RFP 2025HCA5 Exhibit G - Plan Design Outline.xlsx

Instructions

NOTE: Fully-insured Health Plan(s) will be offered to non-Medicare Public Employees Benefits Board (PEBB) and School Employees Benefits Board (SEBB) Program Subscribers and their Dependents. The Health Plans offered to PEBB must be identical in plan design to the Health Plans offered to SEBB but, because each program has a separate risk pool, the plans will each be separately rated for the PEBB program and the SEBB program.

NOTE: HCA, at its sole discretion, will determine the Health Plans to be presented for final approval of the Boards. All Health Plans must be approved by both the PEB Board and the SEB Board and must be open only to PEBB and SEBB Members.

Tab Titled “Plan A” For the purpose of HCA evaluation, Bidder’s Health Plans designated as Plan A must match Uniform Medical Plan (UMP) Classic in all aspects of deductible, maximum out of pocket, copays and coinsurances, visit limitations, and other accumulators. Pharmacy tiers are also defined, but Bidders are not required to match the drugs assigned to each tier in the UMP Formulary. Reviewing the UMP Certificate of Coverage (CoC) may be helpful in completing this tab. It is available at UMP Classic CoC.

Please use the Tab A in the Exhibit G_ Plan Design Outline_RFP to add the details of Bidder’s Plan A for PEBB and SEBB. Gray boxes in the spreadsheet indicate where Bidder is to fill in values.

Tab Titled “Plan B” Bidder’s Health Plan designated as “Plan B” will be required to match certain elements of deductible, maximum out of pocket, and pharmacy structure that HCA has laid out in Exhibit G_ Plan Design Outline_RFP. However, other portions of plan design like amounts of coinsurance and copays are left open to Bidder’s offering. Gray boxes in the spreadsheet indicate where Bidder is to fill in values.

Please use the Tab B in Exhibit G_ Plan Design Outline_RFP to add the details of Bidder’s Plan B for PEBB and SEBB.

Tab Titled “Plan C” Bidder’s Health Plan designated as “Plan C” will be required to use the medical and pharmacy deductible and maximum out of pocket guidelines in Exhibit G_ Plan Design Outline_RFP, but Bidder may decide most other elements of plan design at Bidder’s discretion. Gray boxes in the spreadsheet indicate where Bidder is to fill in values.

Please use the Tab C in Exhibit G_ Plan Design Outline_RFP to add the details of Bidder’s Plan C for PEBB and SEBB.

Tab Titled “Rx Class & Tiers” This tab is intended to provide information to HCA about the preferred drug list of each Bidder. Please complete the required fields with the requested details about drug product name, proposed tier, cost share, and whether prior authorization is required for the drug. Gray boxes in the spreadsheet indicate where Bidder is to fill in values.

Plan A Plan A - UMP Classic (Base Plan Design) See instuctions for how to complete on the "Instructions" tab.

Plan Approximate Actuarial Value: 93%

• Contraceptive drugs and devices including condoms

• Voluntary and involuntary termination of pregnancy (abortion or miscarriage), including prescription drugs

$0 member cost share once every 36 months, for prescribed

Limited Benefit: Plan covers 100% of $1,000 per case before deductible. Member's Claim for re-imbursement with appropriate receipts. Providers must be certified by DOH.

(vaccines, routine exams, and some

Plan A - UMP Classic (Base Plan Design)

Bidder to use their own formulary to complete the tiers and cost structure provided below.

• 0–30-day supply:

5% coinsurance or $10, whichever is less

• 31–60-day supply:

5% coinsurance or $20, whichever is less

• 61–90-day supply:

5% coinsurance or $30, whichever is less • No deductible

• 0-30 day supply:

5% coinsurance or $10, whichever is less Tier 1 (Tier 1/Tier 1 Specialty) Select generic drugs • No deductible

• 0–30-day supply:

10% coinsurance or $25, whichever is less

• 31–60-day supply:

10% coinsurance or $50, whichever is less

• 61–90-day supply:

10% coinsurance or $75, whichever is less • No deductible

• 0-30 day supply:

10% coinsurance or $25, whichever is less

• 0–30-day supply:

30% coinsurance or $75, whichever is less**

• 31–60-day supply:

30% coinsurance or $150, whichever is less**

• 61–90-day supply:

30% coinsurance or $225, whichever is less** • Deductible applies

• 0-30 day supply:

30% coinsurance or $75, whichever is less

** Except for certain covered Tier 2 prescription drugs as outlined in the Preferred Drug List. See the UMP Preferred Drug List for cost limits.

https://www.hca.wa.gov/assets/pebb/54-0015-ump-classic-coc-2025.pdf Plan B Plan B

What Plan Actuarial Value (Federal AV of 80-92%) does Bidder propose for Plan B:

• Contraceptive drugs and devices including condoms

• Voluntary and involuntary termination of pregnancy (abortion or miscarriage), including prescription drugs

$0 member cost share once every 36 months, for prescribed

Per case:

4 total visits (pre or post-partum ) +

(vaccines, routine exams, and some

Add exceptions, notes, etc.:

Plan C Plan C

What Plan Actuarial Value (Federal AV of 80-92%) does Bidder propose for Plan C:

(air or ground, per trip)

(laboratory and imaging) Durable Medical Equipment (DME) (supplies,equipment, and prostheses)

The following are covered as preventive:

• Contraceptive drugs and devices including condoms

• Voluntary and involuntary termination of pregnancy (abortion or miscarriage), including prescription drugs

• Education and counseling related to contraception

At a minimum:

Up to allowed amount $3,000 per ear every 36 months

Members age 40 and older: Preventive; not subject to deductible Members under age 40: covered as preventive and not subject to deductible for members who are at an increased risk for breast cancer and billed with an "at risk" diagnosis.

Additional coverage info:

Covered as preventive (with valid prescription); not subject to deductible.

Can include nicotine replacement therapy, counseling, tobacco cessation program. NOTE: Prescription drugs may have some limitations

Per case:

4 total visits (pre or post-partum ) + One doula attended delivery

Tell us what your benefit would include:

Is it a limited benefit?

First dollar coverage?

Do you offer a "richer" benefit?

(vaccines, routine exams, and some

Bidder to propose 1-2 tiered designs (Plan C-1 and Plan C-2, below) which you have used in other jumbo plans;

For plans C-1 and C-2, we would allow Bidder to bid their preferred tiering structures and copay/coinsurance.

Add exceptions, notes, etc.:

Add exceptions, notes, etc.:

Rx Class & Tiers