HEALTH INSURANCE FOR INDIVIDUALS AND FAMILIES. Insuring Minnesota One Life At A Time.

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1 foreveryone HEALTH INSURANCE FOR INDIVIDUALS AND FAMILIES Insuring Minnesota One Life At A Time

2 for EveryOne Insuring Minnesota One Life At A Time Thank you for your interest in the PreferredOne for Everyone health insurance plan for individuals and families. To apply for coverage, you must be a Minnesota resident between the ages of 19 and 64. Eligible Dependents are welcome to apply with an adult. On the following pages and the rate sheet, you will find everything you need to apply for coverage: Highlights/Plan Options, Rates & Payment Options, Website and Health & Wellness information. When assessing your health care options and costs, it pays to look at the whole picture. What are you getting for your monthly premium? PreferredOne for Everyone Benefit Highlights: $35 copay for the first 5 office visits per calendar year per person 100% coverage for preventive care $10 copay for generic drugs Health club discounts Plan Options You may choose from five deductible plans and each includes a $35 office visit copay for the first 5 office visits per calendar year per person (not subject to deductible). You may add a Chemical Dependency Rider Option at the time of your initial enrollment. Provider Network You will have convenient access to the providers in the PreferredOne Open Access Network 300, with over 8,300 primary care physicians, 8,700 specialists and 279 hospitals. You may see any provider in the network and referrals are not required. You do not have to select a primary care clinic. Visit click Find a Provider and Open Access Network 300 to search for providers. Pharmacy Access For information about pharmacy locations, formulary drugs, mail service and other pharmacy services, go to Register/Login, click View My Benefits and Pharmacy Information. You may also call PreferredOne Customer Service. If you have any questions, please contact your PreferredOne agent, go to and click Individual Plan or call PreferredOne Customer Service at or toll free at , Monday through Friday, 7 a.m. to 7 p.m. CST.

3 PreferredOne for Everyone Plan Highlights The information below provides a summary of benefits and is not meant to be all-inclusive. The Contract will include a complete description of benefits and exclusions. IN-NETWORK SERVICES Coinsurance Annual Deductible equal to the individual deductible if only one person is covered on the plan; equal to the family deductible if more than one person is covered on the plan Annual Benefit Maximum Lifetime Benefit Maximum Office Visits, Sickness or Injury Preventive Health Care Services, as defined by PIC and preventive services as required under the Patient Protection and Affordable Care Act and any amendments or rules issued with respect to the Act. Convenient Care Clinic Urgent Care Chiropractic Services (maximum 12 visits per calendar year) Prescription Drugs - Brand formulary and generic drugs: Up to a 31-day supply of prescription drugs, oral contraceptives and one type of insulin - Mail order drugs for up to a 93-day supply Hospital Services, Inpatient and Outpatient Emergency Room Services Lab and X-ray Services, Inpatient and Outpatient Ambulance Durable Medical Equipment Home Health Care, as an alternative to hospital confinement or skilled nursing facility care (maximum of 180 visits per person per calendar year) Physical, Occupational and Speech Therapy Maternity Labor, (labor and delivery subject to an 18-month exculsionary period for individuals age 19 and older) Mental Health Care Health Club Discount Chemical Dependency Rider Option PE Plan PE Plan PE Plan PE Plan PE Plan Provided by participating providers 100% of eligible charges after deductible $3,500 individual or $5,500 individual or $7,500 individual or $9,500 individual or $11,500 individual or $7,000 family $11,000 family $15,000 family $19,000 family $23,000 family $3,000,000 Unlimited $35 copay* per visit for the first 5 visits per member per year, subsequent visits covered at 100% after deductible 100% of eligible charges (no deductible) $10 copay, no limit Covered under Office Visits Covered under Office Visits Generic drugs: $10 copay* Brand formulary drugs: Discount only Specialty Drugs: 100% of eligible charges after deductible 100% of eligible charges after deductible No Coverage Receive up to $20 monthly credit towards your membership fees at participating health clubs. See details on page % of eligible charges after deductible (only applies if selected upon initial enrollment) OUT-OF-NETWORK SERVICES These plans cover out-of-network services from non-participating providers. For non-participating providers, in addition to any deductible and coinsurance, you pay all charges that exceed the PIC non-participating provider reimbursement value. Please refer to the Individual Contract for complete details. Out-of-Network Coinsurance 60/40% coverage after deductible Out-of-Network Annual Deductible Double the in-network deductible Out-of-Network Annual Out-of-Pocket Limit No out-of-pocket limit for out-of-network services Out-of-Network Annual Benefit Maximum $2,000,000 Out-of-Network Lifetime Benefit Maximum Unlimited Out-of-Network Emergency Room Services Out-of-network coverage same as in-network benefit *Copayments do not apply toward the deductible or out-of-pocket. Once you have enrolled with PreferredOne Insurance Company, you will receive a new member packet that will include your ID card and Individual Contract. These plan options do not cover all health care expenses. A brief summary of excluded or limited benefits includes, but is not limited to: eyeglasses; contact lenses; Non-formulary brand drugs; cosmetic surgery; mental nervous services and associated prescription drugs; weight loss surgery and associated prescription drugs; treatment, service or procedures which are experimental, investigative or are not medically necessary. Your contract will explain your coverage terms and conditions in detail.

4 Staying Healthy & Well At PreferredOne we believe that your health care needs are as individual as you are. Staying physically active, eating healthy and managing stress are important elements in managing and maintaining your health. PreferredOne can assist you by offering health information and programs that will help you achieve and maintain your health goals. Once you are a member, PreferredOne offers the following at Health Club Discounts Receive up to $20 monthly credit towards your membership fees at participating health clubs when you work out 12 times a month. Members with dependent coverage may add one covered dependent (must be 18 years or older) to qualify for a total monthly credit of up to $40 per month. Online Health Risk Assessment Tobacco Cessation Program QUITPLAN Online Interactive Lifestyle Improvement Programs Healthwise Online Health Resources Member Discount Programs - exercise equipment, weight loss programs, etc. A Step by Step Guide to Apply for Coverage Step 1 Select the deductible level that fits your needs. Step 2 You may select the Chemical Dependency Rider Option for an additional cost. Step 3 Choose the date you want coverage to start. Your application, if approved will be effective on: The day the completed application is received by mail in the home office of PreferredOne; or The date after the completed application is received in the home office of PreferredOne if delivered to the lobby or submitted electronically; or A later date as requested on the application. (You may select an effective date from the 1st through the 28th provided the date is not greater than 60 days from the signature date.) Step 4 Complete the online application at or complete the paper application form and return it. Since 1992 PreferredOne has been a major sponsor of the Get in Gear 2K/5K/10K & Half Marathon Annual Rite of Spring events held in Minnehaha Park on the last Saturday of April each year. Go to for more information. Get In Gear for EveryOne

5 for EveryOne As a PreferredOne member you have access to a comprehensive range of online tools and information to help simplify and manage your health care coverage, check medical cost information and improve your health. Save With PreferredOne s Medical Cost Tools - Reprice existing claims with other PreferredOne providers - View a cost comparison for frequently performed services by clinic - Submit medical cost questions to a PreferredOne physician - View cost comparisons for MRI, CT & PET/CT scans - And more Find a Healthcare Provider Close to Home or Work Search for a doctor or clinic by name, specialty, city, or zip View My Health Account Statement Create your own medical/dental/rx claim history statement sorted by name and date. View My Benefits Access your Certifi cate of Coverage/Summary Plan Description explaining your benefi ts in detail, pharmacy information and more. Sign Up for Online Explanation of Benefits (EOB) Notification, Change Password and Login ID Questions? Please call Customer Service at or

6 fo r Ev very On ne PreferredOne PIC /07/2011

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