City of Sun Prairie 2025 Renewal Folder.pdf

January 1, 2025 Renewal for:

Presented by: Al Jaeger

Usi Insurance Services Llc

Large Group Renewal

CITY OF SUN PRAIRIE

Group Health Cooperative of South Central Wisconsin

Emmy Caloud

City Of Sun Prairie

300 E Main St

Sun Prairie, WI 53590

Dear Emmy Caloud, CC: Al Jaeger

Usi Insurance Services Llc

September 2024

Thank you for selecting Group Health Cooperative of South Central Wisconsin (GHC-SCW) as a health care provider for your employees and their families.

The following pages outline your January 1, 2025 renewal, an overall increase of 6.24%.

The Notice of Changes and Clarifications describing universal benefit changes, certificate clarifications, and cost-sharing changes to GHC-SCW's Large Group plans is provided. In addition, the Cost-Sharing Change Summary, highlighting the cost-sharing changes that affect your plan(s), is included. Please review these documents.

To ensure timely delivery of your new ID Cards for the coming plan year, we ask that you please return a signed copy of your Renewal Plan Option form within 45 days of receipt of your renewal.

We look forward to continuing to provide impeccable service to you and your group.

Sincerely, GHC-SCW Sales Team

2025 Underwriting Renewal Exhibit

Group Name: CITY OF SUN PRAIRIE

Corp ID: 447

Renewal Date: January 1, 2025

Plan Type: Blended

Claims Rx Claims Total Claims

Average

Members

3,370,884 416,291 3,787,175 658

Prior Recent

Rating 2024 2025

$0

Premium with ACA fees $4,394,430 $5,252,300

Blended Claims Projection 4,732,824

Employer Claims Projection 3,991,874

Adjusted Incurred Claims

Underwriting Adjustment 1.000

Weighted Prior and Recent 0% 100%

Experience Credibility 27%

Claims Trended to Renewal Rating Period 0 4,073,983

Total Expected Claims 0 3,991,874

Benefit and Size Adjustment - -

Manual Claims Projection 5,002,260

Final Overall Premium

Final Overall Rate Increase 6.24%

$4,394,430

Pooling Costs 23,040

$4,668,642

Recent Members 640

Premium

Admin Costs 496,435

Claims Projection Plus Admin 5,252,300

$4,394,430 $5,252,300

Calculated Overall Rate Increase 19.52%

ACA Fees $0

Claims Reporting Period

Pooled Claims 0 0

3,787,175

0 3,787,175

1/1/24 to 4/30/24 *Annualized*

Claims 0

Blended - 8/28/2024

2024 Underwriting Renewal Exhibit

Corp ID: 447

Renewal Date:

Plan Type: Blended

Final Overall Rate Increase

HMO Rates PPO Rates

Premium Breakdown 2024 2025 Premium Breakdown 2024 2025 Premium Breakdown 2024 2025 0 $0.00 $0.00

0 $0.00 $0.00

Employee $713.00 $757.49 0 $0.00 $0.00 Employee $963.00 $1,023.09

Family $1,836.00 $1,950.57 0 $0.00 $0.00 Family $2,479.00 $2,633.69

0 $0.00 $0.00

0 $0.00 $0.00

Employee $606.05 $643.87 0 $0.00 $0.00 Employee $818.55 $869.63 0 $0.00 $0.00

Employee +1 (1on) $1,319.05 $1,401.36 0 $0.00 $0.00 Employee +1 (1on) $1,781.55 $1,892.72 0 $0.00 $0.00

Employee +1 (2on) $1,212.10 $1,287.74 0 $0.00 $0.00 Employee +1 (2on) $1,637.10 $1,739.26

Family $1,729.05 $1,836.94 0 $0.00 $0.00 Family $2,334.55 $2,480.23

0 $0.00 $0.00

0 $0.00 $0.00

0 $0.00 $0.00 0 $0.00 $0.00 0 $0.00 $0.00 0 $0.00 $0.00

0 $0.00 $0.00 0 $0.00 $0.00 0 $0.00 $0.00 0 $0.00 $0.00

0 $0.00 $0.00 0 $0.00 $0.00 0 $0.00 $0.00 0 $0.00 $0.00

0 $0.00 $0.00 0 $0.00 $0.00 0 $0.00 $0.00

0 $0.00 $0.00 0 $0.00 $0.00 0 $0.00 $0.00

2402739 - HMO - Select PCP $500 Ded/$1,000 MOOP - Medicare 2403819 - PPO - PCP $500 Ded/$1,000 MOOP - Medicare

Renewal Rates TableJanuary 1, 2025

2402739 - HMO - Select PCP $500 Ded/$1,000 MOOP 2403819 - PPO - PCP $500 Ded/$1,000 MOOP

6.24%

Rates - 8/28/2024

Corp ID: 447

Renewal Date: January 1, 2025

Plan Type: HMO

Claims Rx Claims Total Claims

Average

Members

2,807,374 367,896 3,175,270 590

Prior Recent

Rating 2024 2025

0.97

ACA Fees $0$0

100%

Total Expected Claims

Benefit and Size Adjustment 1.00

0%

3,303,313

Employer Claims Projection

Admin Costs

Weighted Prior and Recent

1/1/24 to 4/30/24 *Annualized*

Claims

Pooled Claims

3,175,270

Claims Reporting Period

Premium $4,485,648$3,825,817

Calculated Overall Rate Increase

Premium with ACA fees $4,485,648$3,825,817

17.25%

27%

4,284,690

Claims Projection Plus Admin

Experience Credibility

Adjusted Incurred Claims

0 3,405,477

3,175,2700

Claims Trended to Renewal Rating Period

3,303,313

Pooling Costs 20,520

Underwriting Adjustment 1.000

Manual Claims Projection

4,022,990Blended Claims Projection

4,485,648

442,138

Recent Members

HMO - 8/28/2024

Corp ID: 447

Renewal Date: January 1, 2025

Plan Type: PPO

Claims Rx Claims Total Claims

Average

Members

563,509 48,395 611,905 68

Prior Recent

Rating 2024 2025

Claims Projection Plus Admin

709,834

54,298

766,652

34.83%

ACA Fees

Recent Members

Premium

Calculated Overall Rate Increase

Premium with ACA fees $568,613 $766,652

$0

Manual Claims Projection

Experience Credibility

Blended Claims Projection

Admin Costs

Pooling Costs

Underwriting Adjustment

688,561

0% 100%

0 668,506

Claims Reporting Period

0 611,905

0 0

Adjusted Incurred Claims

Claims Trended to Renewal Rating Period

1/1/24 to 4/30/24 *Annualized*

Claims

Pooled Claims

Employer Claims Projection 688,561

1.00 1.03

0 611,905

Benefit and Size Adjustment

Total Expected Claims

Weighted Prior and Recent

$568,613 $766,652

717,570

27%

$0

2,520

1.000

PPO - 8/28/2024

Current Subscriber/Member Count

Single Family(A) TOTALS

Benefit Plan ID

Plan Group ID Plan Group Name Subs Members Subs Members Subs Members

2402739 7764000 CITY OF SUN PRAIRIE 78 79 144 485 222 564

7764100 CITY OF SUN PRAIRIE-RETIREE 1 2 1 2

Plan Totals 78 79 145 487 223 566

HMO TOTAL 223 566

HMO

Single Family(A) TOTALS

Benefit Plan ID

Plan Group ID Plan Group Name Subs Members Subs Members Subs Members

2403819 7764001 CITY OF SUN PRAIRIE-PPO 5 5 16 61 21 66

Plan Totals 5 5 16 61 21 66

PPO TOTAL 21 66

PPO

Employer Name: CITY OF SUN PRAIRIE Employer ID: 447

Coverage Date: 2024 August

Single Family(A) TOTALS

ALL PLAN GROUPS COMBINED Subs Members Subs Members Subs Members

COMBINED TOTAL 83 84 161 548 244 632

OVERALL

2025 Renewal Plan Options

Corp ID: 447

Renewal Date:

Today's Date:

Current Plan: 2402739* Renewal Plan: 2502739* Alternate 1: Alternate 2: Alternate 3:

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

Member $500 No Out-of-Network Benefit $500 No Out-of-Network Benefit -- -- -- -- -- --

Family $1,000 No Out-of-Network Benefit $1,000 No Out-of-Network Benefit -- -- -- -- -- --

Member $1,000 No Out-of-Network Benefit $1,000 No Out-of-Network Benefit -- -- -- -- -- --

Family $2,000 No Out-of-Network Benefit $2,000 No Out-of-Network Benefit -- -- -- -- -- --

Member -- -- -- -- -- --

Family -- -- -- -- -- --

20% No Out-of-Network Benefit 20% No Out-of-Network Benefit -- -- -- -- -- --

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

No Charge No Out-of-Network Benefit No Charge No Out-of-Network Benefit -- -- -- -- -- --

$75 No Out-of-Network Benefit $75 No Out-of-Network Benefit -- -- -- -- -- --

No Charge No Out-of-Network Benefit No Charge No Out-of-Network Benefit -- -- -- -- -- --

No Charge No Out-of-Network Benefit No Charge No Out-of-Network Benefit -- -- -- -- -- --

No Charge No Out-of-Network Benefit No Charge No Out-of-Network Benefit -- -- -- -- -- --

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

No Charge No Charge No Charge No Charge -- -- -- -- -- --

$250 $250 $250 $250 -- -- -- -- -- --

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

Tier 1 $10 $10 -- -- --

Tier 2 $30 $30 -- -- --

Tier 3 $50 $50 -- -- --

Tier 4 (Specialty) $100 $100 -- -- --

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

20% after Deductible No Out-of-Network Benefit 20% after Deductible No Out-of-Network Benefit -- -- -- -- -- --

20% after Deductible No Out-of-Network Benefit 20% after Deductible No Out-of-Network Benefit -- -- -- -- -- --

Premium Breakdown Current Subs Rates Rates Rates

Employee 78 -- -- --

Family 144 -- -- --

Monthly Total -- -- --

Annual Total -- -- --

Increase of 6.24% -- -- -- -- -- --

Benefit Change Premium Credit/Charge Decrement -- -- -- -- -- --

*Member Benefit Accumulation: This plan is Embedded. Embedded means each individual Member has his/her own deductible and maximum out-of-pocket (MOOP) for a benefit plan. In addition, there is a shared family deductible and maximum out-of-pocket (MOOP).

**Member Benefit Accumulation: This plan is Non-Embedded. Non-Embedded means every member on your benefit plan shares one deductible and one maximum out-of-pocket (MOOP).

Plan Selection Renewal Plan: 2502739* Alternate 1: Alternate 2: Alternate 3:

Initial in this box to choose this plan:

Initial in this box to choose this plan:

Initial in this box to choose this plan:

Initial in this box to choose this plan:

Group Approval Signature: Date:

$757.49

$4,079,595.60

$339,966.30

$1,950.57

Policy Coinsurance

Specialist Care Office Visit

Advanced Radiology

Emergency Room Visit

X-ray, Diag Imaging, Outpatient Lab

Prescription Drugs

Outpatient Prescription

Drugs on GHC-SCW

Formulary

Clinic Services

Primary Care Office Visit

Emergency and Urgent Care

Urgent Care Visit

Outpatient Rehabilitation Therapy (PT/OT)

Renewal RatesCurrent Rates

Core Benefits

Deductible

Maximum Out-of-Pocket

Pharmacy Maximum

Out-of-Pocket

HMO Select Primary Care Preferred $500 Ded/$1,000

MOOP Plan

Better Together HMO Primary Care Preferred

$500 Ded/$1,000 MOOP Plan

September 2024

January 1, 2025

As the group's representative, I, the undersigned, have reviewed the offered coverages and benefits and choose to renew with the following selection:

Premium Adjustment to Current

Hospital Services

Inpatient Hospital Services

Outpatient Hospital Services

$3,839,976.00

$319,998.00

$1,836.00

$713.00

Corp ID: 447

Renewal Date:

Today's Date:

Current Plan: 2402739* Renewal Plan: 2502739* Alternate 1: Alternate 2: Alternate 3:

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

Member $500 No Out-of-Network Benefit $500 No Out-of-Network Benefit -- -- -- -- -- --

Family $1,000 No Out-of-Network Benefit $1,000 No Out-of-Network Benefit -- -- -- -- -- --

Member $1,000 No Out-of-Network Benefit $1,000 No Out-of-Network Benefit -- -- -- -- -- --

Family $2,000 No Out-of-Network Benefit $2,000 No Out-of-Network Benefit -- -- -- -- -- --

Member -- -- -- -- -- --

Family -- -- -- -- -- --

20% No Out-of-Network Benefit 20% No Out-of-Network Benefit -- -- -- -- -- --

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

No Charge No Out-of-Network Benefit No Charge No Out-of-Network Benefit -- -- -- -- -- --

$75 No Out-of-Network Benefit $75 No Out-of-Network Benefit -- -- -- -- -- --

No Charge No Out-of-Network Benefit No Charge No Out-of-Network Benefit -- -- -- -- -- --

No Charge No Out-of-Network Benefit No Charge No Out-of-Network Benefit -- -- -- -- -- --

No Charge No Out-of-Network Benefit No Charge No Out-of-Network Benefit -- -- -- -- -- --

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

No Charge No Charge No Charge No Charge -- -- -- -- -- --

$250 $250 $250 $250 -- -- -- -- -- --

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

Tier 1 $10 $10 -- -- --

Tier 2 $30 $30 -- -- --

Tier 3 $50 $50 -- -- --

Tier 4 (Specialty) $100 $100 -- -- --

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

20% after Deductible No Out-of-Network Benefit 20% after Deductible No Out-of-Network Benefit -- -- -- -- -- --

20% after Deductible No Out-of-Network Benefit 20% after Deductible No Out-of-Network Benefit -- -- -- -- -- --

Premium Breakdown Current Subs Rates Rates Rates

Employee -- -- --

Employee +1 (1on) -- -- --

Employee +1 (2on) -- -- --

Family 1 -- -- --

Monthly Total -- -- --

Annual Total -- -- --

Increase of 6.24% -- -- -- -- -- --

Benefit Change Premium Credit/Charge Decrement -- -- -- -- -- --

*Member Benefit Accumulation: This plan is Embedded. Embedded means each individual Member has his/her own deductible and maximum out-of-pocket (MOOP) for a benefit plan. In addition, there is a shared family deductible and maximum out-of-pocket (MOOP).

**Member Benefit Accumulation: This plan is Non-Embedded. Non-Embedded means every member on your benefit plan shares one deductible and one maximum out-of-pocket (MOOP).

Plan Selection Renewal Plan: 2502739* Alternate 1: Alternate 2: Alternate 3:

Initial in this box to choose this plan:

Initial in this box to choose this plan:

Initial in this box to choose this plan:

Initial in this box to choose this plan:

Group Approval Signature: Date:

January 1, 2025

September 2024

Medicare HMO Select Primary Care Preferred $500 Ded/$1,000

MOOP Plan

Better Together HMO Primary Care Preferred

$500 Ded/$1,000 MOOP Plan

Emergency and Urgent Care

Core Benefits

Deductible

Maximum Out-of-Pocket

Pharmacy Maximum

Out-of-Pocket

Policy Coinsurance

Clinic Services

Primary Care Office Visit

Specialist Care Office Visit

Advanced Radiology

X-ray, Diag Imaging, Outpatient Lab

Outpatient Rehabilitation Therapy (PT/OT)

Urgent Care Visit

Emergency Room Visit

Prescription Drugs

Outpatient Prescription

Drugs on GHC-SCW

Formulary

Hospital Services

Inpatient Hospital Services

Outpatient Hospital Services

Current Rates Renewal Rates

$606.05 $643.87

$1,319.05 $1,401.36

$1,212.10 $1,287.74

$1,729.05 $1,836.94

As the group's representative, I, the undersigned, have reviewed the offered coverages and benefits and choose to renew with the following selection:

1 $1,729.05 $1,836.94

$20,748.60 $22,043.28

Premium Adjustment to Current

Corp ID: 447

Renewal Date:

Today's Date:

Current Plan: 2403819* Renewal Plan: 2503819* Alternate 1: Alternate 2: Alternate 3:

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

Member $500 $1,000 $500 $1,000 -- -- -- -- -- --

Family $1,000 $2,000 $1,000 $2,000 -- -- -- -- -- --

Member $1,000 $2,000 $1,000 $2,000 -- -- -- -- -- --

Family $2,000 $4,000 $2,000 $4,000 -- -- -- -- -- --

Member -- -- -- -- -- --

Family -- -- -- -- -- --

20% 40% 20% 40% -- -- -- -- -- --

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

No Charge 40% after Deductible No Charge 40% after Deductible -- -- -- -- -- --

$75 40% after Deductible $75 40% after Deductible -- -- -- -- -- --

No Charge 40% after Deductible No Charge 40% after Deductible -- -- -- -- -- --

No Charge 40% after Deductible No Charge 40% after Deductible -- -- -- -- -- --

No Charge 40% after Deductible No Charge 40% after Deductible -- -- -- -- -- --

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

No Charge No Charge No Charge No Charge -- -- -- -- -- --

$250 $250 $250 $250 -- -- -- -- -- --

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

Tier 1 $10 $10 -- -- --

Tier 2 $30 $30 -- -- --

Tier 3 $50 $50 -- -- --

Tier 4 (Specialty) $100 $100 -- -- --

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

20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible -- -- -- -- -- --

20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible -- -- -- -- -- --

Premium Breakdown Current Subs Rates Rates Rates

Employee 5 -- -- --

Family 16 -- -- --

Monthly Total -- -- --

Annual Total -- -- --

Increase of 6.24% -- -- -- -- -- --

Benefit Change Premium Credit/Charge Decrement -- -- -- -- -- --

*Member Benefit Accumulation: This plan is Embedded. Embedded means each individual Member has his/her own deductible and maximum out-of-pocket (MOOP) for a benefit plan. In addition, there is a shared family deductible and maximum out-of-pocket (MOOP).

**Member Benefit Accumulation: This plan is Non-Embedded. Non-Embedded means every member on your benefit plan shares one deductible and one maximum out-of-pocket (MOOP).

Plan Selection Renewal Plan: 2503819* Alternate 1: Alternate 2: Alternate 3:

Initial in this box to choose this plan:

Initial in this box to choose this plan:

Initial in this box to choose this plan:

Initial in this box to choose this plan:

Group Approval Signature: Date:

Maximum Out-of-Pocket

January 1, 2025

September 2024

PPO Primary Care Preferred $500 Ded/$1,000 MOOP

PPO Plan

Core Benefits

Deductible

Connections PPO Primary Care Preferred $500

Ded/$1,000 MOOP

Hospital Services

Pharmacy Maximum

Out-of-Pocket

Policy Coinsurance

Clinic Services

Primary Care Office Visit

Specialist Care Office Visit

Advanced Radiology

Emergency and Urgent Care

Urgent Care Visit

Emergency Room Visit

Prescription Drugs

Outpatient Prescription

Drugs on GHC-SCW

Formulary

X-ray, Diag Imaging, Outpatient Lab

Outpatient Rehabilitation Therapy (PT/OT)

Inpatient Hospital Services

Outpatient Hospital Services

Current Rates Renewal Rates

$963.00 $1,023.09

Premium Adjustment to Current

As the group's representative, I, the undersigned, have reviewed the offered coverages and benefits and choose to renew with the following selection:

$2,479.00 $2,633.69

21 $44,479.00 $47,254.49

$533,748.00 $567,053.88

Corp ID: 447

Renewal Date:

Today's Date:

Current Plan: 2403819* Renewal Plan: 2503819* Alternate 1: Alternate 2: Alternate 3:

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

Member $500 $1,000 $500 $1,000 -- -- -- -- -- --

Family $1,000 $2,000 $1,000 $2,000 -- -- -- -- -- --

Member $1,000 $2,000 $1,000 $2,000 -- -- -- -- -- --

Family $2,000 $4,000 $2,000 $4,000 -- -- -- -- -- --

Member -- -- -- -- -- --

Family -- -- -- -- -- --

20% 40% 20% 40% -- -- -- -- -- --

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

No Charge 40% after Deductible No Charge 40% after Deductible -- -- -- -- -- --

$75 40% after Deductible $75 40% after Deductible -- -- -- -- -- --

No Charge 40% after Deductible No Charge 40% after Deductible -- -- -- -- -- --

No Charge 40% after Deductible No Charge 40% after Deductible -- -- -- -- -- --

No Charge 40% after Deductible No Charge 40% after Deductible -- -- -- -- -- --

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

No Charge No Charge No Charge No Charge -- -- -- -- -- --

$250 $250 $250 $250 -- -- -- -- -- --

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

Tier 1 $10 $10 -- -- --

Tier 2 $30 $30 -- -- --

Tier 3 $50 $50 -- -- --

Tier 4 (Specialty) $100 $100 -- -- --

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

20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible -- -- -- -- -- --

20% after Deductible 40% after Deductible 20% after Deductible 40% after Deductible -- -- -- -- -- --

Premium Breakdown Current Subs Rates Rates Rates

Employee -- -- --

Employee +1 (1on) -- -- --

Employee +1 (2on) -- -- --

Family -- -- --

Monthly Total -- -- --

Annual Total -- -- --

Increase of 6.24% -- -- -- -- -- --

Benefit Change Premium Credit/Charge Decrement -- -- -- -- -- --

*Member Benefit Accumulation: This plan is Embedded. Embedded means each individual Member has his/her own deductible and maximum out-of-pocket (MOOP) for a benefit plan. In addition, there is a shared family deductible and maximum out-of-pocket (MOOP).

**Member Benefit Accumulation: This plan is Non-Embedded. Non-Embedded means every member on your benefit plan shares one deductible and one maximum out-of-pocket (MOOP).

Plan Selection Renewal Plan: 2503819* Alternate 1: Alternate 2: Alternate 3:

Initial in this box to choose this plan:

Initial in this box to choose this plan:

Initial in this box to choose this plan:

Initial in this box to choose this plan:

Group Approval Signature: Date:

January 1, 2025

September 2024

Medicare PPO Primary Care Preferred $500 Ded/$1,000 MOOP

PPO Plan

Connections PPO Primary Care Preferred $500

Ded/$1,000 MOOP

Emergency and Urgent Care

Core Benefits

Deductible

Maximum Out-of-Pocket

Pharmacy Maximum

Out-of-Pocket

Policy Coinsurance

Clinic Services

Primary Care Office Visit

Specialist Care Office Visit

Advanced Radiology

X-ray, Diag Imaging, Outpatient Lab

Outpatient Rehabilitation Therapy (PT/OT)

Urgent Care Visit

Emergency Room Visit

Prescription Drugs

Outpatient Prescription

Drugs on GHC-SCW

Formulary

Hospital Services

Inpatient Hospital Services

Outpatient Hospital Services

Current Rates Renewal Rates

$818.55 $869.63

$1,781.55 $1,892.72

$1,637.10 $1,739.26

$2,334.55 $2,480.23

As the group's representative, I, the undersigned, have reviewed the offered coverages and benefits and choose to renew with the following selection:

0 $0.00 $0.00

$0.00 $0.00

Premium Adjustment to Current

Employer Name

Plan Type

HMO

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

ACA Maximum Out-of-Pocket (MOOP) - Individual $1,000 $1,000

High Deductible Health Plan (HDHP)

Deductible - Individual N/A N/A

High Deductible Health Plan (HDHP)

Maximum Out-of-Pocket (MOOP) - Individual N/A N/A

Plan Specific Benefit Realignment In-Network Out-of-Network In-Network Out-of-Network

Outpatient Prescription Drugs Tier 1 $10 No Out-of-Network Benefit $10 No Out-of-Network Benefit

Outpatient Prescription Drugs Tier 2 $30 No Out-of-Network Benefit $30 No Out-of-Network Benefit

Outpatient Prescription Drugs Tier 3 $50 No Out-of-Network Benefit $50 No Out-of-Network Benefit

Outpatient Prescription Drugs Tier 4 $100 No Out-of-Network Benefit $100 No Out-of-Network Benefit

2025 GHC-SCW Cost-Sharing Change Summary

Renewal Date

1/1/2025

2024 Plan Number 2025 Plan Number

Notice Of Change Benefit Benefit Under Current Plan Benefit for 2025

2402739 2502739

Employer Name

Plan Type

PPO

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

ACA Maximum Out-of-Pocket (MOOP) - Individual $1,000 $2,000 $1,000 $2,000

High Deductible Health Plan (HDHP)

Deductible - Individual N/A N/A N/A N/A

High Deductible Health Plan (HDHP)

Maximum Out-of-Pocket (MOOP) - Individual N/A N/A N/A N/A

Plan Specific Benefit Realignment In-Network Out-of-Network In-Network Out-of-Network

Outpatient Prescription Drugs Tier 1 $10 No Out-of-Network Benefit $10 No Out-of-Network Benefit

Outpatient Prescription Drugs Tier 2 $30 No Out-of-Network Benefit $30 No Out-of-Network Benefit

Outpatient Prescription Drugs Tier 3 $50 No Out-of-Network Benefit $50 No Out-of-Network Benefit

Outpatient Prescription Drugs Tier 4 $100 No Out-of-Network Benefit $100 No Out-of-Network Benefit

2025 GHC-SCW Cost-Sharing Change Summary

Renewal Date

1/1/2025

2024 Plan Number 2025 Plan Number

Notice Of Change Benefit Benefit Under Current Plan Benefit for 2025

2403819 2503819

2025 NOTICE OF COST-SHARING CHANGES

Large Group Member Certificate and Plans – Partners HMO & Better Together HMO

Notice of Cost-Sharing Changes/2025 Large Group Partners HMO & Better Together HMO Plans Group Health Cooperative of South Central Wisconsin (GHC-SCW)

Group Health Cooperative of South Central Wisconsin (GHC-SCW) continually monitors Federal and State rules and regulations to ensure our plan design and benefits are compliant. Certain changes and clarifications outlined below reflect ongoing requirements of the Patient Protection and Affordable Care Act and other changes to Federal and State rules and regulations.

This Notice of Cost-Sharing Changes provides a list of significant Cost-Sharing Changes to GHC-SCW’s 2025 Large Group Partners HMO and Better Together HMO plans with an effective date on or after January 1, 2025. A Cost-Sharing Change communicates a change to a Member’s out-of-pocket cost for a covered Benefit. A Cost-Sharing Change does not result in a change to the Benefit covered, only the cost of utilizing such Benefit. Not all communicated Cost-Sharing Changes will affect all plans.

2025 COST-SHARING CHANGES

Benefit Plan Type 2025 Cost-Sharing Change

ACA Maximum Out-of-Pocket (MOOP)

All 2024 Plans with an In-Network Individual MOOP of $9,450

The In-Network ACA Maximum Out-of-Pocket (MOOP) for an Individual is decreasing from $9,450 to $9,200. Based on plan benefit design, plans with an In-Network Individual MOOP of $9,450 will be decreasing to $9,200. Family MOOPs will also reflect a decrease. Please see Your Benefit Summary for Your plan’s Family MOOP.

2024 Individual ACA MOOP: $9,450 2025 Individual ACA MOOP: $9,200

High Deductible Health Plan (HDHP) Deductible

All 2024 HSA-eligible High Deductible Health Plans (HDHP) with an In-Network Individual Deductible of $1,600 or In-Network Family Deductible of $3,200

The High Deductible Health Plan (HDHP) (HSA-eligible) Deductible for an Individual is increasing from $1,600 to $1,650 and for a Family is increasing from $3,200 to $3,300.

Based on plan benefit design, HDHPs (HSA-eligible) with an In-Network Individual Deductible of $1,600 will be increasing to $1,650 and those with an In-Network Family Deductible of $3,200 will be increasing to $3,300.

2024 Individual HDHP Deductible: $1,600 2025 Individual HDHP Deductible: $1,650 2024 Family HDHP Deductible: $3,200 2025 Family HDHP Deductible: $3,300

High Deductible Health Plan (HDHP) Maximum Out-of- Pocket (MOOP)

All 2024 HSA-eligible High Deductible Health Plans (HDHP) with an In-Network Individual MOOP of $8,050

The High Deductible Health Plan (HDHP) (HSA-eligible) Maximum Out-of-Pocket (MOOP) for an Individual is increasing from $8,050 to $8,300. Based on plan benefit design, HDHPs (HSA-eligible) with an In-Network Individual MOOP of $8,050 will be increasing to $8,300. Family MOOPs will also reflect an increase. Please see Your Benefit Summary for Your plan’s Family MOOP.

2024 Individual HDHP MOOP: $8,050 2025 Individual HDHP MOOP: $8,300

For a complete description of services and coverage, please refer to your 2025 Large Group Member Certificate, Benefit Summary, Summary of Benefit and Coverage (“SBC”), Formulary, and any applicable Amendments. Your plan documents are available at http://planfinder.ghcscw.com/.

http://planfinder.ghcscw.com/

2025 NOTICE OF COST-SHARING CHANGES

Large Group Member Certificate and Plans – Connections PPO

Notice of Cost-Sharing Changes/2025 Large Group Connections PPO Plans Group Health Cooperative of South Central Wisconsin (GHC-SCW)

Group Health Cooperative of South Central Wisconsin (GHC-SCW) continually monitors Federal and State rules and regulations to ensure our plan design and benefits are compliant. Certain changes and clarifications outlined below reflect ongoing requirements of the Patient Protection and Affordable Care Act and other changes to Federal and State rules and regulations.

This Notice of Cost-Sharing Changes provides a list of significant Cost-Sharing Changes to GHC-SCW’s 2025 Large Group Connections PPO plans with an effective date on or after January 1, 2025. A Cost-Sharing Change communicates a change to a Member’s out-of-pocket cost for a covered Benefit. A Cost-Sharing Change does not result in a change to the Benefit covered, only the cost of utilizing such Benefit. Not all communicated Cost-Sharing Changes will affect all plans.

2025 COST-SHARING CHANGES

Benefit Plan Type 2025 Cost-Sharing Change

ACA Maximum Out-of-Pocket (MOOP)

All 2024 Plans with an In- Network Individual MOOP of $9,450

The In-Network ACA Maximum Out-of-Pocket (MOOP) for an Individual is decreasing from $9,450 to $9,200. Based on plan benefit design, plans with an In-Network Individual MOOP of $9,450 will be decreasing to $9,200. Family and Out-Of-Network MOOPs will also reflect a decrease. Please see Your Benefit Summary for Your plan’s Family and Out-of-Network MOOPs.

2024 Individual ACA MOOP: $9,450 2025 Individual ACA MOOP: $9,200

High Deductible Health Plan (HDHP) Deductible

All 2024 HSA-eligible High Deductible Health Plans (HDHP) with an In-Network Individual Deductible of $1,600 or In-Network Family Deductible of $3,200

The High Deductible Health Plan (HDHP) (HSA-eligible) Deductible for an Individual is increasing from $1,600 to $1,650 and for a Family is increasing from $3,200 to $3,300.

Based on plan benefit design, HDHPs (HSA-eligible) with an In-Network Individual Deductible of $1,600 will be increasing to $1,650 and those with an In-Network Family Deductible of $3,200 will be increasing to $3,300. Out-of-Network MOOPs will also reflect an increase. Please see Your Benefit Summary for Your plan’s Out-of-Network MOOPs.

2024 Individual HDHP Deductible: $1,600 2025 Individual HDHP Deductible: $1,650 2024 Family HDHP Deductible: $3,200 2025 Family HDHP Deductible: $3,300

High Deductible Health Plan (HDHP) Maximum Out-of- Pocket (MOOP)

All 2024 HSA-eligible High Deductible Health Plans (HDHP) with an In-Network Individual MOOP of $8,050

The High Deductible Health Plan (HDHP) (HSA-eligible) Maximum Out-of-Pocket (MOOP) for an Individual is increasing from $8,050 to $8,300. Based on plan benefit design, HDHPs (HSA-eligible) with an In-Network Individual MOOP of $8,050 will be increasing to $8,300. Family and Out-of-Network MOOPs will also reflect an increase.

Please see Your Benefit Summary for Your plan’s Family and Out-of-Network MOOPs.

2024 Individual HDHP MOOP: $8,050 2025 Individual HDHP MOOP: $8,300

For a complete description of services and coverage, please refer to your 2025 Large Group Member Certificate, Benefit Summary, Summary of Benefit and Coverage (“SBC”), Formulary, and any applicable Amendments. Your plan documents are available at http://planfinder.ghcscw.com/.

http://planfinder.ghcscw.com/

Clinic Services Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes Primary Care Office Visits No No Charge Not Covered Example: Office visits with Your Primary Care

Provider (PCP) Chiropractic Office Visits No No Charge Not Covered Preventive Health Examinations No No Charge Not Covered Coverage is limited to preventive services as defined by the Affordable Care Act.

Specialist Care Office Visits Yes $75 Not Covered Examples: Specialist Hearing Exams, Autism Spectrum

Specialist Office Visit; Most Specialists do not require Prior Authorization

Preventive Immunizations No No Charge Not Covered Coverage is limited to preventive services as defined by the Affordable Care Act.

Prenatal and Postnatal Maternity Care No No Charge Not Covered Coverage is limited to preventive services as defined by the Affordable Care Act.

Diagnostic X-Ray and Laboratory Tests Yes No Charge Not Covered X-rays and routine lab tests ordered by Your Provider do not require Prior Authorization.

Advanced Radiology Yes No Charge Not Covered Examples: CT, PET Scans, MRIs

Emergency and Urgent Care Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes Urgent Care Visits No No Charge No Charge Emergency Ambulance Service (air/ground)

No 20% after Deductible 20% after Deductible Coverage is limited to emergency care

Emergency Room Visits No $250 $250 Coverage is limited to emergency care; Copayment waived if admitted as a hospital inpatient

Prescription Drugs Tier You Pay In-Network You Pay Out-of-Network Benefit Notes Outpatient Prescription Drugs on GHC-SCW Formulary

Prior Authorizations, quantity limits, step therapy, age restrictions and other limits may apply

Tier 1 $10 Not Covered Covers up to a 30-day supply; 31-90 day supply available for multiple Copays - subject to a maximum cost limit; Some brand names and many generics;

Drugs in Tier 1 are the greatest value

Tier 2 $30 Not Covered Covers up to a 30-day supply; 31-90 day supply available for multiple Copays - subject to a maximum cost limit; Many brand names and some generics

Tier 3 $50 Not Covered Covers up to a 30-day supply; 31-90 day supply not available; There are often similar or equivalent drugs in either Tier 1 or Tier 2

Tier 4 (Specialty)

$100 Not Covered Covers up to a 30-day supply; 31-90 day supply not available; May require the use of a specialty-designated pharmacy

The Prescription Drugs Benefit is administered by GHC-SCW Clinic pharmacies and Navitus. Prescription Drugs are NOT COVERED outside of the GHC-SCW network of providers. For a list of formulary drugs, tier ($) placement, prior authorization requirements and other limitations that may apply, see https://www.ghcscw.com.

Supplies and Equipment Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes Diabetic Disposable Supplies No 20% up to maximum Not Covered Member pays Coinsurance up to $500 maximum Durable Medical Equipment Yes 20% Not Covered Hearing Aids for Members age 18 and over

Yes 20% Not Covered Limited to one hearing aid per ear per 36 months;

GHC-SCW designates specific models or other cost limitations may apply

Select Primary Care Preferred $500 Ded/$1,000 MOOP Plan

Plan Number: 2402739 Benefits Accumulate on a Plan Year.

Policy Coinsurance In-Network: 20% Out-of-Network: Not Covered

MEMBER FAMILY

In-Network Deductible $500 $1,000

Out-of-Network Deductible Not Covered Not Covered In-Network Maximum Out-of-Pocket (MOOP) $1,000 $2,000

Out-of-Network Maximum Out-of-Pocket (MOOP) Not Covered Not Covered

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Hearing Aids for children age 17 and under

Yes 20% Not Covered Limited to one hearing aid per ear per 36 months

Cochlear Implants and Bone Anchored Hearing Aids

Yes 20% after Deductible Not Covered

Supplies and Equipment Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes

Hospital Services Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes Inpatient Hospital Services: Physician Services, Surgery, Facility Fees

Yes 20% after Deductible Not Covered

Outpatient Hospital Surgical/Non- Surgical Services, Facility Fees

Yes 20% after Deductible Not Covered Certain oral surgeries do not require Prior Authorization

Skilled Nursing Facility Services Yes 20% after Deductible Not Covered Limited to 30 days per inpatient stay per Member Bariatric Surgery Yes 20% after Deductible Not Covered

Vision Services Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes Vision Examinations No No Charge Not Covered Routine Eye Examinations must be provided by an In-

Network Optometrist (OD); Limited to one eye exam per Member per year

Mental Health & Substance Use Disorder Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes Mental Health/Substance Use Disorder Outpatient Services

No No Charge Not Covered Prior Authorization is required for Health Psychology, Diagnostic Testing, ECT, and TMS. All services may be subject to ongoing review for medical necessity.

Mental Health/Substance Use Disorder Inpatient Services

Yes 20% after Deductible Not Covered

Mental Health/Substance Use Disorder Transitional Services

Yes 20% after Deductible Not Covered

Dental Services Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes Accidental Dental No 20% after Deductible Not Covered Initial repair of accidental injury to sound, natural teeth Oral Surgeries Yes 20% after Deductible Not Covered Certain oral surgeries do not require Prior

Authorization

Additional Services Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes Hospice Yes 20% after Deductible Not Covered Example: End of Life Services Home Health Services Yes 20% after Deductible Not Covered Limited to 60 visits per Member per year Health Counseling Education No No Charge Not Covered Conception Services No 50% up to maximum Not Covered Lifetime Benefit maximum payment of $2,000 by

GHC-SCW, which is accrued by GHC-SCW paying 50% Coinsurance of the first $4,000 of Conception Services

Speech Therapy Yes No Charge Not Covered Includes Rehabilitation and Habilitation Therapy;

Limited to 20 visits per therapy per Member per year

Outpatient Habilitation Therapy Yes No Charge Not Covered Includes Physical and Occupational Therapy; Limited to 40 combined visits per Member per year; See Certificate for additional information

Cardiac Rehabilitation Therapy Yes No Charge Not Covered Limited to 36 visits per Member per year

Year.

Policy Coinsurance In-Network: 20% Out-of-Network: Not Covered

MEMBER FAMILY

In-Network Deductible $500 $1,000

Out-of-Network Deductible Not Covered Not Covered In-Network Maximum Out-of-Pocket (MOOP) $1,000 $2,000

Out-of-Network Maximum Out-of-Pocket (MOOP) Not Covered Not Covered

CSC16-25-01-1(06/16)C 2024 Benefit Summary (Page 2 of 3) GHC-2402739-BR

Outpatient Rehabilitation Therapy Yes No Charge Not Covered Includes Physical and Occupational Therapy; Limited to 40 combined visits per Member per year; See Certificate for additional information

Additional Services Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes

Benefit Summary Notes Prior Authorizations

Prior Authorization is required when services are not provided in a primary care setting by an In-Network Provider. Prior Authorization does not guarantee that services will be fully covered. Coverage is determined by the terms and conditions of the Certificate. Please refer to your Member Certificate for Benefits that require Prior Authorization. In addition, services and items requiring Prior Authorization are listed on GHC-SCW’s website at https://www.ghcscw.com.

It is the Member’s responsibility to ensure a Prior Authorization has been obtained when required. Failure to obtain Prior Authorization when required may result in the Member receiving a reduction in or no Benefit. To obtain Prior Authorization, call (608) 257-5294.

Provider Information For Providers see the "Find a Provider" link at https://www.ghcscw.com or contact Member Services at (608) 828-4853 or (800) 605-4327, ext. 4504.

In-Network Providers: For a list of In-Network Providers, see the "Find a Provider" link at https://www.ghcscw.com or contact Member Services at (608)

828-4853 or (800) 605-4327, ext. 4504.

Out-of-Network Providers: Out-of-Network Providers are not covered under an HMO plan, unless Prior Authorization has been acquired for such services.

GHC-SCW Notices to Members Qualified Maximum Dependent Age: Dependents are covered until the end of the month at age 26.

This is only a summary. You are responsible for knowing the full Benefits and provisions of your policy. Please read all documents carefully including your

Member Certificate, Formulary, Benefit Summary and Summary of Benefits and Coverage (SBC). To find these documents, visit https://www.ghcscw.com or contact Member Services at (608) 828-4853 or (800) 605-4327, ext. 4504.

Questions or Concerns?

For any questions or concerns regarding your benefits, please visit https://www.ghcscw.com, or contact Member Services at (608) 828-4853 or (800) 605-

4327, ext. 4504.

Year.

Policy Coinsurance In-Network: 20% Out-of-Network: Not Covered

MEMBER FAMILY

In-Network Deductible $500 $1,000

Out-of-Network Deductible Not Covered Not Covered In-Network Maximum Out-of-Pocket (MOOP) $1,000 $2,000

Out-of-Network Maximum Out-of-Pocket (MOOP) Not Covered Not Covered

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CSC18-29-01-1(07/18)F Version 2: 7/2018

GHC-SCW Nondiscrimination Notice

Group Health Cooperative of South Central Wisconsin (GHC-SCW) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. GHC-SCW does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

GHC-SCW:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:

o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats)

• Provides free language services to people whose primary language is not English, such as:

o Qualified interpreters o Information written in other languages

If you need these services, contact GHC-SCW Member Services at (608) 828-4853 or (800) 605-4327, ext. 4504 (TTY: 1- 608-828-4815).

If you believe that GHC-SCW has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with GHC-SCW’s Corporate Compliance Officer, 1265 John Q. Hammons Drive, Madison, WI 53717, Telephone: (608) 251-4156, TTY: (608) 828-4815, or Fax: (608) 257-3842.

If you need help filing a grievance, GHC-SCW’s Corporate Compliance Officer is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue SW.

Room 509f, HHH Building Washington, DC 20201

1-800-368-1019, 1-800-537-7697 (TDD).

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

GHC-SCW Language Assistance Services

English:

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-608-828-4853 or 1-800-605-4327, ext. 4504 (TTY: 1-608-828-4815).

Español (Spanish):

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-608-828-4853 or 1-800-605-4327, ext. 4504 (TTY: 1-608-828-4815).

Hmoob (Hmong):

LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 1-608-828-4853 or 1- 800-605-4327, ext. 4504 (TTY: 1-608-828-4815).

繁體中文 (Chinese):

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-608-828-4853 or 1-800-605-4327, ext. 4504

(TTY: 1-608-828-4815)。

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

Deutsch (German):

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung.

Rufnummer: 1-608-828-4853 or 1-800-605-4327, ext. 4504 (TTY: 1-608-828-4815).

:(Arabic) العربیة

رقم( ext. 4504 ,4327-605-800-1 ,4853-828-608-1 برقم اتصلاللغویة تتوافر لك بالمجان. ملحوظة: إذا كنت تتحدث العربیة، فإن خدمات المساعدة 4815-828-608-1) والبكم الصم ھاتف

Русский (Russian):

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-608- 828-4853 or 1-800-605-4327, ext. 4504 (TTY: 1-608-828-4815).

한국어 (Korean):

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-608-828-4853 or 1-800-605- 4327, ext. 4504 (TTY: 1-608-828-4815) 번으로 전화해 주십시오.

Tiếng Việt (Vietnamese):

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-608-828-4853 or 1-800- 605-4327, ext. 4504 (TTY: 1-608-828-4815).

Deitsch (Pennsylvania Dutch):

Wann du [Deitsch (Pennsylvania German / Dutch)] schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call 1-608-828-4853 or 1-800-605-4327, ext. 4504 (TTY: 1-608-828- 4815).

ພາສາລາວ (Lao):

ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວົ ້ າພາສາ ລາວ, ການບໍ ລິ ການຊ່ວຍເຫືຼອດ້ານພາສາ, ໂດຍບໍ່ ເສັຽຄ່າ, ແມ່ນມີ ພ້ອມໃຫ້ທ່ານ. ໂທຣ 1- 608-828-4853 or 1-800-605-4327, ext. 4504 (TTY: 1-608-828-4815).

Français (French):

ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-608- 828-4853 or 1-800-605-4327, ext. 4504 (TTY: 1-608-828-4815).

Polski (Polish):

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-608-828- 4853 or 1-800-605-4327, ext. 4504 (TTY: 1-608-828-4815).

�हदं� (Hindi):

ध्यान द�: य�द आप �हदं� बोलत ेह� तो आपके �लए मुफ्त म� भाषा सहायता सेवाएं उपलब्ध ह�। 1-608-828-4853 or 1-800-605-

4327, ext. 4504 (TTY: 1-608-828-4815) पर कॉल कर�।

Shqip (Albanian):

KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 1-608- 828-4853 or 1-800-605-4327, ext. 4504 (TTY: 1-608-828-4815).

Tagalog (Tagalog – Filipino):

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-608-828-4853 or 1-800-605-4327, ext. 4504 (TTY: 1-608-828-4815).

Clinic Services Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes Primary Care Office Visits No No Charge 40% after Deductible Example: Office visits with Your Primary Care

Provider (PCP) Chiropractic Office Visits No No Charge 40% after Deductible Preventive Health Examinations No No Charge 40% after Deductible Coverage is limited to preventive services as defined by the Affordable Care Act.

Specialist Care Office Visits No $75 40% after Deductible Example: Specialist Hearing Exams Preventive Immunizations No No Charge 40% after Deductible Coverage is limited to preventive services as defined by the Affordable Care Act.

Prenatal and Postnatal Maternity Care No No Charge 40% after Deductible Coverage is limited to preventive services as defined by the Affordable Care Act.

Diagnostic X-Ray and Laboratory Tests Yes No Charge 40% after Deductible X-rays and routine lab tests ordered by Your Provider do not require Prior Authorization.

Advanced Radiology Yes No Charge 40% after Deductible Examples: CT, PET Scans, MRIs

Emergency and Urgent Care Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes Urgent Care Visits No No Charge No Charge Emergency Ambulance Service (air/ground)

No 20% after Deductible 20% after Deductible Coverage is limited to emergency care

Emergency Room Visits No $250 $250 Coverage is limited to emergency care; Copayment waived if admitted as a hospital inpatient

Prescription Drugs Tier You Pay In-Network You Pay Out-of-Network Benefit Notes Outpatient Prescription Drugs on GHC-SCW Formulary

Prior Authorizations, quantity limits, step therapy, age restrictions and other limits may apply

Tier 1 $10 Not Covered Covers up to a 30-day supply; 31-90 day supply available for multiple Copays - subject to a maximum cost limit; Some brand names and many generics;

Drugs in Tier 1 are the greatest value

Tier 2 $30 Not Covered Covers up to a 30-day supply; 31-90 day supply available for multiple Copays - subject to a maximum cost limit; Many brand names and some generics

Tier 3 $50 Not Covered Covers up to a 30-day supply; 31-90 day supply not available; There are often similar or equivalent drugs in either Tier 1 or Tier 2

Tier 4 (Specialty)

$100 Not Covered Covers up to a 30-day supply; 31-90 day supply not available; May require the use of a specialty-designated pharmacy

The Prescription Drugs Benefit is administered by GHC-SCW Clinic pharmacies and Navitus. Prescription Drugs are NOT COVERED outside of the GHC-SCW network of providers. For a list of formulary drugs, tier ($) placement, prior authorization requirements and other limitations that may apply, see https://www.ghcscw.com.

Supplies and Equipment Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes Diabetic Disposable Supplies No 20% up to maximum Not Covered Member pays Coinsurance up to $500 maximum Durable Medical Equipment Yes 20% 40% after Deductible Hearing Aids for Members age 18 and over

Yes 20% 40% after Deductible Limited to one hearing aid per ear per 36 months;

GHC-SCW designates specific models or other cost limitations may apply

Hearing Aids for children age 17 and under

Yes 20% 40% after Deductible Limited to one hearing aid per ear per 36 months

Primary Care Preferred $500 Ded/$1,000 MOOP PPO Plan

Plan Number: 2403819

Year.

Policy Coinsurance In-Network: 20% Out-of-Network: 40%

MEMBER FAMILY

In-Network Deductible $500 $1,000

Out-of-Network Deductible $1,000 $2,000 In-Network Maximum Out-of-Pocket (MOOP) $1,000 $2,000

Out-of-Network Maximum Out-of-Pocket (MOOP) $2,000 $4,000

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Cochlear Implants and Bone Anchored Hearing Aids

Yes 20% after Deductible 40% after Deductible

Supplies and Equipment Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes

Hospital Services Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes Inpatient Hospital Services: Physician Services, Surgery, Facility Fees

Yes 20% after Deductible 40% after Deductible

Outpatient Hospital Surgical/Non- Surgical Services, Facility Fees

Yes 20% after Deductible 40% after Deductible Certain oral surgeries do not require Prior Authorization

Skilled Nursing Facility Services Yes 20% after Deductible 40% after Deductible Limited to 30 days per inpatient stay per Member Bariatric Surgery Yes 20% after Deductible 40% after Deductible

Vision Services Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes Vision Examinations No No Charge 40% after Deductible Routine Eye Examinations must be provided by an

Optometrist (OD); Limited to one eye exam per Member per year

Mental Health & Substance Use Disorder Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes Mental Health/Substance Use Disorder Outpatient Services

No No Charge 40% after Deductible

Mental Health/Substance Use Disorder Inpatient Services

Yes 20% after Deductible 40% after Deductible

Mental Health/Substance Use Disorder Transitional Services

Yes 20% after Deductible 40% after Deductible

Dental Services Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes Accidental Dental No 20% after Deductible 40% after Deductible Initial repair of accidental injury to sound, natural teeth Oral Surgeries Yes 20% after Deductible 40% after Deductible Certain oral surgeries do not require Prior

Authorization

Additional Services Prior Auth You Pay In-Network You Pay Out-of-Network Benefit Notes Hospice Yes 20% after Deductible 40% after Deductible Example: End of Life Services Home Health Services Yes 20% after Deductible 40% after Deductible Limited to 60 visits per Member per year Health Counseling Education No No Charge 40% after Deductible Conception Services No 50% up to maximum 50% up to maximum Lifetime…