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City of New Brighton Health Insurance Plan Options- City Councilmembers Effective 1-1-2012 This is a general plan comparison only. For exact terms and conditions of your insurance coverage,please contact Health Partners at 952-883-5000 or 1-800-883-2177 100%Plan $40 Co-Pay Plan 1 Health Partners Health Partners Benefit Open Access Choice Open Access Choice Lifetime Maximum In-Network: Unlimited In-Network: Unlimited Out-of-Network: $1 Million Out-of-Network:$1 Million In-Network Benefits Calendar year Plan deductible None-In Network None-In Network Annual medical out-of-pocket $2,500 Per Person $2,500 Per Person Maximum $4,000 Per Family $4,000 Per Family Annual pharmacy out-of- $500 Per Person $500 Per Person Pocket maximum $1000 Per Family $1000 Per Family Preventive health care 100%Coverage 100%Coverage Office visits 100%Coverage $40 Co-Pay Hospital—Inpatient care 100%Coverage 80%Coverage Hospital—Outpatient care 100%Coverage 80%Coverage Urgent care 100%Coverage $40 Co-Pay Emergency Care&Ambulance $40 Co-Pay $75 Co-Pay Prescription drugs 80%Co-Insurance;$10 min/$25 80%Co-Insurance;$10 min/$25 Maximum Formulary Drugs Maximum Formulary Drugs Out-of-Network Benefits Calendar year deductible-Out of $300 Per Person $300 Per Person Network $900 Per Family $900 Per Family Annual medical out-of-pocket $2,500 Per Person $2,500 Per Person Maximum $4,000 Per Family $4,000 Per Family Annual pharmacy out-of- $500 Per Person $500 Per Person Pocket maximum $1,000 Per Family $1,000 Per Family Coinsurance 80%Coverage After Deductible 80%Coverage After Deductible Utilization of an Out of Network 80%Coverage After deductible 80%Coverage After Deductible Provider 2012 Employee Premium Share Single: ($0.00) Single:($0.00) (Monthly Cost) Single+1: $830.00 Single+1:$631.12 Family:$1,037.68 Family:$790.80 H:\Assistant to the City Manager\City Council\2012 Retreat Follow-up Items\2012 Council Health Insurance Info\Benefits Sheet 2012-City Councilmembers,doc Updated 9/1 8/2007