WEST SUBURBAN HEALTH GROUP. HEALTH PLAN COMPARISON CHART July 1, 2016

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1 WEST SUBURBAN HEALTH GROUP Effective HEALTH PLAN COMPARISON CHART July 1, 2016 red font indicates change or Lifetime Benefit Maximum None None None None None None None None None None Deductible - None (Benchmark Plans only) applies to: In-patient Admission; Out-patient Surgery; ER, High Tech Imaging (MRI, CT, & PET) and Diagnostic Tests & Procedures. Does not apply to office s or pharmacy. Per plan (July 1 to June 30) - See plan document for full details IND $100 / FAM $200 per calendar None IND $300/ FAM $900 None IND $300/ FAM $900 None IND $300/ FAM $900 None IND $300/ FAM $900 Out-of-Pocket (OOP) Maximum - Once your out-of-pocket expenses for applicable services reaches this amount, you pay $0 for remainder of plan. Effective July 1, 2015, out-of-pocket maximums for prescription s have been added as required by ACA (in-network only). Not required per the ACA Medical & Prescription Combined - $1,000 Individual $2,000 Family per plan Medical & Prescription Combined - $2,000 Individual $4,000 Family per plan Family Covered and adult children until age 26 and adult children until age 26 to age 26 Selection of Primary Care Physician (PCP) Any PCP in network No selection required Member must select Member must select Member must select Member must select No selection required No selection required Member must select Member must select Specialist Referrals Any HPHC Specialist Any licensed specialist PCP must refer PCP must refer PCP must refer PCP must refer No referral required No referral required PCP must refer PCP must refer 1

2 Providers of Service HARVARD PILGRIM Any licensed - Members provider; any hospital also have access to a wide range of through the Private Health Care Systems network while outside of MA, NH and ME HARVARD PILGRIM HARVARD PILGRIM HMO BLUE in all 6 New England states Hospital Tiers: Tier 1: Enhanced Tier 2: Standard Tier 3: Basic HMO BLUE in all 6 New England states TUFTS HEALTH PLAN TUFTS HEALTH PLAN **SELECT CARE - An expansive **SELECT CARE - An expansive network that network that includes includes physician physician practices, community-based hospitals and medical facilities across the practices, communitybased hospitals and medical facilities across the Commonwealth. The Commonwealth. The network encompasses network encompasses more than 40,000 more than 40,000 and 60 hospitals. and 60 *DIRECTCARE - A *DIRECTCARE - A tailored network custom-built around several of the Commonwealth's premier provider groups and community-based hospitals. The network has more than 30,000 and 30 hospitals. tailored network custom-built around several of the Commonwealth's premier provider groups and communitybased hospitals. The network has more than 30,000 and 30 hospitals. Pre-existing Conditions No restrictions No restrictions No restrictions No restrictions No restrictions No restrictions No restrictions No restrictions No restrictions No restrictions INPATIENT General Hospital/Mental Hospital/Substance Abuse Facility (semiprivate room and board and ancillary services) $250 Deductible applies then: Tier 1 : $250 Tier 2 :$500 Tier 3 : $1500 per/admit NOTE-Mental Abuse $250 Enhanced: $250 Standard: $500 Basic: $500 Out-of-state : $250 NOTE-Mental Abuse $250 Deductible, then Tier 1: $500 Tier 2: 1500 Semi-private room & board & ancillary services Tier 1: $150 Tier 2: $250 NOTE-Mental Abuse $150 Semi-private room & board & ancillary services Tier 1: $500, applies Tier 2: $1500, applies NOTE- Mental Abuse $500 $250 per admission ($1,000 out-of-pocket maximum) No co-pay or deductible for Mental Hospital/Substance Abuse Facility $500 per admission, then deductible No co-pay or deductible for Mental Hospital/Substance Abuse Facility Physician Services (Hospital applies), after deductible Skilled Nursing Facility up to 100 days per calendar up to 100 days per $250 ment for each admission, up to 100 days per then 20% Coinsurance - Limited to 100 days per Plan Year up to 100 days per Covered in full up to 100 days per plan Covered in Full after Deductible, up to 100 days per plan $250 ment for each admission, up to 100 days per $500 per admission, then deductible Max of 100 days per. 2

3 Newborn Well Baby Care (Inpatient) OUTPATIENT Emergency Room Visits for Emergency or Accident Care $40, waived if admitted $40, waived if admitted $75 (Inpatient applies if admitted) in Service Area then $100 Copay per. Copay is waived if admitted to the hospital directly from the emergency room, then Inpatient would apply $75 (Inpatient applies if admitted) then $100 Copay per. Copay is waived if admitted to the hospital directly from the emergency room, then Inpatient would apply $75 (Inpatient applies if admitted) $100, then deductible applies (Inpatient applies if admitted) $75 (waived if admitted then Inpatient applies) $100, then deductible applies (waived if admitted, then Inpatient applies) Emergency Care in Doctor's Office n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a Outpatient Surgery in a Day Surgery facility or Hospital $125 per outpatient surgery then $250 per Enhanced: $150 Standard: $250 Basic: $250 Out-of-State $150 then $250 per $125 per outpatient surgery $250 per outpatient surgery, $125 per outpatient surgery $250 per outpatient surgery, CT, MRI and Pet Scans then $100 Copay per procedure General Hospitals: Enhanced: $75 Standard: $150 Basic: $150 Other Providers: $75 $100 (scheduled outpatient) $75 *Copay will not be charged when a member has a cancer diagnosis $100, then Deductible $100, then deducutible Hemodialysis Non - hospital based - then no charge Hospital based - See Inpatient Services Physical Therapy $5 per $20 (shortterm); up to 90 consecutive days per condition Copay: $20 per - Limited to 30 s per PlanYear $45 ; up to 60 s per calendar $20 ; up to 60 s per calendar Speech and shortterm PT/OT $20 per ; 30 s per plan Speech and shortterm PT/OT $20 per ; 30 s per plan $20. PT / OT Max limit up to 60 s per calendar $20. PT / OT Max limit up to 60 s per Office Visits Primary Care Physician $5 per Not covered $20 per $20 per Enhanced: $15 Standard: $25 Basic $45 Out-of-state $15 $20 $20 per $20 per $20 per $20 per Preventive OV - PCP 3

4 Medical Care/Mental Health Care/Substance Abuse Care (Mental Health s excluded from OOP max) $5 per $20 per $20 per Enhanced: $15 Standard: $25 Basic: $45 Out-of-state : $15 NOTE: Mental Health Care $15 $20 per $20 per $20 per $20 per $20 per Office Visits - Specialist $5 per $35 per Tier 1 : $30 per Tier 2: $60 per Tier 3: $90 per $45 per $60 per $35 per $60 per $35 per $60 per OB/GYN $5 per GYN-Preventive Office Diagnostic X-ray and Lab $20 per $20 per $45 per $20 per $20 per $20 per $20 per $20 per Routine Vision Exam $5 per ; one per calendar. $0 for children under 5 s of age one per calendar. $0 for children under 5 s of age one exam every 2 plan s $0 for children under 5 s of age $0 ; one every 24 months $0 ; one every 12 months one per plan one per plan $0 per ; one every 12 months $0 per ; one every 12 months EYEMed EYEMed Pre-Admission Testing - Maternity Care s for prenatal and postnatal outpatient care for prenatal and postnatal outpatient care Prenatal: $20 first only; Post natal: $20 per Prenatal: $20 first only; Post natal: $20 per 4

5 Dental Services 14 - Covered in full for preventative care. All members - $5 for extraction of impacted teeth and initial emergency treatment % coinsurance after deductible for preventative care. All members - for extraction of impacted teeth and initial emergency treatment Preventative dental when authorized by PCP; up to two exams per, including cleaning, and x-rays. Initial emergency treatment (within 72 hours of injury) necessary to repair oral injuries. Extraction of impacted teeth. Preventative dental No coverage for children up to age 13 - Tier 1 Copayment per up to two exams per, including cleaning, and x-rays. Initial emergency treatment (within 72 hours of injury) necessary to repair oral injuries. Extraction of impacted teeth. 12: Preventive dental up to two exams per cal. yr., incl. Cleaning, fluoride treatment and x-rays. All members: Extraction of impacted teeth imbedded in the bone. Facility charges ONLY when a serious medical condition that requires admittance to a network hospital as inpatient in order for dental care to be safely performed. 12; Preventative dental, periodic oral exam, cleaning, once every six X-rays: Full mouth once every five s, bitewing x-rays once every six months, and periapicals as needed. MUST use dentist.emergency Services - LIMITED TO X RAYS AND EMERGENCY ORAL SURGERY ER or OFFICE VISIT COPAY WILL APPLY 12; Preventative dental, periodic oral exam, cleaning, once every six X-rays: Full mouth once every five s, bitewing x- rays once every six months, and periapicals as needed. MUST use dentist. Emergency Services - LIMITED TO X RAYS AND EMERGENCY ORAL SURGERY ER or OFFICE VISIT COPAY WILL APPLY Family dental coverage: $10 for exam, cleaning, x-rays every 6 Variable s for minor restorative (fillings) % discount available for sealants, crowns and inlays, bridges, root canals, gingivectomies and dentures. Must use dentists. Family dental coverage: $10 for exam, cleaning, x-rays every 6 Variable s for minor restorative (fillings) % discount available for sealants, crowns and inlays, bridges, root canals, gingivectomies and dentures. Must use dentists. OTHER FEATURES Private Duty Nursing when when when when when when when when when (only when medically necessary) Home Health Care Member cost sharing depends on types of services provided and tier placement of provider rendering dervices, as listed in the Schedule of Benefits. For example, for services provided by a physician, see "physician and Other Professional Office Visits." For inpatient hospital care, see "Hospital - Inpatient Services." Hospice Care Same as Home Health Care 5

6 Durable Medical Equipment 20% of equipment cost to HPHC not to exceed a member's expense of $1000, 20% of equipment cost to HPHC not to exceed a member's expense of $ % of HPHC cost 20% coinsurance 80% Covered Prosthetics covered in full 20% coinsurance for prosthetic limbs which replace, in whole or in part, an arm or leg. after the deductlbe for prosthetic limbs which replace, in whole or in part, an arm or leg. Ambulance, when, when when when when Deductible then when Deductible then when Covered in full when Radiation Therapy Chemotherapy Chiropractor Visits $5 per, up to $500 per calendar $35 per. $20, 20 s 12 maximum per per plan $45 per. 12 s maximum per $20 per. 12 s maximum per up to 12 s per up to 12 s per up to 12 s per. up to 12 s per. Prescription Drugs Retail Pharmacy: Retail Pharmacy: Retail Pharmacy: Retail Pharmacy: Retail Pharmacy: Retail Pharmacy: Retail Pharmacy: Retail Pharmacy: Retail Pharmacy: Retail Pharmacy: (Inpatient drugs paid in Tier 1: $5 Tier 1: $5 Tier 1: $10.00 Tier 1: $10.00 Tier 1: $15.00 Tier 1: $10.00 Tier 1: $10.00 Tier 1: $10.00 Tier 1: $10.00 Tier 1: $10.00 full) Tier 2: $10 Tier 2: $10 Tier 2: $25.00 Tier 2: $30.00 Tier 2: $30.00 Tier 2: $30.00 Tier 2: $25.00 Tier 2: $30.00 Tier 2: $25.00 Tier 2: $30.00 Co-pays do not count Tier 3: $25 Tier 3: $25 Tier 3: $45.00 Tier 3: $65.00 Tier 3: $50.00 Tier 3: $65.00 Tier 3: $45.00 Tier 3: $65.00 Tier 3: $45.00 Tier 3: $65.00 towards OOP Maximum up to a 30 day supply up to a 30 day supply (up to a 30-day (up to a 30-day (up to a 30-day (up to a 30-day (up to a 30-day (up to a 30-day (up to a 30-day (up to a 30-day MedImpact Mail Order: No mail order coverage except through MedImpact Tier 1: $10 Mail Order Tier 1: $20.00 Tier 1: $25.00 Tier 1: $30.00 Tier 1: $25.00 Tier 1: $20.00 Tier 1: $25.00 Tier 1: $20.00 Tier 1:$25.00 Tier 2: $20 Tier 2: $50.00 Tier 2: $75.00 Tier 2: $60.00 Tier 2: $75.00 Tier 2: $50.00 Tier 2: $75.00 Tier 2: $50.00 Tier 2: $75.00 Tier 3: $75 Tier 3: $90.00 Tier 3: $ Tier 3: $ Tier 3: $ Tier 3: $90.00 Tier 3: $ Tier 3: $90.00 Tier 3: $ up to a 90 day supply 6

7 Fitness Benefit Reimbursement Reimbursement Reimbursement Reimbursement Reimbursement Reimbursement Reimbursement Reimbursement Reimbursement Reimbursement Up to $300 reimbursement Up to $300 reimbursement at a Health & Fitness at a Health & Fitness at a Health & Fitness at a Health & Fitness toward membership toward membership at a Health & Fitness at a Health & Fitness club per calendar club per calendar club per calendar club per calendar or exercise classes or exercise classes club, including club, including. Must be an. Must be an. Must be an. Must be an at a health club. at a health club. exercise classes per exercise classes per. See plan materials for. See plan materials for months and an active months and an active months and an active months and an active member of the health member of the health member of the health member of the health details. details. It Fits! Program reimburses families on Select Care up to $400 per family contract ($200 for individual contracts)and Direct Care members up to $500 per family contract ($250 for individual contracts) to use toward health club memberships, Pilates, Yoga classes Weight programs, and local, school sports programs and now fitness related equipment. It Fits! Program reimburses families on Select Care up to $400 per family contract ($200 for individual contracts)and Direct Care members up to $500 per family contract ($250 for individual contracts) to use toward health club memberships, Pilates, Yoga classes Weight programs, and local, school sports programs and now fitness related equipment. Enroll in a qualified Weight or hospital based weight loss program and receive up to $150 per calendar toward your program fees. Enroll in a qualified Weight or hospital based weight loss program and receive up to $150 per calendar toward your program fees. JENNY CRAIG DISCOUNTS: -FREE 30 DAY -25% OFF A PREMIUM/METABO LIC NUTRISYSTEM DISCOUNT: -12% DISCOUNT - OFF CURRENT PROMO -CORE OR SELECT JENNY CRAIG DISCOUNTS: -FREE 30 DAY -25% OFF A PREMIUM/METABO LIC NUTRISYSTEM DISCOUNT: -12% DISCOUNT - OFF CURRENT PROMO -CORE OR SELECT The equipment must be new, purchased from a retail store and not Craig's List or EBay. Other discounts also available. See plan materials The equipment must be new, purchased from a retail store and not Craig's List or EBay. Other discounts also available. See plan materials for details. * Fallon DirectCare - Members now have access to Acton Medical Associates, Charles River Medical Associates and Southboro Medical Group, Fallon Clinic, Highland Healthcare Associates IPA, Lahey Clinic, Lawrence General IPA, Lowell General PHO, Mount Auburn Cambridge IPA, and Northeast PHO. **FCHP SelectCare - Members have access to FCHP Clinic, as well as hundreds of private practice physicians in Central, Northern, Eastern and Southeastern, Massachusetts. 7