Summary of Coverage. $6,350 / $12,700 (Includes Deductibles, Copays and Coinsurance Amounts) Preventive Care Covered at 100%

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1 Benefits for Medical Summary of Coverage Plan Features Blue Care Network HMO HRA IN NETWORK Purchased Deductible * Employee Deductible * $4,000 individual / $8,000 family * $500 individual / $1,000 family * *An HRA set-up with Blue Care Network pays the remaining Deductible after you meet your portion; Please see the HRA Flowchart on the next page for more information Coinsurance 10% after Deductible; up to out of Pocket Maximum Out-of-Pocket Max (Ind. / Family) $6,350 / $12,700 (Includes Deductibles, Copays and Coinsurance Amounts) Preventive Care Covered at Primary Care Visit Specialist Visit X-Rays Complex Images Outpatient Procedure Inpatient Visit Emergency Room Urgent Care Pharmacy / RX (30 Day Supply) Pharmacy / RX (90 Day Supply) OUT OF NETWORK $30 Copay $30 Copay; Deductible Applies 10% Coinsurance; Deductible Applies $150 Copay; Deductible Applies 10% Coinsurance; Deductible Applies 10% Coinsurance; Deductible Applies $150 Copay waived if admitted; Deductible Applies $50 Copay $20 Generic/$60 Formulary Brand/50% ($80 min/$100 max) Non-Formulary Brand 2 times the Copay Not Covered Semi-Monthly Rates Employee $24.02 Employee + 1 $55.02 Family $ Benefits Open Enrollment This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider s contract.

2 Integrity Educational Services Benefits for Health Reimbursement Account (HRA) Benefits Open Enrollment This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider s contract.

3 Integrity Educational Services Key Terms to Remember Managemen HMO A network t Account that requires you to select a Primary Marketing Care Physician Banking (PCP) who coordinates your Finance health care Plan Types HRA Employer Money that is set aside to reimburse specific expenses. Out-of-Pocket Maximum This is the total amount you can pay out of pocket each plan year before the plan pays 100 percent of covered expenses for the rest of the plan year. Most expenses that meet provider network requirements count toward the out-of-pocket maximum, including expenses paid to the deductible, copays and coinsurance. college of a rts & Deductible science The amount you have to pay each plan year before the plan starts Humanities paying a portion of medical expenses. All family members expenses Science that Biology count toward a health plan deductible accumulate together in the Social aggregate; however, each person also has a limit on their own Science individual accumulated expenses. History Copays and Coinsurance These expenses are your share of cost paid for covered health care services. Copays are a fixed dollar amount, and are usually due at the time you receive care. Coinsurance is your share of the allowed amount charged for a service, and is generally billed to you after the health insurance company reconciles the bill with the provider. The Value of Preventive Care Wellness and Health Management Understanding the full value of covered benefits allows you to take responsibility for maintaining good health and incorporating healthy habits into your lifestyle. Some examples include getting regular physical examinations, mammograms and immunizations. Through the plans offered by Integrity Educational Services, all covered individuals and family members are eligible to receive routine wellness services like these, at no cost; all copays, coinsurance, and deductibles are waived. Which Preventive Care Services Are Covered? The US Preventive Services Task Force maintains a regular list of recommended services that all Affordable Care Act (i.e. Health Care Reform) compliant insurance plans should cover at for in-network providers. Below is a list of common services that are included in the plans offered this year: Routine Physical Exam Well Baby and Child Care Well Woman Visits Immunizations Routine Bone Density Test Routine Breast Exam Routine Gynecological Exam Screening for Gestational Diabetes Obesity Screening and Counseling Routine Digital Rectal Exam Routine Colonoscopy Routine Colorectal Cancer Screening Routine Prostate Test Routine Lab Procedures Routine Mammograms Routine Pap Smear Smoking Cessation Programs Health Education/Counseling Services Health Counseling for STDs and HIV Testing for HPV and HIV Screening and Counseling for Domestic Violence Benefits Open Enrollment This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider s contract.

4 9/1/2016-8/31/2017 All Contract Types HMO (800)

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12 CLSSLG with Deductibles Integrity Educational Services Deductible, Copays and Dollar Maximums Note: The Deductible will apply to certain services as defined below. Deductible Fixed Dollar Copays Coinsurance Annual Coinsurance Maximum (ACM) Out of Pocket Maximum - applies to deductibles, copays and coinsurance amounts for all covered services Preventive Services Health Maintenance Exam Annual Gynecological Exam Pap Smear Screening Well-Baby and Child Care Immunizations Prostate Specific Antigen (PSA) Screening Routine Colonoscopy Mammography Screening Voluntary Female Sterilization Breast Pumps (DME guidelines apply.) Maternity Pre-Natal care Physician Office Services Office Visits Online Visits Consulting Specialist Care Emergency Medical Care Hospital Emergency Room - Copay waived if admitted Urgent Care Center Ambulance Services $4,000 individual/$8,000 family per benefit year $5 for allergy injections $30 for office visits and online visits $50 for urgent care visits $150 for emergency room visits No fixed dollar copay for ambulance services. See below for applicable coinsurance. $30 for referral physician visits 50% for select services as noted below 10% for select services as noted below None $6,350 per individual/$12,700 per family $30 Copay $30 Copay $150 Copay after deductible $50 Copay Benefits Selected - CI10%,D4000,DSRCW,IMG150,DME5,ER150,CO30,6350PM,2065%C,MOPD2O,BENYR,P&O5,UR50 bcbsm.com 07/06/ :40:44 am BENEFITS EFF 9/1/16 LDP

13 CLSSLG with Deductibles Integrity Educational Services Diagnostic Services Laboratory and Pathology Tests Diagnostic Tests and X-rays High Technology Radiology Imaging (MRI, MRA, CAT, PET) Radiation Therapy $150 copay after deductible Maternity Services Provided by a Physician Post-Natal and Non-routine Pre-Natal Care (See Preventive Services section for routine Pre-Natal Care) Delivery and Nursery Care $30 Copay For professional services. (See Hospital Care for facility charges) after deductible Hospital Care General Nursing Care, Hospital Services and Supplies Outpatient Surgery - included all related surgical services and anesthesia - see member certificate for specific surgical copays. Alternatives to Hospital Care Skilled Nursing Care Hospice Care Home Health Care Surgical Services Surgery - includes all related surgical services and anesthesia - see member certificate for specific surgical copays. Voluntary Male Sterilization See Preventive Services section for voluntary female sterilization Elective Abortion (One procedure per two year period of membership) Human Organ Transplants Reduction Mammoplasty Male Mastectomy Temporomandibular Joint Syndrome Orthognathic Surgery Weight Reduction Procedures (Limited to one procedure per lifetime) Up to 45 days per member per benefit year (When authorized) after deductible Not Covered Benefits Selected - CI10%,D4000,DSRCW,IMG150,DME5,ER150,CO30,6350PM,2065%C,MOPD2O,BENYR,P&O5,UR50 bcbsm.com 07/06/ :40:44 am BENEFITS EFF 9/1/16 LDP

14 CLSSLG with Deductibles Integrity Educational Services Mental Health Care and Substance Abuse Treatment Inpatient Mental Health Care Inpatient Substance Abuse Care Outpatient Mental Health Care Outpatient Substance Abuse Autism Spectrum Disorders, Diagnoses and Treatment Applied behavioral analyses (ABA) treatment Outpatient physical therapy, speech therapy, occupational therapy, nutritional counseling for autism spectrum disorder through age 18 Other covered services, including mental health services, for Autism Spectrum Disorder See your outpatient mental health benefit and medical office visit benefit Other Services Allergy Testing and Therapy Allergy Injections Chiropractic Spinal Manipulation - when referred Outpatient Physical, Speech and Occupational Therapy Infertility Counseling and Treatment (Excludes Invitro fertilization) Durable Medical Equipment (DME) Prosthetic and Orthotic Appliances (P&O) Diabetic Supplies Prescription Drugs Mail Order Prescription Drugs Prescription Drug Deductible Hearing Aid $5 copay (up to 30 visits per benefit year) One period of treatment for any combination of therapies within 60 consecutive days per benefit year Tier 1 - $20 copay, Tier 2 - $60 copay, Tier 3-50% (min $80/max $100); 30 day supply with contraceptives Sexual Dysfunction drugs - 50% coinsurance Women's Contraceptives - Tier 1 -, Tier 2 - Tier 2 Copayment/Coinsurance above applies, Tier 3 - Tier 3 Copayment/Coinsurance above applies Two times the applicable copay up to a 90 day supply None Not Covered Benefits Selected - CI10%,D4000,DSRCW,IMG150,DME5,ER150,CO30,6350PM,2065%C,MOPD2O,BENYR,P&O5,UR50 bcbsm.com 07/06/ :40:45 am BENEFITS EFF 9/1/16 LDP

15 CLSSLG with Deductibles Integrity Educational Services This is intended as an easy to read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and exclusions may apply to covered services. For a complete description of benefits, please see the applicable Blue Care Network certificates and riders. Payment amounts are based on the Blue Care Network approved amount, less any applicable deductible, coinsurance and copay amounts required by the plan. If there is a discrepancy between the Benefits-at-a-Glance and any applicable plan documents, the plan document will control. This coverage is provided pursuant to a contract entered into in the State of Michigan and shall be construed under the jurisdiction and according to the laws of the State of Michigan. Services must be provided or arranged by member's primary care physician or health plan. Benefits Selected - CI10%,D4000,DSRCW,IMG150,DME5,ER150,CO30,6350PM,2065%C,MOPD2O,BENYR,P&O5,UR50 bcbsm.com 07/06/ :40:45 am BENEFITS EFF 9/1/16 LDP