ID Prefix XQW RDP RDP Annual Enrollment

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1 ID Prefix XQW RDP RDP Annual Enrollment Employees who are not currently enrolled in a MIIP Employees who are not currently enrolled in a MIIP health insurance plan can NOT come on to this plan at health insurance plan can come on to this plan as a Annual Enrollment. late enrollee. Provider Choice Out-of-Pocket Maximum (OPM) Comparison of Health Care Plans Metro Interagency Insurance Program Effective Date: July 1, 2017 Wellmark Blue Cross Blue Shield Customer Service: Participating Provider Directory Information: Each member selects a primary care provider (PCP) who will coordinate care and women may also select an OB/GYN. Members must utilize Blue Advantage providers. Referrals are required for certain services. Copayment stops once your out-of-pocket maximum is met. 25% (20% for prosthetic limbs from network providers) Copayment stops once your out-of-pocket maximum PPO Providers: 20% Non-PPO Providers: 30% Copayment stops once your out-of-pocket maximum PPO Providers: 10% Non-PPO Providers: 20% stops once your out-of-pocket maximum stops once your out-of-pocket maximum stops once your out-of-pocket maximum Single: $4,000 Single: $3,500 Single: $2,500 Family: $8,000 Family: $7,000 Family: $5,000 OPM is Separate between health and drug OPM is Separate between health and drug OPM is Separate between health and drug Deductible, copayments and coinsurance apply to your out-of-pocket maximum. Members may go to any provider they choose. Financial incentives encourage members to receive services from a PPO provider. Provider Network Blue Advantage Alliance Select Alliance Select Annual Deductible The amount you pay for covered services before your benefits Single: $2,000 Family: $4,000 Single: $1,250 Family: $2,500 Single: $750 Family: $1,500 become available. Services subject to copayments are not subject to the deductible. Services subject to copayments are not subject to the deductible. Services subject to copayments are not subject to the deductible. Copayment $35 Copayment: $25 Copayment: $20 Copayment: A flat dollar amount for which you Office, independent lab, walk-in clinic Office, walk-in clinic from PPO Providers ONLY Office, walk-in clinic from PPO Providers ONLY are responsible each time you There is no coinsurance required for services There is no coinsurance required for services There is no coinsurance required for services receive medical care at a specified provider. A fixed percentage of medical expenses for which you are responsible. Deductible, copayments and coinsurance apply to your out-of-pocket maximum. Deductible, copayments and coinsurance apply to your out-of-pocket maximum. MIIP Plan Comparison xlsx 1

2 Office Care $35 Copayment PPO Office: $25 Copayment PPO Office: $20 Copayment Office care includes x-rays, lab Non-PPO Providers: $1,250/$2,500 Deductible tests, and minor surgeries then 30% performed in the practitioner s office or walk-in clinic. Independent Lab and X-Ray Chiropractic Care Non-PPO Providers: 20% Applies once per provider per date of service. Applies per date of service. Applies per date of service. There is no coinsurance required for services $35 Copayment PPO Providers: Deductible waived, 20% PPO Providers: Deductible waived, 10% coinsurance coinsurance Applies once per provider per date of service. Non-PPO Providers: $1,250/$2,500 Deductible Non-PPO Providers: then 30% coinsurance 20% coinsurance $35 Copayment PPO Office: $25 Copayment PPO Office: $20 Copayment You may access a Blue Advantage chiropractor up to 12 visits/times per year without a referral from PCP. Non-PPO Providers: $1,250/$2,500 Deductible then 30% Non-PPO Providers: 20% Accident Care Office: $35 Copayment PPO Office: $25 Copayment PPO Office: $20 Copayment All Other: All Other: Out of network emergency room Emergency Room: $2,000/$4,000 Deductible then 20% (PPO Provider) 10% (PPO Provider) services paid at in-network benefits 25% 30% (Non-PPO) 20% (Non-PPO) Inpatient Hospital: $2,000/$4,000 Deductible then 25% Inpatient Outpatient Hospital Hospital: $2,000/$4,000 Deductible then 25% Physician: $2,000/$4,000 Deductible then 25% Hospital: $2,000/$4,000 Deductible then 25% Physician: $2,000/$4,000 Deductible then 25% 20% (PPO Provider) 30% (Non-PPO) 20% (PPO Provider) 30% (Non-PPO) 10% (PPO Provider) 20% (Non-PPO) 10% (PPO Provider) 20% (Non-PPO) MIIP Plan Comparison xlsx 2

3 Preventive Care * Annual Routine Physical * Annual OB/GYN Exams * Pap Smears * Well-Child Care to Age 7 * Immunizations * Mammograms *Routine Colo-Rectal Exam (sigmoidoscopy) *Colonoscopy * Routine labs * PSA tests Maternity $0 Copayment Women can choose a Blue Advantage OB/GYN specialist on their enrollment form or by calling Customer Service. Women who do not select an OB/GYN specialist will need to have all of their routine care provided by their PCP. One routine or diagnostic colonoscopy is covered per year and is not subject to deductible or coinsurance. Any subsequent colonoscopies done in the year will apply deductible and coinsurance. Hospital: $2,000/$4,000 Deductible then 25% Physician: Covered at 100% Routine prenatal and postnatal care is covered in full. Non-routine care is subject to deductible / coinsurance and/or copayments. Maternity care will be provided by your PCP or with a referral to an OB/GYN specialist unless you list a Blue Advantage specialist prior to scheduling your care. An OB/GYN specialist can be selected on your enrollment form or by calling Customer Service: PPO Providers: $0 Copayment, $0 Deductible, $0 Non- PPO Providers: $1,250/$2,500 Deductible then 30% One routine or diagnostic colonoscopy is covered per year and is not subject to deductible and coinsurance. Any subsequent colonoscopies done in the year will apply deductible and coinsurance. 20% (PPO Provider) 30% (Non-PPO) applied once your annual deductible You will be responsible for coinsurance until you reach practitioner s office. PPO Providers: $0 Copayment, $0 Deductible, $0 Non- PPO Providers: 20% One routine or diagnostic colonoscopy is covered per year and is not subject to deductible or coinsurance. Any subsequent colonoscopies done in the year will apply deductible and coinsurance. 10% (PPO Provider) 20% (Non-PPO) applied once your annual deductible You will be responsible for coinsurance until you reach the Allergy Services in Office $35 Copayment PPO Office: $25 Copayment PPO Office: $20 Copayment - Shots - Testing Non-PPO: 30% Non-PPO: 20% - Serum practitioner s office. MIIP Plan Comparison xlsx 3

4 Other Covered Services - Home Health Visit* - Home Infusion Therapy* - Home/Durable Medical Equipment - Oxygen & Equipment - Private Duty Nursing* *Precertification is required Infertility - Transfer procedures up to $15,000 lifetime maximum $2,000/$4,000 Deductible then 25% 20% (PPO Provider) 30% (Non-PPO) applied once your annual deductible You will be responsible for coinsurance until you reach the OPM. 10% (PPO Provider) 20% (Non-PPO) applied once your annual deductible You will be responsible for coinsurance until you reach the OPM. Office: $35 Copayment PPO Office: $25 Copayment PPO Office: $20 Copayment Outpatient/Inpatient: $2,000/$4,000 Deductible then 25% All Other: All Other: 20% (PPO Provider) 10% (PPO Provider) 30% (Non-PPO) 20% (Non-PPO) Mental Health and Chemical Dependency - Unlimited Office: $35 Copayment PPO Office: $25 Copayment PPO Office: $20 Copayment Skilled Nursing Vision Outpatient/Inpatient: $2,000/$4,000 Deductible then 25% Hospital: $2,000/$4,000 Deductible then 25% All Other: 20% (PPO Provider) 30% (Non-PPO) 20% (PPO Provider) 30% (Non-PPO) All Other: 10% (PPO Provider) 20% (Non-PPO) 10% (PPO Provider) 20% (Non-PPO) Physician: $2,000/$4,000 Deductible then 25% Vision benefits are covered under Vision Service Plan, which includes a $10 copayment for a routine vision exam. See Vision Service Plan (VSP) Summary of Benefits in KIN-Employee Information-Benefits for details and participating providers. The HMO Essential plan also offers one routine annual vision exam that may be used in addition to the VSP benefit with a $35 copayment; however the HMO plan does not provide a benefit for glasses and/or contacts. The HMO member must seek services from a Blue Advantage provider. MIIP Plan Comparison xlsx 4

5 Prescription Drugs Tier 1: $10 Tier 1: $10 Tier 1: $10 Blue Rx Complete Tier 2: $40 Tier 2: $40 Tier 2: $40 Network Tier 3: $70 Tier 3: $70 Tier 3: $70 Tier 4: $100 Tier 4: $100 Tier 4: $100 Preferred Specialty Drug copay: $50 Preferred Specialty Drug copay: $50 Preferred Specialty Drug copay: $50 Non-Preferred Specialty Drug copay: $200 Non-Preferred Specialty Drug copay: $200 Non-Preferred Specialty Drug copay: $200 Out-of-State Care Specialty drugs are covered only when obtained through Specialty Pharmacy Program Specialty drugs are covered only when obtained through Specialty Pharmacy Program Specialty drugs are covered only when obtained through Specialty Pharmacy Program Prescription Drug OPM : Prescription Drug OPM : Prescription Drug OPM : Single $2,600 Family $5,200 Single $2,600 Family $5,200 Single $2,600 Family $5,200 Quantity Limits: Quantity Limits: Quantity Limits: Retail: Generic: up to 90 day supply (3 copayments) Brand Name: up to 30 day supply (1 copayment) Retail: Generic: up to 90 day supply (3 copayments) Brand Name: up to 30 day supply (1 copayment) Retail: Generic: up to 90 day supply (3 copayments) Brand Name: up to 30 day supply (1 copayment) Immunizations are covered Immunizations are covered Immunizations are covered Medical emergencies and accidental injuries are The Blue Card PPO program provides benefits based on the local Blue Plan s negotiated payment covered without a referral. Follow-up care should rates. PPO providers are available in most states. Call: to locate a PPO provider or be coordinated by your PCP. visit Dependents that live out-of-area for part of the year may be able to enroll as a guest in the local Blue Plan. Members under a guest membership must Benefits are available anywhere in the world. contact customer service to select a new PCP before services are received. Lifetime Maximum Unlimited This is a general description of coverage. It is not a statement of contract. Actual coverage is subject to terms and conditions specified in the certificate itself and enrollment regulations in force when the certificate becomes effective. Certain exclusions and limitations apply. Updated 03/20/2017 MIIP Plan Comparison xlsx 5