Plans and Rates Health Insurance. Available directly through Highmark for Individuals and Families

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1 2016 Health Insurance Plans and Rates Available directly through Highmark for Individuals and Families BENEFIT PERIOD: JANUARY 1, 2016 TO DECEMBER 31, B

2 GET COVERED DIRECTLY THROUGH HIGHMARK At Highmark Blue Shield, we believe that change is a good thing. Because health care can, and should, be a better experience. With plans and services that put you first. And easy access to health and wellness tools and services that help you make more informed health care decisions. If you don t have health insurance through your employer, Highmark can help you find an affordable 2016 qualified health plan option that is right for you. Listed in this brochure are Highmark plans that are available directly through Highmark. For more than 75 years, Highmark has been helping people like you in our area find the right health insurance plan that fits their needs and budget. This dedication has helped make Highmark the preferred health insurance company in the areas we serve. 1 Highmark also offers plans with financial help through the Health Insurance Marketplace. Financial help is only available with plans purchased through the Health Insurance Marketplace. To see if you qualify for financial help please contact the Health Insurance Marketplace at or The Highmark Difference Highmark is dedicated to making health insurance easier for you when and where you need it. Our goal is to transform health care, because you deserve a better health care experience: Lower Costs Get the most out of your health care dollars with the best quality care at the most competitive price Higher Quality Standards Hospitals and doctors close to where you live and work for the best access to care Better Health Outcomes Get better access to doctors and specialists who meet the highest benchmarks for delivering quality, cost-effective care And when you become a Highmark member, you have access to exclusive health and wellness tools and services for when you need care, to check health care costs before a procedure is done and most importantly, to help you make good decisions to keep you healthy. If you are already a Highmark member, visit HighmarkBlueShield.com and Log In to your secure member website to see more. My Care Navigator SM A built-in guide for navigating the health care system. Whether it s help with a care claim or assistance with provider billing, My Care Navigator helps members understand and manage their care costs. BlueCard Wherever you go nationwide as a Highmark member, you re in a Blue network. Just show your BlueCard to the thousands of participating physicians and hospitals across the country, and you ll receive in-network access away from home. Find a Doctor or RX Now Highmark gives you more ways than ever to find a health care provider that s right for you. Our easy-to-use online directory can help you find doctors, dentists, pharmacies, and even search for covered medications. To Find a Doctor, visit HighmarkBlueShield.com. Blues On Call SM Your medical questions don t just come up during offce hours. That s why Blues On Call gives you a 24/7 hotline to a team of registered nurses to help you with personal health questions. Health & Wellness Tools Members get access to today s leading-edge, online health and wellness tools. With Highmark you get what you need to launch your journey toward better health and wellness. It s convenient, easy to use, and best of all, it s free. Care Cost Estimator When you re planning a medical treatment, Highmark s Care Cost Estimator online tool lets you find and compare costs just like you do for other big purchases for more than 1,600 kinds of care visits. 1 Highmark Brand Perception Study Conducted by Lynx Research Consulting. 1 Call (TTY/TDD 711) to enroll or learn more.

3 QUALITY, AFFORDABLE COVERAGE FROM HIGHMARK Highmark offers a variety of affordable plan options. All of our plans: Let you see a specialist without needing a referral from your primary care doctor, so you can get the care that you need when you need it Offer covered emergency care at in-network rates at any emergency room Cover these Essential Health Benefits: Ambulatory services, such as primary care and specialist visits Maternity and newborn care Emergency services Prescription drugs, including retail and mail order Pediatric services, including oral and vision care Mental health and substance abuse services Rehabilitative services and devices Hospitalization Laboratory services No-cost preventive and wellness services, and chronic disease management Cover preventive services like annual physicals, immunizations and screenings at no cost to you, when delivered by a doctor in the Highmark network Include coverage for dependents up to age 26 Cover you even if you have a pre-existing health or medical condition Things You Need to Know Choosing a health plan can be complicated. There are a lot of things to take into account. It s important that you have all the information you need to make the best possible health insurance decision. To help you get a better understanding of the basics of health insurance, here are some of the most common health insurance terms that are important to know: Premium The amount you pay each month for your health insurance. Deductible The dollar amount you must pay each benefit period (usually a year) for your health care expenses before your plan begins to pay. Out-of-Pocket Maximum The highest amount you will need to pay each benefit period (usually a year) for covered in- network care before your insurance company pays 100% of covered in-network services. Coinsurance The part of a medical bill that you pay after reaching your deductible. Copayment (Copay) Fixed, upfront dollar amounts that you pay each time you receive certain health care services; can be before or after deductible. Formulary A formulary is a list of prescription drugs that are covered by your health insurance plan; out-of-pocket costs may apply. Call (TTY/TDD 711) to enroll or learn more. 2

4 IMPORTANT 2016 OPEN ENROLLMENT DATES The Open Enrollment Period for 2016 health insurance coverage starts November 1, Coverage may begin as soon as January 1, 2016 depending on when you enroll. Enroll in a 2016 plan any time between November 1, 2015 and January 31, NOVEMBER 1, 2015 Open Enrollment Begins If you don t enroll before Open Enrollment ends on January 31, 2016 you may pay a fee on your federal income tax return for To learn more about fee exceptions visit HealthCare.gov. DECEMBER 15, 2015 Enroll by this date for coverage to begin January 1, 2016 There is a Special Enrollment Period if you have a qualifying life event.* Examples include, but are not limited to, certain permanent moves, certain changes in your income, and changes in your family size (such as marriage, childbirth or adoption). JANUARY 15, 2016 Documentation that shows you are eligible for the Special Enrollment Period must be submitted to Highmark if you do not enroll in a 2016 plan during the Open Enrollment Period. Enroll by this date for coverage to begin February 1, 2016 *A special enrollment period may occur during or outside of Open Enrollment. JANUARY 31, 2016 Open Enrollment Ends Enroll by this date for coverage to begin March 1, 2016 HOW TO ENROLL THROUGH HIGHMARK Highmark is here to be your health insurance partner, every step of the way. Together, we ll help you find the coverage you need. 1 2 Review your 2016 Highmark plan options in this booklet on pages 4-5. Please note that some plans are only available in certain counties. Gather the documents you ll need to complete the enrollment application for yourself and every family member you want to enroll in your 2016 plan, including: Social Security Numbers (or documents for legal immigrants) Birth dates Policy numbers for any current health insurance Information about any health insurance you or your family could get from your jobs Calculate your rate by first finding the county you live in for your rate on pages 8-11.* Then find your age, tobacco use and the plan you wish to purchase directly from Highmark.** The base rate listed is the maximum amount you will pay every month. You may save on monthly premiums if you qualify for financial help and purchase a plan through the Health Insurance Marketplace. Highmark offers plans on the Marketplace. To see if you qualify for financial help please contact the Health Insurance Marketplace at HealthCare.gov or Complete the Highmark paper Application for New 2016 Individual/Family Plan Health Insurance and return it to Highmark with payment. (See rates on pages 8-11 to calculate payment amount.) Contact Highmark for questions or to enroll in a Highmark plan by calling or by visiting your local Highmark Direct store or Highmark insurance agent. * If you are over 21 years of age, find the county where you reside. If you are under 21 years of age, either find the county where you reside, or the county where you reside with your parent or guardian. ** For two-parent families with more than three children under age 21: Only include rates for you, your spouse/domestic partner, children between ages 21-26, and/ or three oldest children under age 21. Your policy automatically covers your remaining children. Please include them on your application as eligible dependents, but without a rate listed with their names. 3 Call (TTY/TDD 711) to enroll or learn more.

5 2016 HIGHMARK PLANS *Plans are available in these counties: Adams, Berks, Centre, Columbia, Cumberland, Dauphin, Franklin, Fulton, Juniata, Lancaster, Lebanon, Lehigh, Miffin, Montour, Northampton, Northumberland, Perry, Schuylkill, Snyder, Union and York Shared Cost plans have copays with coverage for some services right from the start. For other services, you first need to meet your deductible. Health Savings plans offer the tax and savings advantages of a Health Savings Account (HSA). You pay all costs until your deductible is met. Then you pay a percentage of costs until you meet your out-ofpocket maximum. Embedded plans have deductibles that have two components, an individual deductible and a family deductible. This allows for each family member to have medical bills covered before the family deductible is met. The individual deductibles add up to meet the family deductible. Specialty pharmacy drugs treat complex, chronic conditions like multiple sclerosis or cancer. They often are more expensive and may require special handling, administering and monitoring, and are distributed by an approved specialty pharmacy. HCR Comprehensive Formulary a list of prescription drugs that your health insurance plan covers. A generic drug will be dispensed unless the prescription order specifies that a brand drug is required. Plan Name Shared Cost Blue PPO 6000 Health Savings Blue PPO Embedded 4500 Health Savings Blue PPO Embedded 2700 Health Savings Blue PPO 1400 Metal Level BRONZE BRONZE SILVER GOLD Deductible (Individual) $6,000 $4,500 $2,700 $1,400 Deductible (Family) 1,2 $12,000 $9,000 $5,400 $2,800 Out-of-Pocket Maximum (Individual) 3 $6,850 $6,450 $5,400 $2,800 Out-of-Pocket Maximum (Family) $13,700 $12,900 $10,800 $5,600 Coinsurance (Plan Pays) Primary Care Visit Specialist or Urgent Care Visit 60% after deductible 70% after deductible 90% after deductible 90% after deductible 100% after $80 copay, no deductible 100% after $125 copay, no deductible 70% after deductible 90% after deductible 90% after deductible 70% after deductible 90% after deductible 90% after deductible Emergency Room Visit 60% after deductible 70% after deductible 90% after deductible 90% after deductible Inpatient Hospital Services Diagnostic Lab 7 60% after deductible 70% after deductible 90% after deductible 90% after deductible 100% after $75 copay, no deductible 70% after deductible 90% after deductible 90% after deductible Prescription Formulary HCR Comprehensive 6 HCR Comprehensive 6 HCR Comprehensive 6 HCR Comprehensive 6 Prescription Drug Coverage Retail Generic/Brand/ Non-Formulary (Member Pays) Specialty Pharmacy Retail Brand/ Non-Formulary (Member Pays) Pediatric Vision 100%, Services 5 no deductible or copay Pediatric Dental Services (Diagnostic & Preventive) 40% after deductible 30% after deductible 10% after deductible 10% after deductible 40% after deductible 30% after deductible 10% after deductible 10% after deductible 100%, no deductible or copay 100%, no deductible or copay 100%, no deductible or copay 100%, no deductible or copay 100%, no deductible or copay 100%, no deductible or copay 100%, no deductible or copay Do you need adult dental insurance? Highmark Blue Edge Dental offers a level of coverage that will fit your budget. Visit HighmarkBlueEdgeDental.com to find out more. Call (TTY/TDD 711) to enroll or learn more. 4

6 2016 ALLIANCE FLEX BLUE PLANS Alliance Flex Blue plans are only available in these counties: Berks, Cumberland, Dauphin, Lebanon and Perry Alliance Flex Blue covers services from in-network health providers participating at two different levels of benefits: 1 Enhanced Value Level of Benefits When you choose health care providers participating at this level of benefits, you generally pay the least in out of-pocket costs 2 Standard Value Level of Benefits You generally pay more out-of-pocket at this level Your out-of-pocket savings on your deductible, coinsurance or copayment will depend on the provider s level of participation. You save the most by using providers who participate at the Enhanced Value Level of Benefits. (See partial provider list on the next page.) Emergency care services are covered at Enhanced Value Level of Benefits no matter where care is provided. Out-of-network hospitals and providers that do not participate in the PremierBlue Shield Preferred Professional Provider Network, the Highmark Blue Shield Participating Facility Provider Network, a local Blue plan or BlueCard networks, will generally have the highest cost sharing. From the full network of providers, at all levels of benefits, you will receive high quality care and easy access to every kind of service. HCR Progressive Formulary a list of prescription drugs that your health insurance plan covers. A generic drug will be dispensed regardless of whether or not the prescription order specifies a brand drug. Members who cannot or will not accept a generic substitution will be required to pay more for the brand drug. Specialty pharmacy drugs treat complex, chronic conditions like multiple sclerosis or cancer. They often are more expensive and may require special handling, administering and monitoring, and are distributed by an approved specialty pharmacy. Plan Name Alliance FLEX Blue PPO 2100 *HCR Progressive Formulary offers $3 low-cost generic drugs. Alliance FLEX Blue PPO 1000 Metal Level SILVER GOLD Deductible (Individual) Deductible (Family) 1,2 Out-of-Pocket Maximum (Individual) 3 Out-of-Pocket Maximum (Family) Coinsurance (Plan Pays) Primary Care Visit Specialist or Urgent Care Visit Emergency Room Visit Inpatient Hospital Services Diagnostic Lab 7 $2,100 (enhanced); $4,200 (standard) $4,200 (enhanced); $8,400 (standard) $6,850 Enhanced and Standard Combined $13,700 Enhanced and Standard Combined 70% after deductible (enhanced); 50% after deductible (standard) 100% after $30 copay, no deductible (enhanced); 100% after $90 copay, no deductible (standard) 100% after $60 copay, no deductible (enhanced); 100% after $120 copay, no deductible (standard) 70% after enhanced deductible 70% after $950 admission copay, no deductible (enhanced); 50% after $2,000 admission copay, no deductible (standard) 100% after $30 copay, no deductible (enhanced); 100% after $120 copay, no deductible (standard) $1,000 (enhanced); $2,000 (standard) $2,000 (enhanced); $4,000 (standard) $5,000 Enhanced and Standard Combined $10,000 Enhanced and Standard Combined 80% after deductible (enhanced); 60% after deductible (standard) 100% after $10 copay, no deductible (enhanced); 100% after $55 copay, no deductible (standard) 100% after $20 copay, no deductible (enhanced); 100% after $70 copay, no deductible (standard) 100% after $150 copay, no deductible (waived if admitted) 80% after $500 admission copay, no deductible (enhanced); 60% after $1,000 admission copay, no deductible (standard) 100% after $20 copay, no deductible (enhanced); 100% after $70 copay, no deductible (standard) Prescription Formulary HCR Progressive* 4 HCR Progressive* 4 Prescription Drug Coverage Retail Generic/Brand/ Non-Formulary (Member Pays) Specialty Pharmacy Retail Brand/ Non-Formulary (Member Pays) $10 copay; $50 copay; $100 copay 50% with $600 max per prescription; 50% up to $1,000 max per prescription $10 copay; $50 copay; $100 copay 50% with $600 max per prescription; 50% up to $1,000 max per prescription Pediatric Vision Services 5 100%, no deductible or copay 100%, no deductible or copay Pediatric Dental Services (Diagnostic & Preventive) 100%, no deductible or copay 100%, no deductible or copay 5 Call (TTY/TDD 711) to enroll or learn more.

7 ALLIANCE FLEX BLUE You decide how much to save on your out-of-pocket costs because you decide which provider to use with our Alliance Flex Blue health plan options. Alliance Flex Blue covers services from health providers participating at two levels of in-network benefits: Enhanced Value Level of Benefits or Standard Value Level of Benefits. Participating at the Enhanced Value Level of Benefits are Penn State Milton S. Hershey Medical Center and PinnacleHealth System Hospitals. They were rated as must have hospitals based on reputation and members personal experience. They were ranked first and second for quality. 1 Alliance Flex Blue is only available in five Pennsylvania counties, Berks, Cumberland, Dauphin, Lebanon, and Perry. Outside of these counties, services received from providers participating in the PremierBlue Shield Preferred Professional Provider Network, the Highmark Blue Shield Participating Facility Provider Network, or a local Blue plan s BlueCard PPO Network will be covered at the Standard Value Level of Benefits. This gives you access to 97 percent of all U.S. hospitals and more than 92 percent of all U.S. physicians nearly 720,000 providers across the country. ALLIANCE FLEX BLUE is only available to individuals that reside in these counties Berks, Cumberland, Dauphin, Lebanon and Perry. Members have access to any of these hospitals and affliated physicians at the in-network levels of benefits.* Plus, access to other in-network hospitals and physicians in the participating networks listed below or BlueCard program at the Standard Value Level of Benefits. ENHANCED Value Level of Benefits Penn State Milton S. Hershey Medical Center Penn State Health St. Joseph PinnacleHealth System Hospitals: - Community General Osteopathic Hospital - Harrisburg Hospital - Polyclinic Hospital - West Shore Hospital STANDARD Value Level of Benefits Carlisle Regional Medical Center Good Samaritan Hospital Holy Spirit Hospital Reading Hospital Surgical Institute of Reading All other providers in the PremierBlue Shield Preferred Professional Provider Network, the Highmark Blue Shield Participating Facility Provider Network, Highmark Managed Care Network, or BlueCard networks *Provider designation within Levels of Benefits and participating hospitals/doctors is subject to change. List current as of 10/15. OUT-OF-NETWORK Hospitals that do not participate in the PremierBlue Shield Preferred Professional Provider Network, the Highmark Blue Shield Participating Facility Provider Network, Highmark Managed Care Network or BlueCard networks To Find a Doctor and check that provider s level of participation visit HighmarkBlueShield.com. The Level of Benefits will be listed under the provider s name. Call (TTY/TDD 711) to enroll or learn more. 6

8 DISCLOSURE Important Benefit Details 1 Alliance Flex Blue, Shared Cost and Health Savings Embedded Family Deductible: For an Agreement covering more than one (1) family member, as each Member satisfies their individual Deductible, the Plan will begin to pay benefits for Covered Services for that Member for the remainder of the Benefit Period (January 1, 2016 December 31, 2016), whether or not the entire family Deductible has been satisfied. When the family Deductible has been satisfied, the family Deductible will be considered to have been satisfied for all remaining covered family members. No individual Member may satisfy the entire family Deductible. 2 Health Savings Family Deductible: For an Agreement covering more than one (1) family member, the ENTIRE family deductible must be met [within a benefit period (January 1, 2016 December 31, 2016)] before Highmark will pay for covered services for ANY family member. The family deductible can be satisfied by an individual family member or a combination of one or more family members. 3 You are responsible for out-of-pocket costs each Benefit Period up to a maximum amount shown. Thereafter, the Plan pays 100% of the Provider s Allowable Charge during the remainder of the Benefit Period. This amount does not include amounts in excess of the Provider s Allowable Charge. 4 HCR Progressive formulary prescription drug copays for a 31-day supply (Retail): $3 low-cost generic; $10 generic; $50 brand; $100 non-formulary brand and nonformulary generic; specialty drug copays vary. The plan has a six-tier structure and utilizes the HCR Progressive Formulary on the National network. Mail order available. If a generic substitution is available but not accepted by the Member they are responsible for paying the difference between the price for a Brand Drug and any available generic equivalent, for each separate Prescription Order or refill plus the drug copay. 5 Vision benefits utilize the Davis National Network. Pediatric Dental benefits utilize United Concordia s Advantage Network 6 The plan utilizes the HCR Comprehensive Formulary on the National network. Specialty drug copays may vary. Mail order available. 7 Basic Diagnostic Services include four types of service: Standard Imaging Services, Laboratory and Pathology, Diagnostic Medical and Allergy Testing. Basic Diagnostic Services require one copay per date of service and type of service. Additional Basic Diagnostic Services are subject to deductible and coinsurance. Advanced Diagnostic Services include but are not limited to CAT Scan, CTA, MRI, MRA, PET Scan and PET/CT Scan. Health Savings Plans are Qualified High Deductible Health Plans that may be coupled with a Health Savings Account (HSA). However, certain Cost-Sharing Reductions (CSR) or plan variations of this plan that are offered through the Health Insurance Marketplace are not intended to be used with an HSA. If you have questions, please check with your financial advisor. Multi-State Plans are only available for enrollment through the Health Insurance Marketplace. Insurance may be provided by Highmark Health Insurance Company or Highmark Select Resources. Highmark Blue Shield, Highmark Health Insurance Company and Highmark Select Resources are independent licensee of the Blue Cross and Blue Shield Association. Blue Shield and the Shield symbol are registered service marks of the Blue Cross and Blue Shield Association. Highmark is a registered mark of Highmark Inc. Information regarding the Patient Protection and Affordable Care Act of 2010 (a.k.a. PPACA, Affordable Care Act, ACA, and/or Health Care Reform ), as amended, and/or any other law, does not constitute legal or tax advice and is subject to change based upon the issuance of new guidance and/or change in laws. State laws may be applicable. Any review of materials, request for information, or application does not obligate you to enroll for coverage. The benefits listed are a summary. Please request the Outline of Coverage for details on benefits, conditions and exclusions. Federal and state laws and regulations govern health insurance and health plans may vary from state to state. Highmark does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations. We are committed to providing outstanding services for our applicants and members. If you require special assistance, including accommodations for disabilities or limited English proficiency, please call us at to request these free services (TTY/TDD users may call 711). To find more information about Highmark s benefits and operating procedures, such as accessing the drug formulary or using network providers, please go to DiscoverHighmark. com/qualityassurance; or for a paper copy, call Highmark Health Insurance Company and Highmark Select Resources are Qualified Health Plan issuers in the Health Insurance Marketplace. Blues On Call and My Care Navigator are service marks and BlueCard is a registered mark of the Blue Cross and Blue Shield Association. If you are looking for additional plan details, each plan s Summary of Benefits and Coverage is available online at Shop.Highmark.com/sales/#/sbcs. With this information, you ll be able to shop and compare with confidence. If you do not have online access, you can get a paper copy of any Summary of Benefits free of charge by calling toll-free Call (TTY/TDD 711) to enroll or learn more.

9 RATES FOR YOUR COUNTY Adams, Columbia, Centre, Lancaster, Lehigh, Miffin, Montour, Northampton, Northumberland, Schuylkill, Snyder, Union, York Age PPO Bronze Bronze Silver Gold Shared Cost Blue PPO 6000 Health Savings Blue PPO Embedded 4500 Health Savings Blue PPO Embedded 2700 Health Savings Blue PPO 1400 Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco 0-20 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $1, $ $ $ $ $ $1, $1, $1, $ $ $ $ $ $1, $1, $1, $ $ $ $ $ $1, $1, $1, $ $ $ $ $ $1, $1, $1, Call (TTY/TDD 711) to enroll or learn more. 8

10 RATES FOR YOUR COUNTY Franklin, Fulton, Juniata Age PPO Bronze Bronze Silver Gold Shared Cost Blue PPO 6000 Health Savings Blue PPO Embedded 4500 Health Savings Blue PPO Embedded 2700 Health Savings Blue PPO 1400 Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco 0-20 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $1, $ $ $ $ $ $1, $1, $1, $ $ $ $ $ $1, $1, $1, $ $ $ $ $ $1, $1, $1, Call (TTY/TDD 711) to enroll or learn more.

11 RATES FOR YOUR COUNTY Berks Age PPO Bronze Bronze Silver Gold Silver Gold Shared Cost Blue PPO 6000 Health Savings Blue PPO Embedded 4500 Health Savings Blue PPO Embedded 2700 Health Savings Blue PPO 1400 Alliance Flex Blue PPO 2100 Alliance Flex Blue PPO 1000 Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco 0-20 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $1, $1, $ $ $ $ $ $ $ $ $ $1, $1, $1, $ $ $ $1, $ $ $ $ $ $1, $1, $1, $ $ $ $1, $ $ $ $ $ $1, $1, $1, $ $ $ $1, Call (TTY/TDD 711) to enroll or learn more. 10

12 RATES FOR YOUR COUNTY Cumberland, Dauphin, Lebanon, Perry Age PPO Bronze Bronze Silver Gold Gold Silver Shared Cost Blue PPO 6000 Health Savings Blue PPO Embedded 4500 Health Savings Blue PPO Embedded 2700 Health Savings Blue PPO 1400 Alliance Flex Blue PPO 1000 Alliance Flex Blue PPO 2100 Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco 0-20 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $1, $1, $ $ $ $ $ $ $ $ $ $1, $1, $1, $ $1, $ $ $ $ $ $ $ $1, $1, $1, $ $1, $ $ Call (TTY/TDD 711) to enroll or learn more.

13 ا COMMITTED TO PROVIDING OUTSTANDING SERVICE We are committed to providing outstanding services for our applicants and members. If you require special assistance, including accommodations for disabilities or limited English proficiency, please call us at to request these free services. (TTY/TDD: 711) Estamos comprometidos a ofrecer servicios excepcionales a nuestros solicitantes y miembros. Si usted necesita ayuda especial, incluyendo acomodaciones para discapacidades o dominio limitado del inglés, por favor llámenos al para solicitar estos servicios gratuitos. (TTY/TDD: 711) Wir haben uns verpflichtet, unseren Bewerbern und Mitgliedern außerordentliche Dienstleistungen anzubieten. Falls Sie beispielsweise Unterkünfte für Menschen mit Behinderungen oder aufgrund eingeschränkter Englischkenntnisse besondere Unterstützung benötigen, kontaktieren Sie uns unter der Rufnummer , um unsere kostenlosen Dienstleistungen in Anspruch zu nehmen. (TTY/TDD: 711) Ci impegniamo a fornire sempre servizi all avanguardia per i nostri candidati e membri. In caso necessitiate di assistenza speciale, compresi alloggi per disabili o supporto per la scarsa padronanza della lingua inglese, contattateci allo per richiedere gratuitamente tali servizi. (TTY/TDD: 711) 我 們 致 力 於 為 我 們 的 申 請 人 和 會 員 們 提 供 卓 越 的 服 務 如 果 您 需 要 特 殊 協 助, 包 括 殘 障 或 英 語 能 力 有 限, 請 致 電 來 要 求 這 些 免 費 服 務 (TTY/TDD: 711) Nous nous engageons à fournir des services exceptionnels pour nos candidats et membres. Si vous avez besoin d'une assistance particulière, y compris pour handicapés ou compétences limitées en anglais, s'il vous plaît appelez-nous au pour demander ces services gratuits. (TTY/TDD: 711) Мы стремимся оказывать первоклассные услуги для наших кандидатов и членов. Если вы нуждаетесь в специальной помощи, включая принятие мер в связи с инвалидностью или ограниченным владением английским языком, пожалуйста, позвоните нам по телефону и попросите об оказании этих бесплатных услуг. (TTY/TDD: 711) Chúng tôi quyết tâm cung cấp dịch vụ xuất sắc cho các đương đơn và hội viên của mình. Nếu quý vị cần được trợ giúp đặc biệt, bao gồm các thích nghi cho người bị khuyết tật hoặc có khả năng Anh Ngữ hạn hẹp, xin gọi chúng tôi tại số để yêu cầu các dịch vụ miễn phí này. (TTY/TDD: 711) Zależy nam, aby usługi, które świadczymy dla naszych kandydatów i członków charakteryzowały się zawsze najwyższą jakością. Jeżeli potrzebna jest specjalna pomoc, np. w przypadku osób niepełnosprawnych lub osób z ograniczoną znajomością języka angielskiego, oferujemy bezpłatne usługi w tym zakresie prosimy o telefon pod numer (TTY/TDD: 711) 저희들은 신청자들과 회원들에게 탁월한 서비스를 제공하고자 노력하고 있습니다. 신체장애인들이나 비영어권 참석자들을 위해 특별한 도움이 필요하시면 전화 로 알려주시기 바랍니다. 이러한 서비스는 무료입니다. (TTY/TDD: 711) نلتزم بتوفير خدمة متميزة للمتقدمين واألعضاء. إذا كنت تتطلب مساعدة خاصة شام ل التجهيزات ال لزمة ل لحتياجات الخاصة أو إجادة محدودة لإلنجليزية برجاء االتصال على لطلب هذه الخدمات المجانية. (711 (TTY/TDD: हम अपन आव दक और सदस य क ल ए उत क ष ट स व ए प द न करन क प त वचनबद ह यदद आपक ववश ष सह य च दहए ह, ज सम अक म अथव स लम अग तनपण ह सम य न भ श लम ह, क पय इन तनशल क स व ओ ह अनर ध क ल ए हम पर क कर (TTY/TDD: 711) Call (TTY/TDD 711) to enroll or learn more. 12

14 COMMITTED TO PROVIDING OUTSTANDING SERVICE અમ અમ ર અરજ કર ઓ અન સભ ય મ ટ ઉમદ સવ ઓ પર પ ડવ કટટબદ છ એ. જ ર મન વવકલ ગર ક અ ગ જ મ મય ટદર વનપણર ધર વન ર ઓ મ ટ સગવડભર ગ ઠવણ સટ ર ન વવશષ સ યર જ ઈર ય, ર આ મફર સવ ઓન વવનર કરવ કપ કર અમન નબર પર ફ ન કર. (TTY/TDD: 711) May pananagutan kaming magbigay ng bukod-tanging mga serbisyo para sa aming mga aplikante at mga miyembro. Kung kailangan mo ng espesyal na tulong, kabilang ang mga akomodasyon para sa mga kapansanan o limitadong kahusayan sa wikang Ingles, mangyaring tawagan kami sa para hilingin ang mga libreng serbisyong ito. (TTY/TDD: 711) Είμαστε δεσμευμένοι να παρέχουμε εξαιρετικές υπηρεσίες για τους αιτούντες και τα μέλη μας. Εάν χρειάζεστε ειδική βοήθεια, συμπεριλαμβανομένων διευκολύνσεων για ειδικές ανάγκες ή περιορισμένη ευχέρεια στα Αγγλικά, παρακαλούμε επικοινωνήστε μαζί μας στο να ζητήσετε τις δωρεάν αυτές παροχές. (TTY/TDD: 711) 私 たちは 入 会 志 願 者 とメンバーのために 卓 越 したサービスを 提 供 することに 全 力 を 注 いでいます あなたが 障 害 者 のための 便 宜 または 制 限 英 語 能 力 を 含 む 特 別 な 支 援 が 必 要 な 場 合 は これらの 無 料 サービスを 受 けるため に までお 電 話 ください (TTY/TDD: 711) ہم اپنے درخواست دہندگان اور ممبران کے لیے عمدہ خدمات فراہم کرنے کے لیے عہد بستہ ہیں اگر آپ کو خصوصی اعانت کی ضرورت ہے جس میں معذوریوں یا انگریزی کی محدود لیاقت کے لیے سہولیات شامل ہیں ان مفت خدمات کی درخواست کرنے کے لیے براہ کرم ہمیں پر کال کریں (711 (TTY/TDD: Estamos empenhados em fornecer serviços especiais para os nossos candidatos e membros. Caso necessite de assistência especial, incluindo alojamento por motivos de deficiência ou conhecimentos limitados de língua inglesa, ligue para o n.º para solicitar estes serviços gratuitos. (TTY/TDD: 711) Ebe fun awon alaabo ara tabi oore ofe lati le so ede geesi to se gbo seti. Ejowo e pe wa fun eyikeyi ohun ti e ba nfe ki a se fun yin lofe. (TTY/TDD: 711) Sisi ni nia ya kutoa huduma bora kwa waombaji wetu na wanachama. Kama unahitaji msaada maalum, ikiwa ni pamoja na malazi kwa ulemavu au mdogo Kiingereza duni, tafadhali wito wetu katika idadi ya kuomba huduma hizi bure. (TTY/TDD: 711) Nihinaanish niizhóni go bee nihiká adiilwołi gi i binahji ts i dá ye ego bidiilkaal, nihi naaltsoos nidahoni łi gi i dóó Bee Atah i dli ni gi i nihił hada di t e hi gi i nihá. Hait e ego da anáhóót i go, bilagáana bizaad t áá nił nanitł ago, áká a ayeed holo, koji be e sh beehane e bee hodi i lnih , e i t áá ji i k eh áká a ayeed biniiye. (TTY/TDD: 711) เรามงมนทจะมอบบรการทโดดเดนใหแกผสมครและสมาชกของเรา หากคณตองการความชวยเหลอเป นพเศษ รวมถงการอานวยความสะดวกใหแกบคคลทพพลภาพหรอผทมความสามารถทางภาษาองกฤษในระด บออน โปรดตดตอเราไดท เพอรองขอบรการด งกลาวไดโดยไมมคาใชจาย (TTY/TDD: 711) 13 Call (TTY/TDD 711) to enroll or learn more.

15 BLANK PAGE Call (TTY/TDD 711) to enroll or learn more. 14

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