#3. Medicare Plan Scenarios 8-9 — File 191787

City of Somerville 8/9/2011 Current BCBS Medex Subscriber Chooses Unicare Indemnity Plan Active and Non-Medicare Retirees - Calendar Year 2012 Projections Note: Copays shown are for non preventive services; certain preventive services are no member cost sharing under either the City or GIC Plans BCBS Below Above Below Above Medex Unicare Indemnity Average Average Average Average Average Average Utilizer Utilizer Utilizer Additional Additional Additional # Services # Services # Services Costs Costs Costs Office Visits $0 $35 deductible 1 2 5 $35 $35 $35 Emergency Room $0 $25 0 2 10 $0 $50 $250 Inpatient Hospitalization $0 $50/One per Qtr 0 1 5 $0 $50 $200 Retail Prescription Drugs (30-Day Supply) $50 deductible Generics $0 $10 14 20 100 $90 $150 $950 Brand-Name 20% $25 1 4 20 $6 $24 $120 Non-Preferred 20% $50 0 1 5 $0 $15 $75 Mail Order Prescription Drugs (90-Day Supply) Generics $2 $20 2 5 25 $36 $90 $450 Brand-Name $15 $50 0 3 15 $0 $105 $525 Non-Preferred $15 $110 0 1 5 $0 $95 $475 City/Retiree Split Total Additional Out of Pocket Costs 75/25 $167 $614 $3,080 Projected Premium Savings ($335) ($335) ($335) Net Impact ($168) $279 $2,745 Note: Mitigation dollars not included. Average Brand and Non Preferred Medex Copays $19 and $35