Page 8 - Playmakers 2020 Renewal Benefits Booklet

Playmakers, Inc.
PHP Buy-up Plan Alternatives

Current Renewal Alternative 2 Alternative 3
Blue Care Network Blue Care Network PHP PPO PHP HMO
HMO 10% HMO 10% Platinum 0 Platinum 0
Rates Counts
Single 3 $604.01 $654.80
Two Person 0 $1,449.63 $1,571.52 PHP Member Level PHP Member Level
Rates
Rates
Family 2 $1,812.04 $1,964.39
Estimated Monthly Premium $5,436 $5,893 $11,502 $9,825
Estimated Annual Premium $65,233 $70,718 $138,020 $117,898
Percentage Change 8.41% 111.58% 80.73%
Deductible In-Network In-Network In-Network In-Network
Individual $0 $0 $0 $0
Family $0 $0 $0 $0
Coinsurance 90% 90% 80% 80%
Max Individual $1,000* $1,000* N/A N/A
Max Family $2,000* $2,000* N/A N/A
Out-of-Pocket Maximum
Individual $5,000** $5,000** $1,500** $1,500**
Family $10,000** $10,000** $3,000** $3,000**
Hospitalization 90% 90% 80% 80%
Emergency Room $250 $250 $150 $150
Urgent Care $35 $35 $50 $50
Office Visit/Online Visit $20 $20 $20/$5 $20/$5
Specialist copay $30 $30 $40 $40
Preventative Care 100% 100% 100% 100%
Prescription Drugs
Tier 1 $4-$15 $4-$15 $10 $10
Tier 2 $40 $40 $40 $40
Tier 3 $80 $80 $80 $80
Tier 4 20% (max $200) 20% (max $200) $150 $150
Tier 5 20% (max $300) 20% (max $300) $150 $150

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.