Page 4 - Affiliate Mortgage Services September 2020 Renewal

Affiliate Mortgage Services: July 2020 BCN Gold Renewal

Current Renewal Option 1 Option 2
Blue Care Network Blue Care Network Blue Care Network Blue Care Network
Gold $1000 PCP Focus 20%
Gold $1,000/20% VA Gold $1000 20% VA Gold $1500 20% VA VA
Plan Type HMO HMO HMO HMO
Plan Year 2019 2020 2020 2020
In-Network In-Network In-Network In-Network
Deductible
Individual $1,000 $1000 $1500 $1000
Couple/Family $2,000 $2000 $3000 $2000
Coinsurance 20% 20% 20% 20%
Coinsurance Max
Individual $2,500 $3500 $2500 $3500
Couple/Family $5,000 $7000 $5000 $7000
Annual Out of Pocket Max
Individual $6,600 $8150 $8150 $8150
Couple/Family $13,200 $16300 $16300 $16300
Physician Copays
Preventive Care Covered 100% No Charge No Charge No Charge
Office Visit $20 $20 $20 $20
Specialty Office Visit $40 $40 $40 $40
Virtual Visits $20 $20 $20 $20
Hospital Services
Urgent Care $50 $50 $50 $50
$250 Copay after $250 Copay after
$250 after deductible $250 Copay after deductible
Emergency Room deductible deductible
Inpatient Hospital 20% after deductible 20% after deductible 20% after deductible 20% after deductible
Outpatient Hospital 20% after deductible 20% after deductible 20% after deductible 20% after deductible
Diagnostic Services
$150 Copay after $150 Copay after
Imaging/CT/PET/MRI $150 after deductible deductible deductible $150 Copay after deductible
Labs 20% after deductible No Charge No Charge No Charge
X-Rays 20% after deductible 20% after deductible 20% after deductible 20% after deductible
Mental Health $20 $20 $20 $20
Chiropractic $40 $40 $40 $40
Prescription Drugs
Generic $6/$25 $10/$30 $6/$25 $10/$30
Preferred Brand $50 $60 $50 $60
Non-Preferred Brand $80 $80 $80 $80
Preferred Specialty 20%/$200 max 20%/$200 max 20%/$200 max 20%/$200 max
Non-Preferred Specialty 20%/$300 max 20%/$300 max 20%/$300 max 20%/$300 max
Effective Date 9/1/2019 9/1/2020 9/1/2020 9/1/2020
Total Number of Employees 5 5 5 5
Monthly Total Medical Premium $2,285.49 $2,421.98 $2,398.51 $2,227.84
Annual Total Medical Premium $27,425.88 $29,063.76 $28,782.12 $26,734.08
Percentage Change From Current 5.97% 4.95% -2.52%
Annual Dollar Change From Current $1,637.88 $1,356.24 ($691.80)

Illustrative purposes only. Rates are subject to DIFS and carrier approval.