FEARLESS IS FINDING THE RIGHT FITbrand.excellusbcbs.com/broker/downloads/EXC_04506_SMGRP_Placemat_ROC.pdfEnhanced Reward Programs Members can now track trips to the gym with the ExerciseRewards

2019 Excellus SimplyBlue Plus Designs At A Glance

FEARLESS IS FINDING THE RIGHT FIT

Subscriber Name

Subscriber ID

Effective DatePlan CodeRxBINRxPCN

PlanPCP CopayChildren up to age 19

Specialist Copay

Emergency Copay

Plan TypeHealth Insurance

9:15 AM 75%

1 2 3

4 5 6

7 8 9

* 0 #

*MDLIVE is an independent company, offering telehealth services in the Excellus BlueCross BlueShield service area.

More Plan and Reimbursement Account Options

New Hybrid and Deductible HSA Plans. Groups and members can make the most of their health care dollars with our Lifetime Benefit Solutions** HSA, HRA and FSA administration services.

Behavioral Health Added to Telemedicine

MDLIVE* now offers behavioral health services to help manage stress, life changes, addiction, and more.

Enhanced Reward Programs

Members can now track trips to the gym with the ExerciseRewards CheckIn!™ app. Plus, the new Active&Fit Direct Program provides fitness center memberships at 8,000+ locations for just $25/month.

What’s New:

All organizations, big and small, are looking for health insurance that provides the maximum level of coverage and protection for employees at a price that works for their business. But while every business wants the same thing, no two businesses are alike.

Small businesses need options. The guidance and reassurance that the choices they make are the right ones for the families they’re looking out for.

Together, that’s what we deliver to your clients. This year there are new plans, added features, and plenty of options to ensure we have the right coverage for every group

CHOOSING A HEALTH PLAN IS A DECISION WE DON’T TAKE LIGHTLY

SimplyBlue Plus – Plans for Small Employer Groups – Go to Blue on Demand for More Details

Stable/Predictable: Designed for people who prefer the peace of mind of minimal out-of-pocket costs

Balanced: Designed for people who want a balance between predictability in out-of-pocket costs and lower premium

Value Maximizing: Designed for people who want the lowest premium and most control over their health care expenses

= New plans: Silver 18 and Silver 19 Benefits in orange represent a cost share change from 2018 to 2019.*Benefit is subject to the plan deductible. **Aggregation Designs Defined: Individual Aggregation: Each covered family member only needs to satisfy his or her individual deductible and/or out of pocket maximum, not the entire family amounts, before the health plan begins to contribute. Family Aggregation: For family coverage, the entire family’s annual deductible and/or out-of-pocket maximum must be met by one or any combination of covered members before the health plan begins to contribute.*** Effective 1/1/2019 – 3/31/2019 Rates include dependent to 26 and coverage for domestic partner, family planning and pediatric dental. See Blue on Demand for other rates. † Preventive drugs are not subject to the deductible.This is not a contract nor a Summary of Benefits and Coverage (SBC). This benefit summary is intended to highlight the coverage of this program. Benefits are determined by the terms of the Member Certificate. All benefits are subject to medical necessity.

PLAN TYPE COPAY

Plan Name Platinum Standard

Platinum2

Platinum3

Platinum5

Platinum6 Gold 1 Gold 5

Enrollment Code SMR5 SMT1 SMW3 SOF5 SOH1 SMU7 SMX9

Deductible: Individual/Family$0/$0

$0/$0

$0/$0

$0/$0

$0/$0

$0/$0

$0/$0

Out-of-Pocket Maximum: Individual/Family

$2,000/$4,000

$6,350/$12,700

$4,500/$9,000

$6,550/$13,100

$6,550/$13,100

$6,850/$13,700

$6,850/$13,700

Aggregation Design** INDIVIDUAL INDIVIDUAL INDIVIDUAL INDIVIDUAL INDIVIDUAL INDIVIDUAL INDIVIDUAL

Coinsurance N/A N/A N/A N/A N/A N/A N/A

MEDICAL

Preventive Care $0 $0 $0 $0 $0 $0 $0

Primary Care Visits $15 $15 $25 $25 $30 $25 $40

Specialist Visit $35 $25 $40 $40 $50 $40 $60

Telemedicine Visit $10 $10 $10 $10 $10 $10 $10

Hospital Facility: Inpatient $500 $250 $500 $750 $750 $1,000 $1,000

Hospital Facility: Outpatient $100 $150 $150 $250 $250 $450 $500

Urgent Care $55 $25 $40 $40 $50 $40 $60

Emergency Room Visit $100 $150 $150 $250 $250 $450 $500

PHARMACY

Prescription Copayment $10/$30/$60 $5/$30/$50 $5/$35/$70 $5/$35/$70 $5/$35/$70 $15/40%/50% $15/$50/50%

OUT-OF-NETWORK COVERAGE

Deductible: Individual/Family$500/$1,000

$500/$1,000

$500/$1,000

$500/$1,000

$500/$1,000

$500/$1,000

$500/$1,000


$2,000/$4,000

$6,350/$12,700

$4,500/$9,000

$6,550/$13,100

$6,550/$13,100

$6,850/$13,700

$6,850/$13,700

Coinsurance 20% 20% 20% 20% 20% 20% 20%

ROCHESTER RATES***

Single $684.76 $682.33 $669.78 $663.07 $656.07 $593.08 $585.78

Subscriber & Spouse $1,369.52 $1,364.66 $1,339.56 $1,326.14 $1,312.14 $1,186.16 $1,171.56

Subscriber & Children $1,164.09 $1,159.96 $1,138.63 $1,127.22 $1,115.32 $1,008.24 $995.83

Family $1,951.57 $1,944.64 $1,908.87 $1,889.75 $1,869.80 $1,690.28 $1,669.47





SimplyBlue Plus – Plans for Small Employer Groups – Cont’d Go to Blue on Demand for More Details

PLAN TYPE HYBRID

Plan Name Platinum 4 Gold 13 Gold 14 Gold 17 Gold 18 Gold 19 Gold Standard Silver 6 New:

Silver 18Silver

Standard

Enrollment Code SNZ1 SNM3 SNN9 SOA7 SOC3 SOI7 SNK7 SNP5 SML1 SNJ1


$750/$1,500

$1,000/$2,000

$750/$1,500

$1,000/$2,000

$2,250/$4,500

$600/$1,200

$2,250/$4,500

$6,550/$13,100

$1,700/$3,400


$2,000/$4,000

$6,850/$13,700

$5,500/$11,000

$7,000/$14,000

$6,000/$12,000

$6,850/$13,700

$4,000/$8,000

$7,500/$15,000

$7,500/$15,000

$7,500/$15,000

Aggregation Design** INDIVIDUAL INDIVIDUAL INDIVIDUAL INDIVIDUAL INDIVIDUAL INDIVIDUAL INDIVIDUAL INDIVIDUAL INDIVIDUAL INDIVIDUAL

Coinsurance 20% 20% 20% 20% 20% 20% 0% 20% 30% 0%

MEDICAL

Preventive Care $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Primary Care Visits $15 $15* $25* $25 $30 $40 $25* $40* $50 $30*

Specialist Visit $25 $25* $40* $40 $50 $60 $40* $60* $75 $50*

Telemedicine Visit $10 $10* $10* $10 $10 $10 $10* $10* $10 $10*

Hospital Facility: Inpatient 20%* 20%* 20%* 20%* 20%* 20%* $1,000* 20%* 30%* $1,500*

Hospital Facility: Outpatient 20%* 20%* 20%* 20%* 20%* 20%* *$100* 20%* 30%* $100*

Urgent Care $25 $25* $40* $40 $50 $60 $60* $60* $75 $70*

Emergency Room Visit $150 $200* $250* $250 $250 $350 $150* $350* $500 $250*

PHARMACY

Prescription Copayment $5/$25/$50 $5/$25/$50 $5/$35/$70 $5/$45/$90 $5/$45/$90 $5/$45/$90 $10/$35/$70 $5/$45/$90 $10/$45/$90 $10/$35/$70



$750/$1,500

$1,000/$2,000

$750/$1,500

$1,000/$2,000

$2,250/$4,500

$600/$1,200

$2,250/$4,500

$6,550/$13,100

$1,700/$3,400


$2,000/$4,000

$6,850/$13,700

$5,500/$11,000

$7,000/$14,000

$6,000/$12,000

$6,850/$13,700

$4,000/$8,000

$7,500/$15,000

$7,500/$15,000

$7,500$15,000

Coinsurance 40% 40% 40% 40% 40% 40% 40% 40% 50% 40%

ROCHESTER RATES***

Single $685.85 $582.24 $576.76 $590.07 $585.81 $555.69 $590.55 $490.45 $466.80 $508.19

Subscriber & Spouse $1,371.70 $1,164.48 $1,153.52 $1,180.14 $1,171.62 $1,111.38 $1,181.10 $980.90 $933.60 $1,016.38

Subscriber & Children $1,165.95 $989.81 $980.49 $1,003.12 $995.88 $944.67 $1,003.94 $833.77 $793.56 $863.92

Family $1,954.67 $1,659.38 $1,643.77 $1,681.70 $1,669.56 $1,583.72 $1,683.07 $1,397.78 $1,330.38 $1,448.34






PLAN TYPE DEDUCTIBLE HSA

Plan Name Gold 6 Gold 20 Silver 2 Silver 4 Silver 14 Silver 16 Silver 17

Enrollment Code SNB1 SOK3 SNC7 SNE3 SNU3 SOL9 SON5

Deductible: Individual/Family$1,400/$2,800

$1,800/$3,600

$2,000/$4,000

$2,500/$5,000

$2,800/$5,600

$3,200/$6,400

$3,600/$7,200


$2,800/$5,600

$3,600/$7,200

$6,650/$13,300

$6,550/$13,100

$6,550/$13,100

$6,550/13,100

$6,550/$13,100

Aggregation Design** FAMILY FAMILY FAMILY FAMILY FAMILY FAMILY FAMILY

Coinsurance 15% 20% 25% 15% 20% 20% 20%

MEDICAL

Preventive Care $0 $0 $0 $0 $0 $0 $0

Primary Care Visits 15%* 20%* 25%* 15%* 20%* 20%* 20%*

Specialist Visit 15%* 20%* 25%* 15%* 20%* 20%* 20%*

Telemedicine Visit 15%* 20%* 25%* 15%* 20%* 20%* 20%*

Hospital Facility: Inpatient 15%* 20%* 25%* 15%* 20%* 20%* 20%*

Hospital Facility: Outpatient 15%* 20%* 25%* 15%* 20%* 20%* 20%*

Urgent Care 15%* 20%* 25%* 15%* 20%* 20%* 20%*

Emergency Room Visit 15%* 20%* 25%* 15%* 20%* 20%* 20%*

PHARMACY

Prescription Copayment $5/$35/$70*† $5/$45/$90*† $5/$45/$90*† $5/$35/$70*† $5/$45/$90*† $5/$45/$90*† $5/$35/$70*†



$1,800/$2,600

$2,000/$4,000

$2,500/$5,000

$2,800/$3,600

$3,200/$6,400

$3,600/$7,200


$2,800/$5,600

$3,600/$7,200

$6,650/$13,300

$6,650/$13,300

$6,650/$13,300

$6,650/$13,300

$6,650/$13,300

Coinsurance 30% 40% 50% 30% 40% 40% 40%

ROCHESTER RATES***

Single $556.85 $532.29 $470.62 $465.34 $457.91 $435.09 $422.79

Subscriber & Spouse $1,113.70 $1,064.58 $941.24 $930.68 $915.82 $870.18 $845.58

Subscriber & Children $946.65 $904.89 $800.05 $791.08 $778.45 $739.65 $718.74






PLAN TYPE DEDUCTIBLE HSA DEDUCTIBLE

Plan Name New: Silver 19 Bronze 3 Bronze 4 Bronze 5 Bronze 6 Bronze Standard

HSABronze

Standard

Enrollment Code SMM7 SNF9 SNH5 SNV9 SOP1 SOD9 SMZ5


$5,000$10,000

$6,550/$13,100

$5,500/$11,000

$4,500/$9,000

$5,500/$11,000

$4,000/$8,000


$6,550/$13,100

$6,550/$13,100

$6,550/$13,100

$6,550/$13,100

$6,550/$13,100

$6,550/$13,100

$8,000/$16,000

Aggregation Design** FAMILY FAMILY FAMILY FAMILY FAMILY INDIVIDUAL INDIVIDUAL

Coinsurance 0% 50% 0% 0% 20% 50% 50%

MEDICAL

Preventive Care $0 $0 $0 $0 $0 $0 $0

Primary Care Visits $25* 50%* 0%* $30* 20%* 50%* 50%*

Specialist Visit $50* 50%* 0%* $50* 20%* 50%* 50%*

Telemedicine Visit $10* 50%* 0%* $10* 20%* 50%* 50%*

Hospital Facility: Inpatient $500* 50%* 0%* $500* 20%* 50%* 50%*

Hospital Facility: Outpatient $300* 50%* 0%* $350* 20%* 50%* 50%*

Urgent Care $50* 50%* 0%* $50* 20%* 50%* 50%*

Emergency Room Visit $300* 50%* 0%* $350* 20%* 50%* 50%*

PHARMACY

Prescription Copayment $5/$45/$90*† $10/40%/50%*† 0%*† $10/$35/$70*† $5/$45/$90*† $10/$35/$70* $10/$35/$70*



$5,000/$10,000

$7,500/$15,000

$5,500/$11,000

$4,500/$9,000

$5,500/$11,000

$4,000/$8,000


$6,650/$13,300

$7,500/$15,000

$7,500/$15,000

$6,650/$13,300

$6,650/$13,300

$7,500/$15,000

$8,000/$16,000

Coinsurance 40% 50% 0% 40% 40% 50% 50%

ROCHESTER RATES***

Single $469.60 $364.54 $353.90 $376.86 $386.47 $367.28 $382.88

Subscriber & Spouse $939.20 $729.08 $707.80 $753.72 $772.94 $734.56 $765.76

Subscriber & Children $798.32 $619.72 $601.63 $640.66 $657.00 $624.38 $650.90

Family $1,338.36 $1,038.94 $1,008.62 $1,074.05 $1,101.44 $1,046.75 $1,091.21

1

2

3

4

* Only available for Self-funded Groups.

Copyright © 2018, Excellus BlueCross BlueShield, a nonprofit independent licensee of the Blue Cross Blue Shield Association. All rights reserved. Please note, this is not a contract. It is intended to highlight some of the options available under our medical plans. Benefits are determined by the terms of the member contract. All benefits are subject to medical necessity.

ROCHESTER

B-6532

MEDICAL

PHARMACY

DENTAL

WELLNESS

STOP LOSS INSURANCE*

ADMINISTRATIVE SERVICES

WELCOME TO SYNCHRONIZED

CARE

Lower Costs We leverage data, innovation, and collaboration with our regional and national network of providers to keep costs down for your business and employees.

Better CareWith a provider network built on 80 years of relationships, no one covers your team better in this region or around the world.

Easier Administration A dedicated single point of contact for all aspects of our relationship, plus helpful online resources, makes it easy to do business with us.

Fewer Disruptions When everything works together in a synchronized network of care, there’s less confusion, fewer questions, and minimal disruptions.

Coverage Works Best When It’s ConnectedWith clinical and administrative offerings working together, care can be more effective and savings more substantial.

Learn more about our synchronized approach to care and how we can provide the best coverage for your employees and business.

ExcellusforBusiness.com

FOUR WAYS WE KEEP EMPLOYEES AND BUSINESSES HEALTHY

Documents

FEARLESS IS FINDING THE RIGHT FITbrand.excellusbcbs.com/broker/downloads/EXC_04506_SMGRP_Placemat_ROC.pdfEnhanced Reward Programs Members can now track trips to the gym with the ExerciseRewards