#3.1 Medicare Plan Scenarios 8-10 Specific — File 191787

City of Somerville Medical Scenario Out of Pocket Costs Accident One PCP visit Twenty four specialist and/or physical therapy office visits One inpatient copayment Twelve brand retail prescription drug copayments Four generic mail order prescription drug copayments Cancer One PCP visit Thirty six specialist office visits Two emergency room copayments Three inpatient copayments Twenty four brand retail prescription drug copayments Twelve brand non formulary retail prescription drug copayments Four brand mail order prescription drug copayments Two brand non-formulary mail order prescription drug payments Depression One PCP visit Eighteen specialist office visits Twelve generic retail prescription drug copayments Twenty four brand retail prescription drug copayments Four brand mail order prescription drug copayments Surgery - Inpatient One PCP visit Eight specialist/physical therapy office visits One emergency room copayment One inpatient copayment Six generic retail prescription drug copayments Six brand retail prescription drug copayments

City of Somerville 8/10/2011 Current BCBS Medex Subscriber Chooses Unicare Indemnity Plan 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 Medex Unicare Indemnity Accident Cancer Depression Surgery Accident Cancer Depression Surgery I/P Additional Additional Additional Additional Costs Costs Costs Costs Office Visits $0 $35 deductible 25 37 19 9 $35 $35 $185 $35 Emergency Room $0 $25 0 2 0 1 $0 $50 $0 $25 Inpatient Hospitalization $0 $50/One per Qtr 1 3 0 1 $50 $150 $0 $50 Retail Prescription Drugs (30-Day Supply) $50 deductible Generics $0 $10 0 0 12 6 $0 $0 $70 $10 Brand-Name 20% $25 12 24 24 6 $22 $94 $144 $36 Non-Preferred 20% $50 0 12 0 0 $0 $180 $0 $0 Generics $2 $20 4 0 0 0 $72 $0 $0 $0 Brand-Name $15 $50 0 4 4 0 $0 $140 $140 $0 Non-Preferred $15 $110 0 2 0 0 $0 $190 $0 $0 Total Additional Out of Pocket Costs $179 $839 $539 $156 Note: Mitigation dollars not included. Average Brand and Non Preferred Medex Copays $19 and $35 Medicare plans subject to Medicare payment/coverage rules