FY 2015 Changes Changes (listed on page 4 of the Benefits Choice book and page 2 of the flyer): – Deductibles and plan year deductible caps – Coinsurance – OAP out-of-pocket maximum – Vision lens benefit frequency – Retiree premiums 2

FY 2015 Changes Remaining the same: – Employee premiums – Employee premium annual salary bands – QCHP deductible salary bands – Life insurance rates – Dental rates 3

Out-of-Pocket Maximum The following do not count toward the out-of-pocket maximum: – Amounts over allowable charges for the plan – Non-covered services – Charges for services deemed to be not medically necessary – Penalties for failing to pre-certify/provide notification – Prescription deductibles and copayments (see Coventry HMO exception) 4

Out-of-Pocket Maximum Effective 7/1/14, Coventry HMO will count prescription deductibles and copayments towards the out-of-pocket maximum. Therefore, once the out-of-pocket maximum has been met, prescription charges will be covered at 100% for the rest of the plan year. In FY 2016, prescriptions will apply to all health plan out-of-pocket maximums. 5

Out-of-Pocket Maximum Out-of-Pocket Max Limits Annual Plan Year Deductible Additional Deductibles (QCHP)/ Copayments CoinsuranceAmounts over Allowed Charges QCHPIn-Network Individual - $1,500 Family - $3,750 Out-of-Network Individual - $6,000 Family - $12,000 XXXQCHP out-of- network providers and OAP Tier III providers: Amounts over the plan’s allowable charges are the member’s responsibility and do not go toward the out- of-pocket maximum. HMOIndividual - $3,000 Family - $6,000 N/AXX OAP Tier IIndividual - $6,250 Family - $12,700 N/AXX OAP Tier IIIndividual - $6,250 Family - $12,700 XXX Eligible charges from Tiers I and II will be added together when calculating the out-of-pocket maximum. Tier III will no longer have an out-of-pocket maximum. 6

FY 2015 Benefit Changes Quality Care Health Plan (QCHP) IndividualFamily Cap Annual Deductibles *FY 2014FY 2015FY 2014FY 2015 Employee $60,700 or less$350$375$875$ $60,701-$75,900$450$475$1,125$1, $75,901 and above$500$525$1,250$1, Retiree/Annuitant/Survivor$350$375$875$ Dependents$350$375N/A * Salary bands for QCHP deductibles did not change this year. 7

QCHP Deductibles DeductiblesFY 2014FY 2015 Inpatient Hospitalization (In-Network)$75$100 Inpatient Hospitalization (Out-of-Network)$400$500 Emergency Care – Hospital$425$450 Individual Out-of-Pocket Maximum (In-Network)$1,500 Individual Out-of-Pocket Maximum (Out-of-Network)$6,000 Family Out-of-Pocket Maximum (In-Network)$3,750 Family Out-of-Pocket Maximum (Out-of-Network)$12,000 8

QCHP Benefit Levels FY 2014FY 2015 After all applicable deductibles are met (in-network)90%85% After all applicable deductibles are met (out-of-network)60% After the out-of-pocket maximums are met100% Note: Percentages are based on the allowable charge for covered services. 9

QCHP Prescriptions FY 2014FY 2015 Deductibles$100$125 Copayments Generic (30-day supply)$10 Preferred brand (30-day supply)$30 Non-preferred brand (30-day supply)$60 Mail order generic (90-day supply)$25 Mail order preferred brand (90-day supply)$75 Mail order non-preferred brand (90-day supply)$150 10

HMO Health Plans CopaymentsFY 2014FY 2015 Office Visit (PCP)$18$20 Office Visit (Specialist)$25$30 Home Health Visit$25$30 Inpatient$325$350 Outpatient$225$250 Emergency Room$225$250 11

Open Access Plans – Tier I CopaymentsFY 2014FY 2015 Physician Office Visit$18$20 Specialist Office Visit$25$30 Home Health Visit$25$30 Inpatient$325$350 Outpatient$225$250 Emergency Room$225$250 12

Open Access Plans – Tier II CopaymentsFY 2014FY 2015 Annual Plan Deductible$250 Inpatient90% after $375 copay90% after $400 copay Outpatient90% after $225 copay90% after $250 copay Emergency Room100% after $225 copay100% after $250 copay Out-of-Pocket Maximum * Individual Family $900 $1,500 $6,250 $12,700 Note: Percentages are based on network charges for covered services. * FY 2015 out-of-pocket maximum includes eligible charges from Tiers I and II combined. 13

Open Access Plans – Tier III FY 2014FY 2015 Annual Plan Deductible$350 Physician Office Visit60% Specialist Office Visit60% Inpatient60% after $475 copay60% after $500 copay Outpatient60% after $225 copay60% after $250 copay Emergency Room100% after $225 copay100% after $250 copay Out-of-Pocket Maximum Individual Family $1,800 $3,800 Unlimited Note: Percentages are based on the allowable charge for covered services. 14

HMO and OAP Prescriptions FY 2014FY 2015 Deductibles$75$100 Copayments Generic (30-day supply)$8 Preferred brand (30-day supply)$26 Non-preferred brand (30-day supply)$50 Mail order generic (90-day supply)$20 Mail order preferred brand (90-day supply)$65 Mail order non-preferred brand (90-day supply)$125 15

Vision FY 2014FY 2015 Eye exam$20$25 Lenses$20$25 Standard frames (available every 24 months)$20$25 Replacement lenses, including contacts24 months12 months 16

Dental FY 2014FY 2015 Annual Deductible$150$175 Annual Max (In-Network)$2,500 Annual Max (Out-of-Network)$2,000 Ortho Max (In-Network)$2,000 Ortho Max (Out-of-Network)$1,500 17

If you have questions… 18 If you have questions, please contact Benefits staff by calling Or review the Benefits Choice Options booklet on the CMS website at: e/Pages/BenefitsBooks.aspxhttp://www2.illinois.gov/cms/Employees/benefits/StateEmploye e/Pages/BenefitsBooks.aspx. Thank you!