Best Buy PPO 1500 w/coinsurance MD New! Best Buy PPO 3500 w/coinsurance MD Best Buy PPO 3 Free 3300 MD BB PPO 3 Free 3000 (MD4218) / BB PPO 3 Free 4000 (MD4219) PPO Plans 2018 Portfolio Snapshot with 2017 Mapping Best Buy PPO 1500 MD BB PPO 1500 (MD4206) Best Buy PPO 3500 MD BB PPO Hospital 3500 (MD4208) / BB PPO 3500 (MD4207) Best Buy PPO CB MD BB PPO 3000 (MD4228) Best Buy PPO CB MD BB PPO Hospital 3750 (MD4229) / BB PPO 2500 (MD4226) Best Buy PPO CB MD BB PPO 4000-CB (MD4230) / BB PPO Hospital 4500 (MD4210) / BB PPO Hospital 5000 (MD4227) / BB PPO 5000 (MD4220) HSA-qualified Plans Best Buy HSA HMO 3000 MD BB HSA HMO 3000 (MD4216) New! Best Buy HSA HMO 4000 w/coinsurance MD BB HSA HMO 6100 (MD4215) Best Buy HSA PPO /70 MD BB HSA PPO /70 (MD4217) Best Buy HSA PPO 2700 MD BB HSA PPO 2600 (MD4214) Best Buy HSA PPO CB MD BB HSA PPO CB (MD4221) Best Buy HSA PPO CB MD BB HSA PPO 3500 (MD4231) New! Best Buy HSA PPO CB MD Best Buy HSA PPO CB MD BB HSA PPO 5000 (MD4222) Best Buy HSA PPO 5500 MD BB HSA PPO 5500 (MD4213) Best Buy HSA PPO CB MD BB HSA PPO 6500 (MD4223) EOC apply. Page 8 of 8

Important: There is no need for you to take any action now. This is for your information only.

Your Harvard Pilgrim Health Care Benefits and Rates are changing on April 1, 2018 January 2018 Dear SBSB Member: Important: There is no need for you to take any action now. This is for your information