2016 Staff Retiree (Under 65)

Transcription

1 2016 Staff Retiree (Under 65) 2016 Open Enrollment Benefit Guide Open Enrollment is the one time each year Oakland University retirees can make changes to their benefit elections. The decisions made at this time remain in effect from January 1, 2016 through December 31, Please complete the 2016 Benefit Election Form and return it in the envelope provided. Your completed form should be returned no later than Friday, December 11, 2015 for benefit changes to take effect January 1, Your contributions are due to either the Cashier s Office or MarketPlace ( on the 20 th of the month preceding coverage. Therefore, the 2016 rates included in this packet will be due on December 20, 2015 for coverage effective January 1, 2016.

2 The Oakland University Human Resource Department has partnered with MarketPlace, OU s online service that provides a user friendly way to accept payment from our retirees for retiree benefits. Using MarketPlace will allow Oakland Retirees a way to pay for their benefits online using a credit card or with payment directly from your checking/savings account. Payments WILL NOT carry forward into 2016 All payments MUST be reset each year in the MarketPlace system, this will not happen automatically. Payments for 2016 are due prior to December 20, 2015 and will continue through November 20 th, Q; Do I have to use MarketPlace or can I continue my current payment process? A: You may continue to use your current process. MarketPlace is just another avenue for you to make payment. Q: How do I get started using MarketPlace? A: You must first click on and follow the process. You do not have to create a user account to use this service. Q: Will I be able to use a credit card to make payment through MarketPlace? A: Yes, you will be able to use your credit card to make payments for all premium amounts. Q: Can I have money directly deducted from a checking or savings account? A: Yes, you will need your ABA routing number and account number. Q: Can I still come to campus and pay for my benefits at the Cashiers office? A: Yes, however if you come to campus to pay your bill only cash or check payments will be accepted. Q: Can I set up a recurring monthly payment? A: Yes, you can have a recurring monthly payment deducted from your checking/savings account or billed to your credit card. When you chose this option it will appear that you are going to be charged the whole period you selected at once, however that amount will be charged monthly for as many months as elected. Q: Do I still need to use my number? A: Yes, you will be asked to provide your name, address, telephone number and SB number during checkout. If you need help setting up this payment please contact the benefits office at: Oakland University Benefits Office 401 Wilson Hall Rochester, MI Phone (248) Fax (248)

3 OAKLAND UNIVERSITY A0KVW Comprehensive Major Medical (CMM) LG Effective Date: On or after January 2016 Benefits-at-a-glance 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. Payment amounts are based on BCBSM's approved amount, less any applicable deductible and/or copay/coinsurance. For a complete description of benefits please see the applicable BCBSM certificates and riders, if your group is underwritten or any other plan documents your group uses, if your group is self-funded. If there is a discrepancy between this Benefits-at-a-Glance and any applicable plan document, the plan document will control. Preauthorization for Select Services-Services listed in this BAAG are covered when provided in accordance with Certificate requirements and, when required, are preauthorized or approved by BCBSM except in an emergency. Note: A list of services that require approval before they are provided is available online at bcbsm.com/importantinfo. Select Approving covered services. Pricing information for various procedures by in-network providers can be obtained by calling the customer service number listed on the back of your BCBSM ID card and providing the procedure code. Your provider can also provide this information upon request. Preauthorization for Specialty Pharmaceuticals-BCBSM will pay for FDA-approved specialty pharmaceuticals that meet BCBSM's medical policy criteria for treatment of the condition. The prescribing physician must contact BCBSM to request preauthorization of the drugs. If preauthorization is not sought, BCBSM will deny the claim and all charges will be the member's responsibility. Specialty pharmaceuticals are biotech drugs including high cost infused, injectable, oral and other drugs related to specialty disease categories or other categories. BCBSM determines which specific drugs are payable. This may include medications to treat asthma, rheumatoid arthritis, multiple sclerosis, and many other disease as well as chemotherapy drugs used in the treatment of cancer, but excludes injectable insulin. Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a "low access area" by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and the provider's charge. Page 1 of

4 Benefits Coverage Member's responsibility (deductibles, copays, coinsurance and dollar maximums) Note: If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and the provider's charge. Benefits Deductibles Flat-dollar copays Coinsurance amounts (percent copays) Coverage None None None Note: Coinsurance amounts apply once the deductible has been met. Annual out-of-pocket maximums-applies to deductibles, copays and coinsurance amounts for all covered services - including cost-sharing amounts for prescription drugs, if applicable Lifetime dollar maximum $1,000 for one member, $2,000 for a family (when two or more members are covered under your contract) each calendar year None Benefits Coverage Preventive care services Benefits Health maintenance exam - includes chest x-ray, EKG, cholesterol screening and other select lab procedures Gynecological exam Pap smear screening - laboratory and pathology services Voluntary sterilizations for females Prescription contraceptive devices - includes insertion and removal of an intrauterine device by a licensed physician Contraceptive Injections Well-baby and child care visits Adult and childhood preventive services and immunuzations as recommended by the USPSTF, ACIP, HRSA or other sources as recognized by BCBSM that are in compliance with the provisions of the Patient Protection and Affordable Care Act Fecal occult blood screening Flexible sigmoidoscopy exam Prostate specific antigen (PSA) screening Coverage, one per member per calendar year Note: Additional well-women visits may be allowed based on medical necessity., one per member per calendar year Note: Additional well-women visits may be allowed based on medical necessity. copay/ coinsurance), one per member per calendar year copay/ coinsurance) 8 visits, birth through 12 months 6 visits, 13 months through 23 months 6 visits, 24 months through 35 months 2 visits, 36 months through 47 months Visits beyond 47 months are limited to one per member per calendar year under the health maintenance exam benefit,one per member per calendar year, one per member per calendar year,one per member per calendar year Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a "low access area" by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and the provider's charge. Page 2 of

5 Benefits Routine mammogram and related reading Colonoscopy -routine or medically necessary Coverage, one per member per calendar year Note: Subsequent medically necessary mammograms performed during the same calendar year are subject to your deductible and coinsurance. for the first billed colonoscopy, one per member per calendar year Note: Subsequent colonoscopies performed during the same calendar year are subject to your deductible and coinsurance. Benefits Physician office services Benefits Office visits Outpatient and home medical care visits Office consultations Coverage Coverage copay/ coinsurance) copay/ coinsurance) copay/ coinsurance) Benefits Emergency medical care Benefits Hospital emergency room Ambulance services-must be medically necessary Coverage Coverage copay/ coinsurance) copay/ coinsurance) Benefits Diagnostic services Benefits Laboratory and pathology services Diagnostic tests and x-rays Therapeutic radiology Coverage Coverage copay/ coinsurance) copay/ coinsurance) copay/ coinsurance) Benefits Coverage Maternity services provided by a physician or certified nurse midwife Benefits Coverage Prenatal care visits Postnatal care copay/ coinsurance) Delivery and nursery care copay/ coinsurance) Benefits Hospital care Benefits Coverage Coverage

6 Benefits Semiprivate room, inpatient physician care, general nursing care, hospital services and supplies Coverage copay/ coinsurance), unlimited days Note: Nonemergency services must be rendered in a participating hospital. Inpatient consultations Chemotherapy copay/ coinsurance) copay/ coinsurance) Benefits Coverage Alternatives to hospital care Benefits Skilled nursing care-must be in a participating skilled nursing facility Hospice care Home health care: must be medically necessary must be provided by a participating home health care agency Infusion therapy: must be medically necessary must be given by a participating Home Infusion Therapy (HIT) provider or in a participating freestanding Ambulatory Infusion Center (AIC) may use drugs that require preauthorization - consult with your doctor Coverage copay/ coinsurance), up to 28 pre-hospice counseling visits before electing hospice services; when elected, four 90-day periods - provided through a participating hospice program only; limited to dollar maximum that is reviewed and adjusted periodically (after reaching dollar maximum, member transitions into individual case management) copay/ coinsurance) copay/ coinsurance) Benefits Coverage Surgical services Benefits Surgery-includes related surgical services and medically necessary facility services by a participating ambulatory surgery facility Presurgical consultations Voluntary sterilization for males Coverage copay/ coinsurance) copay/ coinsurance) Note: For voluntary sterilizations for females, see "Preventive care services." Elective abortions copay/ coinsurance) Benefits Coverage Human organ transplants Benefits Specified human organ transplants-must be in a designated facility and coordinated through the BCBSM Human Organ Transplant Program ( ) Bone marrow transplants - must be coordinated through the BCBSM Human Organ Transplant Program ( ) Experimental bone marrow transplants-must be in a designated facility and coordinated through the BCBSM Human Organ Transplant Program ( ) Kidney, cornea and skin transplants Coverage copay/ coinsurance) copay/ coinsurance) copay/ coinsurance)

7 Benefits Coverage Mental health care and substance abuse treatment Benefits Inpatient mental health care and inpatient substance abuse treatment Residential psychiatric treatment facility: covered mental health services must be performed in a residential psychiatric treatment facility treatment must be preauthorized subject to medical criteri Outpatient mental health care Outpatient substance abuse treatment- in approved facilities only Coverage copay/ coinsurance), unlimited days copay/ coinsurance) copay/ coinsurance) copay/ coinsurance) Benefits Coverage Autism spectrum disorders, diagnoses and treatment Benefits Applied behavioral analysis (ABA) treatment-when rendered by an approved board-certified behavioral analyst - is covered through age 18, subject to preauthorization Coverage copay/ coinsurance) Note: Diagnosis of an autism spectrum disorder and a treatment recommendation for ABA services must be obtained by a BCBSM approved autism evaluation center (AAEC) prior to seeking ABA treatment. Outpatient physical therapy, speech therapy, occupational therapy, nutritional counseling for autism spectrum disorder Other covered services, including mental health services, for Autism Spectrum Disorder copay/ coinsurance) copay/ coinsurance) Benefits Coverage Other covered services Benefits Outpatient Diabetes Management Program (ODMP) Coverage copay/ coinsurance) Note: Screening services required under the provisions of PPACA are covered at 100% of approved amount with no cost-sharing when rendered by a participating provider. Note: When you purchase your diabetic supplies via mail order you will lower your out-of-pocket costs. Allery tesing and therapy Chiropractic spinal manipulation and osteopathic manipulative therapy Outpatient physical, speech and occupational therapy- provided for rehabilitation Durable medical equipment copay/ coinsurance) copay/ coinsurance), limited to a combined 38- visit maximum per member, per calendar year copay/ coinsurance), unlimited treatment copay/ coinsurance) Note: DME items required under the provisions of PPACA are covered at 100% of approved amount with no in-network cost-sharing when rendered by an innetwork provider. For a list of covered DME items required under PPACA, call BCBSM. Prosthetic and orthotic appliances Private duty nursing copay/ coinsurance)

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9 OAKLAND UNIVERSITY A0KVW BCBSM Preferred RX Program Effective Date: On or after January 2016 Benefits-at-a-glance 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 an exclusions may apply. Payment amounts are based on BCBSM's approved amount, less any applicable deductible and/or copay/coinsurance. F complete description of benefits please see the applicable BCBSM certificates and riders, if your group is underwritten or any other plan docum your group uses, if your group is self-funded. If there is a discrepancy between this Benefits-at-a-Glance and any applicable plan document, the document will control. Specialty Pharmaceutical Drugs - The mail order pharmacy for specialty drugs is Walgreens Specialty Pharmacy, LLC, an independent comp Specialty prescription drugs (such as Enbrel and Humira ) are used to treat complex conditions such as rheumatoid arthritis, multiple scleros cancer. These drugs require special handling, administration or monitoring. Walgreens Specialty Pharmacy will handle mail order prescriptions specialty drugs while many in-network retail pharmacies will continue to dispense specialty drugs (check with your local pharmacy for availabilit Other mail order prescription medications can continue to be sent to Express Scripts. (Express Scripts is an independent company providing ph benefit services for Blues members.) A list of specialty drugs is available on our Web site at bcbsm.com/pharmacy. If you have any questions, p call Walgreens Specialty Pharmacy customer service at We will not pay for more than a 30-day supply of a covered prescription drug that BCBSM defines as a "specialty pharmaceutical" whether or no drug is obtained from a 90-Day Retail Network provider or mail-order provider. We may make exceptions if a member requires more than a 30- supply. BCBSM reserves the right to limit the quantity of select specialty drugs to no more than a 15-day supply for each fill. Your copay/coinsu will be reduced by one-half for each fill once applicable deductibles have been met. Select Controlled Substance Drugs - BCBSM will limit the initial fill of select controlled substances to a 15-day supply. The member will be resp for only one-half of their cost-sharing requirement typically imposed on a 30-day fill. Subsequent fills of the same medication will be eligible to b as prescribed, subject to the applicable cost-sharing requirement. Select controlled substances affected by this prescription drug requirement a available online at bcbsm.com/pharmacy. Benefits In-network pharmacy Out-of-network pharmacy Member's responsibility (copays and coinsurance amounts) Note: Your prescription drug copays and coinsurance amounts, including mail order copay and coinsurance amounts, are subject to the same annual out-of-pocket maximum required under your medical coverage. The following prescription drug expenses will not apply to your annual out-of-pocket maximum. any difference between the Maximum Allowable Cost and BCBSM's approved amount for a covered brand name drug the 25% member liability for covered drugs obtained from an out-of-network pharmacy Benefits In-network pharmacy Out-of-network pharmacy Copay You pay $10 copay You pay $10 copay plus an additional 25% of BCBSM approved amount for the drug Mail order (home delivery) prescription drugs Copay for up to a 90 day supply: You pay $10 copay Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Page 7 of

10 Note: An in-network pharmacy is a Preferred Rx pharmacy in Michigan or an Express Scripts pharmacy outside Michigan. Express Scripts is an independent company providing pharmacy benefit services for Blues members. An out-of-network pharmacy is a pharmacy NOT in the Preferred Rx or Express Scripts networks. Note: Over-the-counter (OTC) drugs are drugs that do not require a prescription under federal law. They are identified by BCBSM as select prescription drugs. A prescription for the select OTC drug is required from the member's physician. In some cases, over-the-counter drugs may need to be tried before BCBSM will approve use of other drugs Benefits In-network pharmacy Out-of-network pharmacy Covered services Benefits In-network pharmacy Out-of-network pharmacy FDA-approved drugs Prescribed over-the-counter drugs - when covered by BCBSM State-controlled drugs FDA-approved generic and select brand-name prescription preventive drugs, supplements and vitamins as required by PPACA (non-self-administered drugs are not covered) Other FDA-approved brand-name prescription preventive drugs, supplements and vitamins as required by PPACA (non-self-administered drugs are not covered) FDA-approved generic and select brand name prescription contraceptive medication (non-selfadministered drugs are not covered) Other FDA-approved brand name prescription contraceptive medication (non-self-administered drugs are not covered) Disposable needles and syringes - when dispensed with insulin or other covered injectable legend drugs 100% of approved amount less plan copay/coinsurance 100% of approved amount less plan copay/coinsurance 100% of approved amount less plan copay/coinsurance 75% of approved amount less plan copay/coinsurance 75% of approved amount less plan copay/coinsurance 75% of approved amount less plan copay/coinsurance 100% of approved amount 75% of approved amount 100% of approved amount less plan copay/coinsurance 75% of approved amount less plan copay/coinsurance 100% of approved amount 75% of approved amount 100% of approved amount less plan copay/ coinsurance 100% of approved amount less plan copay/coinsurance for the insulin or other covered injectable legend drug 75% of approved amount less plan copay/ coninsurance 75% of approved amount less plan copay/coinsurance for the insulin or other covered injectable legend drug Note: Needles and syringes have no copay/ coinsurance. Note: An in-network pharmacy is a Preferred Rx pharmacy in Michigan or an Express Scripts pharmacy outside Michigan. Express Scripts is an independent company providing pharmacy benefit services for Blues members. An out-of-network pharmacy is a pharmacy NOT in the Preferred Rx or Express Scripts networks. Note: Over-the-counter (OTC) drugs are drugs that do not require a prescription under federal law. They are identified by BCBSM as select prescription drugs. A prescription for the select OTC drug is required from the member's physician. In some cases, over-the-counter drugs may need to be tried before BCBSM will approve use of other drugs Features of your prescription drug plan Drug interchange and generic copay/ coinsurance waiver BCBSM's drug interchange and generic copay/ coinsurance waiver programs encourage physicians to prescribe a less-costly generic equivalent. If your physician rewrites your prescription for the recommended generic or OTC alternate drug, you will only have to pay a generic copay/ coinsurance. In select cases BCBSM may waive the initial copay/ coinsurance after your prescription has been rewritten. BCBSM will notify you if you are eligible for a waiver.

11 Prescription drug preferred therapy A step-therapy approach that encourages physicians to prescribe generic, generic alternative or over-the-counter medications before prescribing a more expensive brand-name drug, It applies only to prescriptions being filled for the first time of a targeted medication. Before filling your initial prescription for select, high-cost, brand-name drugs, the pharmacy will contact your physician to suggest a generic alternative. A list of select brand-name drugs targeted for the preferred therapy program is available at bcbsm.com/pharmacy, along with the preferred medications. Quantity limits Clinical Drug List If our records indicate you have already tried the preferred medication(s), we will authorize the prescription. If we have no record of you trying the preferred medication(s), you may be liable for the entire cost of the brand-name drug unless you first try the preferred medication(s) or your physician obtains prior authorization from BCBSM. These provisions affect all targeted brand-name drugs, whether they are dispensed by a retail pharmacy or through a mail order provider. To stay consistent with FDA approved labeling for drugs, some medications may have quantity limits. A continually updated list of FDA-approved medications that represent each therapeutic class. The drugs on the list are chosen by the BCBSM Pharmacy and Therapeutics Committee for their effectiveness, safety, uniqueness and cost efficiency. The goal of the drug list is to provide members with the greatest therapeutic value at the lowest possible cost.

12 OAKLAND UNIVERSITY A0KVW Hearing Care Coverage Effective Date: On or after January 2016 Benefits-at-a-glance 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. Payment amounts are based on BCBSM's approved amount, less any applicable deductible and/or copay. For a complete description of benefits please see the applicable BCBSM certificates and riders, if your group is underwritten or any other plan documents your group uses, if your group is self-funded. If there is a discrepancy between this Benefits-at-a-Glance and any applicable plan document, the plan document will control. Benefits Participating provider Nonparticipating provider Member's responsibility (deductible and copay) Benefits Participating provider Nonparticipating provider Deductible None Not applicable Copay None Not applicable Benefits Participating provider Nonparticipating provider Covered services You must receive the following services from a hearing participating provider. Hearing care services are not covered when performed by nonparticipating providers unless the services are performed outside of Michigan and the local Blue Cross and Blue Shield plan does not contract with providers for hearing care services. In this case, BCBSM will pay the approved amount for hearing aids and related covered services obtained from a nonparticipating provider. You may be responsible for charges that exceed our approved amount. If you select a digitally controlled programmable hearing device, you may be responsible for charges that exceed the cost of a covered hearing aid. Benefits Participating provider Nonparticipating provider Audiometric exam - one every 36 months 100% of approved amount Hearing aid evaluation- one every 36 months 100% of approved amount Ordering and fitting the hearing aid (a monaural hearing aid only)- one every 36 months 100% of approved amount Hearing aid conformity test- one every 36 months 100% of approved amount Note: You must obtain a medical evaluation (sometimes called a medical clearance exam) of the ear performed by a physician-specialist before you receive your hearing aid. If a physician-specialist is not accessible, your primary care doctor may perform the medical evaluation. This evaluation is not covered under your hearing care coverage, so you must pay for this exam unless your medical coverage includes coverage for office visits. A physician-specialist is a licensed doctor of medicine or osteopathy who is also board certified or in the process of being board certified as an otolaryngologist. A physician-specialist determines whether a patient has a hearing loss and whether such loss can be offset by a hearing aid. Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Page 10 of

13 OAKLAND UNIVERSITY N7H Effective Date: 01/01/2016 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. Payment amounts are based on BCBSM's approved amount, less any applicable deductible and/or copay/coinsurance. For a complete description of benefits please see the applicable BCBSM certificates and riders, if your group is underwritten or any other plan documents your group uses, if your group is self-funded. If there is a discrepancy between this Benefits-at-a-Glance and any applicable plan document, the plan document will control. Preauthorization for Select Services - Services listed in this BAAG are covered when provided in accordance with Certificate requirements and, when required, are preauthorized or approved by BCBSM except in an emergency. Note:A list of services that require approval before they are provided is available online at bcbsm.com/importantinfo. Select Approving covered services. Pricing information for various procedures by in-network providers can be obtained by calling the customer service number listed on the back of your BCBSM ID card and providing the procedure code. Your provider can also provide this information upon request. Preauthorization for Specialty Pharmaceuticals - BCBSM will pay for FDA-approved specialty pharmaceuticals that meet BCBSM's medical policy criteria for treatment of the condition. The prescribing physician must contact BCBSM to request preauthorization of the drugs. If preauthorization is not sought, BCBSM will deny the claim and all charges will be the member's responsibility. Specialty pharmaceuticals are biotech drugs including high cost infused, injectable, oral and other drugs related to specialty disease categories or other categories. BCBSM determines which specific drugs are payable. This may include medications to treat asthma, rheumatoid arthritis, multiple sclerosis, and many other diseases as well as chemotherapy drugs used in the treatment of cancer, but excludes injectable insulin. Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a "low access area" by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and the provider's charge. Page 1 of

14 Eligibility information Member Eligibility Criteria Dependents Subscriber's legal spouse Dependent children: related to you by birth, marriage, legal adoption or legal guardianship; eligible for coverage until the end of the year in which they turn age 26 Sponsored dependents Dependents of the subscriber related by blood, marriage or legal adoption, over age 19 and not eligible as a dependent under the provisions of the subscriber's contract, provided the dependent meets all eligibility requirements. The subscriber is responsible for paying the cost of this coverage. Member's responsibility (deductibles, copays, coinsurance and dollar maximums) Deductibles None $250 for one member, $500 for the family (when two or more members are covered under your contract) each calendar year Flat-dollar copays $10 copay for office visits and office consultations $25 copay for emergency room visits $10 copay for urgent care visits Coinsurance amounts (percent copays) 50% of approved amount for private duty nursing care Note: Coinsurance amounts apply once the deductible has been met. Annual out-of-pocket maximums - applies to deductibles, flat-dollar copays and coinsurance amounts for all covered services - including cost-sharing amounts for prescription drugs, if applicable $6,350 for one member, $12,700 for the family (when two or more members are covered under your contract) each calendar year Note: Out-of-network deductible amounts also count toward the innetwork deductible, if applicable $25 copay for emergency room visits 50% of approved amount for private duty nursing care 20% of approved amount for mental health care and substance abuse treatment 20% of approved amount for most other covered services $6,350 for one member, $12,700 for the family (when two or more members are covered under your contract) each calendar year Lifetime dollar maximum None Note: Out-of-network cost-sharing amounts also count toward the innetwork out-of-pocket maximum. Preventive care services Health maintenance exam - includes chest x-ray, EKG, cholesterol screening and other select lab procedures, one per member per calendar year Note: Additional well-women visits may be allowed based on medical necessity. Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a "low access area" by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and the provider's charge. Page 2 of

15 Gynecological exam, one per member per calendar year Note: Additional well-women visits may be allowed based on medical necessity. Pap smear screening - laboratory and pathology services Voluntary sterilizations for females Prescription contraceptive devices - includes insertion and removal of an intrauterine device by a licensed physician Contraceptive injections Well-baby and child care visits Adult and childhood preventive services and immunizations as recommended by the USPSTF, ACIP, HRSA or other sources as recognized by BCBSM that are in compliance with the provisions of the Patient Protection and Affordable Care Act Fecal occult blood screening Flexible sigmoidoscopy exam Prostate specific antigen (PSA) screening Routine mammogram and related reading Colonoscopy - routine or medically necessary, one per member per calendar year 8 visits, birth through 12 months 6 visits, 13 months through 23 months 6 visits, 24 months through 35 months 2 visits, 36 months through 47 months Visits beyond 47 months are limited to one per member per calendar year under the health maintenance exam benefit, one per member per calendar year, one per member per calendar year, one per member per calendar year Note: Subsequent medically necessary mammograms performed during the same calendar year are subject to your deductible and coinsurance, for the first billed colonoscopy 80% after out-of-network deductible 100% after out-of-network deductible 80% after out-of-network deductible One per member per calendar year 80% after out-of-network deductible Note: Out-of-network readings and interpretations are payable only when the screening mammogram itself is performed by an in-network provider. 80% after out-of-network deductible Note: Subsequent colonoscopies performed during the same calendar year are subject to your deductible and coinsurance. One per member per calendar year Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a "low access area" by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and the provider's charge. Page 3 of

16 Physician office services Office visits - must be medically necessary $10 copay per office visit 80% after out-of-network deductible Outpatient and home medical care visits - must be medically necessary 80% after out-of-network deductible Office consultations - must be medically necessary $10 copay per office consultation 80% after out-of-network deductible Urgent care visits - must be medically necessary $10 copay per urgent care visit 80% after out-of-network deductible Emergency medical care Hospital emergency room Ambulance services - must be medically necessary Diagnostic services $25 copay per visit (copay waived if admitted or for an accidental injury) $25 copay per visit (copay waived if admitted or for an accidental injury) Laboratory and pathology services Diagnostic tests and x-rays Therapeutic radiology Maternity services provided by a physician or certified nurse midwife 80% after out-of-network deductible 80% after out-of-network deductible 80% after out-of-network deductible Prenatal care visits Postnatal care visits Delivery and nursery care Hospital care 80% after out-of-network deductible 80% after out-of-network deductible 80% after out-of-network deductible Semiprivate room, inpatient physician care, general nursing care, hospital services and supplies Unlimited days 80% after out-of-network deductible Note: Nonemergency services must be rendered in a participating hospital. Inpatient consultations Chemotherapy 80% after out-of-network deductible 80% after out-of-network deductible Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a "low access area" by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and the provider's charge. Page 4 of

17 Alternatives to hospital care Skilled nursing care - must be in a participating skilled nursing facility Hospice care Home health care: must be medically necessary must be provided by a participating home health care agency Infusion therapy: must be medically necessary must be given by a participating Home Infusion Therapy (HIT) provider or in a participating freestanding Ambulatory Infusion Center (AIC) may use drugs that require preauthorization - consult with your doctor Limited to a maximum of 120 days per member per calendar year Up to 28 pre-hospice counseling visits before electing hospice services; when elected, four 90-day periods - provided through a participating hospice program only; limited to dollar maximum that is reviewed and adjusted periodically (after reaching dollar maximum, member transitions into individual case management) Surgical services Surgery - includes related surgical services and medically necessary facility services by a participating ambulatory surgery facility Presurgical consultations Voluntary sterilization for males Note: For voluntary sterilizations for females, see "Preventive care services." Elective Abortions 80% after out-of-network deductible 80% after out-of-network deductible 80% after out-of-network deductible 80% after out-of-network deductible Human organ transplants Specified human organ transplants - must be in a designated facility and coordinated through the BCBSM Human Organ Transplant Program ( ) Bone marrow transplants - must be coordinated through the BCBSM Human Organ Transplant Program ( ) Experimental bone marrow transplants - when coordinated through the BCBSM Human Organ Transplant Program ( ) Kidney, cornea and skin transplants - in designated facilities only 80% after out-of-network deductible 80% after out-of-network deductible 80% after out-of-network deductible Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a "low access area" by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and the provider's charge. Page 5 of

18 Mental health care and substance abuse treatment Note: Some mental health and substance abuse services are considered by BCBSM to be comparable to an office visit. When a mental health or substance abuse service is considered by BCBSM to be comparable to an office visit, we will process the claim under your office visit benefit. Inpatient mental health care and inpatient substance abuse treatment Residential psychiatric treatment facility: covered mental health services must be performed in a residential psychiatric treatment facility treatment must be preauthorized subject to medical criteria Outpatient mental health care: Facility and clinic Physician's office Outpatient substance abuse treatment - in approved facilities only Unlimited days 80% after out-of-network deductible 80% after out-of-network deductible in participating facilities only 80% after out-of-network deductible 80% after out-of-network deductible (in-network cost-sharing will apply if there is no PPO network) Autism spectrum disorders, diagnoses and treatment Applied behavioral analysis (ABA) treatment - when rendered by an approved board-certified behavioral analyst - is covered through age 18, subject to preauthorization Note: Diagnosis of an autism spectrum disorder and a treatment recommendation for ABA services must be obtained by a BCBSM approved autism evaluation center (AAEC) prior to seeking ABA treatment. Outpatient physical therapy, speech therapy, occupational therapy, nutritional counseling for autism spectrum disorder Other covered services, including mental health services, for autism spectrum disorder 80% after out-of-network deductible Physical, speech and occupational therapy with an autism diagnosis is unlimited 80% after out-of-network deductible Other covered services Outpatient Diabetes Management Program (ODMP) Note: Screening services required under the provisions of PPACA are covered at 100% of approved amount with no in-network cost-sharing when rendered by an in-network provider. for diabetes medical supplies; for diabetes selfmanagement training 80% after out-of-network deductible Note: When you purchase your diabetic supplies via mail order you will lower your out-of-pocket costs. Allergy testing and therapy 80% after out-of-network deductible Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a "low access area" by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and the provider's charge. Page 6 of

19 Chiropractic spinal manipulation and osteopathic manipulative therapy Outpatient physical, speech and occupational therapy - when provided for rehabilitation Durable medical equipment Note: DME items required under the provisions of PPACA are covered at 100% of approved amount with no in-network cost-sharing when rendered by an in-network provider. For a list of covered DME items required under PPACA, call BCBSM. Prosthetic and orthotic appliances 80% after out-of-network deductible Limited to a combined 24-visit maximum per member per calendar year 80% after out-of-network deductible Note: Services at nonparticipating outpatient physical therapy facilities are not covered. Limited to a combined 60-visit maximum per member per calendar year Private duty nursing care 50% (no deductible) 50% (no deductible) Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a "low access area" by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and the provider's charge. Page 7 of

20 BCBSM Preferred RX Program 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. Payment amounts are based on BCBSM's approved amount, less any applicable deductible and/or copay/coinsurance. For a complete description of benefits please see the applicable BCBSM certificates and riders, if your group is underwritten or any other plan documents your group uses, if your group is self-funded. If there is a discrepancy between this Benefits-at-a-Glance and any applicable plan document, the plan document will control. Specialty Pharmaceutical Drugs - The mail order pharmacy for specialty drugs is Walgreens Specialty Pharmacy, LLC, an independent company. Specialty prescription drugs (such as Enbrel and Humira ) are used to treat complex conditions such as rheumatoid arthritis, multiple sclerosis and cancer. These drugs require special handling, administration or monitoring. Walgreens Specialty Pharmacy will handle mail order prescriptions only for specialty drugs while many in-network retail pharmacies will continue to dispense specialty drugs (check with your local pharmacy for availability). Other mail order prescription medications can continue to be sent to Express Scripts. (Express Scripts is an independent company providing pharmacy benefit services for Blues members.) A list of specialty drugs is available on our Web site at bcbsm.com/pharmacy. If you have any questions, please call Walgreens Specialty Pharmacy customer service at We will not pay for more than a 30-day supply of a covered prescription drug that BCBSM defines as a "specialty pharmaceutical" whether or not the drug is obtained from a 90-Day Retail Network provider or mail-order provider. We may make exceptions if a member requires more than a 30-day supply. BCBSM reserves the right to limit the initial quantity of select specialty drugs. Your copay will be reduced by one-half for this initial fill (15 days). Member's responsibility (copays and coinsurance amounts) Note: Your prescription drug copays and coinsurance amounts, including mail order copay and coinsurance amounts, are subject to the same annual out-of-pocket maximum required under your medical coverage. The following prescription drug expenses will not apply to your annual out-of-pocket maximum. any difference between the Maximum Allowable Cost and BCBSM's approved amount for a covered brand name drug the 25% member liability for covered drugs obtained from an out-of-network pharmacy Benefits In-network pharmacy Out-of-network pharmacy Copay You pay $10 copay You pay $10 copay plus an additional 25% of BCBSM approved amount for the drug Mail order (home delivery) prescription drugs Copay for up to a 90 day supply: You pay $10 copay Note: An in-network pharmacy is a Preferred Rx pharmacy in Michigan or an Express Scripts pharmacy outside Michigan. Express Scripts is an independent company providing pharmacy benefit services for Blues members. An out-of-network pharmacy is a pharmacy NOT in the Preferred Rx or Express Scripts networks. Note: Over-the-counter (OTC) drugs are drugs that do not require a prescription under federal law. They are identified by BCBSM as select prescription drugs. A prescription for the select OTC drug is required from the member's physician. In some cases, over-the-counter drugs may need to be tried before BCBSM will approve use of other drugs Covered services Benefits In-network pharmacy Out-of-network pharmacy FDA-approved drugs Prescribed over-the-counter drugs - when covered by BCBSM State-controlled drugs FDA-approved generic and select brand-name prescription preventive drugs, supplements and vitamins as required by PPACA (non-self-administered drugs are not covered) Other FDA-approved brand-name prescription preventive drugs, supplements and vitamins as required by PPACA (non-self-administered drugs are not covered) 100% of approved amount less plan copay/coinsurance 100% of approved amount less plan copay/coinsurance 100% of approved amount less plan copay/coinsurance 75% of approved amount less plan copay/coinsurance 75% of approved amount less plan copay/coinsurance 75% of approved amount less plan copay/coinsurance 100% of approved amount 75% of approved amount 100% of approved amount less plan copay/coinsurance 75% of approved amount less plan copay/coinsurance Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Page 8 of

21 Benefits In-network pharmacy Out-of-network pharmacy FDA-approved generic and select brand name prescription contraceptive medication (non-selfadministered drugs are not covered) Other FDA-approved brand name prescription contraceptive medication (non-self-administered drugs are not covered) Disposable needles and syringes - when dispensed with insulin or other covered injectable legend drugs Note: Needles and syringes have no copay/ coinsurance. 100% of approved amount 75% of approved amount 100% of approved amount less plan copay/ coinsurance 100% of approved amount less plan copay/coinsurance for the insulin or other covered injectable legend drug 75% of approved amount less plan copay/ coninsurance 75% of approved amount less plan copay/coinsurance for the insulin or other covered injectable legend drug Note: An in-network pharmacy is a Preferred Rx pharmacy in Michigan or an Express Scripts pharmacy outside Michigan. Express Scripts is an independent company providing pharmacy benefit services for Blues members. An out-of-network pharmacy is a pharmacy NOT in the Preferred Rx or Express Scripts networks. Note: Over-the-counter (OTC) drugs are drugs that do not require a prescription under federal law. They are identified by BCBSM as select prescription drugs. A prescription for the select OTC drug is required from the member's physician. In some cases, over-the-counter drugs may need to be tried before BCBSM will approve use of other drugs Features of your prescription drug plan Drug interchange and generic copay/ coinsurance waiver BCBSM's drug interchange and generic copay/ coinsurance waiver programs encourage physicians to prescribe a less-costly generic equivalent. Prescription drug preferred therapy If your physician rewrites your prescription for the recommended generic or OTC alternate drug, you will only have to pay a generic copay/ coinsurance. In select cases BCBSM may waive the initial copay/ coinsurance after your prescription has been rewritten. BCBSM will notify you if you are eligible for a waiver. A step-therapy approach that encourages physicians to prescribe generic, generic alternative or over-the-counter medications before prescribing a more expensive brand-name drug, It applies only to prescriptions being filled for the first time of a targeted medication. Before filling your initial prescription for select, high-cost, brand-name drugs, the pharmacy will contact your physician to suggest a generic alternative. A list of select brand-name drugs targeted for the preferred therapy program is available at bcbsm.com/pharmacy, along with the preferred medications. Quantity limits Clinical Drug List If our records indicate you have already tried the preferred medication(s), we will authorize the prescription. If we have no record of you trying the preferred medication(s), you may be liable for the entire cost of the brand-name drug unless you first try the preferred medication(s) or your physician obtains prior authorization from BCBSM. These provisions affect all targeted brand-name drugs, whether they are dispensed by a retail pharmacy or through a mail order provider. To stay consistent with FDA approved labeling for drugs, some medications may have quantity limits. A continually updated list of FDA-approved medications that represent each therapeutic class. The drugs on the list are chosen by the BCBSM Pharmacy and Therapeutics Committee for their effectiveness, safety, uniqueness and cost efficiency. The goal of the drug list is to provide members with the greatest therapeutic value at the lowest possible cost. Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Page 9 of

22 Hearing Care Coverage 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. Payment amounts are based on BCBSM's approved amount, less any applicable deductible and/or copay. For a complete description of benefits please see the applicable BCBSM certificates and riders, if your group is underwritten or any other plan documents your group uses, if your group is self-funded. If there is a discrepancy between this Benefits-at-a-Glance and any applicable plan document, the plan document will control. Member's responsibility (deductible and copay) Benefits Participating provider Nonparticipating provider Deductible None Not applicable Copay None Not applicable Covered services You must receive the following services from a hearing participating provider. Hearing care services are not covered when performed by nonparticipating providers unless the services are performed outside of Michigan and the local Blue Cross and Blue Shield plan does not contract with providers for hearing care services. In this case, BCBSM will pay the approved amount for hearing aids and related covered services obtained from a nonparticipating provider. You may be responsible for charges that exceed our approved amount. If you select a digitally controlled programmable hearing device, you may be responsible for charges that exceed the cost of a covered hearing aid. Benefits Participating provider Nonparticipating provider Audiometric exam - one every 36 months 100% of approved amount Hearing aid evaluation- one every 36 months 100% of approved amount Ordering and fitting the hearing aid (a monaural hearing aid only)- one every 36 months 100% of approved amount Hearing aid conformity test- one every 36 months 100% of approved amount Note: You must obtain a medical evaluation (sometimes called a medical clearance exam) of the ear performed by a physician-specialist before you receive your hearing aid. If a physician-specialist is not accessible, your primary care doctor may perform the medical evaluation. This evaluation is not covered under your hearing care coverage, so you must pay for this exam unless your medical coverage includes coverage for office visits. A physician-specialist is a licensed doctor of medicine or osteopathy who is also board certified or in the process of being board certified as an otolaryngologist. A physician-specialist determines whether a patient has a hearing loss and whether such loss can be offset by a hearing aid. Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Page 10 of

23 Oakland University 04KY Community Blue PPO SM LG Effective Date: On or after January 2016 Benefits-at-a-glance 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. Payment amounts are based on BCBSM's approved amount, less any applicable deductible and/or copay/coinsurance. For a complete description of benefits please see the applicable BCBSM certificates and riders, if your group is underwritten or any other plan documents your group uses, if your group is self-funded. If there is a discrepancy between this Benefits-at-a-Glance and any applicable plan document, the plan document will control. Preauthorization for Select Services - Services listed in this BAAG are covered when provided in accordance with Certificate requirements and, when required, are preauthorized or approved by BCBSM except in an emergency. Note:A list of services that require approval before they are provided is available online at bcbsm.com/importantinfo. Select Approving covered services. Pricing information for various procedures by in-network providers can be obtained by calling the customer service number listed on the back of your BCBSM ID card and providing the procedure code. Your provider can also provide this information upon request. Preauthorization for Specialty Pharmaceuticals - BCBSM will pay for FDA-approved specialty pharmaceuticals that meet BCBSM's medical policy criteria for treatment of the condition. The prescribing physician must contact BCBSM to request preauthorization of the drugs. If preauthorization is not sought, BCBSM will deny the claim and all charges will be the member's responsibility. Specialty pharmaceuticals are biotech drugs including high cost infused, injectable, oral and other drugs related to specialty disease categories or other categories. BCBSM determines which specific drugs are payable. This may include medications to treat asthma, rheumatoid arthritis, multiple sclerosis, and many other diseases as well as chemotherapy drugs used in the treatment of cancer, but excludes injectable insulin. Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a "low access area" by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and the provider's charge. Page 1 of

24 Member's responsibility (deductibles, copays, coinsurance and dollar maximums) Deductibles $250 for one member, $500 for the family (when two or more members are covered under your contract) each calendar year $500 for one member, $1,000 for the family (when two or more members are covered under your contract) each calendar year Flat-dollar copays Coinsurance amounts (percent copays) Note: Coinsurance amounts apply once the deductible has been met. Annual coinsurance maximums - applies to coinsurance amounts for all covered services - but does not apply to deductibles, flat-dollar copays, private duty nursing care coinsurance amounts and prescription drug cost-sharing amounts Note: Deductible may be waived for covered services performed in an innetwork physician's office and for covered mental health and substance abuse services that are equivalent to an office visit and performed in an innetwork physician's office. $20 copay for office visits and office consultations $20 copay for chiropractic and osteopathic manipulative therapy $50 copay for emergency room visits $20 copay for urgent care visits 50% of approved amount for private duty nursing care 20% of approved amount for mental health care and substance abuse treatment 20% of approved amount for most other covered services (coinsurance waived for covered services performed in an in-network physician's office) $1,000 for one member, $2,000 for the family (when two or more members are covered under your contract) each calendar year Note: Out-of-network deductible amounts also count toward the innetwork deductible $50 copay for emergency room visits 50% of approved amount for private duty nursing care 40% of approved amount for mental health care and substance abuse treatment 40% of approved amount for most other covered services $3,000 for one member, $6,000 for the family (when two or more members are covered under your contract) each calendar year Annual out-of-pocket maximums - applies to deductibles, flat-dollar copays and coinsurance amounts for all covered services - including cost-sharing amounts for prescription drugs, if applicable $6,350 for one member, $12,700 for the family (when two or more members are covered under your contract) each calendar year Note: Out-of-network cost-sharing amounts also count toward the innetwork out-of-pocket maximum. $6,350 for one member, $12,700 for the family (when two or more members are covered under your contract) each calendar year Lifetime dollar maximum None Note: Out-of-network cost-sharing amounts also count toward the innetwork out-of-pocket maximum. Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a "low access area" by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and the provider's charge. Page 2 of

25 Preventive care services Health maintenance exam - includes chest x-ray, EKG, cholesterol screening and other select lab procedures, one per member per calendar year Gynecological exam Note: Additional well-women visits may be allowed based on medical necessity., one per member per calendar year Note: Additional well-women visits may be allowed based on medical necessity. Pap smear screening - laboratory and pathology services Voluntary sterilizations for females Prescription contraceptive devices - includes insertion and removal of an intrauterine device by a licensed physician Contraceptive injections Well-baby and child care visits Adult and childhood preventive services and immunizations as recommended by the USPSTF, ACIP, HRSA or other sources as recognized by BCBSM that are in compliance with the provisions of the Patient Protection and Affordable Care Act Fecal occult blood screening Flexible sigmoidoscopy exam Prostate specific antigen (PSA) screening Routine mammogram and related reading, one per member per calendar year 60% after out-of-network deductible 100% after out-of-network deductible 60% after out-of-network deductible 8 visits, birth through 12 months 6 visits, 13 months through 23 months 6 visits, 24 months through 35 months 2 visits, 36 months through 47 months Visits beyond 47 months are limited to one per member per calendar year under the health maintenance exam benefit 80% after in-network deductible, one per member per calendar year, one per member per calendar year, one per member per calendar year 60% after out-of-network deductible Note: Subsequent medically necessary mammograms performed during the same calendar year are subject to your deductible and coinsurance One per member per calendar year Note: Out-of-network readings and interpretations are payable only when the screening mammogram itself is performed by an in-network provider.

26 Colonoscopy - routine or medically necessary, for the first billed colonoscopy 60% after out-of-network deductible Note: Subsequent colonoscopies performed during the same calendar year are subject to your deductible and coinsurance. One per member per calendar year Physician office services Office visits - must be medically necessary $20 copay per office visit 60% after out-of-network deductible Outpatient and home medical care visits - must be medically necessary 80% after in-network deductible 60% after out-of-network deductible Office consultations - must be medically necessary $20 copay per office consultation 60% after out-of-network deductible Urgent care visits - must be medically necessary $20 copay per urgent care visit 60% after out-of-network deductible Emergency medical care Hospital emergency room $50 copay per visit (copay waived if admitted or for an accidental injury) $50 copay per visit (copay waived if admitted or for an accidental injury) Ambulance services - must be medically necessary 80% after in-network deductible 80% after in-network deductible Diagnostic services Laboratory and pathology services 80% after in-network deductible 60% after out-of-network deductible Diagnostic tests and x-rays 80% after in-network deductible 60% after out-of-network deductible Therapeutic radiology 80% after in-network deductible 60% after out-of-network deductible Maternity services provided by a physician or certified nurse midwife Prenatal care visits Postnatal care visits 60% after out-of-network deductible 60% after out-of-network deductible Delivery and nursery care 80% after in-network deductible 60% after out-of-network deductible

27 Hospital care Semiprivate room, inpatient physician care, general nursing care, hospital services and supplies 80% after in-network deductible 60% after out-of-network deductible Unlimited days Note: Nonemergency services must be rendered in a participating hospital. Inpatient consultations 80% after in-network deductible 60% after out-of-network deductible Chemotherapy 80% after in-network deductible 60% after out-of-network deductible Alternatives to hospital care Skilled nursing care - must be in a participating skilled nursing facility 80% after in-network deductible 80% after in-network deductible Limited to a maximum of 120 days per member per calendar year Hospice care Up to 28 pre-hospice counseling visits before electing hospice services; when elected, four 90-day periods - provided through a participating hospice program only; limited to dollar maximum that is reviewed and adjusted periodically (after reaching dollar maximum, member transitions into individual case management) Home health care: 80% after in-network deductible 80% after in-network deductible must be medically necessary must be provided by a participating home health care agency Infusion therapy: must be medically necessary must be given by a participating Home Infusion Therapy (HIT) provider or in a participating freestanding Ambulatory Infusion Center (AIC) may use drugs that require preauthorization - consult with your doctor 80% after in-network deductible 80% after in-network deductible Surgical services Surgery - includes related surgical services and medically necessary facility services by a participating ambulatory surgery facility Presurgical consultations Voluntary sterilization for males 80% after in-network deductible 60% after out-of-network deductible 60% after out-of-network deductible 80% after in-network deductible 60% after out-of-network deductible Note: For voluntary sterilizations for females, see "Preventive care services." Elective Abortions 80% after in-network deductible 60% after out-of-network deductible

28 Human organ transplants Specified human organ transplants - must be in a designated facility and coordinated through the BCBSM Human Organ Transplant Program ( ) Bone marrow transplants - must be coordinated through the BCBSM Human Organ Transplant Program ( ) Experimental bone marrow transplants - when coordinated through the BCBSM Human Organ Transplant Program ( ) - in designated facilities only 80% after in-network deductible 60% after out-of-network deductible 80% after in-network deductible 60% after out-of-network deductible Kidney, cornea and skin transplants 80% after in-network deductible 60% after out-of-network deductible Mental health care and substance abuse treatment Note: Some mental health and substance abuse services are considered by BCBSM to be comparable to an office visit. When a mental health or substance abuse service is considered by BCBSM to be comparable to an office visit, we will process the claim under your office visit benefit. Inpatient mental health care and inpatient substance abuse treatment 80% after in-network deductible 60% after out-of-network deductible Unlimited days Residential psychiatric treatment facility: 80% after in-network deductible 60% after out-of-network deductible covered mental health services must be performed in a residential psychiatric treatment facility treatment must be preauthorized subject to medical criteria Outpatient mental health care: Facility and clinic 80% after in-network deductible 80% after in-network deductible in participating facilities only Physician's office 80% after in-network deductible 60% after out-of-network deductible Outpatient substance abuse treatment - in approved facilities only 80% after in-network deductible 60% after out-of-network deductible (in-network cost-sharing will apply if there is no PPO network)

29 Autism spectrum disorders, diagnoses and treatment Applied behavioral analysis (ABA) treatment - when rendered by an approved board-certified behavioral analyst - is covered through age 18, subject to preauthorization 80% after in-network deductible 80% after in-network deductible Note: Diagnosis of an autism spectrum disorder and a treatment recommendation for ABA services must be obtained by a BCBSM approved autism evaluation center (AAEC) prior to seeking ABA treatment. Outpatient physical therapy, speech therapy, occupational therapy, nutritional counseling for autism spectrum disorder Other covered services, including mental health services, for autism spectrum disorder 80% after in-network deductible 60% after out-of-network deductible Physical, speech and occupational therapy with an autism diagnosis is unlimited 80% after in-network deductible 60% after out-of-network deductible Other covered services Outpatient Diabetes Management Program (ODMP) Note: Screening services required under the provisions of PPACA are covered at 100% of approved amount with no in-network cost-sharing when rendered by an in-network provider. Note: When you purchase your diabetic supplies via mail order you will lower your out-of-pocket costs. Allergy testing and therapy 80% after in-network deductible for diabetes medical supplies; for diabetes selfmanagement training 60% after out-of-network deductible 60% after out-of-network deductible Chiropractic spinal manipulation and osteopathic manipulative therapy $20 copay per visit 60% after out-of-network deductible Limited to a combined 24-visit maximum per member per calendar year Outpatient physical, speech and occupational therapy - when provided for rehabilitation Durable medical equipment 80% after in-network deductible 60% after out-of-network deductible Note: Services at nonparticipating outpatient physical therapy facilities are not covered. Limited to a combined 60-visit maximum per member per calendar year 80% after in-network deductible 80% after in-network deductible Note: DME items required under the provisions of PPACA are covered at 100% of approved amount with no in-network cost-sharing when rendered by an in-network provider. For a list of covered DME items required under PPACA, call BCBSM. Prosthetic and orthotic appliances 80% after in-network deductible 80% after in-network deductible Private duty nursing care 50% after in-network deductible 50% after in-network deductible

30 Oakland University 04KY BCBSM Preferred RX Program Effective Date: On or after January 2016 Benefits-at-a-glance 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 an exclusions may apply. Payment amounts are based on BCBSM's approved amount, less any applicable deductible and/or copay/coinsurance. complete description of benefits please see the applicable BCBSM certificates and riders, if your group is underwritten or any other plan docum your group uses, if your group is self-funded. If there is a discrepancy between this Benefits-at-a-Glance and any applicable plan document, the document will control. Specialty Pharmaceutical Drugs - The mail order pharmacy for specialty drugs is Walgreens Specialty Pharmacy, LLC, an independent comp Specialty prescription drugs (such as Enbrel and Humira ) are used to treat complex conditions such as rheumatoid arthritis, multiple scleros cancer. These drugs require special handling, administration or monitoring. Walgreens Specialty Pharmacy will handle mail order prescriptions specialty drugs while many in-network retail pharmacies will continue to dispense specialty drugs (check with your local pharmacy for availabilit Other mail order prescription medications can continue to be sent to Express Scripts. (Express Scripts is an independent company providing ph benefit services for Blues members.) A list of specialty drugs is available on our Web site at bcbsm.com/pharmacy. If you have any questions, p call Walgreens Specialty Pharmacy customer service at We will not pay for more than a 30-day supply of a covered prescription drug that BCBSM defines as a "specialty pharmaceutical" whether or n drug is obtained from a 90-Day Retail Network provider or mail-order provider. We may make exceptions if a member requires more than a 30- supply. BCBSM reserves the right to limit the quantity of select specialty drugs to no more than a 15-day supply for each fill. Your copay/coinsu will be reduced by one-half for each fill once applicable deductibles have been met. Select Controlled Substance Drugs - BCBSM will limit the initial fill of select controlled substances to a 15-day supply. The member will be resp for only one-half of their cost-sharing requirement typically imposed on a 30-day fill. Subsequent fills of the same medication will be eligible to b as prescribed, subject to the applicable cost-sharing requirement. Select controlled substances affected by this prescription drug requirement a available online at bcbsm.com/pharmacy. Benefits In-network pharmacy Out-of-network pharmacy Member's responsibility (copays and coinsurance amounts) Note: Your prescription drug copays and coinsurance amounts, including mail order copay and coinsurance amounts, are subject to the same annual out-of-pocket maximum required under your medical coverage. The following prescription drug expenses will not apply to your annual out-of-pocket maximum. any difference between the Maximum Allowable Cost and BCBSM's approved amount for a covered brand name drug the 25% member liability for covered drugs obtained from an out-of-network pharmacy Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Page 8 of

31 Benefits In-network pharmacy Out-of-network pharmacy Copay You pay $10 copay You pay $10 copay plus an additional 25% of BCBSM approved amount for the drug Brand name prescription drugs You pay $20 copay for brand name drugs Mail order (home delivery) prescription drugs Copay for up to a 30 day supply: You pay $10 copay for generic You pay $20 copay for brand name Copay for a 31 to 90 day supply: You pay $20 copay for generic You pay $40 copay for brand name You pay $20 copay plus an additional 25% of BCBSM approved amount for the drug Note: An in-network pharmacy is a Preferred Rx pharmacy in Michigan or an Express Scripts pharmacy outside Michigan. Express Scripts is an independent company providing pharmacy benefit services for Blues members. An out-of-network pharmacy is a pharmacy NOT in the Preferred Rx or Express Scripts networks. Note: Over-the-counter (OTC) drugs are drugs that do not require a prescription under federal law. They are identified by BCBSM as select prescription drugs. A prescription for the select OTC drug is required from the member's physician. In some cases, over-the-counter drugs may need to be tried before BCBSM will approve use of other drugs Benefits In-network pharmacy Out-of-network pharmacy Covered services Benefits In-network pharmacy Out-of-network pharmacy FDA-approved drugs Prescribed over-the-counter drugs - when covered by BCBSM State-controlled drugs FDA-approved generic and select brand-name prescription preventive drugs, supplements and vitamins as required by PPACA (non-self-administered drugs are not covered) Other FDA-approved brand-name prescription preventive drugs, supplements and vitamins as required by PPACA (non-self-administered drugs are not covered) FDA-approved generic and select brand name prescription contraceptive medication (non-selfadministered drugs are not covered) Other FDA-approved brand name prescription contraceptive medication (non-self-administered drugs are not covered) Disposable needles and syringes - when dispensed with insulin or other covered injectable legend drugs 100% of approved amount less plan copay/coinsurance 100% of approved amount less plan copay/coinsurance 100% of approved amount less plan copay/coinsurance 75% of approved amount less plan copay/coinsurance 75% of approved amount less plan copay/coinsurance 75% of approved amount less plan copay/coinsurance 100% of approved amount 75% of approved amount 100% of approved amount less plan copay/coinsurance 75% of approved amount less plan copay/coinsurance 100% of approved amount 75% of approved amount 100% of approved amount less plan copay/ coinsurance 100% of approved amount less plan copay/coinsurance for the insulin or other covered injectable legend drug 75% of approved amount less plan copay/ coninsurance 75% of approved amount less plan copay/coinsurance for the insulin or other covered injectable legend drug Note: Needles and syringes have no copay/ coinsurance. Note: An in-network pharmacy is a Preferred Rx pharmacy in Michigan or an Express Scripts pharmacy outside Michigan. Express Scripts is an independent company providing pharmacy benefit services for Blues members. An out-of-network pharmacy is a pharmacy NOT in the Preferred Rx

32 or Express Scripts networks. Note: Over-the-counter (OTC) drugs are drugs that do not require a prescription under federal law. They are identified by BCBSM as select prescription drugs. A prescription for the select OTC drug is required from the member's physician. In some cases, over-the-counter drugs may need to be tried before BCBSM will approve use of other drugs Features of your prescription drug plan Drug interchange and generic copay/ coinsurance waiver BCBSM's drug interchange and generic copay/ coinsurance waiver programs encourage physicians to prescribe a less-costly generic equivalent. If your physician rewrites your prescription for the recommended generic or OTC alternate drug, you will only have to pay a generic copay/ coinsurance. In select cases BCBSM may waive the initial copay/ coinsurance after your prescription has been rewritten. BCBSM will notify you if you are eligible for a waiver. Prescription drug preferred therapy A step-therapy approach that encourages physicians to prescribe generic, generic alternative or over-the-counter medications before prescribing a more expensive brand-name drug, It applies only to prescriptions being filled for the first time of a targeted medication. Before filling your initial prescription for select, high-cost, brand-name drugs, the pharmacy will contact your physician to suggest a generic alternative. A list of select brand-name drugs targeted for the preferred therapy program is available at bcbsm.com/pharmacy, along with the preferred medications. Quantity limits Clinical Drug List If our records indicate you have already tried the preferred medication(s), we will authorize the prescription. If we have no record of you trying the preferred medication(s), you may be liable for the entire cost of the brand-name drug unless you first try the preferred medication(s) or your physician obtains prior authorization from BCBSM. These provisions affect all targeted brand-name drugs, whether they are dispensed by a retail pharmacy or through a mail order provider. To stay consistent with FDA approved labeling for drugs, some medications may have quantity limits. A continually updated list of FDA-approved medications that represent each therapeutic class. The drugs on the list are chosen by the BCBSM Pharmacy and Therapeutics Committee for their effectiveness, safety, uniqueness and cost efficiency. The goal of the drug list is to provide members with the greatest therapeutic value at the lowest possible cost.

33 Oakland University 04KY Hearing Care Coverage Effective Date: On or after January 2016 Benefits-at-a-glance 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. Payment amounts are based on BCBSM's approved amount, less any applicable deductible and/or copay. For a complete description of benefits please see the applicable BCBSM certificates and riders, if your group is underwritten or any other plan documents your group uses, if your group is self-funded. If there is a discrepancy between this Benefits-at-a-Glance and any applicable plan document, the plan document will control. Benefits Participating provider Nonparticipating provider Member's responsibility (deductible and copay) Benefits Participating provider Nonparticipating provider Deductible None Not applicable Copay None Not applicable Benefits Participating provider Nonparticipating provider Covered services You must receive the following services from a hearing participating provider. Hearing care services are not covered when performed by nonparticipating providers unless the services are performed outside of Michigan and the local Blue Cross and Blue Shield plan does not contract with providers for hearing care services. In this case, BCBSM will pay the approved amount for hearing aids and related covered services obtained from a nonparticipating provider. You may be responsible for charges that exceed our approved amount. If you select a digitally controlled programmable hearing device, you may be responsible for charges that exceed the cost of a covered hearing aid. Benefits Participating provider Nonparticipating provider Audiometric exam - one every 36 months 100% of approved amount Hearing aid evaluation- one every 36 months 100% of approved amount Ordering and fitting the hearing aid (a monaural hearing aid only)- one every 36 months 100% of approved amount Hearing aid conformity test- one every 36 months 100% of approved amount Note: You must obtain a medical evaluation (sometimes called a medical clearance exam) of the ear performed by a physician-specialist before you receive your hearing aid. If a physician-specialist is not accessible, your primary care doctor may perform the medical evaluation. This evaluation is not covered under your hearing care coverage, so you must pay for this exam unless your medical coverage includes coverage for office visits. A physician-specialist is a licensed doctor of medicine or osteopathy who is also board certified or in the process of being board certified as an otolaryngologist. A physician-specialist determines whether a patient has a hearing loss and whether such loss can be offset by a hearing aid. Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Page 11 of

34 HealthyBlue Living SM Oakland University Enhanced Benefits (CLSSLG) Standard Benefits (CLSSLG) Deductible, Copays and Dollar Maximums Deductible Fixed Dollar Copays Coinsurance Annual Coinsurance Maximum (ACM) Out of Pocket Maximum - applies to deductibles, copays and coinsurance amounts for all covered services Enhanced Benefits : CLSSLG : 6600PM, SMVLW, 100MSR, CO20, VACR50, OPTHEP, OEACR, AS5, DME5, ER100, I, 0MHSA, 71530C, MOPD2O, P&O5, SN730, UR20, DSRCW, WRCWR Standard Benefits : CLSSLG : AS5, DME20%, ER150, IN20%, 10205C, MOPD2O, PO20%, UR30, DSR20%, WDEDFC, 6600PM, SMVLW, MSR20C, D200, CO30, CI20%, OPTHEP, VACR50, 2KECM bcbsm.com 09/30/ :57:02 pm Eff. 1/1/16

35 HealthyBlue Living SM Oakland University Enhanced Benefits (CLSSLG) Standard Benefits (CLSSLG) 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. Limited to no more than one per 24 month period.) Maternity Pre-Natal care Physician Office Services Office Visits Consulting Specialist Care Emergency Medical Care Hospital Emergency Room - Copay waived if admitted Urgent Care Center Ambulance Services Enhanced Benefits : CLSSLG : 6600PM, SMVLW, 100MSR, CO20, VACR50, OPTHEP, OEACR, AS5, DME5, ER100, I, 0MHSA, 71530C, MOPD2O, P&O5, SN730, UR20, DSRCW, WRCWR Standard Benefits : CLSSLG : AS5, DME20%, ER150, IN20%, 10205C, MOPD2O, PO20%, UR30, DSR20%, WDEDFC, 6600PM, SMVLW, MSR20C, D200, CO30, CI20%, OPTHEP, VACR50, 2KECM bcbsm.com 09/30/ :57:02 pm Eff. 1/1/16

36 HealthyBlue Living SM Oakland University Enhanced Benefits (CLSSLG) Standard Benefits (CLSSLG) Diagnostic Services Laboratory and Pathology Tests Diagnostic Tests and X-rays High Technology Radiology Imaging (MRI, MRA, CAT, PET) Radiation Therapy 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 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. Enhanced Benefits : CLSSLG : 6600PM, SMVLW, 100MSR, CO20, VACR50, OPTHEP, OEACR, AS5, DME5, ER100, I, 0MHSA, 71530C, MOPD2O, P&O5, SN730, UR20, DSRCW, WRCWR Standard Benefits : CLSSLG : AS5, DME20%, ER150, IN20%, 10205C, MOPD2O, PO20%, UR30, DSR20%, WDEDFC, 6600PM, SMVLW, MSR20C, D200, CO30, CI20%, OPTHEP, VACR50, 2KECM bcbsm.com 09/30/ :57:02 pm Eff. 1/1/16

37 HealthyBlue Living SM Oakland University 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) Enhanced Benefits (CLSSLG) Standard Benefits (CLSSLG) Enhanced Benefits : CLSSLG : 6600PM, SMVLW, 100MSR, CO20, VACR50, OPTHEP, OEACR, AS5, DME5, ER100, I, 0MHSA, 71530C, MOPD2O, P&O5, SN730, UR20, DSRCW, WRCWR Standard Benefits : CLSSLG : AS5, DME20%, ER150, IN20%, 10205C, MOPD2O, PO20%, UR30, DSR20%, WDEDFC, 6600PM, SMVLW, MSR20C, D200, CO30, CI20%, OPTHEP, VACR50, 2KECM bcbsm.com 09/30/ :57:03 pm Eff. 1/1/16

38 HealthyBlue Living SM Oakland University 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 Enhanced Benefits (CLSSLG) Standard Benefits (CLSSLG) Enhanced Benefits : CLSSLG : 6600PM, SMVLW, 100MSR, CO20, VACR50, OPTHEP, OEACR, AS5, DME5, ER100, I, 0MHSA, 71530C, MOPD2O, P&O5, SN730, UR20, DSRCW, WRCWR Standard Benefits : CLSSLG : AS5, DME20%, ER150, IN20%, 10205C, MOPD2O, PO20%, UR30, DSR20%, WDEDFC, 6600PM, SMVLW, MSR20C, D200, CO30, CI20%, OPTHEP, VACR50, 2KECM bcbsm.com 09/30/ :57:03 pm Eff. 1/1/16

39 HealthyBlue Living SM Oakland University Other Services Allergy Testing and Therapy Allergy Injections Chiropractic Spinal Manipulation - when referred Outpatient Physical, Speech and Occupational Therapy Infertility Counseling and Treatment (Excludes In-vitro fertilization) Durable Medical Equipment (DME) Prosthetic and Orthotic Appliances (P&O) Diabetic Supplies Prescription Drugs Mail Order Prescription Drugs Prescription Drug Deductible Enhanced Benefits (CLSSLG) Standard Benefits (CLSSLG) Enhanced Benefits : CLSSLG : 6600PM, SMVLW, 100MSR, CO20, VACR50, OPTHEP, OEACR, AS5, DME5, ER100, I, 0MHSA, 71530C, MOPD2O, P&O5, SN730, UR20, DSRCW, WRCWR Standard Benefits : CLSSLG : AS5, DME20%, ER150, IN20%, 10205C, MOPD2O, PO20%, UR30, DSR20%, WDEDFC, 6600PM, SMVLW, MSR20C, D200, CO30, CI20%, OPTHEP, VACR50, 2KECM bcbsm.com 09/30/ :57:03 pm Eff. 1/1/16

40 HealthyBlue Living SM Oakland University Hearing Aid Enhanced Benefits (CLSSLG) Standard Benefits (CLSSLG) Healthy Text291: Blue Living members (subscribers and covered spouse) must complete program requirements within the first 90 days of enrollment or re-enrollment. To qualify for or maintain enhanced benefits, members need to complete a health assessment and qualification form during the first 90 days and follow their primary care physician's recommendations for a healthy lifestyle. Members who use tobacco must enroll in BCN s smoking cessation program within 120 days of enrollment or re-enrollment. Members with a BMI of 30 or above must choose one of two BCN-sponsored weight management programs (Weight Watchers or Walkingspree pedometer plan) within 120 days of enrollment or re-enrollment. Enhanced Benefits : CLSSLG : 6600PM, SMVLW, 100MSR, CO20, VACR50, OPTHEP, OEACR, AS5, DME5, ER100, I, 0MHSA, 71530C, MOPD2O, P&O5, SN730, UR20, DSRCW, WRCWR Standard Benefits : CLSSLG : AS5, DME20%, ER150, IN20%, 10205C, MOPD2O, PO20%, UR30, DSR20%, WDEDFC, 6600PM, SMVLW, MSR20C, D200, CO30, CI20%, OPTHEP, VACR50, 2KECM bcbsm.com 09/30/ :57:04 pm Eff. 1/1/16