2016 HealthFlex Plan Comparison: PPO B1000 with HRA and CDHP C2000 with HRA

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1 Caring For Those Who Serve 1901 Chestnut Avenue Glenview, Illinois HealthFlex Plan Comparison: PPO B1000 with HRA and CDHP C2000 with HRA Please note: This comparison highlights key differences and similarities between the HealthFlex PPO B1000 plan with a health reimbursement account (HRA) and the HealthFlex CDHP C2000 plan (also with an HRA). Please refer to the HealthFlex benefit booklet for more details. Both plans use the same network of providers (physicians, hospitals and other health care providers). Benefits can vary significantly depending on whether you choose an in-network or out-of-network provider. To help offset your out-of-pocket costs, your plan sponsor is offering a health reimbursement account (HRA) that you can use to pay for eligible unreimbursed expenses, such as your deductible, co-payments and co-insurance amounts described below. See HRA Funding details below. If you do not spend all the funds in your HRA during a calendar year, the remaining amount will roll over to the following year, with no cap on accumulated rolled-over funds as long as you remain eligible for the HRA. The deductible, co-payment and annual out-of-pocket limit are the participant s share to pay. All other benefits are the amounts or percentages that the plan (HealthFlex) pays for a service. If you do not take the HealthQuotient (HQ) during the 2015 incentive period, your deductible will be increased by $250 (individual coverage) or $500 (family coverage) see Standard Deductible details below (footnote). Health Reimbursement Account (HRA) Comparison Health Reimbursement Account (HRA) Funding PPO B1000 Individual Coverage: $ plan year HRA funding Family Coverage (at least one dependent): $ plan year HRA funding CDHP C2000 Individual Coverage: $1,000 Family Coverage (at least one dependent): $2,000 Medical Plan Benefits Comparison Non- Plan Feature Lifetime Benefit Maximum None None None None Annual Deductible 2 (Participant pays) Deductible includes medical and behavioral health. Co-payments are not included in annual deductible. ( Family deductible applies if at least one dependent is covered.) $1,000 per person $2,000 per family $2,000 per person $4,000 per family $2,000 per person $4,000 per family $3,000 per person $6,000 per family Annual Out-of-Pocket Limit (Participant pays) Includes annual deductible, co-insurance and office visit co-payments. Excludes any charges in excess of Reasonable and Customary charges and non-participating hospital admission co-payment. 1 With P1 $5,000 per person $10,000 per family With P2 $5,500 per person $11,000 per family $6,000 per person $12,000 per family With P1 $10,000 per person $20,000 per family With P2 $11,000 per person $22,000 per family $12,000 per person $24,000 per family 1 2 Out-of-Network: Any and all benefits to be paid are subject to Reasonable and Customary provisions, meaning reimbursements are limited to the Maximum Allowance under the plan, and covered individuals are responsible for amounts out-of-network providers charge in excess of the Maximum Allowance. Standard deductible: Assumes participant and covered spouse met the HealthQuotient (HQ) incentive requirement in Please note: If you did not take the HealthQuotient (HQ), your deductible will be increased by $250 for individuals or those with only children covered (no spouse in HealthFlex), or by $500 if you also cover your spouse and either you or your spouse did not take the HQ. CDHP Consumer-driven health plan HRA Health reimbursement account P1/P2 Pharmacy (Rx) plans (See page 5 for details) Page 1 of 5

2 Plan Feature Non- Co-insurance (Plan pays) Primary Care Physician (PCP) Office Visits Primary care physicians include internists, general and family practitioners, obstetricians, gynecologists and pediatricians. Outpatient Therapies Physical therapy Occupational therapy Speech therapy Chiropractic care Specialist Office Visits Preventive Care Well child benefits (under age 16): Includes charges for office visits, age-appropriate immunizations and routine diagnostic tests. There is a one visit per year maximum for children age 2 and older. $50 co-payment, Well adult benefits (16 and over): One well person exam annually including charges for an office visit, mammogram, pap smear, prostate exam, routine blood work and colorectal screening for cancer. Colonoscopy Licensed Dietitian Office visit Outpatient Care and Treatment Ambulatory surgery Diagnostic services physician office $50 co-payment per specialist visit, then plan pays 100% Diagnostic services hospital, independent lab and X-ray facility Page 2 of 5

3 Plan Feature Non- Emergency Care Notification required within 48 hours if admitted Physician office $50 co-payment per specialist visit, $50 co-payment per specialist visit, then plan pays 100% 3 4 Hospital emergency room $200 co-payment 3, $200 co-payment 2, 3 4 Outpatient facility or other urgent care facility $100 co-payment 3, $100 co-payment 2, 3 4 Ambulance (must be a true emergency as defined in the plan) Maternity Care/Physician Charges (verify with physician) for prenatal care (except ultrasounds) for ultrasounds and subsequent eligible physician charges (includes delivery and postnatal visits) for prenatal care (except ultrasounds) for ultrasounds and subsequent eligible physician charges (includes delivery and postnatal visits) for initial visit to confirm pregnancy Newborn Inpatient Services (NICU and other non-routine) Separate deductible for newborn Inpatient Hospital Care (verify with physician) $200 co-payment per hospital admission, then 60% after deductible $200 co-payment per hospital admission, then 60% after deductible Alternative Therapies Massage therapy Acupuncture Naprapathy Coverage for naprapathy, acupuncture and massage therapy is limited to 35 combined visits per calendar year. 3 Waived if admitted to hospital. 4 For true emergency as defined in the plan; if not a true emergency, the benefit is 60% after the deductible. Page 3 of 5

4 Non- Plan Feature Special Services Skilled nursing facility: 120 days maximum per calendar year Private duty nursing: Home health care: 60-visit maximum per calendar year Hospice Hearing Benefit Hearing aids every 24 months up to $1,000 up to $1,000 up to $1,000 up to $1,000 Exam $50 co-payment, then plan pays 100% This summary highlights some of the features of these benefit plans. The summary is for illustrative purposes only and is subject to change at any time. The controlling terms and conditions of the benefit plan are contained in the plan documents, policies and the HealthFlex Benefit Booklet (collectively, the Documents ) maintained by the General Board of Pension and Health Benefits. If there are any conflicts between the information in this summary and the terms of the Documents, the terms of the Documents shall control. Please Note: Due to federal health care reform legislation, certain benefits may be subject to change in the future. See Pharmacy Plan Benefits Comparison page 5. Page 4 of 5

5 Pharmacy Plan Benefits Comparison Your Share to Pay Medical Plan B1000 CDHP C2000 Pharmacy Plan P1 P2 P2 Deductible None None None Annual Out-of-Pocket Maximum Combined Medical and Pharmacy Costs $5,000 individual $10,000 family $5,500 individual $11,000 family $6,000 individual $12,000 family Co-Payments Generic $15 $35 $15 $35 $15 $35 Preferred Brand Name Minimum Maximum Non-Preferred Brand Name Minimum Maximum 20% 20% 25% 25% 25% 25% $20 $50 $25 $60 $25 $60 $55 $140 $65 $150 $65 $150 25% 25% 30% 30% 30% 30% $40 $85 $50 $95 $50 $95 $110 $240 $120 $260 $120 $260 Formulary Management Program is designed to control costs for you and the plan. The formulary includes U.S. Food and Drug Administration (FDA)-approved Prescription Drugs that have been placed in tiers based on their clinical effectiveness, safety and cost. Generally, Tier 1 includes Generic Drugs; Tier 2 includes Formulary Brand-Name Drugs; and Tier 3 includes Non-Formulary Brand-Name Drugs. The formulary is the same for all HealthFlex pharmacy plans. Mandatory Generics: HealthFlex (plan) will cover only the cost of the Generic Drug equivalent. If you request a Brand-Name Drug when there is an equivalent Generic Drug available, you will be charged one amount equal to the applicable Generic Drug Co-payment (e.g., $15 at retail) plus the cost difference between the Brand-Name Drug and the Generic Drug. Refill Allowance (RRA) Program: Under the plan, participants are allowed a total of three fills of a maintenance medication at a Pharmacy (one original fill plus two refills), at which time the medication must be obtained through the OptumRx (formerly Catamaran) -Order Pharmacy. Additional fills at will not be covered by the plan; you will pay for such fills at the full price if a Pharmacy is used, even if it is a Participating (in-network) pharmacy. Each prescription fill can be for no more than a. This summary highlights some of the features of these benefit plans. The summary is for illustrative purposes only and is subject to change at any time. The controlling terms and conditions of the benefit plan are contained in the plan documents, policies and the HealthFlex Benefit Booklet (collectively, the Documents ) maintained by the General Board of Pension and Health Benefits. If there are any conflicts between the information in this summary and the terms of the Documents, the terms of the Documents shall control. Please note: Due to federal health care reform legislation, certain benefits may be subject to change in the future. Page 5 of /090815