Page 7 - Playmakers 2020 Renewal Benefits Booklet

Playmakers, Inc.

BCN Buy-up Plan Alternative

Current Renewal Alternative 1
Blue Care Network Blue Care Network Blue Care Network
HMO 10% HMO 10% HMO 20%
Rates Counts
Single 3 $604.01 $654.80 $628.63
Two Person 0 $1,449.63 $1,571.52 $1,508.72
Family 2 $1,812.04 $1,964.39 $1,885.90
Estimated Monthly Premium $5,436 $5,893 $5,658
Estimated Annual Premium $65,233 $70,718 $67,892
Percentage Change 8.41% 4.08%
Deductible In-Network In-Network In-Network
Individual $0 $0 $0
Family $0 $0 $0
Coinsurance 90% 90% 80%
Max Individual $1,000* $1,000* $1,000*
Max Family $2,000* $2,000* $2,000*
Out-of-Pocket Maximum
Individual $5,000** $5,000** $8,150**
Family $10,000** $10,000** $16,300**
Hospitalization 90% 90% 80%
Emergency Room $250 $250 $250
Urgent Care $35 $35 $35
Office Visit/Online Visit $20 $20 $25
Specialist copay $30 $30 $35
Preventative Care 100% 100% 100%
Prescription Drugs
Tier 1 $4-$15 $4-$15 $10-$30
Tier 2 $40 $40 $60
Tier 3 $80 $80 $80
Tier 4 20% (max $200) 20% (max $200) 20% (max $200)
Tier 5 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.