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54 Attachment B: 2006 Medical Options Comparison

BENEFIT PPO OPTION

POS OPTION

HMO OPTION

In-Network Out-of-Network In-Network Out-of-Network

Annual Deductible* $300 per individual; $750 family* None $300 per individual; $750 family None Preexisting Condition Requirement 6 months if no immediately prior coverage 6 months if no immediately prior coverage None Physician Office Visit 90% of MAC 70% of MAC $20 copay general***; $25 copay specialist 70% of MAC after deductible $15 copay PCP; $20 copay specialist Hospital Care 90% of MAC 70% of MAC $100 per admission $300 per admission then 70% per diem after deductible $100 per admission Prescription Drug Coinsurance/Copay** $5 generic; $20 preferred brand; $40 non-preferred brand** $5 generic; $20 preferred brand; $40 non-preferred brand + amount exceeding MAC** $5 generic; $20 preferred brand; $40 non-preferred brand** 70% of MAC after deductible $5 generic; $20 preferred brand; $40 non-preferred brand** Maternity 90% of MAC 70% of MAC $20 copay OB, first visit only; $25 copay specialist; $100 copay per hospital admission $300 copay then 70% per diem after deductible $15 copay OB, first visit only; $20 copay specialist; $100 hospital admission Routine Health Assessment and Immunizations – Child 90% of MAC; Covered through age 5; Maximum of 12 visits 70% of MAC; Covered through age 5; Maximum of 12 visits 100% benefit; Covered through age 5; Maximum of 12 visits 70% of MAC after deductible; Covered through age 5; Maximum of 12 visits $15 copay PCP; $20 copay specialist; Covered through age 17 Routine Health Assessment – Adult not covered 100% benefit 70% of MAC after deductible $15 copay PCP; $20 copay specialist Emergency Care $25 copay (waived if certain conditions are met); 90% of MAC $25 copay (waived if certain conditions are met); 70% of MAC $50 copay per visit (waived if certain conditions are met) $50 copay per visit then 70% of MAC after deductible (copay waived if $50 copay per visit (waived if certain conditions are met)