INDIVIDUAL & FAMILY Health Insurance Plans

Transcription

1 INDIVIDUAL & FAMILY Health Insurance Plans For more information, call or visit us online!

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3 LAND OF LINCOLN HEALTH Health Insurance Plans CONTENTS: About Health PPO Plans Traditional Health Plans Health Plan Highlights About Health At Health, we know how complicated and impersonal health insurance can feel. That s why we re here to help you every step of the way. We make it easy to understand, easy to make good decisions and easy to use your insurance when you need to. We provide two plan types that offer low out-of-pocket expenses, allow you to choose your doctors and provide the security of knowing you have nationwide coverage. 21 AFFORDABLE Individual and Family Plan Options How to Enroll Visit /Plans or talk to an enrollment specialist at. We are committed to making health insurance easier to understand, easy to buy and easy to use. Our PPO Plans offer innovative partnerships with major Illinois health systems, making it even easier and more affordable for you and your family to receive care from your chosen doctors and hospitals. Our Traditional PPO Plans provide rich benefits with one of the strongest and widest networks of healthcare providers across the nation. That s the way health insurance should be we re changing health insurance for the better for you and your family. Our strong benefits and network of trusted doctors and hospitals have made our 50,000 members think differently about health insurance. 1

4 PREFERRED PARTNER 3-TIER PLANS PREFERRED PARTNER PPO Our 3-Tier Plans PREFERRED PARTNER PPO 3-Tier Plans OUR PREFERRED PARTNERS These plans were created for you and your family to visit the doctors and hospitals you trust most. Each plan is backed by a prominent health system, providing the best benefits and most savings when you seek care within a health system. If you want to see other doctors, you can still utilize Land of Lincoln Health s nationwide network of doctors and hospitals Includes the reputable doctors and hospitals. Save the most money by receiving care from an provider. Health Extensive network of world-class doctors and hospitals across the nation. Does not include In-Network doctors and hospitals. No out-of-pocket maximum. 2

5 PREFERRED PARTNER PPO 3-TIER PLANS Adventist Health PPO Adventist Midwest Health s nonprofit hospitals and healthcare facilities operate in Chicago s western suburbs. Adventist takes a holistic, whole person approach to wellness, partnering with patients, families and healers to achieve optimal health for their patients and the communities they serve. New for 2016: Adventist Midwest Health and Alexian Brothers Health System have merged, forming a new health system, AMITA Health. While this merger includes both hospital systems, our Adventist Health Plans DO NOT include Alexian Brothers doctors and hospitals. If you seek care with any Alexian Brothers doctors or hospitals, unless the coverage of such care is legally required to be paid at the In-Network rate (e.g. emergency care), the visit or service will be considered. Please make sure to confirm that your chosen doctor or hospital is In-Network for your Adventist Health Plan. This can be done by utilizing our Find-a-Doctor tool located on our website or by contacting our Member Services team at Centegra Health PPO Centegra Health System is committed to meeting the healthcare needs of the residents of greater McHenry County and to making services available in multiple convenient locations, including hospitals in McHenry and Woodstock, Immediate and Physician Care Centers, Centegra Sage Cancer Center, and Health Bridge Fitness Centers. As the region s leading healthcare system, Centegra s Health & Wellness Network offers access to more than 350 healthcare providers, the latest treatments and technology. The skills of nearly 4,000 associates help meet the needs of the growing McHenry County community. See page: 7 See page: 8 Champion Health PPO If Advocate is your preferred healthcare system, choose the Champion Plan. Advocate is one of the nation s top healthcare systems. We have more than 200 sites of care, including hospitals, medical groups, home health services and a network of outpatient centers. Our Physician Partners integrated approach has achieved nationally ranked outcomes for their chronic disease management programs. Advocate provides progressive and innovative healthcare services to its members, believing the best way to treat the whole person is through an integrated system of care. See page: 9 3

6 PREFERRED PARTNER PPO 3-TIER PLANS Chicago Health System Health PPO Chicago Health System s nationally-recognized doctors and hospitals are all uniquely qualified and united in their goals of providing superior personalized care and individual patient relationships that last a lifetime. Chicago Health System partners with four quality-driven hospitals including MacNeal in Berwyn, Weiss Memorial in Chicago, Westlake in Melrose Park and West Suburban in Oak Park, to place the patient at the center of their care to support them in living their best life. Through a network of community-based doctors and hospitals, Chicago Health System patients have access to care in their communities to meet their needs. Family Health Network Health PPO Family Health Network (FHN) is a health insurer with 20 years of experience in the Chicago community. As a nonprofit health plan that is governed by local medical providers, FHN s main focus is providing affordable, high-quality care for its members. With a robust network of doctors and hospitals, including psychiatric and children s hospitals, FHN encourages members to routinely and conveniently access healthcare. For a better health plan and high quality healthcare you and your family deserves, join the FHN family! See page: 10 See page: 11 Illinois Health Partners Health PPO Illinois Health Partners includes a network of more than 1,100 primary and specialty care physicians who are affiliated with DuPage Medical Group, Edward-Elmhurst Healthcare, and Northwest Community Healthcare. IHP serves nearly 250,000 patients in the west, southwest and northwest suburbs of Chicago with a mission of improving the quality of healthcare and delivering value through access and efficiency. You ll find convenient locations, same-day appointments in many offices, and many other patient conveniences. Presence Health Health PPO Presence Health is a large health system of more than 150 locations in communities large and small, making access to healthcare convenient. In addition to delivering excellent care and service, Presence Health wants to inspire people to see their health in a new way. More than doctor visits and medical tests, it s a lifelong journey of small, manageable steps. The goal of Presence Health is to empower those they serve to take a few of those steps every day to achieve their best health. And there s no better time to start than today. See page: 12 See page: 13 4

7 PREFERRED PARTNER PPO 3-TIER PLANS Riverside HealthCare Health PPO Riverside HealthCare is a fully integrated healthcare system serving the needs of patients throughout Kankakee, Iroquois, Will, and Grundy counties. Our network of the region s premier physicians includes over 75 primary care doctors and specialists. Riverside HealthCare is comprised of Riverside Medical Center, Riverside Senior Life Communities, Riverside HealthCare Foundation and Oakside Corporation. See page: 14 Swedish Covenant Hospital Health PPO Swedish Covenant Hospital and their Network has been serving the Chicago area for more than 125 years. Swedish Covenant Hospital excels in safety, outcomes and the patient experience by providing expert care and outstanding health and wellness services in state-of-the-art facilities. Swedish Covenant Hospital is committed to providing a safe, quality hospital experience and is consistently recognized, including most recently in 2015 when they were awarded the Leadership in Safety Award from CNA Healthcare. See page: 15 5

8 TRADITIONAL PPO 2-TIER PLANS Health is proud to continue offering our Traditional PPO Plans. These plans provide access to Health s extensive network, which includes most of the doctors and hospitals across the nation. Traditional Plan Health PPO Our HSA-compatible plan offers great benefits and access to our Traditional PPO network, one of the largest networks of doctors and hospitals in the state. Offering one deductible for medical and pharmacy benefits and generous coinsurance paid by your health plan, you will find the Traditional PPO plan simple to use and highly effective if you prefer an HSA-compatible plan. 1 TRADITIONAL PPO Our 2-Tier Plans Health In-Network Extensive network of world-class doctors and hospitals across the nation. See page: 16 2 Does not include In-Network doctors and hospitals. No out-of-pocket maximum. 6

9 ADVENTIST LAND OF LINCOLN PLANS Individual and Family Health Insurance Highlights ADVENTIST LLH 3-TIER GOLD PPO ADVENTIST LLH 3-TIER SILVER PPO ADVENTIST LLH 3-TIER BRONZE PPO Adventist Adventist Adventist Deductible 1 / $1,000 $6,000 / $12,000 $3,400 / $6,800 $10,000 / $20,000 $6,000 / $12,000 $15,000 / $30,000 Coinsurance 2 45% Out-of-Pocket Maximum 3 $5,500 / $11,000 Unlimited / Unlimited Primary Care Physician $15 5 $30 $70 (first 2 visits); then subject to deductible/coinsurance Specialist Visit $160 ER Urgent Care $100 $100 Inpatient Hospital Stay 4 00 $900 $850 $1,800 Outpatient Hospital Services 5 45% X-Rays & Labs $25 0 Physical, Occupational & Speech Therapy $105 $65 $130 Chiropractic 45% Generic Rx 6 Preferred Brand Rx 6 Non-Preferred Brand Rx 6 opay/prescription Specialty Rx 6 1. Copays are not. Coinsurances are. The deductible for the and Health In-Network Tier 2 Providers is integrated, meaning qualified payments made within either of those networks apply to that single deductible. 2. Coinsurance is the percentage paid by member after meeting the deductible. Percentages shown within this table represent coinsurance amounts and are always subject to the deductible. Health is responsible for the remainder of the covered services. 3. Out-of-pocket maximum is the most you will ever have to pay in the plan year for covered services under a specific plan. Deductibles, coinsurance and copays in either the or with Health Providers all apply to your out-of-pocket maximum. 4. Includes room and board and some other additional charges. After the first three days of copays, Health pays 100% of covered services for that hospital stay. Includes services provided for mental/ 5. May include an outpatient clinic or same-day surgery center. Also includes services provided for mental/ 6. All Prescription Drug Benefits listed are for a 34-day supply. Copay for 90-day mail order prescriptions is 2½ times the 34-day retail copay. Coinsurance for mail order is the same as retail. Mutual Health Insurance Company ( Health ) is offering individual and family health insurance plans described herein. This brochure is distributed for marketing purposes and is not your policy. Some health care services will require precertification. If there is any difference between this brochure and the policy, the provisions of the policy will control. For more information on Health, call or visit. All Individual and Family Plans sold through the Marketplace are considered QHPs (Qualified Health Plans) as determined by the Affordable Care Act. 7 Adventist Midwest Health and Alexian Brothers Health System have merged, forming a new health system, AMITA. While this merger includes both hospital systems, our Adventist Health Plan DOES NOT include Alexian Brothers doctors and hospitals. If you seek care with any Alexian Brothers doctors or hospitals, unless the coverage of such care is legally required to be paid at the in-network rate (e.g. emergency care), the visit or service will be considered out-of-network. Please make sure to confirm that your chosen doctor or hospital is in-network for your Adventist Health Plan. This can be done by utilizing our Find-a-Doctor tool located on our website or by contacting our Member Services team at

10 CENTEGRA LAND OF LINCOLN PLANS Individual and Family Health Insurance Highlights Deductible 1 Coinsurance 2 Out-of-Pocket Maximum 3 Primary Care Physician Specialist Visit ER Urgent Care Inpatient Hospital Stay 4 Outpatient Hospital Services 5 X-Rays & Labs Physical, Occupational & Speech Therapy Chiropractic Generic Rx 6 Preferred Brand Rx 6 Non-Preferred Brand Rx 6 Specialty Rx 6 CENTEGRA LLH 3-TIER GOLD PPO Centegra 0 / $1,500 $6,000 / $12,000 15% $ $85 $900 15% $15 $105 15% 15% 15% CENTEGRA LLH 3-TIER SILVER PPO Centegra $3,100 / $6,200 $10,000 / $20,000 45% $30 $950 $160 $1,600 45% 0 $65 $130 45% 1. Copays are not. Coinsurances are. The deductible for the Preferred Partner and Health Providers is integrated, meaning qualified payments made within either of those networks apply to that single deductible. 2. Coinsurance is the percentage paid by member after meeting the deductible. Percentages shown within this table represent coinsurance amounts and are always subject to the deductible. Land of Lincoln Health is responsible for the remainder of the covered services. 3. Out-of-pocket maximum is the most you will ever have to pay in the plan year for covered services under a specific plan. Deductibles, coinsurance and copays in either the or with Health Providers all apply to your out-of-pocket maximum. 4. Includes room and board and some other additional charges. After the first three days of copays, Land of Lincoln Health pays 100% of covered services for that hospital stay. Includes services provided for mental/ 5. May include an outpatient clinic or same-day surgery center. Also includes services provided for mental/ 6. All Prescription Drug Benefits listed are for a 34-day supply. Copay for 90-day mail order prescriptions is 2½ times the 34-day retail copay. Coinsurance for mail order is the same as retail. Mutual Health Insurance Company ( Health ) is offering individual and family health insurance plans described herein. This brochure is distributed for marketing purposes and is not your policy. Some health care services will require precertification. If there is any difference between this brochure and the policy, the provisions of the policy will control. For more information on Health, call or visit. All Individual and Family Plans sold through the Marketplace are considered QHPs (Qualified Health Plans) as determined by the Affordable Care Act. 8

11 LAND OF LINCOLN CHAMPION PPO GOLD Individual and Family Health Insurance Highlights Deductible 1 Coinsurance 2 Out-of-Pocket Maximum 3 Primary Care Physician Specialist Visit ER Urgent Care Inpatient Hospital Stay 4 Outpatient Hospital Services 5 X-Rays & Labs Physical, Occupational & Speech Therapy Chiropractic Generic Rx 6 Preferred Brand Rx 6 Non-Preferred Brand Rx 6 Specialty Rx 6 CHAMPION LLH 3-TIER GOLD PPO Champion / $1,000 $6,000 / $12,000 $ $5,800 / $11,600 Unlimited / Unlimited 5 $900 $25 $105 CHAMPION LLH 3-TIER SILVER PPO Champion $3,100 / $6,200 $10,000 / $20,000 45% $30 $950 $145 $1,600 45% 0 $65 $130 45% 1. Copays are not. Coinsurances are. The deductible for the Preferred Partner and Health Providers is integrated, meaning qualified payments made within either of those networks apply to that single deductible. 2. Coinsurance is the percentage paid by member after meeting the deductible. Percentages shown within this table represent coinsurance amounts and are always subject to the deductible. Health is responsible for the remainder of the covered services. 3. Out-of-pocket maximum is the most you will ever have to pay in the plan year for covered services under a specific plan. Deductibles, coinsurance and copays in either the or with Health Providers all apply to your out-of-pocket maximum. 4. Includes room and board and some other additional charges. After the first three days of copays, Land of Lincoln Health pays 100% of covered services for that hospital stay. Includes services provided for mental/ 5. May include an outpatient clinic or same-day surgery center. Also includes services provided for mental/ 6. All Prescription Drug Benefits listed are for a 34-day supply. Copay for 90-day mail order prescriptions is 2½ times the 34-day retail copay. Coinsurance for mail order is the same as retail. Mutual Health Insurance Company ( Health ) is offering individual and family health insurance plans described herein. This brochure is distributed for marketing purposes and is not your policy. Some health care services will require precertification. If there is any difference between this brochure and the policy, the provisions of the policy will control. For more information on Health, call or visit. All Individual and Family Plans sold through the Marketplace are considered QHPs (Qualified Health Plans) as determined by the Affordable Care Act. 9

12 CHICAGO HEALTH SYSTEM LAND OF LINCOLN PLANS Individual and Family Health Insurance Highlights Deductible 1 Coinsurance 2 Out-of-Pocket Maximum 3 Primary Care Physician Specialist Visit ER Urgent Care Inpatient Hospital Stay 4 Outpatient Hospital Services 5 X-Rays & Labs Physical, Occupational & Speech Therapy Chiropractic Generic Rx 6 Preferred Brand Rx 6 Non-Preferred Brand Rx 6 Specialty Rx 6 CHICAGO HEALTH SYSTEM LLH 3-TIER GOLD PPO CHS 0 / $1,500 $6,000 / $12,000 $ $5,100 / $10,200 Unlimited / Unlimited $900 $20 $105 CHICAGO HEALTH SYSTEM LLH 3-TIER SILVER PPO CHS $3,100 / $6,200 $10,000 / $20,000 45% $30 $160 $950 $1,600 45% 0 $65 $130 45% 1. Copays are not. Coinsurances are. The deductible for the Preferred Partner and Health Providers is integrated, meaning qualified payments made within either of those networks apply to that single deductible. 2. Coinsurance is the percentage paid by member after meeting the deductible. Percentages shown within this table represent coinsurance amounts and are always subject to the deductible. Health is responsible for the remainder of the covered services. 3. Out-of-pocket maximum is the most you will ever have to pay in the plan year for covered services under a specific plan. Deductibles, coinsurance and copays in either the or with Health Providers all apply to your out-of-pocket maximum. 4. Includes room and board and some other additional charges. After the first three days of copays, Land of Lincoln Health pays 100% of covered services for that hospital stay. Includes services provided for mental/ 5. May include an outpatient clinic or same-day surgery center. Also includes services provided for mental/ 6. All Prescription Drug Benefits listed are for a 34-day supply. Copay for 90-day mail order prescriptions is 2½ times the 34-day retail copay. Coinsurance for mail order is the same as retail. Mutual Health Insurance Company ( Health ) is offering individual and family health insurance plans described herein. This brochure is distributed for marketing purposes and is not your policy. Some health care services will require precertification. If there is any difference between this brochure and the policy, the provisions of the policy will control. For more information on Health, call or visit. All Individual and Family Plans sold through the Marketplace are considered QHPs (Qualified Health Plans) as determined by the Affordable Care Act. 10

13 FAMILY HEALTH NETWORK LAND OF LINCOLN PLANS Individual and Family Health Insurance Highlights Deductible 1 Coinsurance 2 Out-of-Pocket Maximum 3 Primary Care Physician Specialist Visit ER Urgent Care Inpatient Hospital Stay 4 Outpatient Hospital Services 5 X-Rays & Labs Physical, Occupational & Speech Therapy Chiropractic Generic Rx 6 Preferred Brand Rx 6 Non-Preferred Brand Rx 6 Specialty Rx 6 FAMILY HEALTH NETWORK LLH 3-TIER SILVER PPO FHN $2,800 / $5,600 $10,000 / $20,000 35% 45% $30 $850 $150 $1,800 35% 45% 0 $65 $130 35% 45% 35% 35% 35% 35% FAMILY HEALTH NETWORK LLH 3-TIER BRONZE PPO FHN $5,000 / $10,000 $15,000 / $30,000 $6,500 / $13,000 Unlimited / Unlimited 1. Copays are not. Coinsurances are. The deductible for the and Land of Lincoln Health Providers is integrated, meaning qualified payments made within either of those networks apply to that single deductible. 2. Coinsurance is the percentage paid by member after meeting the deductible. Percentages shown within this table represent coinsurance amounts and are always subject to the deductible. Land of Lincoln Health is responsible for the remainder of the covered services. 3. Out-of-pocket maximum is the most you will ever have to pay in the plan year for covered services under a specific plan. Deductibles, coinsurance and copays in either the In-Network Tier 1 or with Health Providers all apply to your out-of-pocket maximum. 4. Includes room and board and some other additional charges. After the first three days of copays, Land of Lincoln Health pays 100% of covered services for that hospital stay. Includes services provided for mental/ 5. May include an outpatient clinic or same-day surgery center. Also includes services provided for mental/ 6. All Prescription Drug Benefits listed are for a 34-day supply. Copay for 90-day mail order prescriptions is 2½ times the 34-day retail copay. Coinsurance for mail order is the same as retail. Mutual Health Insurance Company ( Health ) is offering individual and family health insurance plans described herein. This brochure is distributed for marketing purposes and is not your policy. Some health care services will require precertification. If there is any difference between this brochure and the policy, the provisions of the policy will control. For more information on Health, call or visit. All Individual and Family Plans sold through the Marketplace are considered QHPs (Qualified Health Plans) as determined by the Affordable Care Act. 11

14 ILLINOIS HEALTH PARTNERS LAND OF LINCOLN PLANS Individual and Family Health Insurance Highlights Deductible 1 Coinsurance 2 Out-of-Pocket Maximum 3 Primary Care Physician Specialist Visit ER Urgent Care Inpatient Hospital Stay 4 Outpatient Hospital Services 5 X-Rays & Labs Physical, Occupational & Speech Therapy Chiropractic Generic Rx 6 Preferred Brand Rx 6 Non-Preferred Brand Rx 6 Specialty Rx 6 ILLINOIS HEALTH PARTNERS LLH 3-TIER GOLD PPO IHP / $1,000 $6,000 / $12,000 $ $6,800 / $13,600 Unlimited / Unlimited 5 $900 $15 $105 ILLINOIS HEALTH PARTNERS LLH 3-TIER SILVER PPO IHP $3,100 / $6,200 $10,000 / $20,000 45% $30 $850 $70 $160 $1,800 45% 0 $65 $130 45% 1. Copays are not. Coinsurances are. The deductible for the Preferred Partner and Health Providers is integrated, meaning qualified payments made within either of those networks apply to that single deductible. 2. Coinsurance is the percentage paid by member after meeting the deductible. Percentages shown within this table represent coinsurance amounts and are always subject to the deductible. Health is responsible for the remainder of the covered services. 3. Out-of-pocket maximum is the most you will ever have to pay in the plan year for covered services under a specific plan. Deductibles, coinsurance and copays in either the or with Health Providers all apply to your out-of-pocket maximum. 4. Includes room and board and some other additional charges. After the first three days of copays, Land of Lincoln Health pays 100% of covered services for that hospital stay. Includes services provided for mental/ 5. May include an outpatient clinic or same-day surgery center. Also includes services provided for mental/ 6. All Prescription Drug Benefits listed are for a 34-day supply. Copay for 90-day mail order prescriptions is 2½ times the 34-day retail copay. Coinsurance for mail order is the same as retail. Mutual Health Insurance Company ( Health ) is offering individual and family health insurance plans described herein. This brochure is distributed for marketing purposes and is not your policy. Some health care services will require precertification. If there is any difference between this brochure and the policy, the provisions of the policy will control. For more information on Health, call or visit. All Individual and Family Plans sold through the Marketplace are considered QHPs (Qualified Health Plans) as determined by the Affordable Care Act. 12

15 PRESENCE HEALTH LAND OF LINCOLN PLANS Individual and Family Health Insurance Highlights Deductible 1 Coinsurance 2 Out-of-Pocket Maximum 3 Primary Care Physician Specialist Visit ER Urgent Care Inpatient Hospital Stay 4 Outpatient Hospital Services 5 X-Rays & Labs Physical, Occupational & Speech Therapy Chiropractic Generic Rx 6 Preferred Brand Rx 6 Non-Preferred Brand Rx 6 Specialty Rx 6 PRESENCE HEALTH LLH 3-TIER GOLD PPO Presence / $1,000 $6,000 / $12,000 $ $6,800 / $13,600 Unlimited / Unlimited 0 $900 $15 $105 PRESENCE HEALTH LLH 3-TIER SILVER PPO Presence $3,400 / $6,800 $10,000 / $20,000 45% $30 $850 $145 $1,800 45% 0 $65 $130 45% 1. Copays are not. Coinsurances are. The deductible for the Preferred Partner and Health Providers is integrated, meaning qualified payments made within either of those networks apply to that single deductible. 2. Coinsurance is the percentage paid by member after meeting the deductible. Percentages shown within this table represent coinsurance amounts and are always subject to the deductible. Health is responsible for the remainder of the covered services. 3. Out-of-pocket maximum is the most you will ever have to pay in the plan year for covered services under a specific plan. Deductibles, coinsurance and copays in either the or with Health Providers all apply to your out-of-pocket maximum. 4. Includes room and board and some other additional charges. After the first three days of copays, Land of Lincoln Health pays 100% of covered services for that hospital stay. Includes services provided for mental/ 5. May include an outpatient clinic or same-day surgery center. Also includes services provided for mental/ 6. All Prescription Drug Benefits listed are for a 34-day supply. Copay for 90-day mail order prescriptions is 2½ times the 34-day retail copay. Coinsurance for mail order is the same as retail. Mutual Health Insurance Company ( Health ) is offering individual and family health insurance plans described herein. This brochure is distributed for marketing purposes and is not your policy. Some health care services will require precertification. If there is any difference between this brochure and the policy, the provisions of the policy will control. For more information on Health, call or visit. All Individual and Family Plans sold through the Marketplace are considered QHPs (Qualified Health Plans) as determined by the Affordable Care Act. 13

16 RIVERSIDE LAND OF LINCOLN PLANS Small Business Health Insurance Highlights Deductible 1 Coinsurance 2 Out-of-Pocket Maximum 3 Primary Care Physician Specialist Visit ER Urgent Care Inpatient Hospital Stay 4 Outpatient Hospital Services 5 X-Rays & Labs Physical, Occupational & Speech Therapy Chiropractic Generic Rx 6 Preferred Brand Rx 6 Non-Preferred Brand Rx 6 Specialty Rx 6 RIVERSIDE LLH 3-TIER SILVER PPO Riverside $3,100 / $6,200 $10,000 / $20,000 45% $30 $950 $160 $1,600 45% 0 $65 $130 45% 1. Copays are not. Coinsurances are. The deductible for the Preferred Partner and Health Providers is integrated, meaning qualified payments made within either of those networks apply to that single deductible. 2. Coinsurance is the percentage paid by member after meeting the deductible. Percentages shown within this table represent coinsurance amounts and are always subject to the deductible. Health is responsible for the remainder of the covered services. 3. Out-of-pocket maximum is the most you will ever have to pay in the plan year for covered services under a specific plan. Deductibles, coinsurance and copays in either the or with Health Providers all apply to your out-of-pocket maximum. 4. Includes room and board and some other additional charges. After the first three days of copays, Land of Lincoln Health pays 100% of covered services for that hospital stay. Includes services provided for mental/ 5. May include an outpatient clinic or same-day surgery center. Also includes services provided for mental/ 6. All Prescription Drug Benefits listed are for a 34-day supply. Copay for 90-day mail order prescriptions is 2½ times the 34-day retail copay. Coinsurance for mail order is the same as retail. Mutual Health Insurance Company ( Health ) is offering individual and family health insurance plans described herein. This brochure is distributed for marketing purposes and is not your policy. Some health care services will require precertification. If there is any difference between this brochure and the policy, the provisions of the policy will control. For more information on Health, call or visit. All Individual and Family Plans sold through the Marketplace are considered QHPs (Qualified Health Plans) as determined by the Affordable Care Act. 14

17 SWEDISH COVENANT LAND OF LINCOLN PLANS Individual and Family Health Insurance Highlights Deductible 1 Coinsurance 2 Out-of-Pocket Maximum 3 Primary Care Physician Specialist Visit ER Urgent Care Inpatient Hospital Stay 4 Outpatient Hospital Services 5 X-Rays & Labs Physical, Occupational & Speech Therapy Chiropractic Generic Rx 6 Preferred Brand Rx 6 Non-Preferred Brand Rx 6 Specialty Rx 6 SWEDISH COVENANT LLH 3-TIER GOLD PPO SCH / $1,000 $6,000 / $12,000 $15 00 $5,500 / $11,000 Unlimited / Unlimited $55 $900 $25 $105 SWEDISH COVENANT LLH 3-TIER SILVER PPO SCH $3,100 / $6,200 $10,000 / $20,000 45% $30 $850 $145 $1,800 45% 0 $65 $130 45% 1. Copays are not. Coinsurances are. The deductible for the Preferred Partner and Health Providers is integrated, meaning qualified payments made within either of those networks apply to that single deductible. 2. Coinsurance is the percentage paid by member after meeting the deductible. Percentages shown within this table represent coinsurance amounts and are always subject to the deductible. Health is responsible for the remainder of the covered services. 3. Out-of-pocket maximum is the most you will ever have to pay in the plan year for covered services under a specific plan. Deductibles, coinsurance and copays in either the or with Health Providers all apply to your out-of-pocket maximum. 4. Includes room and board and some other additional charges. After the first three days of copays, Land of Lincoln Health pays 100% of covered services for that hospital stay. Includes services provided for mental/ 5. May include an outpatient clinic or same-day surgery center. Also includes services provided for mental/ 6. All Prescription Drug Benefits listed are for a 34-day supply. Copay for 90-day mail order prescriptions is 2½ times the 34-day retail copay. Coinsurance for mail order is the same as retail. Mutual Health Insurance Company ( Health ) is offering individual and family health insurance plans described herein. This brochure is distributed for marketing purposes and is not your policy. Some health care services will require precertification. If there is any difference between this brochure and the policy, the provisions of the policy will control. For more information on Health, call or visit. All Individual and Family Plans sold through the Marketplace are considered QHPs (Qualified Health Plans) as determined by the Affordable Care Act. 15

18 LAND OF LINCOLN HEALTH TRADITIONAL PPO Individual and Family Health Insurance Highlights Deductible 1 Coinsurance 2 Out-of-Pocket Maximum 3 Primary Care Physician Specialist Visit ER Urgent Care Inpatient Hospital Stay 4 Outpatient Hospital Services 5 X-Rays & Labs Physical, Occupational & Speech Therapy Chiropractic Generic Rx 6 Preferred Brand Rx 6 Non-Preferred Brand Rx 6 LAND OF LINCOLN HEALTH TRADITIONAL GOLD PPO In-Network $1,350 / $2,700 $5,000 / $10,000 $3,300 / $6,600 Unlimited / Unlimited LAND OF LINCOLN HEALTH TRADITIONAL SILVER PPO In-Network $1,900 / $3,800 $8,000 / $16,000 $6,500 / $13,000 Unlimited / Unlimited LAND OF LINCOLN HEALTH TRADITIONAL BRONZE PPO In-Network $5,500 / $11,000 $12,000 / $24,000 $6,500 / $13,000 Unlimited / Unlimited 1. Copays are not. Coinsurances are. The deductible for the Preferred Partner and Health Providers is integrated, meaning qualified payments made within either of those networks apply to that single deductible. 2. Coinsurance is the percentage paid by member after meeting the deductible. Percentages shown within this table represent coinsurance amounts and are always subject to the deductible. Health is responsible for the remainder of the covered services. 3. Out-of-pocket maximum is the most you will ever have to pay in the plan year for covered services under a specific plan. Deductibles, coinsurance and copays in either the or with Health Providers all apply to your out-of-pocket maximum. 4. Includes room and board and some other additional charges. After the first three days of copays, Land of Lincoln Health pays 100% of covered services for that hospital stay. Includes services provided for mental/ 5. May include an outpatient clinic or same-day surgery center. Also includes services provided for mental/ 6. All Prescription Drug Benefits listed are for a 34-day supply. Copay for 90-day mail order prescriptions is 2½ times the 34-day retail copay. Coinsurance for mail order is the same as retail. Specialty Rx 6 Mutual Health Insurance Company ( Health ) is offering individual and family health insurance plans described herein. This brochure is distributed for marketing purposes and is not your policy. Some health care services will require precertification. If there is any difference between this brochure and the policy, the provisions of the policy will control. For more information on Health, call or visit. All Individual and Family Plans sold through the Marketplace are considered QHPs (Qualified Health Plans) as determined by the Affordable Care Act. 16

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20 Plans Built Hand-in-Hand with Doctors and Hospitals You Trust Questions? call one of our experts today: Visit our website for more information: Like our Facebook page and stay connected: Facebook.com/LandofLincolnHealth Join us on Twitter and get the latest updates: Twitter.com/LLHInsured