Paychex Health & Benefit Services

Annual Enrollment Benefits at a Glance

Rates as of 01/01/2017

BCFL BCFL BCFL BCFL

BLUE CARE 61 BLUE OPTS 05771 BLUE CARE 59 BLUE OPTS 05773
Deductible: $1,250/$3,750 Deductible: $1,500/$4,500 Deductible: $750/$2,250 Deductible: $2,500/$7,500
Out of Pocket Max: $3,000/$9,000 Out of Pocket Max: $3,000/$9,000 Out of Pocket Max: $1,800/$5,400 Out of Pocket Max: $2,500/$7,500
Lifetime Max: Lifetime Max: Lifetime Max: Lifetime Max:
Primary Physician: $30 Primary Physician: $30 Primary Physician: $20 Primary Physician: $40
Specialist: $55 Specialist: $55 Specialist: $45 Specialist: $60
Hospitalization: 20% AD Hospitalization: 20% AD Hospitalization: 10% AD Hospitalization: 0% AD
Out Patient Surgery: 20% AD Out Patient Surgery: 20% AD Out Patient Surgery: 10% AD Out Patient Surgery: 0% AD
Emergency Room: $250 Emergency Room: $250 Emergency Room: $250 Emergency Room: $100
Rx: $20/40/70 20% to $250 max Rx: $20/40/70 20% to $250 max Rx: $15/35/50 20% to $250 max Rx: $15/35/50 20% to $250 max
Referral Required: N Referral Required: N Referral Required: N Referral Required: N
Out of Network Out of Network Out of Network Out of Network
Deductible: N/A Deductible: $2,000/$6,000 Deductible: N/A Deductible: $6,000/$18,000
Out of Pocket Max: N/A Out of Pocket Max: $6,000/$18,000 Out of Pocket Max: N/A Out of Pocket Max: $12,000/$36,000
Co-Insurance: N/A Co-Insurance: 40% AD Co-Insurance: N/A Co-Insurance: 30% AD
Hospitalization: Hospitalization: Hospitalization: Hospitalization:

067259 BCFL HMO 61 FL- SFL 067261 BCFL PPO BLUE OP 05771 -SFL 067269 BCFL HMO 59 FL -SFL 067272 BCFL PPO BLUE OP 05773 -SFL
Employee 194.26 Employee 221.32 Employee 217.38 Employee 220.68
Employee+Child(ren) 385.62 Employee+Child(ren) 439.76 Employee+Child(ren) 431.84 Employee+Child(ren) 438.46
EE+Spouse/Domestic Partner 423.88 EE+Spouse/Domestic Partner 483.44 EE+Spouse/Domestic Partner 474.74 EE+Spouse/Domestic Partner 482.00
Family 596.12 Family 680.02 Family 667.78 Family 678.02

Page: 1 Additional plan information is available at http://www.paychexflex.com. Print Date: 11/19/2016

 Paychex Health & Benefit Services
Annual Enrollment Benefits at a Glance
Rates as of 01/01/2017

BCFL BCFL BCFL PRU

BLUE OPTS 03769 BLUE CARE 60 BLUE OPTS 03768 FOC
Deductible: $750/$2,250 Deductible: $500/$1,000 Deductible: $250/$750 Deductible: DMO None, PPO$50/$150
Out of Pocket Max: $2,000/$6,000 Out of Pocket Max: $3,500/$7,000 Out of Pocket Max: $3,000/$6,000 Out of Pocket Max: DMO None, FOC $1,000 Ind
Lifetime Max: Lifetime Max: Lifetime Max: Lifetime Max: N/A
Primary Physician: $25 Primary Physician: $25 Primary Physician: $20 Primary Physician: DMO $5 Copay, FOC N/A
Specialist: $45 Specialist: $45 Specialist: $45 Specialist: N/A
Hospitalization: 10% AD Hospitalization: $325 up to $1,625 max Hospitalization: 1: $700, 2: $1,000 Hospitalization: N/A
Out Patient Surgery: 10% AD Out Patient Surgery: $275 Out Patient Surgery: 1: $300, 2: $600 Out Patient Surgery: N/A
Emergency Room: $250 Emergency Room: $100 Emergency Room: $200 Emergency Room: N/A
Rx: $15/35/50 20% to $250 max Rx: $15/35/50 20% to $250 max Rx: $15/35/50 20% to $250 max Rx: N/A
Referral Required: N Referral Required: N Referral Required: N Referral Required: N
Out of Network Out of Network Out of Network Out of Network
Deductible: $2,000/$6,000 Deductible: N/A Deductible: $1,000/$3,000 Deductible: N/A
Out of Pocket Max: $4,000/$12,000 Out of Pocket Max: N/A Out of Pocket Max: $6,000/$12,000 Out of Pocket Max: N/A
Co-Insurance: 30% AD Co-Insurance: N/A Co-Insurance: 50% AD Co-Insurance: N/A
Hospitalization: Hospitalization: Hospitalization: Hospitalization:

067282 BCFL PPO BLUE OP 03769 -SFL 073630 BCFL HMO 60 FL - SFL 073631 BCFL PPO BLUE OP 03768 - SFL FOC001 AETNA FOC DENTAL PLAN
Employee 248.66 Employee 228.10 Employee 268.32 Employee 19.08
Employee+Child(ren) 494.40 Employee+Child(ren) 453.30 Employee+Child(ren) 533.72 Employee+Child(ren) 42.28
EE+Spouse/Domestic Partner 543.54 EE+Spouse/Domestic Partner 498.32 EE+Spouse/Domestic Partner 586.80 EE+Spouse/Domestic Partner 38.14
Family 764.72 Family 701.02 Family 825.68 Family 57.42

Page: 2 Additional plan information is available at http://www.paychexflex.com. Print Date: 11/19/2016

 Paychex Health & Benefit Services
Annual Enrollment Benefits at a Glance
Rates as of 01/01/2017

PRU ECPA ECPA METV

DMO VISION CORE VISION PLUS HIGH
Deductible: None Deductible: N/A Deductible: N/A
Out of Pocket Max: None Out of Pocket Max: N/A Out of Pocket Max: N/A
Lifetime Max: N/A Lifetime Max: N/A Lifetime Max: N/A
Primary Physician: $0 Copay Primary Physician: $0 Copay Primary Physician: $0 Copay
Specialist: N/A Specialist: N/A Specialist: N/A
Hospitalization: N/A Hospitalization: N/A Hospitalization: N/A
Out Patient Surgery: N/A Out Patient Surgery: N/A Out Patient Surgery: N/A
Emergency Room: N/A Emergency Room: N/A Emergency Room: N/A
Rx: N/A Rx: N/A Rx: N/A
Referral Required: N Referral Required: N Referral Required: N
Out of Network Out of Network Out of Network
Deductible: N/A Deductible: N/A Deductible: N/A
Out of Pocket Max: N/A Out of Pocket Max: N/A Out of Pocket Max: N/A
Co-Insurance: N/A Co-Insurance: N/A Co-Insurance: N/A
Hospitalization: Hospitalization: Hospitalization:

PRUDMO AETNA DENTAL DMO SELECT 003043 ECPA VISION CORE 075780 ECPA VISION PLUS VAI001 METV ACCIDENT HI PLAN
Employee 9.16 Employee 2.52 Employee 8.06 Employee 16.00
Employee+Child(ren) 19.28 Employee+Child(ren) 5.00 Employee+Child(ren) 15.98 Employee+Child(ren) 30.52
EE+Spouse/Domestic Partner 16.34 EE+Spouse/Domestic Partner 4.76 EE+Spouse/Domestic Partner 15.20 EE+Spouse/Domestic Partner 24.00
Family 24.96 Family 7.32 Family 23.48 Family 39.36

Page: 3 Additional plan information is available at http://www.paychexflex.com. Print Date: 11/19/2016

 Paychex Health & Benefit Services
Annual Enrollment Benefits at a Glance
Rates as of 01/01/2017

METV METV METV METV

LOW HIGH LOW HIGH

VAI002 METV ACCIDENT LO PLAN VCI001 METV CRITICAL HI PLAN VCI002 METV CRITICAL LO PLAN VHI001 METV HOSPITAL HI PLAN
Employee 8.48 Employee 9.32 Employee 4.68 Employee 30.52
Employee+Child(ren) 16.00 Employee+Child(ren) 21.92 Employee+Child(ren) 10.96 Employee+Child(ren) 61.68
EE+Spouse/Domestic Partner 12.72 EE+Spouse/Domestic Partner 18.60 EE+Spouse/Domestic Partner 9.32 EE+Spouse/Domestic Partner 47.04
Family 20.64 Family 31.20 Family 15.60 Family 78.84

Page: 4 Additional plan information is available at http://www.paychexflex.com. Print Date: 11/19/2016

 Paychex Health & Benefit Services
Annual Enrollment Benefits at a Glance
Rates as of 01/01/2017

METV METV
LOW GENERAL

VHI002 METV HOSPITAL LO PLAN VLG001 MET LAW LEGAL PLAN

Employee 15.20 Employee 16.52
Employee+Child(ren) 30.68
EE+Spouse/Domestic Partner 23.40
Family 38.84

Page: 5 Additional plan information is available at http://www.paychexflex.com. Print Date: 11/19/2016