Small Group Plan Options HMO

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1 HMO Platinum Plans These plans will cover about 90% of your service and you are responsible for the other 10% Benefits Platinum Platinum Platinum 25 / 50 / 500 HMO 20 / 40 / 1000 HMO 20 / 40 HMO Deductible (Single / Family) $500 / $1,000 $1,000 / $2,000 $0 Coinsurance 20% 10% 0% Medical Maximum Out-of-Pocket (Single / Family) $1,000 / $2,000 $1,300 / $2,600 $3,300 / $6,600 Office Visit Copay (PCP / Specialist) $25 / $50 $20 / $40 $20 / $40 E-Visits $15 $15 $10 Urgent Care Copay $50 $40 $40 Emergency Room Copay $100 $100 $150 Mental Health Outpatient Copay $25 $20 $20 Hospital Copay (Inpatient / Outpatient) Pharmacy Copays $5 / $10 / $35 / $60 / $100 Pharmacy Maximum Out-of-Pocket (Single / Family) Dental Coverage Family coverage available for additional charge

2 HMO Gold Plans These plans will cover about 80% of your service and you are responsible for the other 20% Benefits Gold Gold Gold Gold 20 / 40 / 1000 HMO 30 / 60 / 1500 HMO 30 / 60 / 2000 HMO HSA 1850 HMO Deductible (Single / Family) $1,000 / $2,000 $1,500 / $3,000 $2,000 / $4,000 $1,850 / $3,700 Coinsurance 20% 20% 20% 0% Medical Maximum Out-of-Pocket (Single / Family) $4,500 / $9,000* $3,500 / $7,000* $3,900 / $7,800* $1,850 / $3,700 Office Visit Copay (PCP / Specialist) $20 / $40 $30 / $60 $30 / $60 E-Visits $10 $20 $20 Urgent Care Copay $40 $60 $60 Emergency Room Copay $150 $150 $150 Mental Health Outpatient Copay $20 $30 $30 Hospital Copay (Inpatient / Outpatient) Pharmacy Copays $5 / $10 / $35 / $60 / $100 $5 / $10 / $35 / $60 / $100 $5 / $10 / $35 / $60 / $100 Pharmacy Maximum Out-of-Pocket (Single / Family) Dental Coverage Family coverage available Family coverage available Family coverage available for additional charge for additional charge for additional charge Not Available

3 HMO Silver Plans These plans will cover about 70% of your service and you are responsible for the other 30% Benefits Silver Silver Silver Maintenance HSA 2500 HMO HSA 3400 HMO 25 / 50 / 1350 HMO Deductible (Single / Family) $2,500 / $5,000 $3,400 / $6,800 $1,350 / $2,700 Coinsurance 20% 0% 0% Medical Maximum Out-of-Pocket (Single / Family) $6,350 / $12,700* $3,400 / $6,800 $6,850 / $13,700* Office Visit Copay (PCP / Specialist) $25 / $50 E-Visits $15 Urgent Care Copay $50 Emergency Room Copay $500 Mental Health Outpatient Copay $25 Hospital Copay (Inpatient / Outpatient) $3,500 per diem IP / Pharmacy Copays $5 / $10 / $50 / $100 / $300 Pharmacy Maximum Out-of-Pocket (Single / Family) Dental Coverage Not Available Not Available Family coverage available for additional charge

4 HMO Bronze Plans These plans will cover about 60% of your service and you are responsible for the other 40% Benefits Bronze HSA 6000 HMO Deductible (Single / Family) $6,000 / $12,000 Coinsurance 20% Medical Maximum Out-of-Pocket (Single / Family) $6,550 / $13,100* Office Visit Copay (PCP / Specialist) E-visits Urgent Care Copay Emergency Room Copay Mental Health Outpatient Copay Hospital Copay (Inpatient / Outpatient) Pharmacy Copays Pharmacy Maximum Out-of-Pocket (Single / Family) Dental Coverage Not Available

5 POS & PPO Platinum Plans These plans will cover about 90% of your service and you are responsible for the other 10% Benefits Platinum Platinum Platinum 25 / 50/ 500 POS & PPO 20 / 40 / 1000 POS & PPO 20 / 40 POS & PPO In Network Out-of-Network In Network Out-of-Network In Network Out-of-Network Deductible (Single / Family) $500 / $1,000 $1,000 / $2,000 $1,000 / $2,000 $2,000 / $4,000 $0 $1,000 / $2,000 Coinsurance 20% 40% 10% 20% 0% 20% Medical Maximum Out-of-Pocket $1,000 / $2,000 $2,000 / $4,000 $1,300 / $2,600 $3,000 / $6,000 $3,300 / $6,600 $4,000 / $8,000* (Single / Family) Office Visit Copay (PCP / Specialist) $25 / $50 Deductible then $20 / $40 Deductible then $20 / $40 Deductible then Coinsurance Coinsurance Coinsurance E-visits $15 Not Covered $15 Not Covered $10 Not Covered Urgent Care Copay $50 Deductible then $40 Deductible then $40 Deductible then Coinsurance Coinsurance Coinsurance Emergency Room Copay $100 $100 $100 $100 $150 $150 Mental Health Outpatient Copay $25 Deductible then $20 Deductible then $20 Deductible then Coinsurance Coinsurance Coinsurance Hospital Copay (Inpatient / Outpatient) Pharmacy Copays $5 / $10 / $35 / $60 / $100 Pharmacy Maximum Out-of-Pocket (Single / Family) Dental Coverage Family coverage available for additional charge

6 POS & PPO Gold Plans These plans will cover about 80% of your service and you are responsible for the other 20% Benefits Gold Gold Gold Gold 20 / 40 / 1000 POS & PPO 30 / 60 / 1500 POS & PPO 30 / 60 / 2000 POS & PPO HSA 1850 POS & PPO In Network Out-of-Network In Network Out-of-Network In Network Out-of-Network In Network Out-of-Network Deductible (Single / Family) $1,000 / $2,000 $3,000 / $6,000 $1,500 / $3,000 $3,000 / $6,000 $2,000 / $4,000 $4,000 / $8,000 $1,850 / $3,700 $3,500 / $7,000 Coinsurance 20% 40% 20% 40% 20% 40% 0% 20% Medical Maximum Out-of-Pocket (Single / Family) $4,500 / $9,000* $6,000 / $12,000* $3,500 / $7,000* $7,000 / $14,000* $3,900 / $7,800* $8,000 / $16,000* $1,850 / $3,700 $7,000 / $14,000* Office Visit Copay $20 / $40 Deductible then $30 / $60 Deductible then $30 / $60 Deductible then Deductible then Deductible then (PCP / Specialist) Coinsurance Coinsurance Coinsurance Coinsurance Coinsurance E-Visits $10 Not Covered $20 Not Covered $20 Not Covered Deductible then Not Covered Coinsurance Urgent Care Copay $40 Deductible then $60 Deductible then $60 Deductible then Deductible then Deductible then Coinsurance Coinsurance Coinsurance Coinsurance Coinsurance Emergency Room Copay $150 $150 $150 $150 $150 $150 Deductible then Deductible then Coinsurance Coinsurance Mental Health $20 Deductible then $30 Deductible then $30 Deductible then Deductible then Deductible then Outpatient Copay Coinsurance Coinsurance Coinsurance Coinsurance Coinsurance Hospital Copay (Inpatient / Outpatient) Pharmacy Copays $5 / $10 / $35 $5 / $10 / $35 $5 / $10 / $35 $5 / $10 / $35 $5 / $10 / $35 / $5 / $10 / $35 / Deductible then Deductible then $60 / $100 $60 / $100 $60 / $100 $60 / $100 $60 / $100 $60 / $100 Coinsurance Coinsurance Pharmacy Maximum Out-of-Pocket (Single / Family) Dental Coverage Family coverage Family coverage Family coverage Family coverage Family coverage Family coverage Not Available Not Available available for available for available for available for available for available for additional charge additional charge additional charge additional charge additional charge additional charge

7 POS & PPO Silver Plans These plans will cover about 70% of your service and you are responsible for the other 30% Benefits Silver Silver Silver HSA 2500 POS & PPO HSA 3400 POS & PPO Maintenance 25 / 50 / 1350 POS & PPO In Network Out-of-Network In Network Out-of-Network In Network Out-of-Network Deductible (Single / Family) $2,500 / $5,000 $5,000 / $10,000 $3,400 / $6,800 $7,000 / $14,000 $1,350 / $2,700 $7,000 / $14,000 Coinsurance 20% 40% 0% 20% 0% 20% Medical Maximum Out-of-Pocket (Single / Family) $6,350 / $12,700* $12,000 / $24,000* $3,400 / $6,800 $14,000 / $28,000* $6,850 / $13,700* $15,000 / $30,000* Office Visit Copay Deductible then Deductible then Deductible then Deductible then $25 / $50 Deductible then (PCP / Specialist) Coinsurance Coinsurance Coinsurance Coinsurance Coinsurance E-Visits Deductible then Not Covered Deductible the Not Covered $15 Not Covered Coinsurance Coinsurance Urgent Care Copay Deductible then Deductible then Deductible then Deductible then $50 Deductible then Coinsurance Coinsurance Coinsurance Coinsurance Coinsurance Emergency Room Copay Deductible then Deductible then Deductible then Deductible then $500 $500 Coinsurance Coinsurance Coinsurance Coinsurance Mental Health Deductible then Deductible then Deductible then Deductible then $25 Deductible then Outpatient Copay Coinsurance Coinsurance Coinsurance Coinsurance Coinsurance Hospital Copay Deductible then Deductible then Deductible then Deductible then $3,500 per diem IP / Deductible then (Inpatient / Outpatient) Coinsurance Coinsurance Coinsurance Coinsurance Coinsurance Pharmacy Copays Deductible then Deductible then Deductible then Deductible then $5 / $10 / $50 / $5 / $10 / $50 / Coinsurance Coinsurance Coinsurance Coinsurance $100 / $300 $100 / $300 Pharmacy Maximum Out-of-Pocket (Single / Family) Dental Coverage Not Available Not Available Not Available Not Available Family Coverage available Family Coverage available for additional charge for additional charge

8 POS & PPO Bronze Plans These plans will cover about 60% of your service and you are responsible for the other 40% Benefits In Network Bronze HSA 6000 POS & PPO Out-of-Network Deductible (Single / Family) $6,000 / $12,000 $10,000 / $20,000 Coinsurance 20% 40% Medical Maximum Out-of-Pocket (Single / Family) $6,550 / $13,100* $13,000 / $26,000* Office Visit Copay (PCP / Specialist) E-Visits N / A Urgent Care Copay Emergency Room Copay Mental Health Outpatient Copay Hospital Copay (Inpatient / Outpatient) Pharmacy Copays Pharmacy Maximum Out-of-Pocket (Single / Family) Dental Coverage Not Available

$243.41 $34.69 16.62% 29497DE0090001 Aetna Bronze $15 Copay PPO Bronze 26 $ 212.88

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