Note: This Comparison Is To Be Used As A Guide Only. Actual Benefits Will Be Governed by The Terms And Conditions of the Master Contract.

Section 1: 2014 Important Information Section 2: 2014 Benefit Information

Section 3: 2014 Medical Plan Options

CCCCITYITYITYITY OOOOFFFF BBBBALTIMOREALTIMOREALTIMOREALTIMORE

2014 B2014 B2014 B2014 BENEFITENEFITENEFITENEFIT PPPPLANLANLANLAN CCCCOMPARISONOMPARISONOMPARISONOMPARISON CCCCHARTHARTHARTHART

October 18, 2013

Section 1: Section 1: Section 1: Section 1:

2222014014014014 Important Information Important Information Important Information Important Information Contact List

Important Notices

Provider Phone Number WebsiteCareFirst PPN 1-800-535-2292 www.carefirst.com

ValueOptions Mental Health (CareFirst Members Only) 1-866-468-5633 www.achievesolutions.net/baltimore

UnitedHealthcare 1-877-462-5027 www.myuhc.com

Optimum Choice 1-800-815-8958 www.myuhc.com

Kaiser Permanente HMO 1-866-248-0715 www.kaiserpermanente.org

Aetna PPO 1-800-900-7562 www.aetna.com

Aetna HMO 1-877-440-4711 www.aetna.com

Express Scripts Prescription Plan 1-800-354-8123 www.express-scripts.com

CareFirst Select Vision 1-800-535-2292 www.carefirst.com

Minnesota Life (Life and AD&D) New for January 1,2012 1-888-658-0193 (Claims) www.lifebenefits.com/plandesign/baltimorecity

ADP COBRA 1-800-526-2750 www.benedirect.adp.com

Vantagen Flexible Spending Account 1-800-307-0230 www.myflexdollars.com

Delta Dental PPO 1-800-471-7081 www.deltadentalins.com/city-of-baltimore

Delta Care USA (Dental HMO) 1-855-830-6581 www.deltadentalins.com/city-of-baltimore

Contact Phone Numbers & Websites

New Plans for 2014

When you (or spouse/child) become disabled as determined by the SSA, you must apply for Medicare Part B through

SSA at the time you become eligible for Medicare Part A and provide Employee Benefits with your Medicare

information immediately. If you decline your Medicare Part B, you will be responsible for all Medicare Part B

(Medical) claims that would ordinarily be covered by Medicare B. Your supplemental medical coverage with the City

will only cover only 20% of the claims up to the Medicare Allowed Amount.

The Patient Protection and Affordable Care Act (PPACA) requires health plans and health insurance issuers to provide

a Summary of Benefits and Coverage (SBC) to applicants and enrollees. The SBC is a concise document providing

simple and consistent information about health plan benefits and coverage. Its purpose is to help health plan

consumers better understand the coverage they have and to help them make easy comparisons of different options

when shopping for new coverage. The City of Baltimore will post this document on its enrollment website:

www.baltimorecity.essbenefits.com under its own drop down menu labeled Summary of Benefits and Coverage.

Under the Medicare Secondary Payer (MSP) Mandatory Reporting, the federal law requires the mandatory collection

and reporting of social security numbers of all covered participants including employees, retirees and their

dependents through employer group health benefits. Noncompliance may result in the loss of coverage for covered

participants with invalid or missing social security numbers.

Change of Address You must notify your agency about your change of address, in writing.

Important Medicare Information

The City requires all its members (including you and your dependents) to enroll in Medicare Part B at the time you

become eligible for Medicare Part A. Once enrolled in Medicare part B, you must remain enrolled in order to continue

receiving the maximum possible benefit from the City's supplemental medical plan.

Information About Your Benefits for 2014

Important NoticesPlease read the information provided in this Comparison Chart

Enrollment Website www.baltimorecity.essbenefits.com

Duplicate Coverage Information

If you and your spouse/partner are both a City employee/retiree, you both cannot enroll each other or the same

eligible dependents on your City medical, dental, vision and prescription plans during any coverage period. You will

be notified to adjust duplicate coverage, if applicable.

Summary Benefits and Coverage (SBC)

Disability Retirees as Determined

by Social Security

Medicare Secondary Payer (MSP)

Mandatory Reporting

Section 2: Section 2: Section 2: Section 2:

2222014014014014 Benefits Information Benefits Information Benefits Information Benefits Information Medical Premium

Dental Premium

Rx Premium

Rx Copays

Vision

Life Insurance

2014 Employee Medical PremiumBi-Weekly

2014 Employee Medical Premium

Weekly

2014 Employee Medical Premium

21-Pay

2014 Employee Dental Premium for Delta Dental (New for 2014)

Coverage Total City Employee Coverage Total City Employee

Level Cost Cost Cost Level Cost Cost Cost

Participant Only $45.74 $35.01 $10.73 Participant Only $43.76 $35.01 $8.75

Participant + Child $88.79 $67.96 $20.83 Participant + Child $84.95 $67.96 $16.99

Participant + Spouse $102.28 $78.29 $23.99 Participant + Spouse $97.86 $78.29 $19.57

Participant + Family $111.02 $84.98 $26.04 Participant + Family $106.22 $84.98 $21.24

Coverage Total City Employee Coverage Total City Employee

Level Cost Cost Cost Level Cost Cost Cost

Participant Only $22.87 $17.51 $5.36 Participant Only $21.88 $17.50 $4.38

Participant + Child $44.39 $33.98 $10.41 Participant + Child $42.48 $33.98 $8.50

Participant + Spouse $51.14 $39.14 $12.00 Participant + Spouse $48.93 $39.14 $9.79

Participant + Family $55.51 $42.49 $13.02 Participant + Family $53.11 $42.49 $10.62

Coverage Total City Employee Coverage Total City Employee

Level Cost Cost Cost Level Cost Cost Cost

Participant Only $56.63 $43.35 $13.28 Participant Only $54.19 $43.35 $10.84

Participant + Child $109.93 $84.15 $25.78 Participant + Child $105.18 $84.14 $21.04

Participant + Spouse $126.64 $96.94 $29.70 Participant + Spouse $121.17 $96.94 $24.23

Participant + Family $137.45 $105.21 $32.24 Participant + Family $131.51 $105.21 $26.30

Express Scripts High Option Rx Plan

Express Scripts High Option Rx Plan Express Scripts Standard Option Rx Plan

21-Pay Deductions

Bi-Weekly DeductionsExpress Scripts Standard Option Rx Plan

Express Scripts High Option Rx Plan Express Scripts Standard Option Rx Plan

Weekly Deductions

2014 Employee Rx PremiumExpress Scripts

The Standard Prescription Drug Plan requries that all plan participants meet a $50.00

deductible, per member, per calendar year. A deductible is the amount of covered

expenses you must pay before your insurance plan will pay benefits.

NOTE: The Copays listed above apply to all participants

in the Standard Option Prescription Plan, there are no

differences in copays for Maps/Unrepresented &

Represented employees under the new plan.

You Pay:

Single Vision Single Vision Balance

Bifocal Bifocal Balance

Trifocal Trifocal Balance

Double Bifocal Double Bifocal BalanceCataract (Aphakic) Cataract (Aphakic) Balance

Medically Required*

Not Medically Required.

Single Vision.**

Not Medically Required.

Bifocal **

CareFirst Select Vision- Schedule of BenefitsIf you go to a ….

Non-Participating Provider

Glasses

Plan Pays 100% of Allowed Benefit.

Participating Provider

Plan pays up to:

Vision Exam

Plan Pays 100% of allowed Benefit;

you pay the balance.

Covered Service (Note: Plan allows one pair of glasses or contacts, per member, in a 24 month period.)

$41.50

$67.00

$89.50

$100.50$156.50

Frames Per Pair Plan Pays up to $29.50 and you pay $0 for select frames. Play pays up to $29.50; you pay the balance.

Plan pays up to $221; you pay the balance.

Plan pays up to $71; you pay the balance.

Plan pays up to $96.50; you pay the balance.

Contact Lenses** Covered only if medically necessary or instead of glasses

Plan pays up to $221.

* Following cataract surgery or when visual acuity of at least 20/70 in the better eye is possible with the use of contact lenses.

** In place of glasses (frames and lenses)

Plan pays up to:

$41.50

$67.00

$89.50

$100.50$156.50

Plan pays up to $71.

Plan pays up to $96.50.

Union

CUB

AFSCME Local 2202

AFSCME Local 44

AFSCME Local 558

Fire

Police

MAPS $2.534

$0.177

$0.299

Age

Cost Per $1,000

of Coverage

Under 30

30-34 $0.064

$0.074

$0.110

Eligibility: Employer Paid Coverage After One Year of Employment

60-64

65-69

70-74

1 x Annual Salary

35-39

40-44

Optional Life Premium

2 1/2 x Annual Salary to a maximum of

$100,000

Benefit Amount

Active Basic Life/AD&D Coverage

1 x Annual Salary + $1,500

1 x Annual Salary, Minimum $17,630

1 x Annual Salary, Minimum $15,000

1 x Annual Salary, Minimum $15,000

1 x Annual Salary, Minimum $15,000

$0.57

$0.023 Per $1,000 of

Coverage Per Month

55-59

Optional AD&D Premium

45-49

50-54

75 & over $3.440

$0.464

$0.742

$1.298

Important Information About Your Life and AD&D Insurance:The City of Baltimore's Life Insurance Vendor Is: Minnesota Life

Phone Number: 1-888-658-0193 (Claims)

Website: www.lifebenefits.com/plandesign/baltimorecity

Beneficiary forms are available on the City of Baltimore Enrollment website:

www.baltimorecity.essbenefits.com

Section 2:Section 2:Section 2:Section 2: Medical Plan OptionsMedical Plan OptionsMedical Plan OptionsMedical Plan Options

PPO, POS, PPN

Aetna

CareFirst

UnitedHealthcare

HMO

Aetna

Kaiser

UnitedHealthcare

Are Referrals Required? No No No No

Deductible$250 per individual

$500 per family

$500 per individual

$1000 per familyNone None

Out-of-Pocket Maximum

(Based on annual salary)

Employee Salary < $45,000: $1,000

per individua/$2,000 per family

Employee Salary > $44,999: $1,500

per individual/$3,000 per family

Employee Salary < $45,000: $2,000

per individua/$4,000 per family

Employee Salary > $44,999: $3,000

per individual/$6,000 per family

$1,000 per individual

$2,000 per family None

Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited

Routine Office Visit

(Annual physical) 100% 100% allowed benefit* covered in full 100% allowed benefit*

Well Baby/Child Care

(Age & frequency

schedule apply)

100% 100% allowed benefit* covered in full 100% allowed benefit*

Routine GYN Examination

(Limit-one per year) 100% 100% allowed benefit* covered in full 100% allowed benefit*

Screenings:

Mammography, Colorectal

& Prostate

100% Allowed Benefit 100% Allowed Benefit 100% Allowed Benefit 80% Allowed Benefit

Physician's Office Visit

(Sickness)$25 copay 80% $5 copay per visit

$5 copay per visit; 100 %

allowed benefit*

Specialist Office Visit $40 copay 80% $5 copay per visit$5 copay per visit; 100 %

allowed benefit*

Hearing Exams 90% 70% $5 copay per visit$5 copay per visit; 100 %

allowed benefit*

Physican Office Visits (Non-Routine)

Aetna PPO

2014 Active Benefit Plan Comparison Charts *All Out of Network benefits paid at Allowed Amount. Allowed Benefit is 50% of R & C

** any out-of-network provider can balance bill the difference between allowed amount and billed amount

Standard Option Plan

In-Network Out-of-Network**

High Option Plan

In-Network Out-of-Network**

Dependent Eligibility: Dependent children, until the end of the calendar year they reach age 26, regardless of student or marital status.

Routine & Preventive Services

Aetna PPO

2014 Active Benefit Plan Comparison Charts *All Out of Network benefits paid at Allowed Amount. Allowed Benefit is 50% of R & C

** any out-of-network provider can balance bill the difference between allowed amount and billed amount

Standard Option Plan

In-Network Out-of-Network**

High Option Plan

In-Network Out-of-Network**

Dependent Eligibility: Dependent children, until the end of the calendar year they reach age 26, regardless of student or marital status.

Ambulance Service

(based on medical

necessity)

90% 90% covered in full 100% allowed benefit*

Emergency Room

(copay waived if

admitted)

90% 90% $50 copay $50 copay

Urgent Care $25 Copay, 90% $25 Copay, 90% $5 copay per visit $5 copay per visit

Anesthesia 90% 70% covered in full 100% allowed benefit*

Hospital Services, including

Room, Board & General

Nursing Services

90% 70% covered in full 100% allowed benefit*

Organ Transplant

(Pre-Auth Required)

90% at Institutes of Excellence

Facilities; 70% at Other In-Network

Facilities

no coverage Covered in full no coverage

Diagnostic Lab Work & X-

rays90% 70% covered in full 100% allowed benefit*

Medical Surgical Physician

Services90% 70% covered in full 100% allowed benefit*

Physical, Speech &

Occupational Therapy90% (Combined 60 visits per year) 70% (Combined 60 visits per year) covered in full 100% allowed benefit*

Chemotherapy &

Radiation90% 70% $5 copay per visit

$5 copay per visit, 100%

allowed benefit*

Renal Dialysis 90% 70% covered in full 100% allowed benefit *

Emergency Room and Urgent Care Services

Hospital Inpatient Services

Outpatient Services

Aetna PPO

2014 Active Benefit Plan Comparison Charts *All Out of Network benefits paid at Allowed Amount. Allowed Benefit is 50% of R & C

** any out-of-network provider can balance bill the difference between allowed amount and billed amount

Standard Option Plan

In-Network Out-of-Network**

High Option Plan

In-Network Out-of-Network**

Dependent Eligibility: Dependent children, until the end of the calendar year they reach age 26, regardless of student or marital status.

Diagnostic Lab Work & X-

rays90% 70% covered in full 100% allowed benefit*

Cardiac Rehab $40 copay per visit 70% $5 copay per visit$5 copay per visit, 100%

allowed benefit*

Outpatient Surgery 90% 70% covered in full 100% allowed benefit*

Physical, Speech &

Occupational Therapy 90% (Combined 60 visits per year) 70% (Combined 60 visits per year)

$5 copay per visit

Call Plan for Visit limits

$5 copay per visit, 100%

allowed benefit* Call Plan for

Visit limits

Pre-Admission Testing 90% 70% covered in full 100% allowed benefit*

Allergy Testing 90% 70% $5 copay per visit $5 copay per visit, 100%

allowed benefit *

Allergy Serum 90%, Call Aetna for plan details 70%, Call Aetna for plan details $5 copay per visit $5 copay per visit, 100%

allowed benefit*

Pre/Post-Natal (Physician

Services)Covered in Full 80% covered in full 100% allowed benefit*

Outpatient Services, Continued

Maternity

Aetna PPO

2014 Active Benefit Plan Comparison Charts *All Out of Network benefits paid at Allowed Amount. Allowed Benefit is 50% of R & C

** any out-of-network provider can balance bill the difference between allowed amount and billed amount

Standard Option Plan

In-Network Out-of-Network**

High Option Plan

In-Network Out-of-Network**

Dependent Eligibility: Dependent children, until the end of the calendar year they reach age 26, regardless of student or marital status.

Fertility Testing &

Family Planning

Member cost sharing based on type of

service performed and place of service

where rendered

Member cost sharing based on type of

service performed and place of service

where rendered

Member cost sharing based

on type of service

performed and place of

service where rendered

100% allowed benefit*

member cost sharing based on

type of service performed and

place of service where

rendered

In-Vitro Fertilization

90%; $100,000 Maximum lifetime

benefit; up to 3 attempts per live birth

combined with ART, AI and AO

70%; $100,000 Maximum lifetime

benefit; up to 3 attempts per live birth

combined with Art, AI and AO

Covered in full; $100,000

Maximum lifetime benefit;

up to 3 attempts per live

birth combined with ART, AI

& AO

100% allowed benefit* covered

in full; $100,000 Maximum

lifetime benefit; up to 3

attempts per live birth

combined with Art, AI & AO

Inpatient Mental Health &

Alcohol & Substance

Abuse

90% 70% covered in full 100% allowed benefit*

Outpatient Mental Health

& Alcohol & Substance

Abuse

$25 copay 80% $5 copay per visit$5 copay per visit

100% allowed benefit*

Nutrition Counseling 90% 70% $5 copay per visit, $5 copay per visit, 100%

allowed benefit*

Diabetic Supplies 90% 70% covered in full 100% allowed benefit*

Durable Medical

Equipment90% 70% covered in full 100% allowed benefit*

Private duty nursing

(pre-authrequired)90% 70% covered in full 100% allowed benefit *

Hospice Care 90% 70% covered in full 100% allowed benefit *

Prosthetic Devices 90% 70% covered in full 100% allowed benefit *

Fertility Testing & Family Planning

Mental Health & Substance Abuse Benefits

Miscellaneous Supplies & Services

Insulin & Syringes Covered by Rx Plan

Are Referrals Required? No No No No

Deductible$250 per individual

$500 per family

$500 per individual

$1000 per familyNone None

Out-of-Pocket Maximum

(Based on annual salary)

Employee Salary < $45,000: $1,000

per individua/$2,000 per family

Employee Salary > $44,999: $1,500

per individual/$3,000 per family

Employee Salary < $45,000: $2,000

per individua/$4,000 per family

Employee Salary > $44,999: $3,000

per individual/$6,000 per family

$1,000 per individual

$2,000 per family None

Plan Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited

Routine Office Visit

(Annual physical) 100% 100% Covered in full

$5 copay per visit,

100% allowed Benefit*

Well Baby/Child Care 100% 100% Covered in full $5 copay per visit;

100% allowed Benefit*

Routine GYN Examination 100% 100% Covered in full $5 copay per visit,

100% allowed Benefit*

Screenings:

Mammography, Colorectal &

Prostate

100% Allowed Benefit 100% Allowed Benefit 100% Allowed Benefit 80% Allowed Benefit

Dependent Eligibility: Dependent children, until the end of the calendar year they reach age 26, regardless of student or marital status.

Routine & Preventive Services

Standard Option Plan

In-Network Out-of-Network**

UnitedHealthcare POS

2014 Active Benefit Plan Comparison Charts *Allowed Benefit is 50% of R & C ** any out-of-network provider can balance bill the difference between allowed amount & billed amount

High Option

In-Network Out-of-Network**

Dependent Eligibility: Dependent children, until the end of the calendar year they reach age 26, regardless of student or marital status.

Standard Option Plan

In-Network Out-of-Network**

UnitedHealthcare POS

2014 Active Benefit Plan Comparison Charts *Allowed Benefit is 50% of R & C ** any out-of-network provider can balance bill the difference between allowed amount & billed amount

High Option

In-Network Out-of-Network**

Physician's Office Visit

(Sickness) $25 copay per visit 80% $5 copay per visit

$5 copay per visit,

100% allowed Benefit*

Specialist Office Visit $40 copay per visit 80% $5 copay per visit$5 copay per visit,

100% allowed Benefit*

Hearing Exams 90% 70% $5 copay per visit $5 copay per visit

100% allowed benefit*

Ambulance Service

(based on medical necessity)90% 90%

Covered in full for

emergency only

100 % allowed benefit for

emergency only

Emergency Room

(copay waived if admitted) 90% 90% $50 copay $50 copay

Urgent Care $25 Copay, 90% $25 Copay, 90% $5 copay per visit$5 copay per visit,

100% allowed Benefit*

Anesthesia 90% 70% covered in full 100% allowed benefit*

Hospital Services, including

Room, Board & General

Nursing Services

90% 70% covered in full 100% allowed benefit*

Diagnostic Lab Work & X-rays 90% 70% covered in full 100% allowed benefit*

Medical Surgical Physician

Services90% 70% covered in full 100% allowed benefit*

Physical, Speech &

Occupational Therapy90% 70% covered in full 100% allowed benefit*

Organ Transplant

(Pre-Authorization Required) 90% for non-experimental transplants 70%

covered in full for non-

experimental transplants100% allowed benefit*

Physican Office Visits (Non-Routine)

Emergency Room and Urgent Care Services

Hospital Inpatient Services

Dependent Eligibility: Dependent children, until the end of the calendar year they reach age 26, regardless of student or marital status.

Standard Option Plan

In-Network Out-of-Network**

UnitedHealthcare POS

2014 Active Benefit Plan Comparison Charts *Allowed Benefit is 50% of R & C ** any out-of-network provider can balance bill the difference between allowed amount & billed amount

High Option

In-Network Out-of-Network**

Cardiac Rehab 90% 70% $5 copay per visit$5 copay per visit, 100%

allowed benefit*

Chemotherapy & Radiation 90% 70% $5 copay per visit$5 copay per visit, 100%

allowed benefit*

Renal Dialysis 90% 70% covered in full 100% allowed benefit*

Diagnostic Lab Work & X-rays 90% 70% covered in full 100% allowed benefit*

Outpatient Surgery 90% 70% covered in full 100% allowed benefit*

Physical, Speech &

Occupational Therapy

(60 visits combined per

therapy/type per year)

90% 70% $5 copay per visit; $5 copay per visit; 100%

allowed benefit*

Pre-Admission Testing 90% 70%$5 copay per visit, testing

covered in full

$5 copay per visit, 100%

allowed benefit*

Allergy Testing 90% 70% $5 copay per visit$5 copay per visit;

100% allowed benefit*

Allergy Serum 90% 70% Covered in Full 100% allowed benefit*

Outpatient Services

Dependent Eligibility: Dependent children, until the end of the calendar year they reach age 26, regardless of student or marital status.

Standard Option Plan

In-Network Out-of-Network**

UnitedHealthcare POS

2014 Active Benefit Plan Comparison Charts *Allowed Benefit is 50% of R & C ** any out-of-network provider can balance bill the difference between allowed amount & billed amount

High Option

In-Network Out-of-Network**

Pre and Post-Natal

(Physician Services)100% 80% Covered in Full

$5 copay for initial visit to

determine pregnancy,

then 100% allowed benefit*

Fertility Testing & Family

Planning 90% 70% $5 copay per visit

$5 copay per visit; 100%

allowed benefit*

In-Vitro Fertilization

90 % allowable charges; $100,000

maximum lifetime benefit; for up to 3

attempts per live birth

70% allowed benefit*; $100,000

maximum lifetime benefit for up to

3 attempts per live birth

100 % allowable charges;

$100,000 maximum

lifetime benefit; for up to 3

attempts per live birth

100% allowed benefit*;

$100,000 maximum lifetime

benefit for up to 3 attempts

per live birth

Inpatient Alcohol & Substance

Abuse/Mental Health 90% 70% covered in full 100% allowed benefit*

Outpatient Alcohol &

Substance Abuse/Mental

Health

$25 copay per visit 80% after deductible $5 copay per visit$5 copay per visit; 100%

allowed benefit*

Maternity

Fertility Testing & Family Planning

Mental Health & Substance Abuse Benefits

Dependent Eligibility: Dependent children, until the end of the calendar year they reach age 26, regardless of student or marital status.

Standard Option Plan

In-Network Out-of-Network**

UnitedHealthcare POS

2014 Active Benefit Plan Comparison Charts *Allowed Benefit is 50% of R & C ** any out-of-network provider can balance bill the difference between allowed amount & billed amount

High Option

In-Network Out-of-Network**

Nutrition Counseling1 90% 70% $5 copay per visit $5 copay per visit

Diabetetic Supplies 90% 70%

covered in full , including

lancets, tests strips and

glucometers

100% allowed benefit,

including lancets, test strips

& glucometers

Durable Medical Equipment

(pre-authorization required)90% 70% covered in full; 100% allowed benefit;

Private duty nursing

(pre-authorization required)Contact plan for details Contact plan for details

covered in full for skilled

care based on medical

necessity

100% allowed benefit*

Hospice Care

(pre-authorization required)90% 70% covered in full; 100% allowed benefit*;

Prosthetic Devices

(Such as artificial limbs)

(pre-authorization required)

90% 70%covered in full after prior

plan approval

100% allowed benefit* after

prior plan approval

Insulin & Syringes Covered by Rx Plan

Miscellaneous Supplies & Services

Are Referrals Required? No No No No

Deductible$250 per individual

$500 per family

$500 per individual

$1,000 per family

Out-of-Pocket Maximum

(Based on annual salary)

Employee Salary < $45,000:

$1,000 individua/$2,000 family

Employee Salary > $44,999:

$1,500 individual/$3,000 family

Employee Salary < $45,000:

$2,000 individua/$4,000 family

Employee Salary > $44,999:

$3,000 individual/$6,000 family

$1,000 per individual

$2,000 per familyN/A

Plan Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited

Routine Office Visit (Annual

physical) 100% Allowed Benefit 100% Allowed Benefit 100% Allowed Benefit 80% of Allowed Benefit

Well Baby/Child Care 100% Allowed Benefit 100% Allowed Benefit 100% Allowed Benefit 80% Allowed Benefit

Routine GYN Examination

(Limit-one per year) 100% Allowed Benefit 100% Allowed Benefit 100% Allowed Benefit 80% allowed benefit

Screenings:

Mammography, Colorectal &

Prostate

100% Allowed Benefit 100% Allowed Benefit 100% Allowed Benefit 80% Allowed Benefit

Physician's Office Visit

(Sickness)

(Maps & Unrepresented)

$25 Copay 80% Allowed Benefit$20 copay per visit

100% allowed benefit80% allowed benefit

Physician's Office Visit

(Sickness)

(Represented)

$25 Copay 80% Allowed Benefit$10 copay per visit

100% allowed benefit80% allowed benefit

Specialist Office Visit

(Maps & Unrepresented)$40 Copay 80% Allowed Benefit

$25 copay per visit

100% allowed benefit80% allowed benefit

Physican Office Visits (Not-Routine)

CareFirst PPN 2014 Active Benefit Plan Comparison Charts

** Any Out-of-Network Provider can balance bill the difference between the allowed amount and the billed amount.

Standard Option Plan

In-Network Out-of-Network**

High Option Plan

In-Network Out-of-Network** Dependent Eligibility: Dependent children, until the end of the calendar year they reach age 26, regardless of student or marital status.

Routine & Preventive Services

CareFirst PPN 2014 Active Benefit Plan Comparison Charts

** Any Out-of-Network Provider can balance bill the difference between the allowed amount and the billed amount.

Standard Option Plan

In-Network Out-of-Network**

High Option Plan

In-Network Out-of-Network**

Specialist Office Visit

(Represented)$40 Copay 80% Allowed Benefit

$15 copay per visit

100% allowed benefit80% allowed benefit

Hearing Exams- one exam every

36 months (routine exams

excluded)

90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit

with medical diagnosis

80% allowed benefit with medical

diagnosis

Ambulance Service

(Based on medical necessity)

(Ground Only)

90% Allowed Benefit 90% Allowed Benefit

major medical subject to

deductible and

coinsurance if applicable

major medical subject to

deductible and coinsurance if

applicable

Emergency Room

(copay waived if admitted) 90% Allowed Benefit 90% Allowed Benefit $50 copay $50 copay

Urgent Care $25 Copay, 90% Allowed Benefit $25 Copay, 90% Allowed Benefit $10 copay per visit; 100% of allowed benefit

Anesthesia 90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit 80% allowed benefit

Maps & Unrepresented

Hospital Services, including

Room, Board & General Nursing

Services

preauthorization required

90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit

preauthorization required

$100 deductible per admission,

then plan pays 70% up to $1,500

out of pocket maximum per

admission, then 100% allowed

benefit.

Represented Hospital Services,

including Room, Board &

General Nursing Services pre-

authorization required

90% Alllowed Benefit 70% Allowed Benefit 100% allowed benefit

$100 deductible per admission,

then plan pays 80% up to $1,500

out of pocket maximum per

admission, then 100% allowed

benefit.

Physican Office Visits (Not-Routine), Continued

Emergency Room and Urgent Care Services

Hospital Inpatient Services

CareFirst PPN 2014 Active Benefit Plan Comparison Charts

** Any Out-of-Network Provider can balance bill the difference between the allowed amount and the billed amount.

Standard Option Plan

In-Network Out-of-Network**

High Option Plan

In-Network Out-of-Network**

Medical Surgical Physician

Services90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit 80% allowed benefit

Physical, Speech &

Occupational Therapy90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit 80% allowed benefit

Organ Transplant

(Pre-Authorization Required) 90% Allowed Benefit

70% Allowed Benefit

($30,000 per transplant max)100% allowed benefit 100% allowed benefit

Cardiac Rehab 90% Allowed Benefit 70% Allowed Benefit 100% Allowed Benefit 80% Allowed Benefit

Chemotherapy & Radiation 90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit 80% allowed benefit

Renal Dialysis 90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit 80% allowed benefit

Diagnostic Lab Work & X-rays 90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit 80% allowed benefit

Outpatient Surgery 90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit 80% allowed benefit

Physical, Speech &

Occupational Therapy

(Maps & Unrepresented)

90% Allowed Benefit - limit 60 visits

combined

70% Allowed Benefit - limit 60

visits combined

100% allowed benefit -

precertification required

after 10th lifetime visit -

limited to 100 combined

visits per calendar year

80% allowed benefit -

precertification required after

10th lifetime visit - limited to 100

combined visits per calendar year

Physical, Speech &

Occupational Therapy

(Represented)

90% Allowed Benefit - limit 60 visits

combined

70% Allowed Benefit - limit 60

visits combined

facility $10 copay; office

100% allowed benefit -

precertification required

after 10th lifetime visit -

limited to 100 combined

visits per calendar year

80% allowed benefit for 100 visits

per calendar year for physical,

speech and occupational

therapies combined. Pre-

certification required after first 10

visits.

Pre-Admission Testing 90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit 80% allowed benefit

Allergy Testing 90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit 80% allowed benefit

Allergy Serum

($200 Annual Maximum)

90% after Deductible up to annual

maximum

70% allowed benefit up to annual

maximum

100% allowed benefit up

to annual maximum

80% allowed benefit up to annual

maximum

Hospital Inpatient Services, Continued

Outpatient Services

CareFirst PPN 2014 Active Benefit Plan Comparison Charts

** Any Out-of-Network Provider can balance bill the difference between the allowed amount and the billed amount.

Standard Option Plan

In-Network Out-of-Network**

High Option Plan

In-Network Out-of-Network**

Pre & Post-Natal (Physician

Services) covered in full 80% Allowed Benefit 100% allowed benefit 80% allowed benefit

Fertility Testing & Family

Planning 90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit 80% allowed benefit

In-Vitro Fertilization

(Pre-Authorization Required)

90% Allowed Benefit

($100,000 lifetime maximum)

70% Allowed Benefit

($100,00 lifetime maximum)

100% allowed benefit*;

$12,000 maximum

lifetime.

80% allowed benefit*;

$12,000 maximum lifetime

Inpatient Alcohol & Substance

Abuse/Mental Health

(Maps & Unrepresented)

Pre-Authorization Required

90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit

$100 deductible per admission,

then plan pays 70% up to $1,500

out of pocket maximum per

admission, then 100% allowed

benefit.

Inpatient Alcohol & Substance

Abuse/Mental Health

(Represented)

Pre-Authorization Required

90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit

$100 deductible per admission,

then plan pays 80% up to $1,500

out of pocket maximum per

admission, then 100% allowed

benefit.

Outpatient Mental

Health/Alcohol & Substance

Abuse (Maps &

Unrepresented)

$25 Copay 80% Allowed Benefit$20 copay per visit; 100%

allowed benefit. 80% allowed benefit.

Outpatient Mental

Health/Alcohol & Substance

Abuse (Represented)

$25 Copay 80% Allowed Benefit$10 copay per visit; 100%

allowed benefit. 80% allowed benefit.

Maternity

Fertility Testing & Family Planning

Inpatient Mental Health & Substance Abuse- Benefits Benefits Provided by Value Option

Outpatient Mental Health & Substance Abuse- Benefits Benefits Provided by Value Option

CareFirst PPN 2014 Active Benefit Plan Comparison Charts

** Any Out-of-Network Provider can balance bill the difference between the allowed amount and the billed amount.

Standard Option Plan

In-Network Out-of-Network**

High Option Plan

In-Network Out-of-Network**

Nutrition Counseling 90% 70%

Covered same as any

office visit- based on

diagnosis.

80% allowed benefit, for specific

diagnosis only

Diabetic Supplies 90% Allowed Benefit 70% Allowed Benefit

100% allowed benefit,

includes lancets test strips

& glucometers

100% allowed benefit, includes

lancets, test strips & glucometers

Durable Medical Equipment 90% Allowed Benefit 70% Allowed Benefit See major medical benefit See major medical benefit

Private duty nursing

(Pre-Authorization required)90% Allowed Benefit 70% Allowed Benefit

based on medical

necessity; See major

medical benefit

based on medical necessity; See

major medical benefit

Hospice Care 90% Allowed Benefit 70% Allowed Benefit 100% allowed benefit 80% allowed benefit

Prosthetic Devices (IE: as

artificial limbs)90% Allowed Benefit 70% Allowed Benefit See major medical benefit See major medical benefit

Major Medical Annual

Deductible

(Maps & Unrepresented) NA NA

Major medical expenses

only - $250 deductible per

person per year

Major medical expenses only -

$250 deductible per person per

year

Major Medical Annual

Deductible (Represented)NA NA

major medical expenses

only; $200 deductible per

person per year

major medical expenses only;

$200 deductible per person per

policy year

Major Medical Yearly Out-Of-

Pocket Maximum

(Maps & Unrepresented) NA NA

Deductible then 100%

first $30,000, then 50% of

allowed benefit

Deductible then 100% first

$30,000, the 50% of allowed

benefit

Major Medical Yearly Out-Of-

Pocket Maximum

(Represented) NA NA

Deductible then 80% of

allowed benefit

Deductible then 80% of allowed

benefit

Miscellaneous Supplies & Services

Insulin & Syringes Covered by Rx Plan

Major Medical- Applies to CareFirst Plans Only

Kaiser HMO Optimum Choice HMO Aetna HMO

Are Referrals Required? Yes Yes Yes

Out- Of- Pocket Maximum$3,500 per individual; $9,400 per

family

$1,100 per Individual; $3,600 per

family

$1,100 per individual; $2,200 per

family

Plan Lifetime Maximum Benefit Unlimited Unlimited Unlimited

Physician's Office Visit (Annual

Physical)Covered in full Covered in full Covered in full

Well Baby/Child Care Covered in full Covered in full Covered in full

Routine GYN Examination Covered in full Covered in full Covered in full

Immunizations Covered in full Covered in full Covered in full

Screenings: Mammography,

Colorectal & Prostate Covered in full - call plan for details Covered in full - call plan for details Covered in full - call plan for details

Specialist Office Visit $5 copay per visit $5 copay per visit $5 copay per visit

Hearing Exams $5 copay per visit $5 copay per visit $5 copay per visit

Ambulance Service

(Based on medical necessity)Covered in full for emergency only Covered in full for emergency only Covered in full for emergency only

Emergency Room (Waived if

admitted)$50 copay $50 copay $50 copay

Urgent Care $5 copay per visit $5 copay per visit $5 copay per visit

HMO 2014 Active Benefit Plan Comparison Charts

NOTE: Referrals Are Required for HMO Plans

Routine & Preventive Services

Emergency Room and Urgent Care Services

Dependent Eligibility: Dependent children, until the end of the calendar year they reach age 26, regardless of student or marital status.

Physican Office Visit (Non-Routine)

Kaiser HMO Optimum Choice HMO Aetna HMO

HMO 2014 Active Benefit Plan Comparison Charts

NOTE: Referrals Are Required for HMO Plans

Anesthesia Covered in full Covered in full Covered in full

Hospital Services Including Room,

Board & General Nursing ServicesCovered in full Covered in full Covered in full

Diagnostic Lab Work & X-rays Covered in full Covered in full Covered in full

Medical Surgical Physician Services Covered in full Covered in full Covered in full

Physical, Speech & Occupational

TherapyCovered in full Covered in full Covered in full

Organ Transplant

Pre-Authorization Required

Covered in full for

non-experimental transplants

Covered in full for

non-experimental transplants

Covered in full for

non-experimental transplants

Cardiac Rehab $5 copay per visit $5 copay per visit $5 copay per visit

Chemotherapy & Radiation $5 copay per visit $5 copay per visit $5 copay per visit

Renal Dialysis $5 copay per visit covered in full covered in full

Diagnostic Lab Work & X-rays covered in full covered in full covered in full

Outpatient Surgery $5 copay per visit covered in full covered in full

Physical, Speech & Occupational

Therapy

$5 copay per visit call plan for visit

limits

$5 copay per visit 90 visits per

therapy type per year

$5 copay per visit

Call plan for visit limits

Pre-Admission Testing $5 copay per visit covered in full covered in full

Allergy Testing $5 copay per visit $5 copay per visit $5 copay per visit

Allergy Serum covered in full covered in full $5 copay per visit

Hospital Inpatient Services

Outpatient Services

Kaiser HMO Optimum Choice HMO Aetna HMO

HMO 2014 Active Benefit Plan Comparison Charts

NOTE: Referrals Are Required for HMO Plans

Pre and Post-Natal (Physician

Services)Covered in full Covered in full Covered in full

Delivery (Inpatient) covered in full covered in full covered in full

Newborn Care (Inpatient) covered in full covered in full covered in full

Fertility Testing & Family Planning

$5 copay per visit for family

planning. Fertility testing office visit

and any other fertility services

covered at 50%

$5 copay per visit for family

planning and fertility testing; other

fertility services 50%

Member cost sharing based on type

of service performed and place of

service where rendered

In-Vitro Fertilization

50% of allowable charges; $100,000

maximum lifetime benefit for up to 3

attempts per live birth

50% of allowable charges;

$100,000 maximum lifetime

benefit for up to 3 attempts per

live birth

Call plan for specific state mandated

benefits

Inpatient

Mental Health/Alcohol &

Substance Abuse

covered in full covered in fullcovered in full;

pre-authorization required

Outpatient

Mental Health/Alcohol &

Substance Abuse

$5 copay per visit $5 copay per visit $5 copay per visit

Maternity

Fertility Testing & Family Planning

Mental Health & Substance Abuse Benefits

Kaiser HMO Optimum Choice HMO Aetna HMO

HMO 2014 Active Benefit Plan Comparison Charts

NOTE: Referrals Are Required for HMO Plans

Nutrition & Health Education $5 copay per visit $5 copay per visit $5 copay per visit

Diabetetic Supplies Covered in full

Lancets & test strips, generic

covered by a $5 copay and brand

covered by a $20 copay.

$5 copay

Durable Medical Equipment

Preauthorization requiredCovered in full Covered in full Covered in full

Private Duty Nursing

Preauthorization requiredCovered in full Not covered Not covered

Hospice Care Covered in full Covered in full Covered in full

Prosthetic Devices Such As Artificial

Limbs)

preauthorization required

Covered in full Covered in full Covered in full

Insulin & Syringes Covered by Rx plan

Miscellaneous Supplies & Services