Page 2 - ECIC 2020 Renewal

Early Childhood Investment Corporation

Group Benefit Offerings

BCBSM Simply Blue PPO Platinum – Medical

$250 Single, $500 Family deductible followed by an 80/20 coinsurance to
an embedded coinsurance maximum of $1000/$2000, then to an overall
maximum of $6600 Single, $13,200 per family per calendar year, $20 PCP
Office Visit Copay and Amwell Online Copay, $40 Specialist Copay, $60
Urgent Care Copay, and $150 Emergency Room Copay, $10 Generic/$40
Preferred Brand Name/$80 Non Preferred Brand Name/15% Preferred
Specialty/25% Non Preferred Specialty Prescription Drugs

BCBSM Simply Blue PPO Gold – Medical – Mapped Renewal

$1000 Single, $2000 Family deductible followed by an 80/20 coinsurance
to an embedded coinsurance maximum of $3000/$6000, then to an overall
maximum of $8150 Single, $16,300 per family per calendar year, $30 PCP
Office Visit Copay and Amwell Online Copay, $50 Specialist Copay, $60
Urgent Care Copay, and $250 Emergency Room Copay, $20 Generic/$60
Preferred Brand Name/50% Non Preferred Brand Name/20% Preferred
Specialty/25% Non Preferred Specialty Prescription Drugs (Previous
copays: $20 PCP/$40 SPEC, $2000/$4000 embedded coinsurance max.,
$6600/$13,200 overall maximum, $15/$50/50%//20%/25% RX)

BCN HMO Platinum – Medical

No Deductible, 80/20 coinsurance to an embedded coinsurance
maximum of $1000/$2000, then to an overall maximum of $6600
Single, $13,200 per family per calendar year, $25 PCP Office Visit
Copay and Amwell Online Copay, $35 Specialist Copay, $35 Urgent
Care Copay, and $150 Emergency Room Copay, $4 Generic (Tier
1)/$15 Generic (Tier 2)/$40 Preferred Brand Name/$80 Non Preferred
Brand Name/20% Preferred Specialty/20% Non Preferred Specialty
Prescription Drugs

Amwell Online copay is $0 until June 30, 2020 for all three plans.