2016 BCBS of WNY Benefit Comparison for Individuals

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1 Page BCBS of WNY Benefit Comparison for Individuals BCBS of WNY BCBS of WNY BCBS of WNY In-Network Benefits: Platinum POS 110E Gold POS 7100 HSAQ Gold Aqua Annual Deductible $0 $1,300 Single/ $2,600 Family $1,000 Single/ $2,000 Family Coinsurance 0% 0% 20% after 1st dollar and deductible Annual Out of Pocket Max $4,000 Single/ $8,000 Family $4,000 Single/ $8,000 Family $5,000 Single/ $10,000 Family PCP Office Visit $20 Copay Deductible then $20 Copay 1st dollar and deductible then 20% Coinsurance Specialist Visit $30 Copay Deductible then $40 Copay 1st dollar and deductible then 20% Coinsurance Sick Child Visit $20 Copay Deductible then $20 Copay 1st dollar and deductible then 20% Coinsurance Radiology $30 Copay Deductible then $40 Copay 1st dollar and deductible then 20% Coinsurance Laboratory $0 Copay Deductible then $40 Copay 1st dollar and deductible then 20% Coinsurance Hospital Inpatient $500 Copay Deductible then $500 Copay 1st dollar and deductible then 20% Coinsurance Outpatient Surgery $150 Copay Deductible then $150 Copay 1st dollar and deductible then 20% Coinsurance Outpatient OT/PT/ST $20 Copay Deductible then $20 Copay 1st dollar and deductible then 20% Coinsurance Emergency Room Care $100 Copay Deductible then $150 Copay 1st dollar and deductible then 20% Coinsurance Ambulance $100 Copay Deductible then $150 Copay 1st dollar and deductible then 20% Coinsurance Urgent Care $40 Copay Deductible then $75 Copay 1st dollar and deductible then 20% Coinsurance Outpatient Mental Health $30 Copay Deductible then $40 Copay 1st dollar and deductible then 20% Coinsurance Chiropractor $20 Copay Deductible then $20 Copay 1st dollar and deductible then 20% Coinsurance Diabetic Supplies $20 Copay Deductible then $20 Copay $15 Copay Copay per 30 Day Supply After Deductible Not Subject to Deductible Tier 1 $5 Tier 1 $5 Tier 1 $15 Tier 2 $30 Tier 2 $30 Tier 2 $50 Tier 3 50% Tier 3 $50 Tier 3 50% Annual Deductible $1,500 Single / $3,000 Family $1,300 Single/ $2,600 Family $1,000 Single / $2,000 Family Coinsurance 40% 40% 50% after 1st dollar and deductible Annual Out of Pocket Max $4,000 Single / $8,000 Family $10,000 Single / $20,000 Family $10,000 Single / $20,000 Family Extra Benefits $250 Wellness Card $250 Wellness Card $250 Wellness Card $500/$1,000 First Dollar Single $ $ $ Subscriber and Spouse $1, $ $ Subscriber and Child(ren) $1, $ $ Family $1, $1, $1,317.07

2 Page BCBS of WNY Benefit Comparison for Individuals BCBS of WNY BCBS of WNY BCBS of WNY BCBS of WNY In-Network Benefits: Silver POS 7100 HSAQ Silver POS 8100E HSAQ Bronze POS 8100E HSAQ Bronze Value HSAQ Annual Deductible $2,000 Single / $4,000 Family $2,000 Single / $4,000 Family $5,000 Single/ $10,000 Family $6,450 Single/ $12,900 Family Coinsurance 0% 20% 20% 0% Annual Out of Pocket Max $5,500 Single/ $11,000 Family $5,000 Single/ $10,000 Family $6,450 Single / $12,900 Family $6,450 Single/ $12,900 Family PCP Office Visit Deductible then $25 Copay Deductible then 20% Coinsurance Deductible then 20% Coinsurance Deductible then 0% Coinsurance Specialist Visit Deductible then $40 Copay Deductible then 20% Coinsurance Deductible then 20% Coinsurance Deductible then 0% Coinsurance Sick Child Visit Deductible then $25 Copay Deductible then 20% Coinsurance Deductible then 20% Coinsurance Deductible then 0% Coinsurance Radiology Deductible then $40 Copay Deductible then 20% Coinsurance Deductible then 20% Coinsurance Deductible then 0% Coinsurance Laboratory Deductible then $40 Copay Deductible then 20% Coinsurance Deductible then 20% Coinsurance Deductible then 0% Coinsurance Hospital Inpatient Deductible then $750 Copay Deductible then $750 Copay Deductible then 20% Coinsurance Deductible then 0% Coinsurance Outpatient Surgery Deductible then $150 Copay Deductible then 20% Coinsurance Deductible then 20% Coinsurance Deductible then 0% Coinsurance Outpatient OT/PT/ST Deductible then $25 Copay Deductible then 20% Coinsurance Deductible then 20% Coinsurance Deductible then 0% Coinsurance Emergency Room Care Deductible then $150 Copay Deductible then 20% Coinsurance Deductible then 20% Coinsurance Deductible then 0% Coinsurance Ambulance Deductible then $150 Copay Deductible then 20% Coinsurance Deductible then 20% Coinsurance Deductible then 0% Coinsurance Urgent Care Deductible then $75 Copay Deductible then 20% Coinsurance Deductible then 20% Coinsurance Deductible then 0% Coinsurance Outpatient Mental Health Deductible then $40 Copay Deductible then 20% Coinsurance Deductible then 20% Coinsurance Deductible then 0% Coinsurance Chiropractor Deductible then $25 Copay Deductible then 20% Coinsurance Deductible then 20% Coinsurance Deductible then 0% Coinsurance Diabetic Supplies Deductible then $25 Copay Deductible then 20% Coinsurance Deductible then 20% Coinsurance Deductible then 0% Coinsurance After Deductible After Deductible After Deductible After Deductible (except tier 1) Tier 1 $5 Tier 1 $5 Tier 1 $5 Tier 1 $0 Tier 2 $30 Tier 2 $30 Tier 2 $30 Tier 2 0% Tier 3 50% Tier 3 50% Tier 3 50% Tier 3 0% Annual Deductible $2,000 Single / $4,000 Family $2,000 Single / $4,000 Family $5,000 Single / $10,000 Family $6,450 Single/ $12,900 Family Coinsurance 40% 40% 40% 50% Annual Out of Pocket Max $10,000 Single / $20,000 Family $10,000 Single / $20,000 Family $10,000 Single / $20,000 Family $6,450 Single/ $12,900 Family Extra Benefits $250 Wellness Card $250 Wellness Card $250 Wellness Card $250 Wellness Card Single $ $ $ $ Subscriber and Spouse $ $ $ $ Subscriber and Child(ren) $ $ $ $ Family $1, $1, $ $894.51

3 Page BCBS of WNY Benefit Comparison for Individuals BCBS of WNY BCBS of WNY BCBS of WNY BCBS of WNY In-Network Benefits: Platinum Standard Gold Standard Silver Standard Bronze Standard Annual Deductible $0 $600 Single/ $1,200 Family $2,000 Single/ $4,000 Family $3,500 Single/ $7,000 Family Coinsurance 0% 0% 0% 50% Annual Out of Pocket Max $2,000 Single / $4,000 Family $4,000 Single/ $8,000 Family $5,500 Single/ $11,000 Family $6,850 Single/ $13,700 Family PCP Office Visit $15 Copay Deductible then $25 Copay Deductible then $30 Copay Deductible then 50% Coinsurance Specialist Visit $35 Copay Deductible then $40 Copay Deductible then $50 Copay Deductible then 50% Coinsurance Sick Child Visit $15 Copay Deductible then $25 Copay Deductible then $30 Copay Deductible then 50% Coinsurance Radiology $35 Copay Deductible then $40 Copay Deductible then $50 Copay Deductible then 50% Coinsurance Laboratory $35 Copay Deductible then $40 Copay Deductible then $50 Copay Deductible then 50% Coinsurance Hospital Inpatient $500 Copay Deductible then $1000 Copay Deductible then $1,500 Copay Deductible then 50% Coinsurance Outpatient Surgery $100 Copay Deductible then $100 Copay Deductible then $100 Copay Deductible then 50% Coinsurance Outpatient OT/PT/ST $25 Copay Deductible then $30 Copay Deductible then $30 Copay Deductible then 50% Coinsurance Emergency Room Care $100 Copay Deductible then $150 Copay Deductible then $150 Copay Deductible then 50% Coinsurance Ambulance $100 Copay Deductible then $150 Copay Deductible then $150 Copay Deductible then 50% Coinsurance Urgent Care $55 Copay Deductible then $60 Copay Deductible then $70 Copay Deductible then 50% Coinsurance Outpatient Mental Health $15 Copay Deductible then $25 Copay Deductible then $30 Copay Deductible then 50% Coinsurance Chiropractor $35 Copay Deductible then $40 Copay Deductible then $50 Copay Deductible then 50% Coinsurance Diabetic Supplies $15 Copay Deductible then $25 Copay Deductible then $30 Copay Deductible then 50% Coinsurance Not Subject to Deductible Not Subject to Deductible Not Subject to Deductible After Deductible Tier 1 $10 Tier 1 $10 Tier 1 $10 Tier 1 $10 Tier 2 $30 Tier 2 $35 Tier 2 $35 Tier 2 $35 Tier 3 $60 Tier 3 $70 Tier 3 $70 Tier 3 $70 Annual Deductible $5,000 Single / $10,000Family $5,000 Single / $10,000Family $5,000 Single / $10,000Family $5,000 Single / $10,000Family Coinsurance 50% 50% 50% 50% Annual Out of Pocket Max $10,000 Single / $20,000 Family $10,000 Single / $20,000 Family $10,000 Single / $20,000 Family $10,000 Single / $20,000 Family Extra Benefits $250 Wellness Card $250 Wellness Card $250 Wellness Card $250 Wellness Card Single $ $ $ $ Subscriber and Spouse $1, $ $ $ Subscriber and Child(ren) $ $ $ $ Family $1, $1, $1, $885.43

4 Page Univera Healthcare Benefit Comparison for Individuals Univera Univera Univera In-Network Benefits: Platinum Select Gold Select Preferred Gold Annual Deductible $0 $750 Single/ $1,500 Family $500 Single/ $1,000 Family Coinsurance 0% 0% 0% Annual Out of Pocket Max $6,350 Single/ $12,700 Family $6,350 Single / $12,700 Family $5,000 Single / $10,000 Family PCP Office Visit $15 Copay Deductible then $25 Copay Deductible then $25 Copay Specialist Visit $25 Copay Deductible then $40 Copay Deductible then $40 Copay Sick Child Visit $15 Copay Deductible then $25 Copay Deductible then $25 Copay Radiology $25 Copay Deductible then $40 Copay Deductible then $40 Copay Laboratory $25 Copay Deductible then $40 Copay Deductible then $40 Copay Hospital Inpatient $750 Copay Deductible then $750 Copay Deductible then $750 Copay Outpatient Surgery $150 Copay Deductible then $250 Copay Deductible then $150 Copay Outpatient OT/PT/ST $25 Copay Deductible then $40 Copay Deductible then $40 Copay Emergency Room Care $150 Copay Deductible then $250 Copay Deductible then $150 Copay Ambulance $150 Copay Deductible then $250 Copay Deductible then $150 Copay Urgent Care $25 Copay Deductible then $40 Copay Deductible then $40 Copay Outpatient Mental Health $25 Copay Deductible then $40 Copay Deductible then $40 Copay Chiropractor $25 Copay Deductible then $40 Copay Deductible then $40 Copay Diabetic Supplies $15 Copay Deductible then $25 Copay Deductible then $25 Copay Copay per 30 Day Supply Copay per 30 Day Supply Copay per 30 Day Supply Annual Deductible Coinsurance Annual Out of Pocket Max Tier 1 $10 Tier 1 $10 Tier 1 $5 Tier 2 $35 Tier 2 $35 Tier 2 $35 Tier 3 $70 Tier 3 $70 Tier 3 $70 Extra Benefits Exercise Rewards up to $600 per year Exercise Rewards up to $600 per year Exercise Rewards up to $600 per year Single $ $ $ Subscriber and Spouse $1, $1, $1, Subscriber and Child(ren) $1, $1, $1, Family $2, $1, $1,789.18

5 Page Univera Healthcare Benefit Comparison for Individuals Univera Univera In-Network Benefits: Silver Select Bronze Select Annual Deductible $2,250 Single/ $4,500 Family $4,500 Single/ $9,000 Family Coinsurance 20% 50% Annual Out of Pocket Max $6,350 Single/ $12,700 Family $6,350 Single/ $12,700 Family PCP Office Visit Deductible then 20% Coinsurance Deductible then 50% Coinsurance Specialist Visit Deductible then 20% Coinsurance Deductible then 50% Coinsurance Sick Child Visit Deductible then 20% Coinsurance Deductible then 50% Coinsurance Radiology Deductible then 20% Coinsurance Deductible then 50% Coinsurance Laboratory Deductible then 20% Coinsurance Deductible then 50% Coinsurance Hospital Inpatient Deductible then 20% Coinsurance Deductible then 50% Coinsurance Outpatient Surgery Deductible then 20% Coinsurance Deductible then 50% Coinsurance Outpatient OT/PT/ST Deductible then 20% Coinsurance Deductible then 50% Coinsurance Emergency Room Care Deductible then 20% Coinsurance Deductible then 50% Coinsurance Ambulance Deductible then 20% Coinsurance Deductible then 50% Coinsurance Urgent Care Deductible then 20% Coinsurance Deductible then 50% Coinsurance Outpatient Mental Health Deductible then 20% Coinsurance Deductible then 50% Coinsurance Chiropractor Deductible then 20% Coinsurance Deductible then 50% Coinsurance Diabetic Supplies Deductible then 20% Coinsurance Deductible then 50% Coinsurance After Deductible Subject to Deductible Tier 1 $10 Tier 1 $10 Tier 2 $45 Tier 2 40% Tier 3 $90 Tier 3 50% Annual Deductible Coinsurance Annual Out of Pocket Max Extra Benefits Exercise Rewards up to $600 per year Exercise Rewards up to $600 per year Single $ $ Subscriber and Spouse $ $ Subscriber and Child(ren) $ $ Family $1, $1,091.75

6 Page Univera Healthcare Benefit Comparison for Individuals Univera Univera Univera Univera Univera In-Network Benefits: Platinum Standard Gold Standard Silver Standard Bronze Standard Bronze Standard HSAQ Annual Deductible $0 $600 Single/ $1,200 Family $2,000 Single/ $4,000 Family $3,500 Single/ $7,000 Family $4,000 Single/ $8,000 Family Coinsurance 0% 0% 0% 50% 50% Annual Out of Pocket Max $2,000 Single/ $4,000 Family $4,000 Single/ $8,000 Family $5,500 Single/ $11,000 Family $6,850 Single/ $13,700 Family $6,450 Single/ $12,900 Family PCP Office Visit $15 Copay Deductible then $25 Copay Deductible then $30 Copay Deductible then 50% Coinsurance Deductible then 50% Coinsurance Specialist Visit $35 Copay Deductible then $40 Copay Deductible then $50 Copay Deductible then 50% Coinsurance Deductible then 50% Coinsurance Sick Child Visit $15 Copay Deductible then $25 Copay Deductible then $30 Copay Deductible then 50% Coinsurance Deductible then 50% Coinsurance Radiology $15/$35 Copay Deductible then $25/$40 Copay Deductible then $30/$50 Copay Deductible then 50% Coinsurance Deductible then 50% Coinsurance Laboratory $15/$35 Copay Deductible then $25/$40 Copay Deductible then $30/$50 Copay Deductible then 50% Coinsurance Deductible then 50% Coinsurance Hospital Inpatient $500 Copay Deductible then $1,000 Copay Deductible then $1,500 Copay Deductible then 50% Coinsurance Deductible then 50% Coinsurance Outpatient Surgery $100 Copay Deductible then $100 Copay Deductible then $100 Copay Deductible then 50% Coinsurance Deductible then 50% Coinsurance Outpatient OT/PT/ST $25 Copay Deductible then $30 Copay Deductible then $30 Copay Deductible then 50% Coinsurance Deductible then 50% Coinsurance Emergency Room Care $100 Copay Deductible then $150 Copay Deductible then $150 Copay Deductible then 50% Coinsurance Deductible then 50% Coinsurance Ambulance $100 Copay Deductible then $150 Copay Deductible then $150 Copay Deductible then 50% Coinsurance Deductible then 50% Coinsurance Urgent Care $55 Copay Deductible then $60 Copay Deductible then $70 Copay Deductible then 50% Coinsurance Deductible then 50% Coinsurance Outpatient Mental Health $15 Copay Deductible then $25 Copay Deductible then $30 Copay Deductible then 50% Coinsurance Deductible then 50% Coinsurance Chiropractor $35 Copay Deductible then $40 Copay Deductible then $50 Copay Deductible then 50% Coinsurance Deductible then 50% Coinsurance Diabetic Supplies $15 Copay Deductible then $25 Copay Deductible then $30 Copay Deductible then 50% Coinsurance Deductible then 50% Coinsurance Copay per 30 Day Supply Copay per 30 Day Supply Copay per 30 Day Supply After Deductible After Deductible Tier 1 $10 Tier 1 $10 Tier 1 $10 Tier 1 $10 Tier 1 $10 Tier 2 $30 Tier 2 $35 Tier 2 $35 Tier 2 $35 Tier 2 $35 Tier 3 $60 Tier 3 $70 Tier 3 $70 Tier 3 $70 Tier 3 $70 Extra Benefits Exercise Rewards up to $600 per year Exercise Rewards up to $600 per year Exercise Rewards up to $600 per year Exercise Rewards up to $600 per year Exercise Rewards up to $600 per year Single $ $ $ $ $ Subscriber and Spouse $1, $1, $1, $ $ Subscriber and Child(ren) $1, $1, $ $ $ Family $2, $1, $1, $1, $1,162.59

7 Benefit Amount Employee Spouse Child(ren) Up to $300,000 of coverage $100,000 guarantee issue for new groups only Up to $100,000 of coverage $20,000 guarantee issue for new groups only $10,000 Increment $25,000 $10,000 $10, Life and Accidental Death & Dismemberment Coverage Varies by age and amount of coverage. From $0.10 to $1.85 per $1,000 Varies by age and amount of coverage. From $0.10 to $1.85 per $1,000 Rates shown above are monthly. Employee must complete a Statement of Health Form for amounts exceeding Guarantee Issue. Employee must elect self-only coverage in order to enroll a dependent. Dependent coverage may not exceed 50% of employee coverage. Children to age 21 or 26 if full-time student. $ Telehealth Discount Program Benefits: Telehealth: Save time and month with 24/7 access to a doctor by phone or online video consult. Medical Bill Saver: Expert negotiators help members save on uncovered medical and dental bills over $400. Medical Health Advisor: Members get one-on-one support from professionals for medical or insurance related issues. Nurseline: Registered nurses are on-call 24/7 to answer member questions. Doctors Online: Fast and easy way to get health information from an online resource that members can trust. Vision: 10% to 60% off of glasses, contacts, laser surgery, eye exams and more. Dental: Members can save big on dental services at thousands of locations nationwide. Pharmacy: Members save an average of 42% on their prescriptions, drastically reducing their out-of-pocket costs. Lab Testing: Save 10% to 80% on typical costs for lab work at over 1,500 major clinical labs nationwide. MRI & CT Scans: Save big on usual charges for MRI, CT Scans and Ultrasounds at thousands of radiology centers nationwide. Hearing Aids: Members receive free initial screening and can save up to 35% at retail locations nationwide. Durable Medical Equipment: Save 20% to 50% on walking aids, wheelchairs, orthopedic products and much more. Dental Preferred Premier Ultimate Employer Paid $11.95 $12.95 $14.95 $18.85 Employee Paid $11.95 $13.95 $15.95 $19.95 Direct to Consumer $11.95 $14.95 $16.95 $19.95 This plan is NOT insurance. The plan is not insurance coverage and does not meet the minimum creditable coverage requirements under the Affordable Care Act. This plan provides discounts at certain healthcare providers for medical services. This plan does not make payments directly to the providers of medical services. The plan member is obligated to pay for all healthcare services but will receive a discount from those healthcare providers who have contracted with the discount plan organization. This discount card program contains a 30 day cancellation Member shall receive a full refund of membership fees, excluding registration fee, if membership is cancelled within the first 30 days after the effective date. AR and TN residents: A refund of all fees will be issued if membership is cancelled within the first 30 days. Discount Medical Plan Organization: New Benefits, Ltd., Attn: Compliance Department, PO Box , Dallas, T , Website to obtain participating providers: MyMemberPortal.com. Available only to NY residents. 11/19/2015