CCMHG Plan Benefit Comparison Harvard Pilgrim Health Care

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1 Deductible Effective EPO RATE SAVER $250 per member $250 per member $500 per family per $500 per family per calendar year, applied to calendar year, applied to eligible expense. eligible expense. Calendar Year Coinsurance Maximum $1,500 per member $3,000 per family $1,500 per member $3,000 per family Lifetime Benefit Maximum INPATIENT YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY General Hospital/Mental Hospital/Substance Abuse Facility (semi-private room and board and special services) $300 per admission $300 per admission Physician Services Skilled Nursing Facility up to 100 up to 100 days per calendar year at a year at a semi-private semi-private rate for rate for each benefit each benefit up to 100 year at a semiprivate rate for each benefit up to 100 year at a semi-private rate for each benefit Rehabilitation Hospital up to 100 up to 100 days per calendar year at a year at a semi-private semi-private rate for rate for each benefit each benefit up to 100 year at a semiprivate rate for each benefit up to 100 year at a semi-private rate for each benefit 1

2 RATE SAVER EPO OUTPATIENT HOSPITAL YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY Emergency Room Visits for Emergency or Accident Care $30 co-pay, waived if Emergency Room Visits for Medical Care $30 co-pay, waived if Surgery $200 copay. Waived for all colonscopies $200 co-pay In- Network. Waived for all colonscopies Radiation and Chemotherapy Diagnostic X-ray and Lab Hemodialysis Physical Therapy $10 co-pay up to 90 $20 co-pay up to 90 $10 co-pay up to 90 consecutive days per $20 co-pay up to 90 2

3 RATE SAVER EPO PHYSICIAN'S OFFICE YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY Surgery $20 PCP $20 PCP Medical Care/Mental Health Care/Substance Abuse Care $20 PCP $20 PCP Well Child Care (including routine physical exams, immunizations, annual eye exam, school, camp, sports) $20 copay (including routine physical exams, immunizations, annual eye exam, school, camp, sports) (diagnostic tests, x- rays, & immunizations will be covered in full if billed without an office visit & no other services are provided $20 copay (diagnostic tests, x- rays, & immunizations will be covered in full if billed without an office visit & no other services are provided Routine GYN Exam $20 copay $20 coapy Routine Vision Exam $20 copay $20 copay Adult Routine Physicals $20 copay $20 copay In- Network OTHER OUTPATIENT YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY Visiting Nurse Home Health Care 3

4 Durable Medical Equipment EPO Covered in full after copay of 20% of equipment cost to, not to exceed a member's total expense of $1,000/calendar year. No coverage after $5,000 has been paid in equipment costs including copayments. Wigs are covered up to $350/member/calend ar year when needed as a result of any form of cancer, leukemia, alopecia areata, alopecia totalis, or permanent hair loss due to RATE SAVER Covered in full after Covered in full after 20% after coinsurance Covered in full after 20% after coinsurance copay of 20% of copay of 20% of of equipment copay of 20% of of equipment equipment cost to equipment cost to cost to. Member equipment cost to cost to. Member, not to exceed a, not to pays a maximum of, not to exceed pays a maximum of $1,000 member's total expense exceed a member's $1,000 in coinsurance a member's total in coinsurance per calendar of $1,000/calendar year. total expense of per calendar year. No expense of year. No coverage after No coverage after $1,000/calendar coverage after 45,000 in $1,000/calendar 45,000 in equipment costs $5,000 has been paid in year. No coverage equipment costs have year. No coverage have been paid, including equipment costs after $5,000 has been paid, including after $5,000 has member copays. Wigs are including copayments. been paid in member copays. Wigs been paid in covered up to Wigs are covered up to equipment costs are covered up to equipment costs $350/member/calendar year $350/member/calendar including $350/member/calendar including when needed as a result of year when needed as a copayments. Wigs year when needed as a copayments. Wigs any form of cancer, result of any form of are covered up to result of any form of are covered up to leukemia, alopecia areata, cancer, leukemia, $350/member/calen cancer, leukemia, $350/member/calend alopecia areata, dar year when alopecia areata, ar year when needed permanent hair loss due to permanent hair loss due to needed as a result of any form of cancer, leukemia, alopecia areata, permanent hair loss due to permanent hair loss due to as a result of any form of cancer, leukemia, alopecia areata, alopecia totalis, or permanent hair loss due to Ambulance Routine Pediatric Dental (through age 11) Covered in full: Preventive care for children under age visits per member per calendar year including exam, cleaning, x-rays, & flouride treatment. Covered in full: Preventive care for children under age visits per member per calendar year including exam, cleaning, x-rays, & flouride treatment. 4

5 Chiropractor Visits EPO RATE SAVER Prescription Drugs Retail: (30 day Retail: (30 day Retail: (30 day supplyretail: (30 day Retail: (30 day Retail: (30 day Tier 1: $5.00 copay Tier 1: $15.00 copay Tier 1: $5.00 copay Tier 1: $5.00 copay Tier 1: $15.00 copay Tier 1: $15.00 copay Tier 2: $10.00 copay Tier 2: $30.00 copay Tier 2: $10.00 copaytier 2: $10.00 copay Tier 2: $30.00 copay Tier 2: $30.00 copay Tier 3: $25.00 copay Tier 3: $50.00 copay Tier 3: $25.00 copaytier 3: $25.00 copay Tier 3: $50.00 copay Tier 3: $50.00 copay Mail Order: (90 day Mail Order: (90 day Mail Order: (90 day Mail Order: (90 day Mail Order: (90 day Mail Order: (90 day Tier 1: $10.00 copay Tier 1: $30.00 copay Tier 1: $10.00 copaytier 1: $10.00 copay Tier 1: $30.00 copay Tier 1: $30.00 copay Tier 2: $20.00 copay Tier 2: $60.00 copay Tier 2: $20.00 copaytier 2: $20.00 copay Tier 2: $60.00 copay Tier 2: $60.00 copay Tier 3: $75.00 copay Tier 3: $ copay Tier 3: $75.00 copaytier 3: $75.00 copay Tier 3: $ copaytier 3: $ copay Fitness Benefit reimbursement per reimbursement per reimbursement per reimbursement per calendar year. Must calendar year. Must be calendar year. Must calendar year. Must be be an active member an active member of be an active an active member of of for at least for at least 4 member of for at least 4 4 months and a months and a member for at least 4 months months and a member member of any of any qualified health & and a member of of any qualified health & qualified health & fitness club for 4 any qualified health fitness club for 4 fitness club for 4 & fitness club for 4 consecutive months. reimbursement per calendar year. Must be an active member of for at least 4 months and a member of any qualified health & fitness club for 4 reimbursement per calendar year. Must be an active member of for at least 4 months and a member of any qualified health & fitness club for 4 *After Deductible These pages summarize benefits of the plan(s). The Subscriber Certificate(s) & applicable riders define the terms & s of these benefits in greater detail. Should any questions arise, the certificate(s) & riders will govern. 5