Page 1 of 12 Selected products You have selected the products and pa ckages below. Thes e products and ra te s a re based on the e ffective date: 01/01/2017 HDEPO Qua lifie d 421 Bronze $405.33 Cost De tails Individua l $405.33 Employee and Spouse $810.66 Employe e a nd Childre n $689.06 Employe e a nd Fa mily $1,155.19 Pla n De tails Office Visit P CP /Spe cia list Deductible the n 0%/0% P re scription Drug Tier1/Tier2/Tier3 Deductible the n 0%/0%/0% In Ne twork De duc tible Single/Fa mily $6,550/$13,100 In Ne twork OOP Ma x S ingle/family $6,550/$13,100 De ductible Type AGGREGATE Inpa tient Facility Deductible the n 0%
Page 2 of 12 Outpatient S urge ry Deductible the n 0% Dia gnos tic Ra diology Services Covered (se e pla n docume nts for details ) La boratory Se rvice s Covered (se e pla n docume nts for details ) Emergency Room Deductible the n 0% (waive if admitted) Urgent Ca re Deductible the n 0% Durable Medical Equipme nt (DME) Deductible the n 0% Medica tions Administered in office (PCP /S pecialis t/outpatie nt Facility) Deductible the n 0% Coins urance Dia betic S ervices Covered (se e pla n docume nts for details ) Vision Exam Routine Adult/Child Embrace Health Bonus Account Life P oints Domestic P artner Coverage Deductible the n Covered in full/deductible then Covered in full N/A Included (Up to $180 pe r contra ct) Included S kille d Nursing Facility 365 Da y Coverage Exte nsion Depe nde nt through Age 29 Coverage Qualified Metal Tie r P lan Type P roduct Include d t Include d Ye s BRONZE deductiblecoins HD P lan Code 421 P roduct Cla s s COMMERCIAL
Page 3 of 12 CDP HP Plan Type S ta ndard P la n HDEPO EPO Hybrid 322 Silve r $525.47 Cost De tails Individua l $525.47 Employe e a nd Spous e $1,050.94 Employe e a nd Childre n $893.30 Employe e a nd Fa mily $1,497.59 Pla n De tails Office Visit P CP /Spe cia list $40/$60 P re scription Drug Tier1/Tier2/Tier3 $10/$50/50% In Ne twork De duc tible Single/Fa mily $2,000/$4,000 In Ne twork OOP Ma x S ingle/family $7,150/$14,300 De ductible Type EMBEDDED Inpa tient Facility Deductible the n 20% Outpatient S urge ry Deductible the n 20% Dia gnos tic Ra diology Services Covered (se e pla n docume nts for details ) La boratory Se rvice s Covered (se e pla n docume nts for details ) Emergency Room Deductible the n 20% (wa ive if admitte d)
Page 4 of 12 Urgent Ca re $70 Durable Medical Equipme nt (DME) 50% Medica tions Administered in office (PCP /S pecialis t/outpatie nt Facility) 20%/20%/Deductible then 20% Dia betic S ervices Covered (se e pla n docume nts for details ) Vision Exam Routine Adult/Child Embrace Health Bonus Account Life P oints Domestic P artner Coverage $60 Copayment/$40 Copayment N/A Included (Up to $180 pe r contra ct) Included S kille d Nursing Facility 365 Da y Coverage Exte nsion Depe nde nt through Age 29 Coverage Qua lifie d Metal Tie r P lan Type P roduct Include d t Include d SILVER tra nsitiona l EP O P lan Code 322 P roduct Cla s s CDP HP Plan Type S ta ndard P la n COMMERCIAL Hybrid EPO
Page 5 of 12 HDEPO Qua lifie d 320 Silver $528.18 Cost De tails Individua l $528.18 Employe e a nd Spous e $1,056.36 Employe e a nd Childre n $897.91 Employe e a nd Fa mily $1,505.31 Pla n De tails Office Visit P CP /Spe cia list Deductible the n $30/$40 P re scription Drug Tier1/Tier2/Tier3 Deductible the n $10/50%/50% In Ne twork De duc tible Single/Fa mily $1,750/$3,500 In Ne twork OOP Ma x S ingle/family $6,550/$13,100 De ductible Type AGGREGATE Inpa tient Facility Deductible the n $750 Outpatient S urge ry Deductible the n $150 Dia gnos tic Ra diology Services Covered (se e pla n docume nts for details ) La boratory Se rvice s Covered (se e pla n docume nts for details ) Emergency Room Deductible the n $150 (waive if admitted) Urgent Ca re Deductible the n $50 Durable Medical Equipme nt (DME) Deductible the n 50% Medica tions Administered in office (PCP /S pecialis t/outpatie nt Facility) Deductible the n 20% Coinsurance Dia betic S ervices Covered (se e pla n docume nts for details )
Page 6 of 12 Vision Exam Routine Adult/Child Embrace Health Bonus Account Life P oints Domestic P artner Coverage Deductible the n $40 Copa yment/de ductible the n $30 Copayment N/A Included (Up to $180 pe r contra ct) Included S kille d Nursing Facility 365 Da y Coverage Exte nsion Depe nde nt through Age 29 Coverage Qualified Metal Tie r P lan Type P roduct Include d t Include d Ye s SILVER copaydeductible HD P lan Code 320 P roduct Cla s s CDP HP Plan Type S ta ndard P la n COMMERCIAL HDEPO EPO Copa yme nt 200 Gold Sta nda rd $638.24 Cost De tails Individua l $638.24
Page 7 of 12 Employe e a nd Spous e $1,276.48 Employe e a nd Childre n $1,085.01 Employe e a nd Fa mily $1,818.98 Pla n De tails Office Visit P CP /Spe cia list Deductible the n $25/$40 P re scription Drug Tier1/Tier2/Tier3 $10/$35/$70 In Ne twork De ductible Single/Fa mily $600/$1,200 In Ne twork OOP Ma x S ingle/family $4,000/$8,000 De ductible Type EMBEDDED Inpa tient Facility Deductible the n $1,000 Outpatient S urge ry Deductible the n $100 Dia gnos tic Ra diology Services Covered (se e pla n docume nts for details ) La boratory Se rvice s Covered (se e pla n docume nts for details ) Emergency Room Deductible the n $150 (waive if admitted) Urgent Ca re Deductible the n $60 Durable Medical Equipme nt (DME) Deductible the n 20% Medica tions Administered in office (PCP /S pecialis t/outpatie nt Facility) Deductible the n $0/$0/$25 Dia betic S ervices Covered (se e pla n docume nts for details ) Vision Exam Routine Adult/Child Embrace Health Bonus Account Life P oints t Cove re d/de ductible then $25 Copayme nt N/A Included (Up to $180 pe r contra ct)
Page 8 of 12 Domestic P artner Coverage Included S kille d Nursing Facility 365 Da y Coverage Exte nsion Depe nde nt through Age 29 Coverage Qua lifie d Metal Tie r P lan Type P roduct Include d t Include d GOLD copaydeductible EP O P lan Code 200 P roduct Class CDP HP Plan Type S ta ndard P la n STANDARD EP O Ye s Embra ce Hea lth EPO Copa yme nt 221 Gold $638.63 Cost De tails Individua l $638.63 Employe e a nd Spous e $1,277.26 Employe e a nd Childre n $1,085.67 Employe e a nd Fa mily $1,820.10 Pla n De tails
Page 9 of 12 Office Visit P CP /Spe cia list Deductible the n $30/$50 P re scription Drug Tier1/Tier2/Tier3 $10/$50/$80 In Ne twork De ductible Single/Fa mily $250/$500 In Ne twork OOP Ma x S ingle/family $7,150/$14,300 De ductible Type EMBEDDED Inpa tient Facility Deductible the n $1,000 Outpatient S urge ry Deductible the n $100 Dia gnos tic Ra diology Services Covered (se e pla n docume nts for details ) La boratory Se rvice s Covered (se e pla n docume nts for details ) Emergency Room Deductible the n $100 (waive if admitted) Urgent Ca re Deductible the n $60 Durable Medical Equipme nt (DME) 50% Medica tions Administered in office (PCP /S pecialis t/outpatie nt Facility) Deductible the n 20% Coinsurance Dia betic S ervices Covered (se e pla n docume nts for details ) Vision Exam Routine Adult/Child Deductible the n $50 Copa yment/de ductible the n $30 Copayment Embrace Health Bonus Account $200 Life P oints Domestic P artner Coverage Included (Up to $180 pe r contra ct) Included S kille d Nursing Facility 365 Da y Coverage Exte nsion Depe nde nt through Age 29 Coverage Include d t Include d
Page 10 of 12 Qua lifie d Metal Tie r P lan Type P roduct GOLD copaydeductible EP O P lan Code 221 P roduct Class CDP HP Plan Type S ta ndard P la n EMBRACE Embra ce He alth EPO EPO Copa yme nt 120 Pla tinum $718.22 Cost De tails Individua l $718.22 Employe e a nd Spous e $1,436.44 Employe e a nd Childre n $1,220.97 Employe e a nd Fa mily $2,046.93 Pla n De tails Office Visit P CP /Spe cia list $15/$25 P re scription Drug Tier1/Tier2/Tier3 $4/$30/$60 In Ne twork De ductible Single/Fa mily $0/$0 In Ne twork OOP Ma x S ingle/family $7,150/$14,300
Page 11 of 12 De ductible Type EMBEDDED Inpa tient Facility $750 Outpatient S urge ry $100 Dia gnos tic Ra diology Services Covered (se e pla n docume nts for details ) La boratory Se rvice s Covered (se e pla n docume nts for details ) Emergency Room $100 (waive if admitted) Urgent Ca re $35 Durable Medical Equipme nt (DME) 50% Medica tions Administered in office (PCP /S pecialis t/outpatie nt Facility) 20% Coinsurance Dia betic S ervices Covered (se e pla n docume nts for details ) Vision Exam Routine Adult/Child Embrace Health Bonus Account Life P oints Domestic P artner Coverage $25 Copayment/$15 Copayment N/A Included (Up to $180 pe r contra ct) Included S kille d Nursing Facility 365 Da y Coverage Exte nsion Depe nde nt through Age 29 Coverage Qua lifie d Metal Tie r P lan Type P roduct Include d t Include d PLATINUM copay EP O
Page 12 of 12 P lan Code 120 P roduct Cla s s COMMERCIAL CDP HP Plan Type EP O S ta ndard P la n Copyright 2016 Benefitfocus.com. Inc. Ques tions? Plea se ca ll iconne ct Support a t 855 554 0414 from 8:30 a.m. to 5:30 p.m. Ea ste rn Time. Te rms of Use (/s ta tic/docs /te rms_conditions.html) Privacy State ment (/s tatic/docs /priva cy_s ta tement.html)