2015 Medical and Dental Plan Comparison Chart

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1 Benefits for Professional Staff 2015 Medical and Dental Plan Comparison Chart This workplace has been recognized by the American Heart Association for meeting criteria for employee wellness.

2 This chart is only a summary. For details, limitations, and exclusions, please contact your Professional Staff Benefits Office for the specific plan s bene PARTNERS PLUS General Provisions Annual Deductible (individual/family) The Plan s Coinsurance Medical Out-of-Pocket Maximum (individual/family) 1 Pre-Admission Certification Primary Care Physician Maximum Lifetime Benefit Inpatient Medical and Surgical Services Per Admission Co-Pay Semiprivate Room and Ancillary Services Inpatient Physician/Surgeon/Anesthesia Private Duty Nursing Inpatient Mental Health and Substance Abuse Services Inpatient Mental Health and Substance Abuse Partners Preferred Network BCBS Plan Network Out-of-Network None $2,500/$5,000 combined maximum 1 N/A $250/$500 $250 after deductible after deductible after deductible $500/$1,000 70% $4,000/$8,000 1 Deductible applies Outpatient Covered Services Primary Care Physician Office Visits Specialist Office Visits Routine Physicals 2 Other Preventive Care 2 Hospital Outpatient Emergency Room Visit Prescriptions CVS/caremark at participating pharmacies 1, 4 60-Day co-pays: $20/$60/$ Day Maintenance Choice co-pays: $20/$60/$100 Outpatient Surgery Pre-Hospital Admission Testing/Labs Routine Pediatric Care (birth through age 18) 2 Immunizations and Inoculations (adult) 2 Pap Smear 2 Routine Mammogram (one baseline mammogram between ages 35 39; one mammogram per year after age 40) 2 Hearing Exams 2 Hearing Aids and Batteries 1,3 Diagnostic X-Ray and Lab Services Ambulatory CT Scan/MRI/PET Physical Therapy Speech Therapy Mental Health and Substance Abuse Durable Medical Equipment Ambulance Service (emergency only) Allergy Testing and Treatment Maternity Coverage In-Hospital (Delivery) Out-of-Hospital (prenatal care) Other Services Skilled Nursing Facilities Home Health Services Hospice Care Cardiac Rehabilitation Chiropractic Services Podiatrist Services co-pay; $0 co-pay; $0 co-pay; co-pay; $0 co-pay; $0 co-pay; $0 co-pay; $0 co-pay; (according to schedule) $0 co-pay; co-pay; (100 visits per calendar year) co-pay; co-pay; co-pay; $0 co-pay; co-pay; co-pay; (limited services only) $40 co-pay; $0 co-pay; $0 co-pay; $40 co-pay; 0 co-pay; $0 co-pay; $0 co-pay; $0 co-pay; $0 co-pay; (according to schedule) $0 co-pay; 0 co-pay; $40 copay (visits 1-15); co-pay (visits ) (100 visits per calendar year) $40 copay (visits 1-15); co-pay (visits 16+) co-pay; $40 co-pay $250 per admission after deductible $0 co-pay; $40 co-pay (visits 1-15); co-pay (visits 16+); after deductible co-pay; (limited services only) (to age 5 only) (according to schedule) (100 visits per calendar year) (limited services only) 1 This is a combined medical out-of-pocket maximum for the Partners Preferred and Plan Networks. Hearing aid co-pays do not count toward the medical out-of-pocket maximum. A separate out-of-pocket maximum applies to the prescription drug plan, based on your salary and medical plan coverage level as of January 1, 2015: 2 No co-pay for in-network preventive care described under the Affordable Care Act; co-pay applies if regular office visit includes non-preventive care. Preventive care includes most routine physical exams and preventive screenings for adults and children; well-child care; preventive immunizations; preventive Pap smears and mammograms; routi 3 Hearing aids are covered up to age 22 under the state mandate. Coverage is $2,000 per ear every 36 months for all plans. In addition, Partners Plus and Partners Value provide coverage of $1,000 per year from age 22 on. 4 Most pharmacies are In-Network for CVS/caremark. No coverage is available for an Out-of-Network pharmacy. Maintenance Choice (mail order or CVS/pharmacy pick up) is required for maintenance drugs.

3 fit description. PARTNERS VALUE General Provisions Annual Deductible (individual/family) The Plan s Coinsurance Medical Out-of-Pocket Maximum (individual/family) 1 Pre-Admission Certification Primary Care Physician Maximum Lifetime Benefit Inpatient Medical and Surgical Services Per Admission Co-Pay Semiprivate Room and Ancillary Services Inpatient Physician/Surgeon/Anesthesia Private Duty Nursing Inpatient Mental Health and Substance Abuse Services Inpatient Mental Health and Substance Abuse Partners Preferred Network BCBS Plan Network Out-of-Network None $250 $3,000/$5,200 combined maximum 1 $500/$1,000 75% $250 after deductible 75% after deductible 75% after deductible after deductible $750/$1,500 65% $5,000/$10,000 Deductible applies Outpatient Covered Services Primary Care Physician Office Visits Specialist Office Visits Routine Physicals 2 Other Preventive Care 2 Hospital Outpatient Emergency Room Visit Prescriptions CVS/caremark at participating pharmacies 1, 4 60-Day co-pays: $20/$60/$ Day Maintenance Choice co-pays: $20/$60/$100 Outpatient Surgery Pre-Hospital Admission Testing/Labs Routine Pediatric Care (birth through age 18) 2 Immunizations and Inoculations (adult) 2 Pap Smear 2 Routine Mammogram (one baseline mammogram between ages 35 39; one mammogram per year after age 40) 2 Hearing Exams 2 Hearing Aids and Batteries 1,3 Diagnostic X-Ray and Lab Services Ambulatory CT Scan/MRI/PET Physical Therapy Speech Therapy Mental Health and Substance Abuse Durable Medical Equipment Ambulance Service (emergency only) Allergy Testing and Treatment $35 $35 co-pay; $0 co-pay; $0 co-pay; $35 co-pay; $0 co-pay; $0 co-pay; $0 co-pay; $0 co-pay; (according to schedule) $0 co-pay; $35 co-pay; (100 visits per calendar year) $35 co-pay; $35 co-pay; $35 co-pay; $35 $50 co-pay; $0 co-pay; $0 co-pay; $50 co-pay; $200 co-pay; $0 co-pay; $0 co-pay; $0 co-pay; $0 co-pay; (according to schedule) $0 co-pay; 0 co-pay; $50 copay (visits 1-15); $35 co-pay (visits ) (100 visits per calendar year) $50 copay (visits 1-15); $35 co-pay (visits 16+) $35 co-pay; $50 co-pay (to age 5 only) (according to schedule) (100 visits per calendar year) Maternity Coverage In-Hospital (Delivery) Out-of-Hospital (prenatal care) Other Services Skilled Nursing Facilities Home Health Services Hospice Care Cardiac Rehabilitation Chiropractic Services Podiatrist Services $0 co-pay; $35 co-pay; $35 co-pay; (limited services only) $250 per admission after deductible; $0 co-pay; $250 co-pay; $50 co-pay (visits 1-15); co-pay (visits 16+); 75% after deductible $35 co-pay; (limited services only) (limited services only) Under $50,000: $250/$500 $50,000 to $100,000: $800/$1,600 Above $100,000: $1,600/$4,000 If you enroll in Partners Value, you will pay twice these amounts before you reach the out-of-pocket maximum. ne gynecology visits; routine vision exams; routine hearing exam office visits and hearing tests; preventive lab tests; family planning services (including contraception); routine Prostate-Specific Antigen (PSA) testing; and routine sigmoidoscopies/colonoscopies, except where surgical removal takes place, which is subject to deductible, co-pay and/or coinsurance

4 HARVARD PILGRIM HEALTH CARE Partners Preferred Network HPHC Plan Network General Provisions Annual Deductible (individual/family) The Plan s Coinsurance Medical Out-of-Pocket Maximum (individual/family) 1 Pre-Admission Certification Primary Care Physician Maximum Lifetime Benefit None $2,500/$5,000 combined maximum 1 $250/$500 Inpatient Medical and Surgical Services Per Admission Co-Pay Semiprivate Room and Ancillary Services Inpatient Physician/Surgeon/Anesthesia Private Duty Nursing Inpatient Mental Health and Substance Abuse Services N/A $250 after deductible after deductible after deductible Inpatient Mental Health and Substance Abuse after deductible Outpatient Covered Services Primary Care Physician Office Visits Specialist Office Visits Routine Physicals 2 Other Preventive Care 2 Hospital Outpatient Emergency Room Visit Prescriptions CVS/caremark at participating pharmacies 1, 4 60-Day co-pays: $20/$60/$ Day Maintenance Choice co-pays: $20/$60/$100 Outpatient Surgery Pre-Hospital Admission Testing/Labs Routine Pediatric Care (birth through age 18) 2 Immunizations and Inoculations (adult) 2 Pap Smear 2 Routine Mammogram (one baseline mammogram between ages 35 39; one mammogram per year after age 40) 2 Hearing Exams 2 Hearing Aids and Batteries 1,3 Diagnostic X-Ray and Lab Services Ambulatory CT Scan/MRI/PET Physical Therapy Speech Therapy Mental Health and Substance Abuse Durable Medical Equipment Ambulance Service (emergency only) Allergy Testing and Treatment Maternity Coverage In-Hospital (Delivery) Out-of-Hospital (prenatal care) Other Services Skilled Nursing Facilities Home Health Services Hospice Care Cardiac Rehabilitation Chiropractic Services Podiatrist Services co-pay; $0 co-pay; $0 co-pay; co-pay; $0 co-pay; $0 co-pay; $0 co-pay; $0 co-pay; (according to schedule) co-pay; co-pay; (100 visits per calendar year) co-pay; co-pay; co-pay; $0 co-pay; (100 days per year maximum) co-pay; co-pay (up to 12 visits per year) (limited services only) $40 co-pay; $0 co-pay; $0 co-pay; $40 co-pay; 0 co-pay; $0 co-pay; $0 co-pay; $0 co-pay; $0 co-pay; (according to schedule) $40 co-pay; 0 co-pay; $40 copay (visits 1-15); co-pay (visits ) (100 visits per calendar year) $40 copay (visits 1-15); co-pay (visits 16+) co-pay; $40 co-pay $250 per admission after deductible $0 co-pay; (100 Days per year maximum) $40 co-pay (visits 1-15); co-pay (visits 16+); co-pay (up to 12 visits per year) (limited services only). Frequency of coverage for services will be based on preventive screening guidelines referenced by the Affordable Care Act.

5 TUFTS HEALTH PLAN General Provisions Annual Deductible (individual/family) The Plan s Coinsurance Medical Out-of-Pocket Maximum (individual/family) 1 Pre-Admission Certification Primary Care Physician Maximum Lifetime Benefit Inpatient Medical and Surgical Services Per Admission Co-Pay Semiprivate Room and Ancillary Services Inpatient Physician/Surgeon/Anesthesia Private Duty Nursing Inpatient Mental Health and Substance Abuse Services Inpatient Mental Health and Substance Abuse Outpatient Covered Services Primary Care Physician Office Visits Specialist Office Visits Routine Physicals 2 Other Preventive Care 2 Hospital Outpatient Emergency Room Visit Prescriptions CVS/caremark at participating pharmacies 1, 4 60-Day co-pays: $20/$60/$ Day Maintenance Choice co-pays: $20/$60/$100 Outpatient Surgery Pre-Hospital Admission Testing/Labs Routine Pediatric Care (birth through age 18) 2 Immunizations and Inoculations (adult) 2 Pap Smear 2 Routine Mammogram (one baseline mammogram between ages 35 39; one mammogram per year after age 40) 2 Hearing Exams 2 Hearing Aids and Batteries 1,3 Diagnostic X-Ray and Lab Services Ambulatory CT Scan/MRI/PET Physical Therapy Speech Therapy Mental Health and Substance Abuse Durable Medical Equipment Ambulance Service (emergency only) Allergy Testing and Treatment Maternity Coverage In-Hospital (Delivery) Out-of-Hospital (prenatal care) Other Services Skilled Nursing Facilities Home Health Services Hospice Care Cardiac Rehabilitation Chiropractic Services Podiatrist Services Partners Preferred Network None N/A co-pay; $0 co-pay; $0 co-pay; co-pay; $0 co-pay; $0 co-pay; $0 co-pay; $0 co-pay; (according to schedule) co-pay; co-pay; (100 visits per calendar year) co-pay; co-pay; co-pay; $0 co-pay; $2,500/$5,000 combined maximum 1 with authorization co-pay; co-pay; (up to 12 visits per year) (limited services only) Tufts Plan Network $250/$500 $250 after deductible after deductible after deductible after deductible $40 co-pay; $0 co-pay; $0 co-pay; $40 co-pay; 0 co-pay; $0 co-pay; $0 co-pay; $0 co-pay; $0 co-pay; (according to schedule) $40 co-pay; 0 co-pay; $40 copay (visits 1-15); co-pay (visits ) (100 visits per calendar year) $40 copay (visits 1-15); co-pay (visits 16+) co-pay; $40 co-pay $250 per admission after deductible $0 co-pay; with authorization $40 co-pay (visits 1-15); co-pay (visits 16+); with authorization co-pay; (up to 12 visits per year) (limited services only)

6 Dental Services Basic Dental Major Dental Calendar-Year Maximum $1,000 per person $2,000 per person (excluding orthodontia) Diagnostic/Preventive Services Complete initial exam and charting once Periodic oral exams twice per calendar year X-Rays: full mouth every 60 months; bitewings twice per calendar year Single tooth X-Rays as needed Comprehensive evaluation every 60 months Preventive Services Teeth cleaning twice per calendar year Fluoride treatment twice per calendar year for members under age 19 Coverage No Deductible Space maintainers (required due to the premature loss of teeth) for members under age 14 and not for the replacement of primary or permanent anterior teeth. Sealants for unrestored permanent molars every 4 years per tooth for members through age 15. Sealants are also covered for members ages 16 up to age 19 who have had a recent cavity and are at risk for decay. Periodontal cleaning Once every three months following active periodontal treatment, not to be combined with preventive cleanings. Minor Restorative Restorative Services Silver and white fillings once every 24 months per surface, per tooth Temporary fillings once per tooth Stainless steel crowns once every 24 months per primary tooth Oral Surgery Simple extractions (non-surgical) in dentist s office Surgical extractions, (including impactions) in dentist s office (Oral surgical benefits not provided when rendered in a surgical day care or hospital setting) Periodontics Scaling and root planing once in 24 months, per quadrant Periodontal Surgery one surgical procedure per quadrant, in 36 months Endodontics Root canal therapy once per tooth Vital pulpotomy limited to deciduous teeth Prosthetic Maintenance Bridge or denture repairs once within 12 months, same repair Rebase of dentures once every 36 months Recementing crowns and onlays once every 12 months per tooth Emergency Dental Care Minor treatment for pain relief three occurrences in 12 months General Anesthesia and IV sedation are allowed with covered surgery for impacted wisdom teeth. After a $50 individual deductible, $100 family, 50% Coverage After a $25 individual deductible, $50 family, Coverage Major Restorative Prosthodontics Dentures once within 60 months Fixed bridges and crowns (when part of a bridge) once every 60 months Implants once every 60 months per tooth Restorative Services Crowns and onlays (when teeth cannot be restored with regular fillings) once every 60 months per tooth Orthodontia Active orthodontic treatment Lifetime orthodontia maximum not available N/A 50% Coverage after plan deductible 50% coverage, no deductible $2,000 lifetime maximum benefit Eligible children covered up to age 26. Contact Delta Dental by phone at or visit them online at:

7 MEDICAL PLAN HIGHLIGHTS FOR 2015 n Each plan has a network known as the Partners Preferred Network. If you want to pay the lowest out-of-pocket claim costs, use a Partners Preferred (or affiliated) Network specialist and facility for your care. n Even if you do not use a Partners Preferred Network specialist or facility, you can still receive comprehensive care, with minimal out-of-pocket claim costs, by using specialists and facilities within your insurance carrier s Plan Network. n Primary care physician (PCP) visits, and mental health/substance abuse co-payments and deductibles, cost the same in the Partners Preferred and Plan Networks. n You do not need to get an insurance referral from your PCP in order to receive coverage for specialist visits and other services. Your insurance carrier does not track your PCP in their files. However, you are encouraged to select a PCP to serve as a home base for your medical care. n Emergency room co-payments are $100, regardless of plan or network. This co-payment is waived if you are admitted. n There are no costs for X-rays or lab tests, regardless of whether you receive the tests at a Partners or non-partners facility. However, your co-payments and deductibles for physical therapy, inpatient admissions, outpatient surgery, and high-cost, ambulatory imaging (MRIs, CT scans and PET scans) will be higher when you use non-partners specialists and facilities. n For more information about the plans networks, or to check your provider s network status, please visit the following websites: BLUE CROSS BLUE SHIELD (for Partners Plus, Partners Value) HARVARD PILGRIM HEALTH CARE TUFTS HEALTH PLAN DID YOU KNOW? n Prescription drug coverage is provided by CVS/caremark based on an Open Formulary a list of covered prescriptions. You can save by filling maintenance prescriptions through Maintenance Choice (mail order or CVS/pharmacy pick up) and receive a three month supply for only a two month co-pay. An out-of-pocket maximum applies to the prescription drug plan, based on your salary and medical plan coverage level as of January 1, 2015: Under $50,000: $250 individual coverage/$500 for all other coverage levels $50,000 to $100,000: $800 individual coverage/$1,600 for all other coverage levels Above $100,000: $1,600 individual coverage/$4,000 for all other coverage levels If you enroll in Partners Value, you will pay twice these amounts before you reach the out-of-pocket maximum. n Co-pays for prescription drugs will remain the same in n The IRS allows you to submit health care expenses incurred through the following March 15 to your Health Care Flexible Spending Account. This gives you an extra 2.5 months to build up expenses that can be reimbursed using last year s account balance. Using a Health Care Flexible Spending Account is a tax-smart way to pay for many qualified expenses not covered by any medical, dental, hearing, or vision coverage. Submit your FSA expenses the easy, online way with FSA Express. Please make sure to submit your expenses by March 31.

8 IMPORTANT INFORMATION ABOUT YOUR HEALTH COVERAGE You have 30 days from the date you first become eligible or the date you experience a Qualified Change of Status (described below) to enroll or change health coverage. Internal Revenue Code regulations prohibit us from accepting enrollments outside of this 30-day period, except during Fall open enrollment. QUALIFIED CHANGE OF STATUS You may change your Medical, Dental, or Vision coverage level or your Health Care and/or Dependent Care Account participation when you experience a qualified change of status. This change must be requested within 30 days of the event and must be consistent with the event. For example: n Marriage or divorce n Addition of a dependent through birth, adoption, or change in custody n Death of spouse or dependent n Gain or loss of eligibility for Medicaid, Medicare, or other group coverage n You or your spouse change from benefits-eligible to benefits-ineligible status, or vice versa n Your spouse s employment ends n You move out of your medical plan s coverage area n Your child under age 26 gains or loses eligibility for coverage on a health plan COVERAGE FOR YOUR ELIGIBLE CHILDREN Your children are eligible for health coverage on your plans up to age 26. If your child under age 26 previously lost coverage, you may enroll your child on your health plans during open enrollment, to be effective the following January 1. YOUR COBRA RIGHTS When you or your covered dependents are no longer eligible for coverage under your MGPO medical, dental, vision plan, or health care flexible spending account, you or your covered dependents may be eligible to continue this coverage as provided by the Consolidated Omnibus Budget Reconciliation Act (COBRA). A description of your COBRA rights is included in your annual open enrollment packet. For further information, or to obtain a copy of the COBRA notice at other times of the year, please contact the Professional Staff Benefits Office: If your last name begins with A to G, call: Susan Frain at or If your last name begins with H to O, call: Linda Gulla at or If your last name begins with P to Z, call: Virginia Rosales, CEBS at or HIPAA PROVISION If You Declined Medical Coverage Because You Have Coverage Elsewhere Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you may have the opportunity to enroll yourself and your eligible dependents for medical coverage during the year if you previously declined coverage as follows: n You and/or your dependents have coverage from another source (such as your spouse s medical plan or COBRA coverage) and you lose that coverage; or n You acquire a dependent through marriage, birth, adoption, or placement for adoption. If you need to enroll for coverage as a result of one of the above events, you must do so within 30 days of the event. Otherwise, you may be required to wait until the next open enrollment period. October MGPO.MC

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