Health Plan Comparison Report (4L) Rockland County, NY Prepared On : 11/1/2015 Report Id :

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1 Gold OAEPO % ID: Silver OAEPO % ID: Silver OAEPO % ID: Silver OAEPO % ID: /40/60/TCS/100 ded T2-T4 20/40/60/TCS/100 ded T2-T4 20/40/60/TCS/100 ded T2-T4 20/40/60/TCS/100 ded T2-T4 Individual/ Deductible $1,000/$2,000 embedded $2,000/$4,000 embedded $2,000/$4,000 embedded $3,000/$6,000 embedded Individual/ OOP Limit $4,000/$8,000 (incl ded) $5,500/$11,000 (incl ded) $6,600/$13,200 (incl ded) $6,600/$13,200 (incl ded) 10% 40% $30 $50 $30 $50 $40 $70 $40 $ Lab-$50 ; X-ray-4 Lab-$70 ; X-ray- Lab-$75 ; X-ray- $50 $50 $70 $75 $150 (waived if admitted) $75 $75 $75 $75 1 x $ x $1, x $1, x $2, x $ x $1, x $1, x $1, x $ x $1, x $1, x $1, x $ x $1, x $1, x $1, $5, $68, $4, $58, $4, $57, $4, $56,124.00

2 Silver OAMC /70 HSA Emb ID: (HSA) (UCR=) Silver OAMC /80 HSA Emb FH ID: (HSA) (UCR=) Silver OAMC /70 HSA Emb ID: (HSA) (UCR=) Bronze OAEPO % HSA PY Emb ID: (HSA) (UCR=) 20/40/60/TCS IntDed 20/40/60/TCS IntDed 20/40/60/TCS IntDed 20/40/60/TCS IntDed Individual/ Deductible Individual/ OOP Limit $3,000/$6,000 embedded $4,000/$8,000 embedded $3,000/$6,000 embedded $4,000/$8,000 embedded $2,600/$5,200 embedded $3,500/$7,000 embedded $5,000/$10,000 embedded $5,500/$11,000 (incl ded) $8,000/$16,000 (incl ded) $5,500/$11,000 (incl ded) $8,000/$16,000 (incl ded) $5,000/$10,000 (incl ded) $7,000/$14,000 (incl ded) $6,450/$12,900 (incl ded) 0% 0% 10% Paid as in-network Paid as in-network 1 Paid as in-network 1 1 x $ x $1, x $1, x $1, x $ x $1, x $1, x $2, x $ x $1, x $1, x $1, x $ x $1, x $ x $1, $5, $63, $5, $64, $5, $62, $4, $49,375.56

3 EmblemHealth Platinum HMO 15/35 (HMO) (UCR=) EmblemHealth Gold HMO 40/60 (HMOc) (UCR=) EmblemHealth Silver HMO 35/55 (HMOc) (UCR=) EmblemHealth Bronze HMO HD6300 (HSA) (UCR=) 10/30/60 15/35/75/100 ded 15/35/75/100 ded 0%/0%/0% IntDed Individual/ Deductible $200/$400 $3,000/$6,000 $6,300/$12,600 Individual/ OOP Limit $2,000/$4,000 $5,500/$11,000 (incl ded) $6,000/$12,000 (incl ded) $6,300/$12,600 (incl ded) 0% 0% $15 $35 $40 after ded $60 after ded $35 $55 $1,500/admit after ded $1,500/admit after ded $100 $35 $60 after ded $55 $15 $40 after ded $35 $100 (waived if admitted) after ded $55 $60 after ded $60 1 x $ x $1, x $1, x $2, x $ x $1, x $1, x $1, x $ x $1, x $ x $1, x $ x $ x $ x $1, $5, $70, $4, $57, $4, $51, $3, $41,785.68

4 F Platinum PPO 20/40 Non-Gated OHI CNT (PPO) (UCR=140mc%) F Gold PPO 25/40 Non-Gated OHI CNT (PPOc) (UCR=140mc%) F Platinum EPO 20/40 Non-Gated OHI CNT (EPO) (UCR=) F Gold EPO 25/40 Non-Gated OHI CNT 5/30/60/100 ded T2-3 10/35/75/100 ded T2-3 5/30/60/100 ded T2-3 10/35/75/100 ded T2-3 Individual/ Deductible $3,000/$6,000 $1,000/$2,000 $3,000/$6,000 $1,250/$2,500 Individual/ OOP Limit $3,000/$6,000 $7,500/$15,000 (incl ded) $4,000/$8,000 (incl ded) $7,500/$15,000 (incl ded) $3,000/$6,000 $5,000/$10,000 (incl ded) 40% $20 $40 $25 4 $40 4 $20 $40 $25 $ Hosp-$300 FS-$100 Hosp-$250 after ded FS- 4 Hosp-$300 FS-$100 Hosp-$250 after ded FS- Lab-No charge; X-ray-$90 Lab-No charge; X-ray- 4 Lab-No charge; X-ray-$90 Lab-No charge; X-ray-$90 $40 $40 4 $40 $40 Paid as in-network $300 (waived if admitted) Paid as in-network $300 (waived if admitted) $50 $75 4 $50 $75 1 x $ x $1, x $1, x $2, x $ x $1, x $1, x $2, x $ x $1, x $1, x $2, x $ x $1, x $1, x $2, $7, $87, $6, $75, $6, $80, $5, $67,728.60

5 L Gold EPO 25/40 Non-Gated OHI CNT L Silver EPO 40/70 Non-Gated OHI CNT L Gold EPO 30/60 Gated OHI CNT (EPOc) (UCR=) L Silver EPO 25/50 Gated OHI CNT (EPOc) (UCR=) 10/35/75/100 ded T2-3 15/45/75/100 ded T2-3 15/35/75/100 ded T2-3 15/65/85/100 ded T2-3 Individual/ Deductible $1,250/$2,500 $2,000/$4,000 $1,000/$2,000 $2,000/$4,000 Individual/ OOP Limit $5,000/$10,000 (incl ded) $6,600/$13,200 (incl ded) $4,000/$8,000 (incl ded) $6,600/$13,200 (incl ded) $25 $40 $40 $70 $30 $60 $25 $50 $500/day after ded; $2,000 max/admit $500/day after ded; $2,000 max/admit Hosp-$250 after ded FS- Hosp-$250 after ded FS- Lab-No charge; X-ray-$90 Lab-No charge; X-ray- Lab-No charge; X-ray-$35 ; $500 max/contr yr Lab-No charge; X-ray- $40 $70 $60 $50 $300 (waived if admitted) $500 (waived if admitted) $500 (waived if admitted) $75 $75 $75 $80 1 x $ x $1, x $1, x $2, x $ x $1, x $1, x $1, x $ x $1, x $1, x $2, x $ x $1, x $1, x $1, $5, $66, $4, $58, $5, $66, $4, $56,362.32

6 M Gold EPO 15/30 Gated OHI CNT (EPOc) (UCR=) M Gold EPO 25/40 Gated OHI CNT (EPOc) (UCR=) M Silver EPO 30/60 Gated OHI CNT (EPOc) (UCR=) M Bronze EPO HSA $5000 Gated OHI CNT (HSA) (UCR=) 5/65/50%to$800 5/65/50%to$800 10/65/50%to$800 10/65/50%to$800 IntDed Individual/ Deductible $750/$1,500 $1,250/$2,500 $2,500/$5,000 $5,000/$10,000 Individual/ OOP Limit $3,500/$7,000 (incl ded) $4,500/$9,000 (incl ded) $5,600/$11,200 (incl ded) $6,450/$12,900 (incl ded) $15 $30 $25 $40 $30 $60 Hosp-$500 after ded FS- $200 after ded Hosp-$500 after ded FS- $200 after ded Lab-No charge; X-ray-$35 Lab-No charge; X-ray-$35 Lab-No charge; X-ray- $30 $40 $60 $400 (waived if admitted) $400 (waived if admitted) $65 $65 $80 1 x $ x $1, x $1, x $1, x $ x $1, x $1, x $1, x $ x $1, x $ x $1, x $ x $ x $ x $1, $4, $58, $4, $56, $4, $48, $3, $38,325.36

7 F Bronze EPO HSA $5000 Non-Gated OHI CNT (HSA) (UCR=) L Bronze EPO HSA $5000 Non-Gated OHI CNT (HSA) (UCR=) 10/40/80 IntDed 10/40/80 IntDed Individual/ Deductible $5,000/$10,000 $5,000/$10,000 Individual/ OOP Limit $6,350/$12,700 (incl ded) $6,350/$12,700 (incl ded) 1 x $ x $1, x $ x $1, x $ x $ x $ x $1, $3, $45, $3, $44,531.16

8 Prepared For: Rockland Rockland County, NY Prepared By: BenefitMall - (914) Footnote Report Effective Date: 01/01/2016 Prepared On: 11/1/2015 Report ID: SIC: 0000 FootNote Report Final Rates and Benefits The rates and benefits in this report are for illustration purposes only. Rates are subject to change up to 60 days prior to the effective date. Final rates will be based on final enrollment and will be determined only after completion of 's underwriting review. compensates its employees on the sale of products based on the services they provide, including providing quotes on, and explanations of, products. The compensation varies depending on a number of factors, including customer segment and products selected. Combining all factors, and excluding limited-benefit plans, compensation for each product quoted averages less than 0.80% of the total first year annual premium. offers additional bonus programs, which may also apply. Neither nor the employee has material ownership interests in the other. The employee may not alter the amount of compensation received from. You may obtain additional information about the compensation expected to be received by eligible employees, based in whole or in part on the sale of an product, or alternative options presented, by contacting at /about-aetna-insurance/contact-us /forms/employer/ transparency.html Make Available Option You are not required to raise the dependent limiting age to 30 under your plan of benefits. However, if you do accept this option, dependents would have to meet eligibility criteria. If you elect this option: The election would take effect upon inception of your plan Your premium rates will be affected You will need to report the dependent to us on your eligibility submission If you wish to elect the 'Make Available Option' which will continue coverage under plan for a dependent child up to age 30, please request in writing and fax to and we will provide the adjusted rates. Dependents not enrolled during your open enrollment period will be treated as late enrollees and will have to wait until your plan's next open enrollment period to enroll. There may be tax consequences to both you as the employer and your employee if you elect coverage for a dependent child up to age 30. It is recommended that employers consult a tax attorney regarding how to handle the imputed wages for any contribution they provide for dependents who are emancipated and no longer dependents for tax purposes of the eligible employee/enrollee. Employee contributions for an emancipated dependent made with pretax dollars may also have tax implications for the employee. NY Producer Transparency Licensed and appointed producers may earn compensation in the form of a commission on the sale of this product. The amount of compensation varies. It depends on a number of factors, including customer segment and the products selected. Additional bonus programs may also apply. Please ask your broker for more information about their compensation for this sale, including commission and any applicable bonus programs. The producer is prohibited by law from altering the amount of compensation they get from us based in whole or in part on the sale. All Information Contained Within This Report Is For Illustration Purposes Only. Final Binding Information Must Be Provided By The Respective Insurance Carrier.

9 Prepared For: Rockland Rockland County, NY Prepared By: BenefitMall - (914) Footnote Report Effective Date: 01/01/2016 Prepared On: 11/1/2015 Report ID: SIC: 0000 FootNote Report compensates its employees on the sale of products based on the services they provide, including providing quotes on, and explanations of, products. The compensation varies depending on a number of factors, including customer segment and products selected. Combining all factors, and excluding limited-benefit plans, compensation for each product quoted averages less than 0.80% of the total first year annual premium. offers additional bonus programs, which may also apply. Neither nor the employee has material ownership interests in the other. The employee may not alter the amount of compensation received from. You may obtain additional information about the compensation expected to be received by eligible employees, based in whole or in part on the sale of an product, or alternative options presented, by contacting at /about-aetna-insurance/contact-us /forms/employer/ transparency.html Summary of Benefits & Coverage NY Provider Network Producers should obtain the Summary of Benefits and Coverage (SBC) documents for medical plans by accessing the following link: Please note: The NY Provider Network is pending approval from the Department of Financial Services. Disclosure NY Commission Disclosure New York Regulation (11 NYCRR 30)) requires disclosure of the compensation a licensed agent or broker (producer) receives from your purchase or renewal of health coverage. Compensation may be in the form of a commission, fee(s), or possibly other valuable consideration, or a combination of all three. Total commission levels per carrier are as follows: Non-HMO business -Based on a tiered per employee, per month (PEPM) model, ranging from $18-$30 PEPM. ; Emblem 3%-4% depending on selected plan; HealthPass -same as commission paid by carrier; Oxford -3%. An additional commission will be paid to a general agent if they are involved in the sale; this amount may vary based on carrier and plan design. The commissions do not directly affect the premium paid for the plan and no plan can be purchased through another distributor or from the carrier directly with a different commission amount or at a lower cost. Final commission dollar amounts cannot be determined until enrollment is complete and is subject to change based on the number of members covered each month. Rx Tier Structure Description Rider Specification Effective 1/1/2007, Pharmacy copayments are based on the following tier structure Tier 1 lowest copay, Tier 2 middle copay and Tier 3 highest copay. Please contact the carrier for additional information. When selecting the Mental Health 30/20 Bio Rider (MH IP 30V / OP 20V BIO), the Mental Health 30/20 Non-Bio Rider (MH IP 30V / OP 20V NON-BIO) rider must be selected as well Rx Tier Structure Description Rider Specification Effective 1/1/2007, Pharmacy copayments are based on the following tier structure Tier 1 lowest copay, Tier 2 middle copay and Tier 3 highest copay. Please contact the carrier for additional information. When selecting the Mental Health 30/20 Bio Rider (MH IP 30V / OP 20V BIO), the Mental Health 30/20 Non-Bio Rider (MH IP 30V / OP 20V NON-BIO) rider must be selected as well Rx Tier Structure Description Effective 1/1/2007, Pharmacy copayments are based on the following tier structure Tier 1 lowest copay, Tier 2 middle copay and Tier 3 highest copay. Please contact the carrier for additional information. All Information Contained Within This Report Is For Illustration Purposes Only. Final Binding Information Must Be Provided By The Respective Insurance Carrier.