Dean Health Plan

With Dean Health Plan, you can find coverage that fits you. We pride ourselves in looking out for our members when they’re sick and when they’re well by offering great reward programs to help you live healthier. Plus, when you have a question or need help, Dean’s support network is local. Whether you call us, visit us online or in person, you’ll be working with someone who knows what you need. And you can rest assured that wherever you are in southern Wisconsin, trusted Dean doctors, hospitals and clinics are right in your neighborhood.

#### Plan Options

| **Copay Plus Plans** give you the flexibility to balance copays against annual out-of-pocket maximums to meet your budget.  
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| **Classic Plans** are designed for those who want their health coverage to be as simple as possible.  
| **Value Copay Plans** build in high deductibles with affordable lower premiums and low out-of-pocket costs.  
| **Health Savings Account (HSA)** eligible plans allow you to begin achieving tax savings and are fully compatible with the HSA of your choice.  
| The **Safety Net Plan** is a catastrophic plan design for individuals under the age of 30 or who meet certain income guidelines.  
  
# Plan Overviews

**Copay Plus & Classic Plan Overview**

**Gold Copay Plus 1500X** | **Silver Copay Plus 2750X** | **Silver Copay Plus 3500X** | **Silver Classic 2500X** | **Silver Classic 3750X**  
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Individual Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. | $1,500 | $2,750 | $3,500 | $2,500 | $3,750  
Individual Out-of-Pocket MaximumAn out-of-pocket maximum is the most you'll have to pay during a policy period (usually a year) for health care services | $3,000 | $7,150 | $7,150 | $7,150 | $6,750  
**Prices before you meet your deductible**  
Primary Care visits | $30 Copay | $30 Copay | $30 Copay | 20% after deductible | 20% after deductible  
Specialist visits | $60 Copay | $60 Copay | $60 Copay | 20% after deductible | 20% after deductible  
CoinsuranceWhat % you pay after your deductible has been met and before your out of pocket max | 20% | 30% | 20% | 20% | 20%  
Preventative Exam* | No Charge  
Urgent Care | $60 Copay | $60 Copay | $60 Copay | 20% after deductible | 20% after deductible  
Emergency Room | $200 Copay before policy deductible & coinsurance  
Outpatient Lab/X-ray | 20% after deductible | 30% after deductible | 20% after deductible | 20% after deductible | 20% after deductible  
Outpatient Surgery | 20% after deductible | 30% after deductible | 20% after deductible | 20% after deductible | 20% after deductible  
Hospitalization | 20% after deductible | 30% after deductible | 20% after deductible | 20% after deductible | 20% after deductible  
  
*Preventive exams are covered in accordance with the recommended preventive services as required by the Patient Protection and Affordable Care Act (PPACA). **Value Copay Plan Overview**

**Gold Value Copay 2650X** | **Silver Value Copay 5000x** | **Bronze Value Copay 7150X**  
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Individual Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. | $2,650 | $5,000 | $7,150  
Individual Out-of-Pocket MaximumAn out-of-pocket maximum is the most you'll have to pay during a policy period (usually a year) for health care services | $2,650 | $7,150 | $7,150  
**Prices before you meet your deductible**  
Primary Care visits | $25 copay for 3 visits then no charge after ded. | $25 copay for 3 visits then 20% coins. after ded. | $25 copay for 3 visits then no charge after ded.  
Specialist visits | No charge after deductible | 20% after deductible | No charge after deductible  
CoinsuranceWhat % you pay after your deductible has been met and before your out of pocket max | 0% | 20% | 0%  
Preventative Exam* | No Charge  
Urgent Care | No charge after deductible | 20% after deductible | No charge after deductible  
Emergency Room |  No charge after deductible | 20% after deductible | No charge after deductible  
Outpatient Lab/X-ray | No charge after deductible | 20% after deductible | No charge after deductible  
Outpatient Surgery | No charge after deductible | 20% after deductible | No charge after deductible  
Hospitalization | No charge after deductible | 20% after deductible | No charge after deductible  
  
*Preventive exams are covered in accordance with the recommended preventive services as required by the Patient Protection and Affordable Care Act (PPACA).

**HSA & Safety Net Plan Overview**

**Silver HSA-E 3000X*** | **Bronze HSA-E 6550X*** | **Catastrophic Safety Net**  
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Individual Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. | $3,000 | $6,550 | $7,150  
Individual Out-of-Pocket MaximumAn out-of-pocket maximum is the most you'll have to pay during a policy period (usually a year) for health care services | $5,000 | $6,550 | $7,150  
**Prices before you meet your deductible**  
Primary Care visits | 20% after deductible | No charge after deductible | $0 copay for 3 visits then no charge after ded.  
Specialist visits | 20% after deductible | No charge after deductible | No charge after deductible  
CoinsuranceWhat % you pay after your deductible has been met and before your out of pocket max | 20% | 0% | 0%  
Preventative Exam** | No Charge  
Urgent Care | 20% after deductible | No charge after deductible | No charge after deductible  
Emergency Room | 20% after deductible | No charge after deductible | No charge after deductible  
Outpatient Lab/X-ray | 20% after deductible | No charge after deductible | No charge after deductible  
Outpatient Surgery | 20% after deductible | No charge after deductible | No charge after deductible  
Hospitalization | 20% after deductible | No charge after deductible | No charge after deductible  
  
*HSA-E 3000X & 6550X plans carry an embedded deductible when purchasing a family plan. These plans also offer the option to choose Dean’s Focus network (Dane, Sauk & Rock counties only) for additional premium savings.

**Preventive exams are covered in accordance with the recommended preventive services as required by the Patient Protection and Affordable Care Act (PPACA).

**Copay Plus 2750X**

**Subsidy Level** | **Standard** | **200-250% FPL** | **150-200% FPL** | **100-150% FPL**  
---|---|---|---|---  
Individual Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. | $2,750 | $2,500 | $400 | $100  
Individual Out-of-Pocket MaximumAn out-of-pocket maximum is the most you'll have to pay during a policy period (usually a year) for health care services | $7,150 | $5,700 | $2,200 | $700  
**Prices before you meet your deductible**  
Primary Care visits | $30 copay | $30 copay | $30 copay | $15 copay  
Specialist visits | $60 copay | $60 copay | $60 copay | $30 copay  
Urgent Care | $60 copay | $60 copay | $60 copay | $60 copay  
Emergency Room | $200 copay before policy deductible & coinsurance  
Outpatient Lab/X-ray | 30% after deductible | 30% after deductible | 10% after deductible | 5% after deductible  
Outpatient Surgery | 30% after deductible | 30% after deductible | 10% after deductible | 5% after deductible  
Hospitalization | 30% after deductible | 30% after deductible | 10% after deductible | 5% after deductible  
**Copay Plus 2750X Prescription Drugs:** Tier 1 Generics: $10 Copay • Tier 2 Preferred Brand: $40 Copay • Tier 3 Non-preferred Brand: 50% Coinsurance • Tier 4 Specialty: 50% Coinurance  
  
**Copay Plus 3500X**

**Subsidy Level** | **Standard** | **200-250% FPL** | **150-200% FPL** | **100-150% FPL**  
---|---|---|---|---  
Individual Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. | $3,500 | $3,000 | $400 | $100  
Individual Out-of-Pocket MaximumAn out-of-pocket maximum is the most you'll have to pay during a policy period (usually a year) for health care services | $7,150 | $5,700 | $2,200 | $700  
**Prices before you meet your deductible**  
Primary Care visits | $30 copay | $30 copay | $30 copay | $15 copay  
Specialist visits | $60 copay | $60 copay | $60 copay | $30 copay  
Urgent Care | $60 copay | $60 copay | $60 copay | $30 copay  
Emergency Room | $200 copay before policy deductible & coinsurance  
Outpatient Lab/X-ray | 20% after deductible | 20% after deductible | 10% after deductible | 5% after deductible  
Outpatient Surgery | 20% after deductible | 20% after deductible | 10% after deductible | 5% after deductible  
Hospitalization | 20% after deductible | 20% after deductible | 10% after deductible | 5% after deductible  
**Copay Plus 3500X Prescription Drugs:** Tier 1 Generics: $10 Copay • Tier 2 Preferred Brand: $40 Copay • Tier 3 Non-preferred Brand: 50% Coinsurance • Tier 4 Specialty: 50% Coinurance  
  
**Classic 2500X**

**Subsidy Level** | **Standard** | **200-250% FPL** | **150-200% FPL** | **100-150% FPL**  
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**The Basics**  
Individual Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim.* | $2,500 | $2,000 | $500 | $100  
Individual Out-of-Pocket MaximumAn out-of-pocket maximum is the most you'll have to pay during a policy period (usually a year) for health care services* | $7,150 | $5,500 | $2,000 | $750  
**Prices before you meet your deductible**  
Primary Care visits | 20% after deductible | 20% after deductible | 10% after deductible | 5% after deductible  
Specialist visits | 20% after deductible | 20% after deductible | 10% after deductible | 5% after deductible  
Urgent Care | 20% after deductible | 10% after deductible | 5% after deductible | 5% after deductible  
Emergency Room | $200 copay before policy deductible & coinsurance  
Outpatient Lab/X-ray | 20% after deductible | 20% after deductible | 10% after deductible | 5% after deductible  
Outpatient Surgery | 20% after deductible | 20% after deductible | 10% after deductible | 5% after deductible  
Hospitalization | 20% after deductible | 20% after deductible | 10% after deductible | 5% after deductible  
**Classic 2500X Prescription Drugs:** Tier 1 Generics: $10 Copay • Tier 2 Preferred Brand: $40 Copay • Tier 3 Non-preferred Brand: 50% Coinsurance • Tier 4 Specialty: 50% Coinurance  
  
**Classic 3750X**

**Subsidy Level** | **Standard** | **200-250% FPL** | **150-200% FPL** | **100-150% FPL**  
---|---|---|---|---  
Individual Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim.* | $3,750 | $3,450 | $800 | $250  
Individual Out-of-Pocket MaximumAn out-of-pocket maximum is the most you'll have to pay during a policy period (usually a year) for health care services* | $6,750 | $5,000 | $2,350 | $1,000  
**Prices before you meet your deductible**  
Primary Care visits | 20% after deductible | 10% after deductible | 5% after deductible | 5% after deductible  
Specialist visits | 20% after deductible | 10% after deductible | 5% after deductible | 5% after deductible  
Urgent Care | 20% after deductible | 10% after deductible | 5% after deductible | 5% after deductible  
Emergency Room | $200 copay before policy deductible & coinsurance  
Outpatient Lab/X-ray | 20% after deductible | 10% after deductible | 5% after deductible | 5% after deductible  
Outpatient Surgery | 20% after deductible | 10% after deductible | 5% after deductible | 5% after deductible  
Hospitalization | 20% after deductible | 10% after deductible | 5% after deductible | 5% after deductible  
**Classic 3750X Prescription Drugs:** Tier 1 Generics: $10 Copay • Tier 2 Preferred Brand: $40 Copay • Tier 3 Non-preferred Brand: 50% Coinsurance • Tier 4 Specialty: 50% Coinurance  
  
**Value Copay 5000X**

**Subsidy Level** | **Standard** | **200-250% FPL** | **150-200% FPL** | **100-150% FPL**  
---|---|---|---|---  
Individual Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim.* | $5,000 | $3,250 | $850 | $125  
Individual Out-of-Pocket MaximumAn out-of-pocket maximum is the most you'll have to pay during a policy period (usually a year) for health care services* | $7,150 | $5,700 | $2,100 | $1,000  
**Prices before you meet your deductible**  
Primary Care visits | $25 copay for 3 visits then 20% coins. after ded. | $25 copay for 3 visits then 20% coins. after ded. | $25 copay for 3 visits then 5% coins. after ded. | $25 copay for 3 visits then 5% coins. after ded.  
Specialist visits | 20% after deductible | 20% after deductible | 5% after deductible | 5% after deductible  
Urgent Care | 20% after deductible | 20% after deductible | 5% after deductible | 5% after deductible  
Emergency Room | $200 copay before policy deductible & coinsurance  
Outpatient Lab/X-ray | 20% after deductible | 20% after deductible | 5% after deductible | 5% after deductible  
Outpatient Surgery | 20% after deductible | 20% after deductible | 5% after deductible | 5% after deductible  
Hospitalization | 20% after deductible | 20% after deductible | 5% after deductible | 5% after deductible  
**Value Copay 5000X Prescription Drugs:** Tier 1 Generics: $10 Copay • Tier 2 Preferred Brand: $40 Copay • Tier 3 Non-preferred Brand: 50% Coinsurance • Tier 4 Specialty: 50% Coinurance  
  
**HSA-E 3000X**

**Subsidy Level** | **Standard** | **200-250% FPL** | **150-200% FPL** | **100-150% FPL**  
---|---|---|---|---  
Individual Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. | $3,000 | $2,000 | $1,000 | $300  
Individual Out-of-Pocket MaximumAn out-of-pocket maximum is the most you'll have to pay during a policy period (usually a year) for health care services | $5,000 | $5,000 | $2,350 | $1,250  
**Prices before you meet your deductible** | 20% after deductible  
Primary Care visits | 20% after deductible  
Specialist visits | 20% after deductible  
Urgent Care | 20% after deductible  
Emergency Room | 20% after deductible  
Outpatient Lab/X-ray | 20% after deductible  
Outpatient Surgery | 20% after deductible  
Hospitalization | 20% after deductible  
**HSA-E 3000X Prescription Drugs:** Policy coinsurance after deductible  
  
*Special Note: These plan options (100-200% FPL) do not meet the IRS qualifications for Health Savings Account (HSA) eligibility.