Page 4 - Tetra Renewal 2020

The Tetra Corporation: June 2020 Medical Analysis

Current Renewal Option 1 Option 2 Option 3
BCBSM BCBSM BCBSM BCBSM Blue Care Network

CB Platinum $500 CB Platinum $500 CB Gold $1500 SB Gold $500 Platinum $500 0%
Plan Type PPO PPO PPO PPO HMO
Plan Year 2019 2020 2020 2020 2020
In-Network In-Network In-Network In-Network In-Network
Deductible
Individual $500 $500 $1500 $500 $500
Couple/Family $1,000 $1000 $3000 $1000 $1000
Coinsurance 10% 10% 20% 20% 0%
Coinsurance Max
Individual $500 $500 $4500 $4500 Not Applicable
Couple/Family $1,000 $1000 $9000 $9000 Not Applicable
Annual Out of Pocket Max
Individual $6,600 $6600 $8150 $8150 $1500
Couple/Family $13,200 $13200 $16300 $16300 $3000
Physician Copays
Preventive Care Covered 100% No Charge No Charge No Charge No Charge
Office Visit $20 $20 $30 $30 $20
Specialty Office Visit $20 $20 $30 $50 $30
Virtual Visits $20 $20 $30 $30 $20
Hospital Services
Urgent Care $60 $60 $60 $60 $35
Emergency Room $150 $150 $250 $250 $150 Copay after deductible
Inpatient Hospital 10% after deductible 10% after deductible 20% after deductible 20% after deductible 0% after deductible
Outpatient Hospital 10% after deductible 10% after deductible 20% after deductible 20% after deductible 0% after deductible
Diagnostic Services
Imaging/CT/PET/MRI 10% after deductible 10% after deductible 20% after deductible 20% after deductible $150 Copay after deductible
Labs 10% after deductible 10% after deductible 20% after deductible 20% after deductible No Charge
X-Rays 10% after deductible 10% after deductible 20% after deductible 20% after deductible 0% after deductible
Mental Health $20 10% after deductible 20% after deductible 20% after deductible $20
Chiropractic $20 $20 $30 $30 $30
Prescription Drugs
Generic $5 $5 $10 $20 $4/$15
Preferred Brand $40 $40 $40 $60 $40
Non-Preferred Brand $80 $80 $80 $80 or 50% $100 max $80
Preferred Specialty $40 $40 $40 20%/$200 max 20%/$200 max
Non-Preferred Specialty $80 $80 $80 25%/$300 max 20%/$300 max
Effective Date 7/1/2019 7/1/2020 7/1/2020 7/1/2020 7/1/2020
Total Number of Employees 12 12 12 12 12
Monthly Total Medical Premium $14,903.55 $15,892.19 $13,126.01 $12,537.59 $12,777.24
Annual Total Medical Premium $178,842.60 $190,706.28 $157,512.12 $150,451.08 $153,326.88
Percentage Change From Current 6.63% -11.93% -15.88% -14.27%
Annual Dollar Change From Current $11,863.68 ($21,330.48) ($28,391.52) ($25,515.72)

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