Common use of Option 1: Physician Open Access (POA) Clause in Contracts

Option 1: Physician Open Access (POA). The POA gives you “open access” to the doctor (or hospital) of your choice, without requiring a referral. Each time you need care, you decide which type of doctor to see and whether to receive services from an in-network provider (one who participates in the plan network) or from an out- of-network provider. Even though you may seek care from any provider, it’s still important to review the extensive network of participating hospitals, doctors, and other providers. That’s because more of your out- of-pocket costs are covered when you use an in-network provider. You’re free to receive care from any network provider to qualify for in-network benefits. When you do, office visits are covered at 100% after a co-payment. Preventive Care Office Visits are covered at 100%. Prescription drugs are covered at 100% after a co-payment that is determined based upon whether the drug is filled with a generic, preferred brand name, or non-preferred brand name. You can receive up to a 30-day supply through a retail pharmacy, and a 90-day supply through the mail-order program. Most other services are subject to an annual deductible, coinsurance, and an out-of-pocket maximum. Listed below is a summary of some fees for commonly used services from network providers. Through After 12/31/2124 12/31/2124 Preventive Care Office Visit $-0- $-0- Office Visits (PCP) $35 $3545 Office Visits (Specialist) $100/50 $100/50 110/55 Cardiac Rehabilitation $-0- $-0- Physical Therapy Office Visit $50 $5055 Chiropractic Office Visit $50 $5055 Allergy Shots Office Visit office visit office visit Prescription Drugs Retail (30-day supply) $10/5060/120130 $10/60/130 Mail Order (90-day supply) $20/100110/240250 $20/110/250 X-rays, Labs, Diagnostics 20%; after deductible 20%; after deductible Emergency Room 20%; after deductible 20%; after deductible Inpatient Hospital Stay 20%; after deductible 20%; after deductible Outpatient Surgery 20%; after deductible 20%; after deductible Here is how your share of the cost for care is determined for those services where coinsurance applies. (Co-payments for office visits and prescription drugs do not count toward the annual deductible and out-of-pocket maximum.) Unless specifically stated above, you need to meet the annual deductible. For in-network care, the annual deductible is: Per Person $600 $800 $600 $800 $800 $1,200 $800 $1,200 Maximum Per Family $1,200 $1,600 $1,200 $1,600 $1,600 $2,400 $1,600 $2,400 Once you meet the annual deductible, you will begin to pay a percentage of covered services. After your deductible and share of coinsurance reaches the out-of-pocket maximum, then the plan pays the remainder of covered services (excluding co-payments) for the rest of the year. This means the plan pays 100% of the usual, customary and reasonable costs for covered services where coinsurance applies. The out-of-pocket maximum is: Per Person $1,900 $2,500 $1,900 $2,500 $2,500 $3,600 $2,500 $3,600 Maximum Per Family $3,800 $5,000 $3,800 $5,000 $5,000 $7,200 $5,000 $7,200 To participate in the POA Option, the following contributions will be deducted from your weekly paycheck. Employee Only $11.33 $16.99 $11.78 $17.67 $12.13 $18.20 $12.49 $18.75 Employee & Spouse $20.76 $32.64 $21.59 $33.95 $22.24 $34.97 $22.91 $36.02 Employee & Child(ren) $20.76 $32.64 $21.59 $33.95 $22.24 $34.97 $22.91 $36.02 Employee & Family $32.09 $49.59 $33.37 $51.57 $34.37 $53.12 $35.40 $54.71

Option 1: Physician Open Access (POA). The POA gives you “open access” to the doctor (or hospital) of your choice, without requiring a referral. Each time you need care, you decide which type of doctor to see and whether to receive services from an in-network provider (one who participates in the plan network) or from an out- out-of-network provider. Even though you may seek care from any provider, it’s still important to review the extensive network of participating hospitals, doctors, and other providers. That’s because more of your out- out-of-pocket costs are covered when you use an in-network provider. You’re free to receive care from any network provider to qualify for in-network benefits. When you do, office visits are covered at 100% after a co-payment. Preventive Preventative Care Office Visits are covered at 100%. Prescription drugs are covered at 100% after a co-co- payment that is determined based upon whether the drug is filled with a generic, preferred brand name, or non-preferred brand name. You can receive up to a 30-day supply through a retail pharmacy, and a 90-day supply through the mail-order program. Most other services are subject to an annual deductible, coinsurance, and an out-of-pocket maximum. Listed below is a summary of some fees for commonly used services from network providers. Through After 12/31/2124 12/31/2124 Preventive Care Office Visit $-0- $-0- Office Visits (PCP) $35 15 $3545 20 Office Visits (Specialist) $100/50 30/15 $100/50 110/55 50/25 Cardiac Rehabilitation $-0- $-0- Physical Therapy Office Visit $50 15 $5055 25 Chiropractic Office Visit $50 15 $5055 25 Allergy Shots Office Visit office visit $15 office visit Prescription Drugs Retail (30-day supply) $10/5060/120130 10/20/50 $10/60/130 10/30/70 Mail Order (90-day supply) $20/100110/240250 20/40/100 $20/110/250 20/60/140 X-rays, Labs, Diagnostics 20%; after no deductible 20%; after deductible Emergency Room 20%; after deductible 20%; after deductible Inpatient Hospital Stay 20%; after deductible 20%; after deductible Outpatient Surgery 20%; after deductible 20%; after deductible Here is how your share of the cost for care is determined for those services where coinsurance applies. (Co-payments for office visits and prescription drugs do not count toward the annual deductible and out-of-pocket maximum.) Unless specifically stated above, you need to meet the annual deductible. For in-in- network care, the annual deductible is: Per Person $600 350 $800 350 $600 400 $400 $400 Maximum Per Family $700 $700 $800 $800 $1,200 $800 $1,200 Maximum Per Family $1,200 $1,600 $1,200 $1,600 $1,600 $2,400 $1,600 $2,400 Once you meet the annual deductible, you will begin to pay a percentage of covered services. After your deductible and share of coinsurance reaches the out-of-pocket maximum, then the plan pays the remainder of covered services (excluding co-payments) for the rest of the year. This means the plan pays 100% of the usual, customary and reasonable costs for covered services where coinsurance applies. The out-of-pocket maximum is: Per Person $1,900 1,500 $2,500 1,500 $1,900 1,700 $2,500 1,700 $2,500 $3,600 $2,500 $3,600 1,700 Maximum Per Family $3,800 3,000 $5,000 3,000 $3,800 3,400 $5,000 3,400 $5,000 $7,200 $5,000 $7,200 To participate in the POA Option, the following contributions will be deducted from your weekly paycheck. Employee Only $11.33 $16.99 $11.78 $17.67 $12.13 $18.20 $12.49 $18.75 Employee & Spouse $20.76 $32.64 $21.59 $33.95 $22.24 $34.97 $22.91 $36.02 Employee & Child(ren) $20.76 $32.64 $21.59 $33.95 $22.24 $34.97 $22.91 $36.02 Employee & Family $32.09 $49.59 $33.37 $51.57 $34.37 $53.12 $35.40 $54.713,400