#5. Active Non Medicare Scenarios 8-10 Specific HR — File 191787

City of Somerville Medical Scenario Out of Pocket Costs Maternity One PCP visit, then prenatal office visits are covered at 100% after deductible (15 OB/GYN visits) One inpatient admission at a Tier 2 hospital Three hi tech Imaging copayments Nine generic retail prescription drug copayments Three brand name retail prescription drug copayments Maternity - Miscarriage One PCP visit, then prenatal office visits are covered at 100% after deductible (15 OB/GYN visits) One inpatient admission at a Tier 2 hospital Three hi tech Imaging copayments Nine generic retail prescription drug copayments Three brand name retail prescription drug copayments Accident One PCP visit Twenty four specialist and/or physical therapy office visits One inpatient copayment at a Tier 2 hospital (assumed entered ER, but admitted) One outpatient follow up surgery copayment Six hi tech imaging copayments 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 at a Tier 2 hospital One outpatient surgery copayment Ten tech imaging copayments Twenty four brand retail prescription drug copayments Twelve brand non formulary retail prescription drug copayments Three 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 Handicap Dependent Surgery - Inpatient One PCP visit Eight specialist/physical therapy office visits One emergency room copayment One inpatient copayment at a Tier 2 hospital Four tech imaging copayments Six generic retail prescription drug copayments Six brand retail prescription drug copayments Epilepsy One PCP visit Six specialist office visits at Tier 2 Two scans per year (MRI) Three bloodtests per year Twelve Tier 1 RX per year Twelve Tier 3 RX per year Three Emergeny Room visits Diabetic - Type 2 One PCP Visit 9 specialist office visits at Tier 3 Annual Eye Exam Two emergency room copayments 48 One MRI Four bloodtests per year Three general retail prescription drug copayments per month Three brand retail prescription drug copayments per month

City of Somerville 8/10/2011 Current BCBS HMO Subscriber Chooses Harvard Pilgrim PPO 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 GIC HMO Harvard Pilgrim Maternity Accident Cancer Depression Surgery Epilepsy Diabetic Maternity Accident Cancer Depression Surgery Epilepsy Diabetic Current Independence I/P Additional Additional Additional Additional Additional Plan Design Element Benefit PPO Costs Costs Costs Costs Costs Calendar Year Deductible None $250 1 1 1 1 1 1 1 $250 $250 $250 $750 $250 $250 $250 Physician Office Visits $5 $20 16 1 1 1 1 1 1 $15 $15 $15 $15 $15 $20 $20 Specialist Office Visits $5 $20/$35/$45 0 24 36 18 8 6 10 $0 $720 $1,080 $540 $240 $210 $450 Emergency Room Visits $25 $100 0 0 2 0 1 3 2 $0 $0 $150 $0 $75 $300 $200 I/P $0 $250/$500/$750 1 1 3 0 1 0 0 $500 $500 $1,500 $0 $500 $0 $0 O/P $0 $150 0 1 1 0 0 1 0 $0 $150 $150 $0 $0 $150 $0 Hi-Tech Imaging $0 $100 3 6 10 0 4 2 1 $300 $600 $1,000 $0 $400 $200 $100 Prescription Drugs-Retail Tier I $5 $10 9 0 0 12 6 12 36 $45 $0 $0 $60 $30 $120 $360 Tier II $10 $25 3 12 24 24 6 12 24 $45 $180 $360 $360 $90 $300 $600 Tier III $10 $50 0 0 12 0 0 0 0 $0 $0 $480 $0 $0 $0 $0 Prescription Drugs-Mail Tier I $5 $20 0 4 0 0 0 0 0 $0 $60 $0 $0 $0 $0 $0 Tier II $10 $50 0 0 4 4 0 0 0 $0 $0 $160 $160 $0 $0 $0 Tier III $10 $110 0 0 2 0 0 0 0 $0 $0 $200 $0 $0 $0 $0 Total Additional Out of Pocket Costs $1,155 $2,475 $5,345 $1,885 $1,600 $1,550 $1,600 Note: Amounts don't include mitigation amounts; Tier 2 assumed when providers are tiered.