Page 5 - Food Bank Council 2020 Renewal Booklet

September 2020 Food Bank Council of Michigan Alternative Carrier

Current Renewal Option 1 Option 2 Option 3
BCN PCP Focus BCN PCP Focus Blue Cross Blue Shield PHP PPO PHP HMO
Platinum $500 0% VA Platinum $500 0% VA CB Platinum $500 EA Platinum 750 Platinum 750
Plan Type HMO HMO PPO PPO HMO
Plan Year 2019 2020 2020 2020 2020
In-Network In-Network In-Network In-Network In-Network
Deductible
Individual $500 $500 $500 $750 $750
Couple/Family $1,000 $1000 $1000 $1500 $1500
Coinsurance 0% 0% 10% 20% 20%
Coinsurance Max
Individual N/A Not Applicable $500 Not Applicable Not Applicable
Couple/Family N/A Not Applicable $1,000 Not Applicable Not Applicable
Annual Out of Pocket Max
Individual $1,500 $1500 $6600 $2700 $2700
Couple/Family $3,000 $3000 $13200 $5400 $5400
Physician Copays
Preventive Care Covered 100% No Charge No Charge No Charge No Charge
Office Visit $20 $20 $20 $20 $20
Specialty Office Visit $30 $30 $20 $40 $40
Virtual Visits $20 $20 $20 $5 $5
Hospital Services
Urgent Care $35 $35 $60 $50 $50
$150 Copay after
Emergency Room $150 after deductible $150 Copay after deductible $150 $150 Copay after deductible deductible
Inpatient Hospital 0% after dedutible 0% after deductible 10% after deductible 20% after deductible 20% after deductible
Outpatient Hospital 0% after dedutible 0% after deductible 10% after deductible 20% after deductible 20% after deductible
Diagnostic Services
Imaging/CT/PET/MRI $150 after deductible $150 Copay after 10% after deductible $150 Copay after deductible $150 Copay after
deductible
deductible
Labs 0% after dedutible No Charge 10% after deductible 20% after deductible 20% after deductible
X-Rays 0% after dedutible 0% after deductible 10% after deductible 20% after deductible 20% after deductible
Mental Health $20 $20 $20 $20 $20
Chiropractic $30 $30 $20 $30 Copay after deductible $30 Copay after deductible
Prescription Drugs
Generic $4/$15 $4/$15 $5 $20 $20
Preferred Brand $40 $40 $40 $50 $50
Non-Preferred Brand $80 $80 $80 $80 $80
Preferred Specialty 20%/$200 max 20%/$200 max $40 $150 $150
Non-Preferred Specialty 20%/$300 max 20%/$300 max $80 $150 $150
Effective Date 9/1/2019 9/1/2020 9/1/2020 9/1/2020 9/1/2020
Total Number of
Employees 7 7 7 7 7
Monthly Total Medical
Premium $5,725.22 $6,166.43 $8,330.11 $7,103.34 $6,063.94
Annual Total Medical
Premium $68,702.64 $73,997.16 $99,961.32 $85,240.08 $72,767.28
Compared To Current Current Current Current
Percentage Change 7.71% 45.50% 24.07% 5.92%
Annual Dollar Change $5,294.52 $31,258.68 $16,537.44 $4,064.64

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