Page 3 - Tetra Renewal 2020
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The Tetra Corporation

    Benefit Analysis- 7/1/2020:  Rates include Medical/RX/Dental/Vision


                                               Current                       Renewal
                                                BCBSM                          BCBSM
                                         CB  PPO Platinum $500          CB  PPO Platinum $500
    Contracts                  12
                                     Member level rating effective  Member level rating effective
                                              7/01/2019                      7/01/2020

    Estimated Monthly Premium                   $15,965                        $16,990
    Estimated Annual Premium                   $191,575                       $203,879
    Percentage Change                                                          6.42%
    Annual Dollar Change                                                       $12,305
    Deductible                                In-Network                     In-Network
        Individual                               $500                           $500
        Family                                  $1,000                         $1,000
    Coinsurance Maximum                          90%                            90%
        Individual                               $500*                         $500*
        Family                                  $1,000*                        $1,000*
    Out-of-Pocket Maximum
        Individual                              $6,600**                      $6,600**
        Family                                 $13,200**                      $13,200**
    Hospitalization                          90% after ded                  90% after ded
    Emergency Room                               $150                           $150
    Urgent Care                                  $60                            $60
    Office Visit/Online                         $20/$20                       $20/$20
    Specialist Visit                             $20                            $20
    Preventative Care                            100%                           100%
    Prescription Drugs
        Tier 1                                    $5                             $5
        Tier 2                                   $40                            $40
        Tier 3                                   $80                            $80
        Tier 4                                   N/A                            N/A
        Tier 5                                   N/A                            N/A

        This is a summary analysis only.  Please refer to certificate of coverage for all specific details.  This summary is not a
        contract and makes no representations or warranties as to final outcomes of claim adjudication.
        Final rates are subject to underwriting approval and are subject to change.  Rates include taxes and fees.
        *Applies to coinsurance amounts only; does not include flat copays, deductible or RX copays.
         ** OOP includes deductible, copays, coinsurance and RX copays.
        All rates include Blue Dental PPO Plus 100/80/50/50, Annual Max $1,000 and VSP 12/12/12-$5/$10
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