We use the case of Susan, who is 55 years old. She purchases the Sharp Silver 70 HMO Performance plan in 2020. All her cost-sharing payments (deductible, co-pays, coinsurance) count towards the out-of-pocket maximum. Note that the superscript ⁷ specifies when the deductible applies. If there is no superscript ⁷, assume that the deductible does not apply. To help you familiarize yourself with the plan, answer the following questions:

What is the medical deductible for an individual with this policy? _________

What is the pharmacy deductible for an individual with this policy? _________ (0.25 point for both questions)

What is the out-of-pocket maximum for an individual with this policy? ___________ (0.25 point)

To obtain Susans premium for 2020, use the Covered California website (https://www.coveredca.com/) as we did in the activity. Use the following information on the website:

• Year: 2020 BE CAREFUL! The website will give you the year 2021 first. You have to change the year to 2020 with the dropdown menu.
• Zip code: 92101
• Household income: $80,000
• People in household: 1
• Age: 55
• You do not need to enter information for Doctor, use of medical services, and use of prescription drugs. Click on NEXT and VIEW PLANS.
• For the results, BE CAREFUL! Sharp has two Silver plans, the Silver 70 HMO Premier plan and the Silver 70 HMO Performance plan. Use the PERFORMANCE plan.

According to the Covered California website, what is the monthly premium for Susan with the Sharp Silver 70 HMO Performance plan? _________ (1 point)

Summary of Benefits Covered California Sharp Silver 70 Performance HMO Covered Benefits cont. Copayments Maternity Care Prenatal and postpartum office visits SO 47 Delivery and all inpatient services - Hospital 20% coinsurance Delivery and all inpatient services - Professional 20% coinsurance Breastfeeding support, supplies and counseling $0 Family Planning Services Injectable contraceptives (including but not limited to Depo Provera) $0 Voluntary sterilization - women $0 Voluntary sterilization - men variable Interruption of pregnancy variable Durable Medical Equipment and Other Supplies Durable medical equipment 20% coinsurance Diabetic supplies 20% coinsurance Prosthetics and orthotics 20% coinsurance Mental Health Services Diagnosis and treatment of Severe Mental Illnesses for all members and Serious Emotional Disturbances for children, and any mental health condition identified as a "mental disorder" in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM IV), are covered with the cost-sharing listed below. Office visits $40 / visit Group therapy $40 / visit Other outpatient items and services 20% coinsurance up to $40 / visit Inpatient facility fee 20% coinsurance Inpatient physician fee 20% coinsurance Emergency services facility fee (waived if admitted) $400 / visit Emergency services physician fee (waived if admitted) $0 Emergency psychiatric transportation $250 Non-emergency psychiatric transportation $250 Urgent care services $40 / visit Chemical Dependency Services Office visits $40 / visit Group therapy $40 / visit Other outpatient items and services 20% coinsurance up to $40 / visit Inpatient facility fee 20% coinsurance Inpatient physician fee 20% coinsurance Emergency services facility fee for acute alcohol or drug detoxification (waived if admitted) $400 / visit Emergency services physician fee for acute alcohol or drug detoxification (waived if admitted) $0 Emergency substance use disorder transportation $250 Non-emergency substance use disorder transportation $250 Urgent care services $40 / visit Skilled Nursing, Home Health and Hospice Services Skilled nursing facility services (maximum of 100 days per benefit period) 20% coinsurance Home health services (cost share per visit - maximum of 100 visits per calendar year) $45 / visit Hospice care - inpatient $0 Hospice care - outpatient $0 Pediatric Vision Services Eye Exam $0 1 pair / year Glasses or contact lenses in lieu of glasses covered in full Pediatric Dental Services Sharp Health Plan's pediatric dental benefits are provided by Access Dental. Please refer to the Access Dental schedule of benefits for applicable cost- sharing information. 47 Summary of Benefits $0 Covered California Sharp Silver 70 Performance HMO THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. PLEASE CONTACT YOUR EMPLOYER FOR SPECIFIC INFORMATION ON YOUR COVERAGE OR VISIT WWW.SHARPHEALTHPLAN.COM TO VIEW THE MEMBER HANDBOOK Covered Benefits Copayments Annual Deductible for Specific Services Calendar year medical deductible (per individual/per family) - applies only to those covered benefits indicated $4,000 / $8,000 Calendar year pharmacy deductible (per individual/per family) - applies to Tier 1, Tier 2, Tier 3, and Tier 4 $300 / $600 Calendar year dental deductible (per individual/per family) $0 / $0 Annual Out of Pocket Maximum Annual out of pocket maximum (per individual/per family) $7,800 / $15,600 Lifetime Maximum There are no lifetime maximums for this plan Unlimited Preventive Care Well-baby and well-child (to age 18) physical exams, immunizations and related laboratory services Routine adult physical exams, immunizations and related laboratory services $0 Laboratory, radiology and other services for the early detection of disease when ordered by a Physician $0 Routine gynecological exams, immunizations and related laboratory services $0 Mammography $0 Prostate cancer screening $0 Colorectal cancer screenings including sigmoidoscopy and colonoscopy $0 Best Health Wellness Services On-line health education and wellness workshops and other wellness tools $0 Telephonic health coaching (weight management, tobacco cessation, stress management, physical activity, nutrition) $0 Professional Services Primary Care Physician office visit for consultation, treatment, diagnostic testing, etc. $40 / visit Specialist Physician office visit for consultation, treatment, diagnostic testing, etc. $80 / visit Other Practitioner office visit, including acupuncture $40 / visit Laboratory tests and services $40 / visit Radiology services (x-rays and diagnostic imaging) $85 / visit Advanced radiology (including but not limited to CT/PET scan, MRI, MRA, MRS, MUGA, SPECT) $325 / procedure Allergy testing $80 / visit Allergy injections $80 / visit Outpatient Services (including but not limited to surgical, diagnostic and therapeutic services) Outpatient surgery facility fee 20% coinsurance Physician/Surgeon fees 20% coinsurance Outpatient visit 20% coinsurance Infusion therapy (including but not limited to chemotherapy) 20% coinsurance Dialysis 20% coinsurance Rehabilitation services: physical, occupational and speech therapy $40 / visit Habilitation services $40 / visit Radiation therapy 20% coinsurance Hospitalization (including but not limited to inpatient services, organ transplant, and inpatient rehabilitation) Facility fee 20% coinsurance Physician/surgeon fee 20% coinsurance Emergency and Urgent Care Services Emergency room facility fee (waived if admitted to the hospital) $400 / visit Emergency room physician fee (waived if admitted to the hospital) $0 Urgent care services $40 / visit Medical Transportation Emergency medical transportation $250 Non-emergency medical transportation $250 Summary of Benefits Covered California Sharp Silver 70 Performance HMO Copayments $16'/ $32 $60 / $120 Covered Benefits cont. Prescription Drug Coverage Tier 1: Most generic drugs and low cost preferred brands (30 day supply/90 day supply). Tier 2: Non-preferred generic drugs, Preferred brand name drugs, and any other drugs recommended by the plan's pharmaceutical and therapeutics (P&T) committee based on safety, efficacy and cost (30 day supply/90 day supply). Tier 3: Non-preferred brand name drugs, drugs that are recommended by P&T committee based on safety, efficacy and cost, or drugs that generally have a preferred and often less costly therapeutic alternative at a lower tier (30 day supply/90 day supply). Tier 4: Drugs that are biologics, drugs that the Food and Drug Administration (FDA) or drug manufacturer requires to be distributed through specialty pharmacies, drugs that require the enrollee to have special training or clinical monitoring; or drugs that cost the health plan (net of rebates) more than six hundred dollars ($600) net of rebates (30 day supply). Preventive prescription drugs including Preferred Generic and prescribed over-the-counter contraceptives $90 / $180 20% coinsurance (Up to $250 per 30-day supply after pharmacy deductible $0 Notes 'In a family plan, an individual is responsible only for the single out-of-pocket deductible and a single out-of-pocket maximum amount. Cost sharing payments (deductibles, copayments and coinsurance, but not premiums) made by each individual in a family contribute to the family deductible and out-of- pocket maximums. The family deductible may be satisfied by any combination of individual deductible payments, after which member copays or coinsurance apply until the family out of pocket maximum is reached. Once the family out-of-pocket maximum is reached, the plan pays all costs for covered services for all family members. Cost sharing payments for all in-network services accumulate toward the deductible, if deductible applies to that service, and the out-of- pocket maximum. Includes preventive services with a rating of A or B from the US Preventive Services Task Force; immunizations for children, adolescents and adults recommended by the Centers of Disease Control; and preventive care and screenings supported by the Health Resources and Services Administration for infants, children, adolescents and women. If preventive care is received at the time of other services, the applicable copayment for such services other than preventive care may apply. SUOther Practitioner Office Visits" includes: Therapy visits, office visits not provided by Primary Care Physicians or Specialty Physicians, and office visits not specified in another benefit category. *Of contracted rates Out of pocket cost is based on type and location of services (e.g. outpatient surgery cost-share for outpatient surgery or specialist office visit cost-share for a service received during a specialist office visit). Severe Mental Illnesses include: schizophrenia, schizoaffective disorder, bi-polar disorder (manic depressive illness), major depressive disorders, panic disorder, obsessive-compulsive disorder, pervasive developmental disorder or autism, anorexia nervosa and bulimia nervosa. A child with Serious Emotional Disturbances is as defined in the current Member Handbook. Other mental health conditions include conditions identified as "mental disorders" in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM IV). Deductible applies *Member cost-share will not exceed $250 per individual prescription of up to a 30-day supply of a covered oral anti-cancer drug. 90-day supply cost share applies to maintenance medications filled by mail order only. Note: Cost sharing for services with copayments is the lesser of the copayment amount or allowed amount the maximum amount on which payment is based for covered health care services). Note: For Mental Health Services, Office Visits cost-share applies to outpatient office visits, psychological testing, and outpatient monitoring of drug therapy. "Group Therapy" cost-share applies to group mental health evaluation and treatment and group therapy sessions. "Other Outpatient Items and Services cost-share applies to short-term multidisciplinary treatment in an intensive outpatient psychiatric treatment program, partial hospitalization, and home-based behavioral health treatment for pervasive developmental disorder or autism. "Inpatient" cost-share applies to inpatient facility and physician services, mental health psychiatric observation and mental health crisis residential treatment. Note: For "Chemical Dependency Services", "Office Visits" cost-share applies to outpatient office visits, medication treatment for withdrawal, and individual evaluation. "Group Therapy" cost-share applies to substance use disorder group evaluation and group therapy sessions. "Other Outpatient Items and Services" cost-share applies to day treatment programs, intensive outpatient programs, and partial hospitalization. "Inpatient" cost-share applies to the inpatient facility and physician services and substance use disorder transitional residential recovery services in a non-medical residential setting. Summary of Benefits Covered California Sharp Silver 70 Performance HMO Covered Benefits cont. Copayments Maternity Care Prenatal and postpartum office visits SO 47 Delivery and all inpatient services - Hospital 20% coinsurance Delivery and all inpatient services - Professional 20% coinsurance Breastfeeding support, supplies and counseling $0 Family Planning Services Injectable contraceptives (including but not limited to Depo Provera) $0 Voluntary sterilization - women $0 Voluntary sterilization - men variable Interruption of pregnancy variable Durable Medical Equipment and Other Supplies Durable medical equipment 20% coinsurance Diabetic supplies 20% coinsurance Prosthetics and orthotics 20% coinsurance Mental Health Services Diagnosis and treatment of Severe Mental Illnesses for all members and Serious Emotional Disturbances for children, and any mental health condition identified as a "mental disorder" in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM IV), are covered with the cost-sharing listed below. Office visits $40 / visit Group therapy $40 / visit Other outpatient items and services 20% coinsurance up to $40 / visit Inpatient facility fee 20% coinsurance Inpatient physician fee 20% coinsurance Emergency services facility fee (waived if admitted) $400 / visit Emergency services physician fee (waived if admitted) $0 Emergency psychiatric transportation $250 Non-emergency psychiatric transportation $250 Urgent care services $40 / visit Chemical Dependency Services Office visits $40 / visit Group therapy $40 / visit Other outpatient items and services 20% coinsurance up to $40 / visit Inpatient facility fee 20% coinsurance Inpatient physician fee 20% coinsurance Emergency services facility fee for acute alcohol or drug detoxification (waived if admitted) $400 / visit Emergency services physician fee for acute alcohol or drug detoxification (waived if admitted) $0 Emergency substance use disorder transportation $250 Non-emergency substance use disorder transportation $250 Urgent care services $40 / visit Skilled Nursing, Home Health and Hospice Services Skilled nursing facility services (maximum of 100 days per benefit period) 20% coinsurance Home health services (cost share per visit - maximum of 100 visits per calendar year) $45 / visit Hospice care - inpatient $0 Hospice care - outpatient $0 Pediatric Vision Services Eye Exam $0 1 pair / year Glasses or contact lenses in lieu of glasses covered in full Pediatric Dental Services Sharp Health Plan's pediatric dental benefits are provided by Access Dental. Please refer to the Access Dental schedule of benefits for applicable cost- sharing information. 47 Summary of Benefits $0 Covered California Sharp Silver 70 Performance HMO THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. PLEASE CONTACT YOUR EMPLOYER FOR SPECIFIC INFORMATION ON YOUR COVERAGE OR VISIT WWW.SHARPHEALTHPLAN.COM TO VIEW THE MEMBER HANDBOOK Covered Benefits Copayments Annual Deductible for Specific Services Calendar year medical deductible (per individual/per family) - applies only to those covered benefits indicated $4,000 / $8,000 Calendar year pharmacy deductible (per individual/per family) - applies to Tier 1, Tier 2, Tier 3, and Tier 4 $300 / $600 Calendar year dental deductible (per individual/per family) $0 / $0 Annual Out of Pocket Maximum Annual out of pocket maximum (per individual/per family) $7,800 / $15,600 Lifetime Maximum There are no lifetime maximums for this plan Unlimited Preventive Care Well-baby and well-child (to age 18) physical exams, immunizations and related laboratory services Routine adult physical exams, immunizations and related laboratory services $0 Laboratory, radiology and other services for the early detection of disease when ordered by a Physician $0 Routine gynecological exams, immunizations and related laboratory services $0 Mammography $0 Prostate cancer screening $0 Colorectal cancer screenings including sigmoidoscopy and colonoscopy $0 Best Health Wellness Services On-line health education and wellness workshops and other wellness tools $0 Telephonic health coaching (weight management, tobacco cessation, stress management, physical activity, nutrition) $0 Professional Services Primary Care Physician office visit for consultation, treatment, diagnostic testing, etc. $40 / visit Specialist Physician office visit for consultation, treatment, diagnostic testing, etc. $80 / visit Other Practitioner office visit, including acupuncture $40 / visit Laboratory tests and services $40 / visit Radiology services (x-rays and diagnostic imaging) $85 / visit Advanced radiology (including but not limited to CT/PET scan, MRI, MRA, MRS, MUGA, SPECT) $325 / procedure Allergy testing $80 / visit Allergy injections $80 / visit Outpatient Services (including but not limited to surgical, diagnostic and therapeutic services) Outpatient surgery facility fee 20% coinsurance Physician/Surgeon fees 20% coinsurance Outpatient visit 20% coinsurance Infusion therapy (including but not limited to chemotherapy) 20% coinsurance Dialysis 20% coinsurance Rehabilitation services: physical, occupational and speech therapy $40 / visit Habilitation services $40 / visit Radiation therapy 20% coinsurance Hospitalization (including but not limited to inpatient services, organ transplant, and inpatient rehabilitation) Facility fee 20% coinsurance Physician/surgeon fee 20% coinsurance Emergency and Urgent Care Services Emergency room facility fee (waived if admitted to the hospital) $400 / visit Emergency room physician fee (waived if admitted to the hospital) $0 Urgent care services $40 / visit Medical Transportation Emergency medical transportation $250 Non-emergency medical transportation $250 Summary of Benefits Covered California Sharp Silver 70 Performance HMO Copayments $16'/ $32 $60 / $120 Covered Benefits cont. Prescription Drug Coverage Tier 1: Most generic drugs and low cost preferred brands (30 day supply/90 day supply). Tier 2: Non-preferred generic drugs, Preferred brand name drugs, and any other drugs recommended by the plan's pharmaceutical and therapeutics (P&T) committee based on safety, efficacy and cost (30 day supply/90 day supply). Tier 3: Non-preferred brand name drugs, drugs that are recommended by P&T committee based on safety, efficacy and cost, or drugs that generally have a preferred and often less costly therapeutic alternative at a lower tier (30 day supply/90 day supply). Tier 4: Drugs that are biologics, drugs that the Food and Drug Administration (FDA) or drug manufacturer requires to be distributed through specialty pharmacies, drugs that require the enrollee to have special training or clinical monitoring; or drugs that cost the health plan (net of rebates) more than six hundred dollars ($600) net of rebates (30 day supply). Preventive prescription drugs including Preferred Generic and prescribed over-the-counter contraceptives $90 / $180 20% coinsurance (Up to $250 per 30-day supply after pharmacy deductible $0 Notes 'In a family plan, an individual is responsible only for the single out-of-pocket deductible and a single out-of-pocket maximum amount. Cost sharing payments (deductibles, copayments and coinsurance, but not premiums) made by each individual in a family contribute to the family deductible and out-of- pocket maximums. The family deductible may be satisfied by any combination of individual deductible payments, after which member copays or coinsurance apply until the family out of pocket maximum is reached. Once the family out-of-pocket maximum is reached, the plan pays all costs for covered services for all family members. Cost sharing payments for all in-network services accumulate toward the deductible, if deductible applies to that service, and the out-of- pocket maximum. Includes preventive services with a rating of A or B from the US Preventive Services Task Force; immunizations for children, adolescents and adults recommended by the Centers of Disease Control; and preventive care and screenings supported by the Health Resources and Services Administration for infants, children, adolescents and women. If preventive care is received at the time of other services, the applicable copayment for such services other than preventive care may apply. SUOther Practitioner Office Visits" includes: Therapy visits, office visits not provided by Primary Care Physicians or Specialty Physicians, and office visits not specified in another benefit category. *Of contracted rates Out of pocket cost is based on type and location of services (e.g. outpatient surgery cost-share for outpatient surgery or specialist office visit cost-share for a service received during a specialist office visit). Severe Mental Illnesses include: schizophrenia, schizoaffective disorder, bi-polar disorder (manic depressive illness), major depressive disorders, panic disorder, obsessive-compulsive disorder, pervasive developmental disorder or autism, anorexia nervosa and bulimia nervosa. A child with Serious Emotional Disturbances is as defined in the current Member Handbook. Other mental health conditions include conditions identified as "mental disorders" in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM IV). Deductible applies *Member cost-share will not exceed $250 per individual prescription of up to a 30-day supply of a covered oral anti-cancer drug. 90-day supply cost share applies to maintenance medications filled by mail order only. Note: Cost sharing for services with copayments is the lesser of the copayment amount or allowed amount the maximum amount on which payment is based for covered health care services). Note: For Mental Health Services, Office Visits cost-share applies to outpatient office visits, psychological testing, and outpatient monitoring of drug therapy. "Group Therapy" cost-share applies to group mental health evaluation and treatment and group therapy sessions. "Other Outpatient Items and Services cost-share applies to short-term multidisciplinary treatment in an intensive outpatient psychiatric treatment program, partial hospitalization, and home-based behavioral health treatment for pervasive developmental disorder or autism. "Inpatient" cost-share applies to inpatient facility and physician services, mental health psychiatric observation and mental health crisis residential treatment. Note: For "Chemical Dependency Services", "Office Visits" cost-share applies to outpatient office visits, medication treatment for withdrawal, and individual evaluation. "Group Therapy" cost-share applies to substance use disorder group evaluation and group therapy sessions. "Other Outpatient Items and Services" cost-share applies to day treatment programs, intensive outpatient programs, and partial hospitalization. "Inpatient" cost-share applies to the inpatient facility and physician services and substance use disorder transitional residential recovery services in a non-medical residential setting