Page 4 - Canada Dry Bottling Renewal 2020

CANADA DRY BOTTLING COMPANY RENEWAL

Effective December 1, 2020

Current Mapped Renewal Alt # 1 Alt # 2
PHP PPO Platinum PHP PPO Platinum PHP PPO Platinum BCBSM Community
PFH004 PFH004 PFH005 Blue PPO Platinum
2 employees
Member Member Member Member
Level Level Level Level
Rating Rating Rating Rating

Est. Monthly Premium $2,573.21 $2,620.36 $2,465.71 $2,696.45
Est. Annual Premium $30,878.52 $31,444.32 $29,588.52 $32,357.40
Includes Taxes and Fees
Change in Premium 1.8% INCREASE 4.2% DECREASE 4.8% INCREASE
Benefits
Deductible
In network None None $250/$500 None
Out Network $1000/$2000 $1000/$2000 $1500/$3000 $250/$500

Prescription drug copay $10/$40/$80/$150 $10/$40/$80/$150 $10/$40/$80/20%($300) $10/$40/$80

Office visit copay $20 PCP/$40 SPEC $20 PCP/$40 SPEC $20 PCP/$40 SPEC $20

Urgent care copay $50 $50 $50 $60

Emergency Room Copay $150 $150 $150 after deductible $150

Hospitalization
In patient 80% 80% 80% after deductible 80%
Out patient 80% 80% 80% after deductible 80%
Lab & X-ray 80% 80% 80% after deductible 80%

Ded. & Coinsurance Max. N/A N/A N/A $1500/$3000

Maximum copayment
In network $1500/$3000 $1500/$3000 $2200/$4400 $6600/$13,200
Out network $4000/$8000 $4000/$8000 $4500/$9000 $13,200/$26,400
2019 rates increased 10.3%, 2018 rates increased 10.8%, 2017 rates increased 6.5%
2016 group had to move to an ACA compliant plan (from a transitional plan) because they had other ACA plans. Rate increase was 20.5%

If a member chooses a brand name drug instead of the generic, they must pay the difference, plus the brand name copay.
**Ancillary services for Office Visits and Urgent Care visits are subject to the deductible and coinsurance on the Simply Blue PPO plans.

Prepared September 2020