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2017 Individual Rates

STANDARD PLANS TRADITION PLANS VALUE PLANS Bronze HSA Platinum Gold Silver Bronze Bronze HSA Catastrophic Platinum 30/30 Gold 30/50 Silver 40/60 Platinum 100% Gold 100% Silver 100% Silver 75% 70% IN-NETWORK COST-SHARE

50% 50% 3 Free PCP 30% 2 Free PCP 2 Free PCP 2 Free PCP 2 Free PCP $25 after $30 after coinsurance coinsurance Visits/Covered coinsurance Visits/Covered Visits/Covered Visits/Covered Visits/25% Primary Care $15 $30 $30 $40 deductible deductible after after in full after after in full after in full after in full after coinsurance deductible deductible deductible deductible deductible deductible deductible after deductible

50% 50% 30% 25% Covered in Covered in Covered in Covered in $40 after $50 after coinsurance coinsurance coinsurance coinsurance Specialist $35 full after $30 $50 $60 full after full after full after deductible deductible after after after after deductible deductible deductible deductible deductible deductible deductible deductible

Emergency 50% 50% 30% 25% Covered in Covered in Covered in Covered in Room (waived if $150 after $250 after coinsurance coinsurance coinsurance coinsurance $100 full after $200 $200 $350 full after full after full after admitted within deductible deductible after after after after deductible deductible deductible deductible 24 hours) deductible deductible deductible deductible

$1,000 $1,500 50% 50% 10% 20% 30% 25% Covered in Covered in Covered in Covered in Inpatient Surgery $500 per admit per admit coinsurance coinsurance $500 coinsurance coinsurance coinsurance coinsurance full after full after full after full after Facility Fee per admission after after after after per admission after after after after deductible deductible deductible deductible deductible deductible deductible deductible deductible deductible deductible deductible

50% 50% 10% 30% 25% Outpatient Covered in Covered in Covered in Covered in $100 after $100 after coinsurance coinsurance coinsurance coinsurance coinsurance Surgery Facility $100 full after $200 $350 full after full after full after deductible deductible after after after after after Fee deductible deductible deductible deductible deductible deductible deductible deductible deductible

Deductible (2x for Family) $0 $600 $2,000 $4,000 $5,500 $7,150 $0 $1,000 $4,250 $5,500 $1,200 $2,250 $4,600 $3,000

Coinsurance 10% 20% 30% 50% 50% 0% 10% 10% 20% 30% 0% 0% 0% 25%

Maximum Out-Of-Pocket $2,000 $4,000 $6,750 $7,150 $6,550 $7,150 $1,000 $3,000 $7,150 $6,550 $1,200 $2,250 $4,600 $6,850 (2x for Family)

$15/$35/$75 $0 Generic/ $10/$50/50% $10/$50/50% $0 Generic/ $0 Generic/ $0 Generic/ $10/$35/$70 $10/$35/$70 Covered in after $100 Rx $15/$35/$75 Tier 2 and 3 Prescription coinsurance coinsurance Tier 2 and 3 Tier 2 and 3 Tier 2 and 3 $10/$30/$60 $10/$35/$70 $10/$35/$70 after after full after deductible after 25% coinsurance Drugs (up to max (up to max covered in full covered in full covered in full deductible deductible deductible (deductible waived deductible after deductible $250) $250) after deductible after deductible after deductible for Tier 1) (max $500) 2017 RATES

Single $746 $637 $544 $430 $443 $203 $761 $649 $565 $436 $688 $625 $501 $487

Couple $1,492 $1,274 $1,088 $860 $886 $406 $1,522 $1,298 $1,130 $872 $1,376 $1,250 $1,002 $974

Parent with $1,268 $1,083 $925 $731 $753 $345 $1,294 $1,103 $961 $741 $1,170 $1,063 $852 $828 Child(ren)

Family $2,126 $1,815 $1,550 $1,226 $1,263 $579 $2,169 $1,850 $1,610 $1,243 $1,961 $1,781 $1,428 $1,388

n 855-706-7545 n CareConnect.com North Shore-LIJ CareConnect Insurance Company, Inc. Individual Rates Our Plans: Benefits: The Basics Standard, Tradition and Value Copay: An amount that members are required to pay toward the cost of a covered service (like a doctor’s visit) We offer a variety of plans to fit your clients’ needs and after their deductible has been met. The copay is usually budget. Standard, Tradition or Value—all provide easy expressed as a fixed dollar amount—say, $15 or $25. access to affordable, superior care. Coinsurance: A percent of the bill for a covered service Standard plans have the classic “deductible first” design that members are required to pay after their deductible that your clients will find familiar. In other words, most has been met. After a member pays the coinsurance, of these plans have a deductible that members must meet CareConnect is responsible for the rest of the bill for the before CareConnect starts to pay for covered, medically covered service. necessary health services. After members with the plans Worry-Free Access to meet their deductible, they are responsible only for Deductible: The amount members are responsible for cost-sharing, which can take the form of copays or paying for covered medical expenses each policy period High-Quality Care coinsurance. (Standard Platinum plans are an exception before CareConnect starts paying. The amount of the to this rule. With a zero deductible made possible by deductible depends on the plan the member has selected. We know that budgets can be tight and higher premiums, Platinum plans offer members a way to After the member meets the deductible for a policy period, 2016 spread their medical costs more predictably over the year. we will take care of the bill for covered services, although life can be hectic for your clients. Health Members receiving covered, medically necessary services the member may have to pay a copay or coinsurance. If are responsible only for cost-sharing.) services are not covered by the plan, the member must insurance should make things easier, Tradition plans offer “first dollar” coverage. Members pay those costs out of pocket, and they do not count not more stressful. That’s why all need not meet a deductible before CareConnect will start toward the deductible. covering doctor visits; instead, they are responsible only Maximum Out of Pocket: The maximum amount the CareConnect plans can save your clients for cost-sharing. Members do have to meet a deductible member has to pay toward covered services during a for inpatient or outpatient care and for ambulance policy period, including deductible, copays and time and money­—while giving them easy services; they also have a small, separate deductible for coinsurance for covered services. After the member pays access to top-rated doctors and pharmacy costs. After these deductibles are met, members the Maximum Out Of Pocket (MOOP), CareConnect will are responsible only for cost-sharing. pay 100% of the cost of covered services. Out of pocket throughout the region. Value plans serve the needs of clients looking for simplicity. payments for services not covered by the plan do not New for 2016, this product line is designed to be one of count toward the MOOP. the most affordable in the marketplace. Value plans have a deductible; after it is met, members are responsible only for coinsurance and for some services have no cost-sharing at all. Members are also entitled to two no-cost PCP visits each plan year, in addition to preventive services.

n Broker Services: 855-228-0541 n CareConnect.com CCIndividualGroupRateCardProducerV8 09. 15 North Shore-LIJ CareConnect Insurance Company, Inc. Broker Services: 855-228-0541 n CareConnect.com CareConnect Facilities

Manhattan Hospitals Yale-New Haven

Northern Harlem Westchester Bridgeport Metropolitan Lenox Hill Eye, Ear & Throat Phelps Memorial Lenox Health Greenwich Greenwich Montefiore White Plains Village Medical Bellevue Centers

Peconic Bay Medical Center North Central Bronx Jacobi Huntington Glen Cove

Lincoln Syosset North Shore University Zucker Hillside Plainview Elmhurst LIJ Medical Center Cohen Children’s LIJ Forest Nassau University Hills Medical Center Southside Woodhull Wyckoff Heights South Oaks Kings County LIJ Valley Stream Maimonides University (North) Coney Island

Staten Island University (South) For a searchable list of CareConnect’s providers, visit CareConnect.com/providersearch Hospitals • Center, 462 First Avenue, New York, NY 10016, P: 212-562-4141 • Bridgeport Hospital, 267 Grant St, Bridgeport, CT 06610, P: 203-688-8412 • , 2601 Ocean Parkway, , NY 11235, P: 718 616-3000 • Elmhurst Hospital Center, 79-01 Broadway, Elmhurst, NY, 11373, P: 718-334-4000 • Glen Cove Hospital, 101 St. Andrews Lane, Glen Cove, NY 11542, P: 516-674-7540 • Greenwich Hospital, 5 Perryridge Road, Greenwich, CT 06 830, P: 203-688-8412 • , 506 Lenox Avenue, New York, NY 10037, P: 212-939-1000 • Huntington Hospital, 270 Park Avenue, Huntington, NY 11743, P: 631-351-2000 • , 1400 Pelham Parkway South, Bronx, NY 10461, P: 718-918-5000 • Kings County Hospital Center, 451 Clarkson Avenue, Brooklyn, NY 11203, P: 718-245-3131 • Lenox Health Greenwich Village, 30 Seventh Avenue, New York, NY 10011, P: 646-665-6000 • , 100 East 77th Street, New York, NY 10021, P: 212-434-2000 • Lincoln Medical & Mental Health Center, 234 East 149th Street, Bronx, NY 10451, P: 718-579-5000 • Long Island Jewish Forest Hills, 102-01 66th Road, Forest Hills, NY 11375, P: 718-830-4000 • Long Island Jewish Medical Center, 270-05 76th Avenue, New Hyde Park, NY 11040, P: 718-470-7000 • Long Island Jewish Valley Stream, 900 Franklin Avenue, Valley Stream, NY 11580, P: 516-256-6000 • Maimonides Medical Center, 4802 Tenth Avenue, Brooklyn, NY 11219, P: 718-283-6000 • Manhattan Eye, Ear & Throat Hospital, 210 East 64th Street, New York, NY 10021, P: 212-838-9200 • Metropolitan Hospital Center, 1901 First Avenue, New York, NY 10029, P: 212-423-6262 • Montefiore Medical Center - Westchester Square, 2475 Saint Raymonds Avenue, Bronx, NY 10461, P: 718-430-7300 • Montefiore Medical Center - Montefiore Hospital, 111 East 210th Street, Bronx, NY 10467, P: 718-920-4321 • Montefiore Medical Center - Wakefield Hospital, 600 East 233rd Street, Bronx, NY 10466, P: 718-920-9000 • Montefiore Medical Center - Weiler Hospital, 1825 Eastchester Road, Bronx, NY 10461, P: 718-904-2000 • Montefiore Mt. Vernon Hospital, 12 North Seventh Avenue, Mt. Vernon, NY 10550, P: 914-664-8000 • Montefiore New Rochelle Hospital, 16 Guion Place, New Rochelle, NY 10801, P: 914-632-5000 • Nassau University Medical Center, 2201 Hempstead Turnpike, East Meadow, NY 11554, P: 516-572-0123 • North Central Bronx Hospital, 3424 Kossuth Avenue, Bronx, NY 10467, 718-519-5000 • North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030, P: 516-562-3456 • Northern Westchester Hospital, 400 East Main Street, Mount Kisco, NY 10549-3417, P: 914-666-1200 • Nyack Hospital, 160 North Midland Avenue, Nyack, NY 10960, P: 845-348-2000 • Peconic Bay Medical Center, 1300 Roanoke Ave, Riverhead, NY 11901, P: 631-548-6000 • Phelps Memorial Hospital, 701 North Broadway, Sleepy Hollow, NY 10591, P: 914-366-3000 • Plainview Hospital, 888 Old Country Road, Plainview, NY 11803, P: 516-719-3000 • , 82-70 164th Street, Jamaica, NY 11432, P: 718-883-3000 • South Oaks Hospital, 400 Sunrise Highway, Amityville, NY 11701, P: 631-608-5610 • Southside Hospital, 301 East Main Street, Bay Shore, NY 11706, P: 631-968-3000 CareConnect Facilities

Hospitals (continued) • Staten Island University Hospital (North Site), 475 Seaview Avenue, Staten Island, NY 10305, P: 718-226-2000 • Staten Island University Hospital (South Site), 375 Seguine Avenue, Staten Island, NY 10305, P: 718-226-2000 • Steven & Alexandra Cohen Children’s Medical Center of NY, 269-01 76th Avenue, New Hyde Park, NY 11040, P: 516-470-7000 • Syosset Hospital, 221 Jericho Turnpike, Syosset, NY 11791, P: 516-496-6400 • White Plains Hospital, 41 East Post Road, White Plains, NY 10601, P: 914-681-0600 • Woodhull Medical & Mental Health Center, 760 Broadway, Brooklyn, NY 11206, P: 718-963-8000 • Wyckoff Heights Medical Center, 374 Stockholm Street, Brooklyn, NY 11237, P: 718-963-7272 • Yale-New Haven Hospital, 20 York Street, New Haven, CT 06510, P: 203-688-4242 • , 75-59 263rd Street, Glen Oaks, NY 11004, P: 516-470-7000 Imaging* • Cardiac Imaging of Yorktown, 2013 Crompound Road, Mount Kisco, NY 10549-3417, P: 914-666-1200 • Highway Imaging Associates, 2095 Flatbush Avenue, Suite A3, Brooklyn, NY 11220, P: 718-338-6868 • Medical Arts Radiology, 146 Mannetto Hill Road, Suite 140, Plainview, NY 11803, P:516-822-3600 • Medical Arts Radiology, 214 Wall Street, Huntington, NY 11743, P: 631-427-8860 • Medical Arts Radiology, 23 Technology Drive, East Setauket, NY 11733, P: 631-689-7300 • Medical Arts Radiology, 240 Patchogue Yaphank Rd, Suite 2, Patchogue, NY 11772, P: 631-475-5300 • Medical Arts Radiology, 267 East Main Street, Building A, Smithtown, NY 11787, P: 631-982-1570 • Medical Arts Radiology, 375 East Main Street, Suite 12, Bay Shore, NY 11706, P: 631-665-2261 • Medical Arts Radiology, 4160 Merrick Road, Massapequa, NY 11758, P: 516-979-6700 • Medical Arts Radiology, 500 Montauk Highway, West Islip, NY 11795, P: 631-422-4474 • Medical Arts Radiology, 55 Veterans Highway, Commack, NY 11725, P: 631-462-0525 • Northern Westchester Hospital-Yorktown Imaging, 1940 Commerce Street, Suite 101, Mount Kisco, NY 10549, P: 914-666-1200 • Imaging Center at Garden City, 711 Stewart Avenue, Garden City, NY 11530, P: 516-321-3456 • Northwell Health Imaging Center at Glen Cove, 10 Medical Plaza, Glen Cove, NY 11542, P: 516-674-0500 • Northwell Health Imaging Center at Great Neck, 611 Northern Boulevard, Great Neck, NY 11021, P: 516-233-3456 • Northwell Health Imaging Center at Great Neck, 935 Northern Boulevard, Great Neck, NY 11021, P: 516-233-3456 • Northwell Health Imaging at Great South Bay, 620 Main Street, 1st Floor, Islip, NY 11751, P: 631-439-7237 • Northwell Health Imaging Center at Syosset, 100 Lafayette Drive, Syosset, NY 11791, P: 516-622-3456 • North Shore University Hospital CFAM-Mitchell A. Goldman, MD Diagnostic Imaging Center, 450 Lakeville Road, Lake Success, NY 11042, P: 516-734-8600 • North Shore University Hospital CFAM-The Schlanger, Gottlieb, Partners Council Breast Imaging Center, 450 Lakeville Road, Lake Success, NY 11042, P: 516-734-8600 • Pinnacle Diagnostic Radiology, 848 49th Street Brooklyn, NY 11220, Brooklyn, NY 11220, P: 718-436-2888 • Reichert Family Imaging Center, 284 Pulaski Road, Greenlawn, NY 11740, P: 631-670-3456 • Staten Island University Hospital Center For Breast Imaging, 256 Mason Avenue, Building B, Staten Island, NY 10305, P: 718-226-7700 • Staten Island University Hospital Verrazano Imaging, 256 Mason Avenue, Building A, Staten Island, NY 10305, P: 718-226-7700 • Wyckoff Imaging Services, PC, 374 Stockholm Street, Brooklyn, NY 11237, P: 718-963-7676 Laboratories* • Bridgeport Hospital Blood Draw Station, 267 Grant Street, Bridgeport, CT 06610, P: 203-384-3386 • Bridgeport Hospital Blood Draw Station, 4775 Main Street, Bridgeport, CT 06610, P: 203-373-1351 • Bridgeport Hospital Blood Draw Station, 2600 Post Road, Southport, CT 06890, P: 203-256-5948 • Bridgeport Hospital Blood Draw Station, 3115 Main Street, Stratford, CT 06614, P: 203-375-5490 • Bridgeport Hospital Blood Draw Station, 15 Corporate Drive, Trumbull, CT 06611, P: 203-268-1413 • Bridgeport Hospital Blood Draw Station, 5220 Park Ave, Trumbull, CT 06611, P: 203-373-0201 • Dyker Labs, 1274 74th Street, Brooklyn, NY 11228, P: 718-256-6500 • Montefiore Medical Arts Pavilion, 3400 Bainbridge Ave, Bronx, NY 10467, P: 718-920-7547 • Montefiore Medical Park Lab Services, 1515 Blondell Ave, Bronx, NY 10461, P: 718-405-8250 • Northwell Health Laboratories, 10 Medical Plaza, Suite 104, Glen Cove, NY 11542, P: 516-674-7906 • Northwell Health Laboratories, 10 Nevada Drive, Lake Success, NY 11042, P: 516-719-1000 • Northwell Health Laboratories, 166 Hicksville Road, Bethpage, NY 11714, P: 516-520-2978 • Northwell Health Laboratories, 674 Central Avenue, Cedarhurst, NY 11516, P: 516-881-7448 • Northwell Health Laboratories, 877 Stewart Avenue, Suite 15, Garden City, NY 11530, P: 516-280-3690 • Northwell Health Laboratories, 800 Northern Boulevard, Suite 5, Great Neck, NY 11021, P: 516-869-8462 • Northwell Health Laboratories, 1991 Marcus Avenue, Suite M113, Lake Success, NY 11042, P: 516-442-2838 • Northwell Health Laboratories, 175 Jericho Turnpike, Suite 304, Syosset, NY 11791, P: 516-802-3380 • Northwell Health Laboratories, 180 East Main Street, Bay Shore, NY 11706, P: 631-206-1030 • Northwell Health Laboratories, 195 East Main Street, Huntington, NY 11743, P: 631-683-5410 • Northwell Health Laboratories, 180 East Pulaski Road, West Wing (lower level) Suite B, Huntington Station, NY 11746, P: 631-923-2750 • Northwell Health Laboratories, 1895 Walt Whitman Road, Suite 304, Melville, NY 11747, P: 631-393-2838 • Northwell Health Laboratories, 285 Sills Road, Building 10, Suite B, Patchogue, NY 11772, P: 631-569-2905 • Northwell Health Laboratories, 222 Middle Country Road, Suite 211, Smithtown, NY 11787, P: 631-724-3516 • Northwell Health Laboratories, 23-91 Bell Boulevard, Bayside, NY 11361, P: 718-631-4930 • Northwell Health Laboratories, 95-25 Queens Boulevard, Rego Park, NY 11374, P: 718-925-6530 • Northwell Health Laboratories, 210 East 64th Street, 4th Floor, New York, NY 10065, P: 212-605-3726 CareConnect Facilities

Laboratories* (continued) • Northwell Health Laboratories, 110 East 59th Street, 10th Floor, New York, NY 10022, P: 646-368-1472 • Staten Island University Hospital Laboratory, 17C Seguine Avenue, Staten Island, NY 10309, P: 718-967-6587 • Staten Island University Hospital Laboratory, 2288 Hylan Blvd, Staten Island, NY 10305, P: 718-987-4900 • Staten Island University Hospital Laboratory, 11 Ralph Place, Suite 111A, Staten Island, NY 10304, P: 718-447-3155 • Staten Island University Hospital Laboratory, 584 Forest Avenue, Staten Island, NY 10310, P: 718-226-5632 • Staten Island University Hospital Laboratory, 78 Cromwell Avenue, Staten Island, NY 10305, P: 718-987-1352 • Staten Island University Hospital Laboratory, 501 Seaview Avenue, Staten Island, NY 10305, P: 718-667-4072 • Yale Physicians Building Blood Draw Station, 800 Howard Avenue, New Haven, CT 06510, P: 203-688-8412 • Yonkers Patient Service Center, 6 Executive Plaza, Yonkers, NY 10701, P: 914-375-4861 Urgent Care • CityMD Urgent Care, 336 East 86th Street New York, NY 10028, P: 212-772-3627 • CityMD Urgent Care, 2398 Broadway, New York, NY 10024, P: 212-721-2111 • CityMD Urgent Care, 37 West 23rd Street New York, NY 10010, New York, P: 646-596-9267 • CityMD Urgent Care, 315 West 57th Street New York, NY 10019, New York, P: 212-315-2330 • CityMD Urgent Care, 14 West 14th Street New York, NY 10011, New York, P: 212-390-0558 • CityMD Urgent Care, 561 3rd Avenue New York, NY 10016, New York, P: 212-729-4668 • CityMD Urgent Care, 1150 3rd Avenue New York, NY 10065, New York, P: 212-933-0007 • CityMD Urgent Care, 457 Atlantic Avenue Brooklyn, NY 11217, Kings, P: 718-530-1144 • CityMD Urgent Care, 256 East Route 59 Building A Nanuet, NY 10954, Rockland, P: 888-713-2067 • CityMD Urgent Care, 904 W. Beech Street Long Beach, NY 11561, Nassau, P: 516-272-4353 • CityMD Urgent Care, 292 Herricks Road, Mineola, NY 11501, Nassau, P: 516-746-2273 • CityMD Urgent Care, 31-11 Steinway St. Astoria, NY 11103, Queens, P: 718-475-2345 • CityMD Urgent Care, 1995 Nesconset Highway Lake Grove, NY 11755, Suffolk, P: 631-731-4449 • CityMD Urgent Care, 8712 4th Ave, Brooklyn, NY 11209, Kings, P: 718-530-1155 • CityMD Urgent Care, 1989 Merrick Road Merrick, NY 11566, Nassau, P: 516-584-4448 • CityMD Urgent Care, 4410 Sunrise Highway Massapequa, NY 11758, Nassau, P: 516-998-1024 • CityMD Urgent Care, 70-49 Austin Street Forest Hills, NY 11375, Queens, P: 718-280-1245 • CityMD Urgent Care, 2393 Central Park Ave. Yonkers, NY 10710, Westchester, P: 914-219-0393 • CityMD Urgent Care, 73-02 Roosevelt Avenue Jackson Heights, NY 11372, Queens, P: 718-475-2351 • CityMD Urgent Care, 154 N. 7th Street, Brooklyn, NY 11249, Kings, P: 718-414-2013 • CityMD Urgent Care, 222 Mamaroneck Avenue White Plains, NY 10605, Westchester, P: 914-401-4282 • CityMD Urgent Care, 216 E. 14th Street New York, NY 10003, New York, P: 212-256-1049 • CityMD Urgent Care, 228-230 Court Street Brooklyn, NY 11201, Kings, P: 718-280-5362 • CityMD Urgent Care, 2025 Broadway New York,NY 10023, New York, P: 212-390-8812 • CityMD Urgent Care, 560 Merrick Road Rockville Centre, NY 11570, Nassau, P: 516-858-2373 • CityMD Urgent Care, 2710 Broadway New York, NY 10025, New York, P: 212-658-0676 • CityMD Urgent Care, 193 W 237th Street Bronx, NY 10463, Bronx, P: 718-303-0479 • CityMD Urgent Care, 2187 Richmond Avenue Staten Island, NY 10314, Richmond, P: 646-682-7364 • CityMD Urgent Care, 138 Delancey Street New York, NY 10002, New York, P: 212-609-2541 • CityMD Urgent Care, 1305 Kings Highway Brooklyn, NY 11229, Kings, P: 718-280-5172 • CityMD Urgent Care, 80 West 125th Street New York, NY 10027, New York, P: 212-913-0820 • CityMD Urgent Care, 585 Merrick Road Lynbrook, NY 11563, Nassau, P: 516-764-2273 • CityMD Urgent Care, 3276 Hempstead Turnpike Levittown, NY 11756, Nassau, P: 516-796-2273 • CityMD Urgent Care, 656 N.Wellwood Avenue Lindenhurst, NY 11757, Suffolk, P: 631-225-4227 • CityMD Urgent Care, 74-25 Grand Avenue Maspeth, NY 11373, Queens, P: 718-803-2273 • CityMD Urgent Care, 2459 Merrick Road Bellmore, NY 11710, Nassau, P: 516-826-2273 • CityMD Urgent Care, 418-420 5th Avenue Brooklyn,NY 11215, Kings, P: 718-965-2273 • CityMD Urgent Care, 415 Northern Boulevard Great Neck, NY 11021, Nassau, P: 516-829-2273 • CityMD Urgent Care, 6500 Jericho Turnpike Suite 23A Commack, NY 11725, Suffolk, P: 631-858-2273 • CityMD Urgent Care, 358 Jericho Turnpike Syosset, NY 11791, Nassau, P: 516-677-9200 • CityMD Urgent Care, 235 Glen Cove Road Carle Place, NY 11514, Nassau, P: 516-877-2273 • CityMD Urgent Care, 1919 Hempstead Tpke, East Meadow, NY 11554, Nassau, P: 516-227-2273 • CityMD Urgent Care, 1500 Lexington Ave, New York, NY 10029, P: 212-710-1065 • CityMD Urgent Care, 345 W 42nd St, New York, NY 10036, P: 646-518-0159 • CityMD Urgent Care, 212 E 23rd St, New York, NY 10010, P: 646-518-0163 • CityMD Urgent Care, 2175 86th St, Brooklyn, NY 11214, P: 646-828-6401 • CityMD Urgent Care, 288 Flatbush Ave, Brooklyn, NY 11217, P: 718-656-1290 • CityMD Urgent Care, 61-18 188th St, Fresh Meadows, NY 11365, P: 718-489-5003 • CityMD Urgent Care, 2146 Bartow Ave, Bronx, NY 10475, P: 646-346-7927 • CityMD Urgent Care, 87 Chambers Street, New York, NY 10007, P: 212-335-0594 • Fairfield Urgent Care Center, 309 Stillson Road, Fairfield, CT 06825 P: 203-331-1924 • MKMG Urgent Care, 185 Route 312, Brewster, NY 10509 P: 845-278-7000 • MKMG Urgent Care, 600 Westage Business Center Drive, Fishkill, NY 12524 P: 845-231-5600 • MKMG Urgent Care, 1561 Ulster Avenue, Lake Katrine, NY 12449 P: 845-231-5600 CareConnect Facilities

Urgent Care (continued) • MKMG Urgent Care, 360 North Bedford Road, Mount Kisco, NY 10549 P: 914-241-1050 • MKMG Urgent Care, 30 Columbia Street, Poughkeepsie, NY 12601 P: 845-231-5600 • MKMG Urgent Care, 6734 Route 9, Rhinebeck, NY 12572 P: 845-231-5600 • MKMG Urgent Care, 225 Veterans Road, Yorktown Heights, NY 10598 P: 914-241-1050 • NSLIJ Medical Group Urgent Care, 4300 Hempstead Turnpike, Bethpage, NY 11714 P: 516-396-8500 • NSLIJ Medical Group Urgent Care, 9525 Queens Boulevard, Rego Park, NY 11374 P: 718-925-6565 • Northwell Health/GoHealth Urgent Care (Bay Shore), 603B E Main Street, Bay Shore, NY 11706, P: 631-238-3064 • Northwell Health/GoHealth Urgent Care (Bellmore), 2640 Merrick Road, Bellmore, NY 11710, P: 516-537-9064 • Northwell Health/GoHealth Urgent Care (East Northport), 4199 Jericho Turnpike, East Northport, NY 11731, P: 631-238-3066 • Northwell Health/GoHealth Urgent Care (Elwood), 1912 Jericho Turnpike, East Northport, NY 11731, P: 631-238-3065 • Northwell Health/GoHealth Urgent Care (Forest Hills), 102-29 Queens Blvd, Forest Hills, NY 11375, P: 718-502-9798 • Northwell Health/GoHealth Urgent Care (Gramercy), 176 Third Ave, New York, NY 10003, P: 646-863-0464 • Northwell Health/GoHealth Urgent Care (LeFrak City), 58-28 99th Street, Corona, NY 11368, P: 718-502-9867 • Northwell Health/GoHealth Urgent Care (Levittown), 3631 Hempstead Turnpike, Levittown, NY 11756, P: 516-558-9860 • Northwell Health/GoHealth Urgent Care (Massapequa), 5165 Merrick Rd, Massapequa, NY 11762, P: 516-858-3724 • Northwell Health/GoHealth Urgent Care (New Rochelle), 77 Quaker Ridge Road, New Rochelle, NY 10804, P: 914-266-3104 • Northwell Health/GoHealth Urgent Care (Plainview), 377 S. Oyster Bay Road, Plainview, NY 11803, P: 516-537-9061 • Northwell Health/GoHealth Urgent Care (Ridgewood), 55-05 Myrtle Ave, Ridgewood, NY 11385, P: 718-502-9063 • Northwell Health/GoHealth Urgent Care (Rockville Centre), 243 Merrick Road, Rockville Centre, NY 11570, P: 516-537-9063 • Northwell Health/GoHealth Urgent Care (Roslyn), 1033 Northern Blvd, Roslyn, NY 11576, P: 516-473-0782 • Northwell Health/GoHealth Urgent Care (Staten Island), 1700 Hylan Blvd, Staten Island, NY 10305, P: 718-502-8425 • Northwell Health/GoHealth Urgent Care (Staten Island), 125 Greaves Lane, Staten Island, NY 10305, P: 718-502-8763 • Northwell Health/GoHealth Urgent Care (Syosset), 103 Jackson Ave, Syosset, NY 11791, P: 516-537-9062 • Northwell Health/GoHealth Urgent Care (Tarrytown), 650 White Plains Road, Tarrytown, NY 10591, P: 914-266-3102 • Northwell Health/GoHealth Urgent Care (Upper West Side), 199 Amsterdam Ave., New York, NY 10023, P: 212-721-4200 • Northwell Health/GoHealth Urgent Care (West Islip), 434 Union Blvd., West Islip, NY 11795, P: 631-238-3067 • Northwell Health/GoHealth Urgent Care (Yorktown Heights), 28 Triangle Center, Yorktown Heights, NY 10598, P: 914-266-3103 • ProHealth Urgent Care (Pediatric), 1167 Wantagh Avenue, Wantagh, NY 11793, P: 516-900-1201 • ProHealth Urgent Care, 555 North Broadway, Jericho, NY 11753, P: 516-597-5070 • ProHealth Urgent Care, 250 South Service Road, Roslyn Heights, NY 11577, P: 516-622-6000 • ProHealth Urgent Care, 1049 Morris Park Avenue, Bronx, NY 10456, P: 929-777-9082 • ProHealth Urgent Care, 1074 Old Country Road, Plainview, NY 11803, P: 516-622-6000 • ProHealth Urgent Care, 132-01 14th Avenue, College Point, NY 11356, P: 917-285-2156 • ProHealth Urgent Care, 254-61 Nassau Boulevard, Little Neck, NY 11362, P: 917-563-1660 • ProHealth Urgent Care, 330 Court Street, Brooklyn, NY 11231, P: 718-625-1600 • ProHealth Urgent Care, 148 Merrick Road, Amityville, NY 11701, P: 631-842-4102 • ProHealth Urgent Care, 4954 Merrick Road, Massapequa Park, NY 11762, P: 516-308-7255 • ProHealth Urgent Care, 148 Sunrise Highway, West Islip, NY 11795, P: 631-620-3580 • ProHealth Urgent Care, 1797 Coney Island Avenue, Brooklyn, NY 11230, P: 718-676-1499 • ProHealth Urgent Care, 331 Kings Highway, Brooklyn, NY 11233, P: 718-974-7818 • ProHealth Urgent Care, 164-50 Cross Bay Boulevard, Howard Beach, NY 11414, P: 718-848-8412 • ProHealth Urgent Care, 129 W Sunrise Highway, Freeport, NY 11520, P: 516-442-7090 • ProHealth Urgent Care, 7001 Amboy Road, Staten Island, NY 10307, P: 347-838-6991 • ProHealth Urgent Care, 4108 Avenue U, Brooklyn, NY 11233, P: 718-252-2581 • ProHealth Urgent Care, 339 Main Street, Huntington, NY 11743, P: 631-470-9000 • ProHealth Urgent Care, 26 Court Street, Brooklyn, NY 11242, P: 347-335-0062 • ProHealth Urgent Care, 6906 18th Avenue, Brooklyn, NY 11204, P: 718-621-5933 • ProHealth Urgent Care, 132-01 14th Avenue, College Point, NY 11356, P: 917-285-2158 • ProHealth Urgent Care, 2960 Victory Boulevard, Staten Island, NY 10314, P: 718-370-2014 • ProHealth Urgent Care, 358 Arden Avenue, Staten Island, NY 10314, P: 718-227-7666 • ProHealth Urgent Care, 254-61 Nassau Boulevard, Little Neck, NY 11362, P: 917-563-1660 • WESTMED, 171 Huguenot Street, New Rochelle, NY 10801, P: 914-848-8000 • WESTMED, 210 Westchester Avenue, West Harrison, White Plains, NY 10604, P: 914-848-8000 • WESTMED, 1 Theall Road, Rye, NY 10580, P: 914-848-8000 • WESTMED, 3030 Westchester Avenue, Purchase, NY 10577, P: 914-831-4100 • WESTMED, 73 Market Street, Yonkers, NY 10710, P: 914-682-0700 • WESTMED, 720 White Plains Road, Suite 270, Scarsdale, NY 10583, P: 914-831-4170 • WESTMED, 899 Park Avenue, Manhattan, NY 10075, P: 212-995-2600

2200 Northern Blvd., Entrance A, East Hills, NY 11548 • 855-706-7545 • CareConnect.com

North Shore-LIJ CareConnect Insurance Company, Inc.

CCFacilitiesProspectV13-07.16 2017 Individual Application

EPO Plan Selection†—Effective Date: / / tandard Bronze EPO Standard Bronze HSA Standard Silver EPO Standard Gold EPO Standard Platinum EPO adition Platinum 30/30 Tradition Gold 30/50 Tradition Silver 40/60 Value Silver 100% Value Silver 75% Value Gold 100% Value Platinum 100% Bronze HSA 70% Catastrophic Other:

† Summary of Benefits and Coverage documents (SBCs) for all CareConnect plans are available at CareConnect.com.

Special Enrollment Period: / / (Enrollment may not be approved until proof of special enrollment has been recieved.) Check triggering event below and attach proof:

Loss of minimum essential coverage Marriage/divorce/birth/adoption/foster care Change in eligibility for financial assistance Dependent attained age 26 and lost coverage Access to new plan due to permanent move Enrollment error by the Marketplace or other entity providing enrollment assistance Other:

Details Applicant Spouse/Domestic Partner Child Child Child

Last Name*

First Name*

Social Security Number*

DOB: (MM/DD/YYYY)* ______/______/______/______/______/______/______/______/______/______/______Street Address*

City, State, Zip*

Phone Number*

E-mail Address*

Gender* Male Female Male Female Male Female Male Female Male Female

PCP Name

PCP ID Number

Prior Carrier

Policy Number

Start Date ______/______/______/______/______/______/______/______/______/______/______End Date ______/______/______/______/______/______/______/______/______/______/______( * required fields) ( Continued on opposite side.)

NSLIJINDAPP010117 CareConnect Insurance Company, Inc.

CC-Individual Application V5 09-16 2017 Individual Application (continued)

Coordination of Benefits

Applicant Spouse/Domestic Partner Child Child Child

Additional Coverage Medicare Medicare Medicare Medicare Medicare Please indicate if you or any covered family Medicaid Medicaid Medicaid Medicaid Medicaid members have:

Have you obtained stand-alone dental coverage that provides a pediatric dental essential health benefit through a NYSOH-certified stand-alone dental plan offered outside the NYSOH? Yes No If you answered “yes”, please provide the name of the company issuing the stand-alone dental coverage. If you answered “no”, we will provide you coverage of the pediatric dental essential health benefit.

Broker/GA Information (if applicable) Broker Co-Broker General Agent Name of Payee Peak Advisors Inc CareConnect’s Broker and/or General Agency Code 153 New York State License # LA1286632 Payee’s SS # or Federal Tax ID # 46-1941735 Commission Split 100% Sales Representative

The undersigned hereby requests that CareConnect Insurance Company, Inc. accept the Broker or Agent named above as an authorized person for purposes of processing any enrollment transactions for my CareConnect Insurance Company, Inc. policy. This authorization shall be effective immediately and shall remain in place until it is expressly revoked by me in writing. Further, I agree that I will be bound by the actions performed by the herein-named Broker or Agent pursuant to this Consent Form. Additionally, I agree that this Consent Form does not authorize anyone to receive individually identifiable health information about me. I acknowledge that I must notify CareConnect Insurance Company, Inc. in writing to void this agreement in the event of a change in my Broker of Record. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed $5,000 dollars and the stated value of the claim for each violation.

/ / Print name of insured or authorized representative xSignature of insured or authorized representative Date

Description of authorized representative’s authority (e.g., power of attorney, guardianship order) Documentation must be made available at CareConnect’s request.

CareConnect Attention: Group Enrollment 2200 Northern Blvd., Suite 104, East Hills, NY 11548 P: 855-706-7545 F: 844-266-4343 CareConnect.com

NSLIJINDAPP010117 CareConnect Insurance Company, Inc.

CC-Individual Application V5 09-16