Page 4 - Playmakers 2020 Renewal Benefits Booklet

Playmakers, Inc. Medical Cost Analysis

Effective November 2020
Buy-up Base
Current Renewal Current Renewal
Blue Care Network Blue Care Network Blue Care Network Blue Care Network
HMO 10% HMO 10% HMO $250 Ded HMO $250 Ded
Rates Counts
Single 3 $604.01 $654.80 4 $556.85 $603.77
Two Person 0 $1,449.63 $1,571.52 0 $1,336.44 $1,449.05
Family 2 $1,812.04 $1,964.39 1 $1,670.55 $1,811.32
Estimated Monthly Premium $5,436 $5,893 $3,898 $4,226
Estimated Annual Premium $65,233 $70,718 $46,775 $50,717
Percentage Change 8.41% 8.43%
Overall Percentage Change 8.42%
Deductible In-Network In-Network In-Network In-Network
Individual $0 $0 $250 $250
Family $0 $0 $500 $500
Coinsurance 90% 90% 80% 80%
Max Individual $1,000* $1,000* $2,500* $2,500*
Max Family $2,000* $2,000* $5,000* $5,000*
Out-of-Pocket Maximum
Individual $5,000** $5,000** $6,350** $6,350**
Family $10,000** $10,000** $12,700** $12,700**
Hospitalization 90% 90% 80% 80%
Emergency Room $250 $250 $250 after ded $250 after ded
Urgent Care $35 $35 $35 $35
Office Visit/Online Visit $20 $20 $20 $20
Specialist copay $30 $30 $30 $30
Preventative Care 100% 100% 100% 100%
Prescription Drugs
Tier 1 $4-$15 $4-$15 $6-$25 $6-$25
Tier 2 $40 $40 $50 $50
Tier 3 $80 $80 $80 $80
Tier 4 20% (max $200) 20% (max $200) 20% (max $200) 20% (max $200)
Tier 5 20% (max $300) 20% (max $300) 20% (max $300) 20% (max $300)

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.
*Applies to coinsurance amounts only; does not include flat copays, deductible or RX copays.
** OOP includes deductible, copays, coinsurance and RX copays.