HBS PPO Standard B1 Benefits-at-a-Glance Trinity Health

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1 HBS PPO Standard B1 Benefits-at-a-Glance Trinity Health Deductible, Copays/Coinsurance and Dollar Maximums Deductible - per calendar year Tier 1 Trinity Health Facilities and Aligned Professional Providers $750 per member $1,500 per family Tier 2 PPO In-Network Facility $750 per member $1,500 per family Tier 3 Out-of-Network Facility $1,500 per member $3,000 per family Copays/Coinsurance Fixed Dollar Copays $25 copay: Office Visits Outpatient Mental Health / Substance Abuse $35 copay: Urgent Care Services $50 copay: Outpatient surgery facility fee only $100 copay: Emergency Room $250 copay: Inpatient Admission $25 copay: Office Visits Outpatient Mental Health / Substance Abuse $35 copay: Urgent Care Services $100 copay: Emergency Room Outpatient surgeryfacility fee only $500 copay: Inpatient Admission $100 copay: Emergency Room $200 copay: Outpatient surgeryfacility fee only $1,000 copay: Inpatient Admission Percent Coinsurance 10% - Trinity Health Facilities 10%/20% - Trinity Health Professional Services 20% 40% Note: Services without a network are covered at the in-network level. Out-of-Pocket Maximum Includes deductible, coinsurance and copays for all covered services including prescription drugs $2,000 per member $4,000 per family $4,000 per member $8,000 per family $8,000 per member $16,000 per family Preventive Services Health Maintenance Exam - one per calendar year (age 18 and over) Routine Physical Related Test X-Rays, EKG and lab procedures performed as part of the health maintenance exam Annual Gynecological Exam - one per calendar year, in addition to health maintenance exam Pap Smear Screening - one per calendar year Mammography Screening - one per calendar year (one baseline age then one annually age 40 and over) Covered - 100% Covered - 100% Covered - 60% Covered - 100% Covered - 100% Covered - 60% Covered - 100% Covered - 100% Covered - 60% Covered - 100% Covered - 100% Covered - 60% Covered - 100% Covered - 100% Covered - 60%

2 Tier 1 Trinity Health Facilities and Aligned Professional Providers Tier 2 PPO In-Network Facility Tier 3 Out-of-Network Facility Prostate Specific Antigen (PSA) Covered - 100% Covered - 100% Covered - 60% Screening - one per calendar year age 40 and Endoscopic over Exams - one per calendar year Covered - 100% Covered - 100% Covered - 60% Well Child Care 7 visits, birth through 12 months Covered - 100% Covered - 100% Covered 60% 3 visits, 13 months through 36 months 2 visits, 37 months through 47 months 1 visit per year thereafter through age 17 Immunizations -Pediatric & Adult Covered - 100% Covered - 100% Covered - 60% Routine Hearing Exam Covered - 100% Covered - 100% Covered - 60% One per calendar year Physician Office Services Office Visits Includes: Primary care and specialist physicians Presurgical consultations Initial visit to determine pregnancy Covered 100% after $25 copay One copay applies to the office visit exam and all services performed during the office visit (e.g., lab, x-ray, etc.) Covered 100% after $25 copay One copay applies to the office visit exam and all services performed during the office visit (e.g., lab, x-ray, etc.) Covered - 60% Emergency Medical Care Hospital Emergency Room Qualified medical emergency Covered - 100% after $100 copay; copay waived if admitted Covered - 100% after $100 copay; copay waived if admitted Covered - 100% after $100 copay; copay waived if admitted Non-Emergency use of the Emergency Room Covered - $100 copay; then 90% Covered - $100 copay; then 80% Covered - $100 copay; then 60% Urgent Care Services Covered - 100% after $35 copay Covered - 100% after $35 copay Covered - 60% Ambulance Services - Medically Necessary Transport Covered - 90% Covered - 80% Covered - 80% Facility Diagnostic and Therapeutic Services MRI,MRA, PET and CAT Scans and Covered - 90% Covered - 80% Covered - 60% Nuclear Medicine Diagnostic Tests, X-rays, Laboratory & Covered - 90% Covered - 80% Covered - 60% Pathology Radiation Therapy and Chemotherapy Covered - 90% Covered - 80% Covered - 60% Professional Diagnostic and Therapeutic Services MRI,MRA, PET and CAT Scans and Covered - 80% Covered - 80% Covered - 60% Nuclear Medicine Diagnostic Tests, X-rays, Laboratory & Covered - 80% Covered - 80% Covered - 60% Pathology Radiation Therapy and Chemotherapy Covered - 80% Covered - 80% Covered - 60% Maternity Services Provided by a Physician Prenatal and Postnatal Care Visits Covered 100% Covered 100% Covered - 60% Delivery and Nursery Care Covered - 80% Covered - 80% Covered - 60% Hospital Care Semi-Private Room, General Nursing Covered 90% after $ 250 copay Covered - $500 copay, then 80% Covered - $1,000 copay, then Care, Hospital Services and Supplies 60% Inpatient Medical Care Covered - 80% Covered - 80% Covered - 60%

3 Tier 1 Trinity Health Facilities and Aligned Professional Providers Tier 2 PPO In-Network Facility Tier 3 Out-of-Network Facility Alternatives to Hospital Care Hospice Care Covered - 100% Covered - 100% Covered - 60% Home Health Care Covered - 90% Covered - 80% Covered - 60% Skilled Nursing Limited to 120 days per calendar year Surgical Services (Outpatient) Surgery (includes related facility surgical services) Covered - 90% Covered - $500 copay, then 80% Covered - 90% after $50 copay Covered - $100 copay then; 80% Sterilization includes reversal sterilization Not Covered Not Covered Not Covered Covered - $1,000 copay, then 60% Covered - $200 copay then; 60% Human Organ Transplants Specified Organ Transplants in designated Covered - 100% Covered - 100% Not covered facilities only, when coordinated through BCBSM Human Organ Transplant Program ( ) Kidney, Cornea, Bone Marrow and Skin Covered - 90% Covered - 80% Covered - 60% Behavioral Health and Substance Abuse Services Inpatient Behavioral Health and Inpatient Substance Abuse Care Covered 90% after $ 250 copay Covered - $500 copay, then 80% Covered - $1,000 copay, then 60% Outpatient Behavioral Health Care Covered - 100% after $25 copay Covered - 100% after $25 copay Covered - 60% Outpatient Substance Abuse Care Covered - 100% after $25 copay Covered - 100% after $25 copay Covered - 60% Other Services Cardiac Rehabilitation Covered - 90% Covered - 80% Covered - 60% Maximum 36 visits in a 12 week period Chiropractic Services Covered - 80% Covered - 80% Covered - 60% 20 visit maximum per calendar year Durable Medical Equipment Covered - 90% Covered - 80% Covered - 60% Prosthetic and Orthotic Devices Covered - 90% Covered - 80% Covered - 60% Private Duty Nursing Covered - 90% Covered - 80% Covered - 60% Limited to 120 visits per calendar year Allergy Testing Covered - 80% Covered - 80% Covered - 60% Allergy Therapy Covered - 80% Covered - 80% Covered - 60% Therapy Services Physical, Occupational and Speech Covered - 90% Covered - 80% Covered - 60% Therapy Limited to 60 visits maximum per therapy per calendar year Note: The following services require preapproval: Inpatient Care, select Radiology Services, Inpatient Mental Health and Substance Abuse Care and Skilled Nursing. The information in this document is based on BCBSM s current interpretation of the Patient Protection and Affordable Care Act (PPACA). Interpretations of PPACA vary and the federal government continues to issue guidance on how PPACA should be interpreted and applied. Efforts will be made to update this document as more information about PPACA becomes available. This document is only an educational tool and should not be relied upon as legal or compliance advice. Additionally, some PPACA requirements may differ for particular members enrolled in certain programs, and those members should consult with their plan administrators for specific details. 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.

4 Selecting a Provider Tier 1: Trinity Health Facilities When you use Trinity Health facilities, satellite locations and/or aligned physicians with Trinity Health, you receive the highest benefit payment level. A listing of eligible facilities is available online at bsbsm.com. Tier 2: Network Providers Network providers have signed agreements with BCBS, which means they agree to accept our approved payment for a covered benefit as payment in full. You will only pay for the deductibles, copayments and coinsurances required by your coverage. Ask your physician if he or she participates with the BCBS PPO network in your plan area. If you need help locating a network provider, please call the phone number to locate a BCBS network provider or visit the Web site listed on the inside front cover of this handbook. When you go to network providers, you do not have to send a claim to us. Network providers submit claims to BCBS for you, and they are paid directly by BCBS. Tier 3: Nonparticipating (Out-of-Network) Providers Nonparticipating providers have not signed agreements with BCBS. This means they may or may not choose to accept the BCBS approved amount as payment in full for your health care services. If your present providers do not participate with BCBS, ask if they will accept the amount we approve as payment in full for the services you need. This is called participating on a "per claim" basis and means that the providers will accept the approved amount as payment in full for the specific services. You are responsible for any deductibles, copayments, and coinsurances required by your plan along with charges for non-covered services. Trinity Health Incentive Programs Non-Surgical Weight Loss Therapy Along with the existing benefits for bariatric surgery, the plan will cover additional services for non-surgical weight loss treatment. Benefits are payable 100% up to an annual benefit maximum of $500* and include: - Outpatient counseling or therapy - Office visits rendered by a licensed physician for the treatment of weight loss - Lab services performed during a course of treatment - Services for weight loss rendered by a Trinity Health Ministry Organization or national recognized programs such as Jenny Craig, Weight Watchers and LA Weight Loss. Weight-loss expenses that are not covered are: - Services administered exclusively through an Internet-based forum - Medication or injection expenses for weight loss, unless otherwise covered for an unrelated medical condition - Charges for food or nutritional supplements, unless included in the initial program fee - Charges for over-the counter diet aids - Health clubs or exercise equipment - Services or programs that are not approved in the United States - Charges in connection with acupuncture, hypnotism or biofeedback training. *Please note that the non-surgical weight loss therapy incentive is considered taxable income to the subscriber.

5 Case Management / Disease Management Program The Case Management / Disease Management Program is available to you and/or your covered dependents (18 or older) and minor dependents (17 and younger). A parent/guardian will need to provide approval for a BCBSM nurse to speak to a minor. If you agree to participate a BCBSM nurse case manager will administer an assessment and an individualized plan that includes condition and goals based on your assessment results. - The nurse will work with you via telephone to address your specific health concerns and goals. - One you have completed the program you will receive a case closure letter via mail and a call explaining that you have completed your program. Note: Cancer Treatment Centers of America (CTCA) there is no Network or Out-Network coverage for both health care services provided by the facility; and health care services provided by physicians and other health care professionals at the facility. Prescription Drugs Administered directly by CVS Caremark Retail 34-day supply Generic Formulary Brand Name Non-Formulary Brand Name Ministry owned on-site pharmacies 34-day supply Generic Formulary Brand Name Non-Formulary Brand Name Ministry owned on-site pharmacies 90-day supply Generic Formulary Brand Name Non-Formulary Brand Name 100% after $10 copay 20% with $30 minimum and $80 maximum 40% with $60 minimum and $100 maximum 100% after $8 copay 16% with $24 minimum and $64 maximum 32% with $48 minimum and $80 maximum 100% after $24 copay* 16% with $72 minimum and $192 maximum* 32% with $144 minimum and $240 maximum* Mail Order 90 day supply Generic Formulary Brand Name Non-Formulary Brand Name 100% after $25 copay 20% with $75 minimum and $200 maximum 40% with $150 minimum and $250 maximum 50% coinsurance for infertility drugs dispensed through pharmacy (no maximum) Pharmacy copays and coinsurance will track to Tier 2 out-of-pocket max If the brand drug has a specific equivalent generic drug available and the plan participant receives the brand, then in addition to the copay, the plan participant must also pay the difference between the ingredient cost of the brand drug and the generic drug.

6 Specialty medications must be filled at a Trinity Health pharmacy or through the CVS Caremark Specialty program; prescriptions limited to a 30 day supply. Mandatory Maintenance is required for each maintenance medication after an initial retail prescription and two refills. Coverage of Preventive Services Medications (under the Patient Protection and Affordable Care Act (No copay): Prescription required - Iron supplements (Ages 6 months through 12 months), Oral Fluorides (Ages 5 and younger), Aspirin (ages 45 and older, male and female; age 12 and older, female), Folic Acid (women age 55 and younger), Immunizations, Vitamin D (Ages 65+), Bowel Preparation Medications Prescription only (ages 50 through 74), and Breast Cancer Drugs (female age 35+) Prescription required (total 168-day supply) - Tobacco Cessation - Nicotine replacement products, including Nicotine patch, gum & lozenges. Also covers generic Zyban or Chantix Exclusions: Cosmetic medication Anti-wrinkle agents, Hair growth / removal, etc Erectile Dysfunction (ED) Medications Non-Sedating Antihistamine (NSA) Drugs Compound pain patches and bulk powders Hypoactive Sexual Desire Disorder (Addyi) The following is a list of the drugs that need prior authorization to be covered (not intended to be an all-inclusive list): (Your physician must call to obtain approval for a period of up to one year) Topical acne Oral contraceptives Compounds $300 an greater Specialty medications Anti-obesity agents Narcolepsy Anabolic steroids

7 The following is a list of most but not all of the drugs that have a quantity limit imposed: Flu medication Migraine medication Due to the large number of available medicines, this list is not all inclusive. Please note that this list does not guarantee coverage and is subject to change. Your prescription benefit plan may not cover certain products or categories, regardless of their appearance on this list. This document is only an educational tool and should not be relied upon as legal or compliance advice. Additionally, some PPACA requirements may differ for particular members enrolled in certain programs, and those members should consult with their plan administrators for specific details. 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. For a complete description of benefits please see the applicable summary plan descriptions. If there is a discrepancy between this summary and any applicable plan document, the plan document will control. More information is available through Caremark.com to help you manage your prescription drug program. You will be able to locate a pharmacy, order mail service refills, track mail service orders, and ask questions. For additional information contact Caremark at