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6 <br />Current Carrier <br />Renewal: Option 1 <br />Current POS <br />Current HSA <br />Current POS <br />Current HSA <br />In- Network <br />In- Network <br />In- Network <br />In- Network <br />Primary Care Physician Visits <br />$20 <br />Deduct /20% <br />$20 <br />Deduct /20% <br />Specialist Physician Visits <br />$40 <br />Deduct /20% <br />$40 <br />Deduct /20% <br />Preventive Care <br />100% <br />100% <br />100% <br />100% <br />Deductible <br />$500 <br />$1,500 <br />$500 <br />$1,500 <br />Deductible - Family Maximum <br />$1,500 <br />$3,000 <br />$1,500 <br />$3,000 <br />Out of Pocket Limit (includes deductible) <br />$1,500 <br />$3,500 <br />$1,500 <br />$3,500 <br />Out of Pocket Limit - Family Max <br />$4,500 <br />$5,000 <br />$4,500 <br />$5,000 <br />Radiology <br />Deduct /20% <br />Deduct /20% <br />Deduct /20% <br />Deduct /20% <br />Minor Surgery in Office <br />Office Copay <br />Deduct /20% <br />Office Copay <br />Deduct /20% <br />Hospital Services <br />Deduct /20% <br />Deduct /20% <br />Deduct /20% <br />Deduct /20% <br />Urgent Care <br />$50 <br />Deduct /20% <br />$50 <br />Deduct /20% <br />Emergency Room <br />$150 <br />Deduct /20% <br />$150 <br />Deduct /20% <br />Pharmacy <br />$4/$25/$45 <br />Deduct /20% <br />$4/$25/$45 <br />Deduct /20% <br />Vision Hardware <br />Not covered <br />Not covered <br />Not covered <br />Not covered <br />HSA <br />$1,237.20 <br />$1,237.20 <br />Lifetime Maximum <br />Unlimited <br />Unlimited <br />Unlimited <br />Unlimited <br />Plan Administration Fee <br />$38.35 <br />Network Access Fee <br />$0.00 <br />Vision Administration <br />$0.00 <br />Specific Stop -loss <br />$88.80 <br />Aggregate Stop -loss <br />$4.99 <br />Total Administration Fees (A) <br />$132.14 <br />Expected Monthly Paid Claims /EE /Month <br />$609.14 <br />Expected Monthly Cost /EE /Month <br />$741.28 <br />Claims Margin /ee /mth <br />$121.83 <br />Maximum Claim Liability (B) <br />$730.97 <br />Total Liability (A+ B) <br />$863.11 <br />Employees <br />995 <br />Estimated Monthly Cost <br />$737,573.60 <br />Estimated Annual HSA - $1,416 <br />$293,112.00 <br />Estimated Annual Cost <br />$8,850,883.20 <br />Estimated Annual With HSA <br />$10,090,923.48 <br />$9,143,995.20 <br />90.62% <br />Maximum Monthly Cost Without HSA <br />$858,792.46 <br />Maximum Annual Cost <br />$10,305,509.52 <br />Estimated Annual HSA - $1,416 <br />$293,112.00 <br />Maximum Annual with HSA <br />$10,090,923.48 <br />$10,598,621.52 <br />Difference <br />1 <br />105.0% <br />6 <br />