Welcome to Blue Cross Blue Shield of Michigan!

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2 Welcome to Blue Cross Blue Shield of Michigan! As a Blues member, you have comprehensive health care coverage that gives you access to the largest network of doctors and hospitals in Michigan and nationwide. Whether home or away, you can be confident that your Blues ID card ensures you ll receive quality health care. You also have benefits that extend beyond doctor visits. This guide will show you how to get the most out of your Blues coverage. We also encourage you to visit bcbsm.com to manage your account. Our site is easy to use and offers tools to help you make informed health care decisions. You can also call us at the Customer Service number on the back of your ID card. Thank you for being Blue.

3 Getting started Your ID card One site. One stop. 24/7. Using your benefits Your PPO coverage Your Pharmacy coverage Your health savings options Your health savings account Understanding your claims Claims forms Your Explanation of Benefits statement Added Blues value BlueHealthConnection SM Healthy Blue Xtras SM Benefits-at-a-Glance

4 Getting Started Your ID card Confidence comes with every card. You should receive your Blues ID card shortly before your plan becomes active. It gives you access to the largest network of doctors and hospitals in Michigan. You are also covered when you travel through our BlueCard programs. You are guaranteed coverage within our network, which extends throughout the U.S. and into more than 200 countries and territories worldwide. Find it online Once you receive your ID card, you can register for online access to your plan and manage your account online at bcbsm.com. When you show your card to your doctor, your services will always be paid according to your plan s coverage requirements. You will only pay the amount of copayment, coinsurance and deductibles outlined in your plan. If you need a replacement card, call the Customer Service number on the back of your card. Or you can request a new card online at bcbsm.com. You ll need to log in to your online member account.

5 1 bcbsm.com Enrollee Name VALUED CUSTOMER Enrollee ID XYP Issuer (80840) Group Number RxBIN RxGRP Blue SM 5 6 Dental 7 XXXXXX XXXXX Blue Cross Blue Shield of Michigan 600 E. Lafayette Blvd., Detroit, MI A nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association Use of this card is subject to terms of applicable contracts, conditions and user agreements. BCBSM assumes no financial risk on ASC claims. Dental, Vision and Pharmacy providers: file claims according to your network contract. All other providers: file claims with the local BCBS plan. For Medicare claims, bill Medicare. Except for emergency care, you may be liable for a copayment if you receive services from a non-network provider. Customer Service: 800-XXX-XXXX To locate participating providers outside of Michigan: 800-XXX-XXXX Misuse may result in prosecution. If you suspect fraud, call: 800-XXX-XXXX Blue Dental Inquiries: Rx Claims/Rx Prior Auth: 888-XXX-XXXX 800-XXX-XXXX Predetermination: 800-XXX-XXXX Mental Health/Substance Abuse Preauthorization: 800-XXX-XXXX Benefits may be limited; predetermination approval is required for hospitalization and certian services. Refer to telephone numbers. 2 3 On the front of the ID card, you ll find the following: 1. Blue Cross Blue Shield of Michigan logo: It s recognized worldwide. 2. Enrollee name: Identifies you as the enrollee the person in whose name the insurance is issued. The names of your family members who are eligible for services are not shown on the card. 3. Enrollee ID number: Identifies you and your health plan benefits to any health care professional you visit. 4. Group number: References your employer group. 5. Suitcase icon: Shows that you can receive coverage throughout the country and abroad. 6. Blue Dental logo: Confirms your Blue Dental SM coverage*. 7. Rx logo: Confirms your prescription drug benefits through Blue Cross Blue Shield of Michigan*. On the back of the ID card: 1. The bcbsm.com member site provides information on participating providers and other health care information. Register on the site as a member to receive access to personalized health information and manage your account online. 2. For identification purposes, this magnetic strip contains key information from the front of the card as well as your birthday. It doesn t contain any benefit details or health information. 3. The phone numbers help you and your doctors answer specific questions about your coverage, approve services or find doctors and hospitals outside of your local area. The first number listed is your primary customer service line. * The ID card shown on this page is a sample ID card. You may not have pharmacy and dental coverage through Blue Cross Blue Shield of Michigan.

6 Getting Started One site. One stop. 24/7. You can manage everything about your Blues coverage at bcbsm.com. It s available to you at home or on the go with your mobile phone or other electronic device. You can quickly access your plan information or find a doctor 24 hours a day, seven days a week. You don t need a special app. The site automatically adapts to your device format. How to create your online account Once you receive your Blues ID card, you re ready to create your online member account. 1. Go to bcbsm.com. 2. Click on the Login button at the upper right corner of the home page. 3. Click on Member. 4. At the bottom of the box, click on Register Now. 5. Follow the registration instructions. Find it online Do you know the difference between coinsurance and copayment? Our comprehensive glossary can help you understand key plan and insurance terms. To access our Glossary, go to bcbsm.com. In the search box, type in Glossary.

7 Now you can explore all the helpful features we offer, including: A personalized dashboard Help center This easy-to-read snapshot of your claims shows you how much you ve paid toward deductibles, coinsurance and other costs. A robust help center is here to make your life easier. It s a great resource for commonly asked questions and is home to important plan documents and forms you may need. Find a Doctor tool Easily find doctors and hospitals as well as dental and vision providers. Quickly perform searches based on location, specialty, extended office hours and more while comparing up to six doctors side by side. You can also read reviews written by other patients or write your own. Virtual ID card If you forget to bring your ID card to your doctor appointment, there s no need to worry. You can access your virtual ID card right from your mobile device.

8 Using your benefits Your PPO With our PPO plan, your medical coverage is easy to use. To get the most from it, you ll need to know: How your plan works Where you can use it to receive prompt, quality medical care The plan gives you and your family access to medical care through our extensive PPO network of doctors, hospitals and health care professionals. To save on costs, network doctors and hospitals accept discounted fees for covered services. Finding a PPO doctor When you receive care from a PPO provider, you save money by paying lower out-of-pocket costs than if you use a non-network doctor. More than 80 percent of the doctors and 90 percent of the hospitals in the United States are part of our PPO network. In Michigan, PPO access is even greater. To see if a doctor, hospital or health care professional in your area participates with the Blue Cross PPO network, use our online search to find one in your area whether you re in Michigan or outside of the state. From there, you can enter in the search information that best fits your needs. You can also call your doctor s office and ask if they participate with the Blue Cross Blue Shield of Michigan PPO network. Care away from home When you re traveling, you re covered through our BlueCard SM program. You have the option of seeing any doctor no matter where you are. However, if you re out of our network, you could pay higher out-of-pocket costs. To find a doctor or hospital outside of Michigan, you can use the Find a Doctor search tool or call Find it online Using our Find a Doctor tool, you can find doctors for primary, urgent and emergency care in and outside of Michigan. Go to bcbsm.com. Click on Find a Doctor. Click Get Started Under What do you want to do? click on Advanced Search. Here you can search by zip code, plan type or specialty. Seeing specialists and non-network doctors Choosing a specialist or doctor that is not in the Blues PPO network can impact your out-of-pocket costs. 1. Seeing a specialist in our PPO network: You do not need a referral from your doctor. You pay the copayment, coinsurance or deductible required by your plan for covered services. 2. Seeing an out-of-network specialist: If your primary care doctor gives you a referral to a nonnetwork specialist, you ll pay your usual copayment, coinsurance or deductible required for covered services. Without the referral, your out-of-pocket costs could be higher. 3. Seeing a non-network doctor with no referral: You re still covered but may have higher charges. Ask if that doctor is part of the Blue Plan. Doctors can participate in the Blue Plan arrangement by agreeing to accept Blue Cross approved payment for covered services on a case-by-case basis. They will not charge you more. As with a network doctor, you re still responsible for your usual copayment, coinsurance or deductible for covered services.

9 If you do not have a referral, and your doctor does not participate with the Blue Plan, your out-of-pocket costs will be higher. And the doctor can charge you the difference between what the doctor s charges and what Blue Cross pays for a covered service. Remember: Show your Blues ID card to your doctor or health care provider to verify your PPO benefits. Finding out more about your benefits To view your PPO benefits, visit bcbsm.com and log in to your online account. 1. Click on the Login button at the upper right corner of the home page. 2. Click on Member. 3. Enter your username and password. 4. Click on Log in. If you need a claim form, you can find one online at bcbsm.com. Log in into your online account and select the Forms tab at the top of the page. For all other questions, please call Customer Service using the toll-free phone number on the back of your Blues ID card. When you need emergency or urgent care For medical emergencies, you re covered anywhere, anytime. If you need emergency care while outside of Michigan, you may be asked to pay at the time you receive care, but we ll reimburse you later. You have many options for care. It is always best to check with your doctor on the many types of care you may need. Whatever the situation, the Blues gives you access to the most appropriate medical care. Here are some guidelines for receiving emergency care. Doctor s office Visit when you need routine care or have a health issue, like: Treatment for a health condition Immunizations Coordinating care with a specialist (if needed) Managing a chronic condition such as diabetes, asthma, arthritis or heart disease. Managing your medications Urgent care center Visit when your doctor is not available for: Sprains Pink eye Sore throat Cuts needing stitches Minor broken bones Emergency room Visit when you need immediate treatment for a lifethreatening condition or one that may permanently damage your health such as: Chest pain Major broken bones Heart attack Major head injury Shock Stroke Snake bites Unconscious state Uncontrolled bleeding Swallowing poisons or objects Severe abdominal pain, asthma attack, burns No matter where you receive care, you should always follow up with your regular doctor to ensure a full and speedy recovery and the best result for your health.

10 Using your benefits Your Pharmacy coverage When you use a PPO pharmacy, you receive your prescriptions at the lowest cost. Your Blues coverage includes pharmacy benefits. Like your medical coverage, your pharmacy benefits also use a PPO network. It s called Preferred Rx. With Preferred Rx, you receive access to more than 98 percent of Michigan pharmacies including all major chains and more than 65,000 pharmacies nationwide. Pharmacy coverage with the Blues offers many advantages, including: Web tools on bcbsm.com: They ll help you locate participating pharmacies, find drug lists and cost estimates for the most commonly prescribed drugs, and even allow you to print a personal prescription history. Convenience: You can use your ID card for all pharmacy benefits as well as your medical benefits. Safety: Blues prescription claims are processed through an online system that helps ensure that the medication you receive is appropriate based on: dosage, age, gender and other medications you take. These checks help lead to fewer drug-related hospitalizations and lower costs. Cost-management initiatives: These ensure that doctors are following appropriate prescribing practices, including generics whenever possible. Consider generic drugs Using generic prescription drugs keeps your costs down while providing you the same safe, effective medication as brand-name drugs. Depending on your plan, you may have a lower copayment or coinsurance when you use generic drugs. Find it online Generics are least expensive. You ll pay more for drugs that are not on your health plan s drug list. To learn more about generic drugs, visit theunadvertisedbrand.com, or bcbsm.com. More patients and doctors are turning to generic prescription drugs because they can save as much as 80 percent when compared to the cost of brand-name medications. Ways to fill your prescription Your prescription drug coverage can include: Retail pharmacies Mail-order pharmacy (if included in your plan) Specialty drug coverage Retail pharmacies You or your eligible family members can have your prescriptions filled at a participating retail pharmacy. Just show your Blues ID card and prescription to the pharmacist. You ll be charged a single copayment or coinsurance for each covered prescription order or refill. You do not have to submit a claim form when you use a participating pharmacy. To locate a participating pharmacy near you, visit bcbsm.com or call the toll-free Customer Service number on the back of your ID card. If you need a pharmacy claim form, you can find one online at bcbsm.com. Log in your online account and select the Forms tab at the top of the page.

11 Mail-order pharmacy Your prescription drug program is administered by Blue Cross Blue Shield of Michigan. But for mail-order prescriptions, we partner with Express Scripts home delivery pharmacy. Express Scripts delivers medications that you take on a regular basis right to your home. If it is appropriate for you, your doctor should prescribe a 90-day supply of your medication. You can order drugs to treat asthma, diabetes or other chronic conditions. Express Scripts also offers you: 24-hour access to pharmacists who can explain how specific drugs work and what to look out for Help from a pharmacist in managing side effects of your medication Fast and free standard delivery of your medication Easy refills online or by phone Medco Pharmacy MAIL-ORDER FORM Start your mail order It s easy to get the information and forms you need to get started: Online Visit bcbsm.com. Login to your member account, click on the Forms tab. Scroll down and click on Pharmacy Frequently Asked Questions and Forms. Click on the Mail Order Drug Form that matches the RX group number on your Blues ID card. Download and print the mail-order form. By phone Call Express Scripts at Request a mail-order form. The mail-order form contains instructions on how to fill out the form. You will need to include your original prescription from your doctor and select your method of payment. When you receive your first prescription from Express Scripts, you will also receive refill forms with instructions. *6101* FOLD HERE 1 Member information: Please verify or provide Member information below. Member ID: Group: BCBSMAN Name: Street Address: Street Address: Street Address: City, ST, ZIP: Please send me notices about the status of the enclosed prescription(s) and online ordering New shipping address: (Express Scripts will keep this address on file for all orders from this membership until another shipping address is provided by any person in this membership.) Daytime phone: Evening phone: 2 Patient/doctor information: Complete one section for each person with a prescription. If a person has prescriptions from more than one doctor, complete a new section for each doctor (additional sections are on back). Send all prescriptions in the envelope provided. First name Last name Birth date (MM/DD/YYYY) Doctor s last name Sex M F Patient s relationship to member Self Spouse Dependent 1st initial Doctor s phone number First name Last name

12 Using your benefits Drug list There is a drug list associated with your Blues coverage that identifies the preferred prescription drugs for your plan for both generic and brand-name drugs. The drugs on the list are chosen by an independent pharmacy and therapeutics committee for their safety, effectiveness and cost value. They only include those approved by the FDA. The listed drugs are organized into tiers that indicate how much your copayment or coinsurance will be for each drug. Tier 1 Lowest copayment: These drugs have a proven track record of safety and effectiveness and have the best value for members. You pay the lowest out of pocket for these drugs. Most are generic drugs and are the least expensive. Tier 1 Tier 2 Tier 3 Find it online You can find the most current drug list at bcbsm.com. 1. Click on Help and then Plan Documents and Forms. 2. Scroll down to Pharmacy and click on Drug Lists. 3. Click on Blue Cross Blue Shield Michigan/PPO. Tier 2 Higher copayment These drugs also have a record for safety and effectiveness. Because more cost-effective therapies or a generic drug alternative are usually available, a higher copayment or coinsurance is required. Tier 3 Highest copayment or not covered: These are nonpreferred brand-name drugs for which there is either a generic alternative or a more costeffective preferred brand. You will pay the highest copayment or coinsurance amount for these drugs or they may not be covered. The higher the tier, the higher your cost share is. Generics are least expensive. You ll pay more for drugs that are not on your Blues drug list. If a generic drug is available, it must be dispensed rather than the brand name. In some cases, depending upon your specific plan, a payment penalty may be required if the generic is not used. You may be required to pay the difference in cost between the brand-name and generic versions. This is in addition to your usual brand-name copayment or coinsurance amount.

13 Specialty drug coverage Your pharmacy coverage includes specialty drugs. Specialty drugs are prescription medications that require special handling, administration or monitoring and are used to treat complex conditions. Blue Cross Blue Shield of Michigan maintains a list of covered specialty drugs. You can purchase specialty drugs at a retail pharmacy, but not all pharmacies will dispense them. Call your pharmacy first to confirm that it can fill your prescription. You can also receive specialty drugs through the mail from Walgreens Specialty Pharmacy. Your order will arrive directly to your home. Just have your doctor fax your prescription for specialty medication to or complete and submit the Walgreens Specialty Pharmacy Enrollment Form. You can find the form in the Specialty Drug Member Guide. The mailing address for submissions is on the form. Find it online To see if your medication is on the list, you can go to bcbsm.com and search for specialty drug program or follow these steps: 1. Click on Help. 2. Click on FAQs. 3. Scroll down to Browse by Plan Type and click on Pharmacy. 4. Click on What are specialty drugs. 5. Click on Specialty Drug Member Guide. Enrollment Form for Walgreens Specialty Pharmacy, LLC. How to place your initial order with Walgreens Specialty Pharmacy: 1) Print and complete this Enrollment Form. Please print clearly. 2) Attach ORIGINAL prescription provided by your physician or ask your physician to fax the prescription to Walgreens Specialty Pharmacy at ) Mail Enrollment Form and ORIGINAL prescription to Walgreens Specialty Pharmacy, 1350 Highland Drive, Suite D, Ann Arbor, Michigan If you have questions or concerns, please call the Walgreens Specialty Pharmacy Customer Care Team toll free at Our hours are Monday through Friday, 8 a.m. to 8 p.m. and Saturday 8 a.m. to 5 p.m. Step 1: Demographic Information Enrollee Name Date of Birth / / Enrollee ID # Group # Patient Name Date of Birth / / Delivery Address Day Phone Number w/area code Evening Phone Number w/area code Address Physician s Name Phone Number w/area code Check One: Original Prescription Enclosed Physician Will Fax Prescription Step 2: Delivery Information Requested Date of Delivery / / (Walgreens Specialty Pharmacy will contact you if the delivery date cannot be accommodated. Deliveries are available Tuesday through Friday.) Medication(s) Requested Supplies Needed* No Yes If yes, please circle supplies needed: Where to find more information If you have any questions about the specialty drug program, call Walgreens Specialty Pharmacy at or visit walgreenshealth.com.* *Blue Cross Blue Shield of Michigan does not control this website or endorse its general content.

14 Your health savings options Your health savings account Your plan includes a health savings account, or HSA. A health savings account allows you, your employer or both to contribute funds to your account. You can use funds to pay for qualified medical expenses and reach your deductible.* You can also use your HSA to save for future qualified medical expenses and retiree health expenses on a taxfree basis. It s like a 401(k) account for your health care. With your HSA, you have access to quality health care, you control your health care dollars and you have the support you need to make informed health care decisions. Important to know Health savings account contributions, investment earnings and withdrawals for qualified medical expenses are all tax free. Here s how it works Let s say you enroll in an HSA-qualified health plan and choose to contribute $3,300. During the year, you have in-network health expenses of $1,000 that are not considered preventive care. The $1,000 expense is out-of-pocket for you. You can pay for those expenses from your HSA. With the remaining $2,300 left in your account, you can save for future health care needs or invest a portion of the money. HSA facts HSA dollars are portable. They follow you from employer to employer. Or if you become unemployed, they are yours and are available for paying your premiums under the Consolidated Omnibus Budget Reconciliation Act (known as COBRA). In addition: Contributions, investment earnings and withdrawals for qualified medical expenses are all tax free. Contributions that are not spent roll over from year to year. Once the account reaches a certain balance, you can invest your money. * Visit irs.gov for a list of qualified medical expenses. Blue Cross Blue Shield of Michigan does not endorse the Internal Revenue Service website or control its general content.

15 The government-required maximum contribution amount you can make toward your HSA is: 2015 Individual coverage $3,350 Family coverage $6,650 Where to find more information You ll receive a separate welcome kit to help you get started. And we ve specially trained our Customer Service representatives to help you make the most of your new plan. Just call the toll-free phone number on the back of your Blues ID card.

16 Understanding your claims Claim forms We want to limit the number of forms you need to fill out. Most doctors file claims electronically after your visits. Many activities, such as updating your plan information, can be done online or with a call to our Customer Service department. You ll find: Blue Cross Blue Shield of Michigan General Member Claim Form Use this form to manually submit a claim for a medical, vision or hearing service. Dental Service Claim Form Use this form to submit a claim for an out-of-network dental service. Find it online Most of the forms you ll need to manage your Blues benefits are available at bcbsm.com. Log in to your online account and select the Forms tab at the top of the page. Prescription Drug Claim Forms Use this form to submit covered prescription drug claims if your pharmacy did not file your claim electronically. Managing your account Change of Status Form Employer-sponsored health plan members can use this form to update us when they have any changes to their status, such as birth, marriage, divorce, etc. Protected Health Information and Privacy Forms These forms are for managing your private medical information that we have on file. Using your pharmacy benefits Mail-order drug forms You ll find links to the mail order-forms you need for using your Blue Cross Blue Shield of Michigan prescription drug coverage. Drug lists You ll find links to documents that will tell you whether your health benefit plan covers your prescription drug and more. Where to find more information If you need another form, just click on the Help tab at the top of the page.

17 Your Explanation of Benefits statement When a claim is filed, you ll receive an Explanation of Benefits statement, also known as an EOB. Your Explanation of Benefits statement shows you medical services we pay for as well as: Any out-of-pocket costs you may owe Your EOB can be sent via mail or can be viewed online by logging in to your account through bcbsm.com. You can view a history of your doctor visits, services received and how much we paid, and more. Your statements are available online for two years. What you ll find on your statement Member contract information: This includes your name, address and the group and contract information that s listed on your insurance card. You ll also see the name of your family member who received the medical care. Customer Service contacts: Your EOB has a toll-free phone number and address so you can contact us with questions about your statement. You can also find this info on your ID card. Find it online You can view your Explanation of Benefits statements online. Login to your online account and click on the Claims tab. On the left of the page, click on View All EOBs. Go paperless: Sign up to receive your EOBs online. Log in to your online account and click on Account Settings. On the left of the page, click on Paperless Options. Summary of services: The summary lists the medical services that you or a family member received since your last statement. You ll see any savings you received because of your Blue Cross member discounts and any charges that you pay. Match this information with your bills to make sure it s accurate. Summary of deductibles, coinsurance and out-of-pocket maximums: This shows you how much of your copayments or coinsurances and deductibles you ve paid to date. Claim detail: This shows you what type of care you received, the date of your appointment and your doctor s name. Compare this information with what is on your health care bills. Amount you pay: This is your share of the cost for health services, based on your Blue Cross health care plan. Get even more information by logging in to your account online. If you still have questions, please call the Customer Service number on the back of your ID card or your EOB and we ll help.

18 Added Blues value BlueHealthConnection With BlueHealthConnection, you have a wealth of health and wellness resources at your fingertips. BlueHealthConnection can help you get healthier, stay well and manage illness. BlueHealthConnection is available to you 24 hours a day, seven days a week by logging in to your account online. It gives you the latest information on health and wellness including: 24-Hour Nurse Line: Get answers to your most important health care questions with telephone support from registered nurses. Engagement Center : Specialists can answer all your BlueHealthConnection questions and enroll you in the appropriate programs. Calls are toll-free Monday through Saturday 8 a.m. to 8 p.m. Eastern Time. Case Management: You don t have to go through difficult medical issues alone. Our case management programs give you access to experts who can answer questions on conditions and treatments while providing the support and guidance you need. Complex Chronic Condition Management: Get the support you need to reduce costs and doctors visits and improve wellness as you manage chronic illness. Health Assessment: This online tool helps you take the first step toward total wellness. Once you have answered some basic questions about your health, you ll get a clearer picture of where you stand and how you can improve. Find it online Your Blues coverage comes with many free wellness programs, including a health assessment, health coaching and discounts. To get connected, go to bcbsm. com and click the Login. Then, click on the Health and Wellness tab at the top of the screen. From there, you can click on BlueHealthConnection to access your health assessment, coaching programs and other features. Online health resources: You can find more than 90,000 medically-reviewed resources in a number of formats including: libraries, encyclopedias and dictionaries. Videos, calculators, podcasts and animations Decision-making guides and interactive quizzes Where to find more information For more information on any of the above programs, contact the BlueHealthConnection Engagement Center at or via TTY at (Monday through Saturday, 8 a.m. to 8 p.m. Eastern Time). TTY callers should start by dialing 711.

19 Healthy Blue Xtras SM Healthy Blue Xtras makes it easier and less expensive to get the balanced lifestyle you deserve. Enjoy exclusive savings on healthy products and services from Michigan companies. Food and nutrition: Take advantage of great savings at local grocery stores for nutritious meals. Health and fitness: Enjoy a massage at 20 percent off and save on fitness club memberships, classes and consultations. Home and garden: Get discounts on plants, flowers and other products for your home. Travel: Pay less at top resorts and destinations for budget-friendly vacations and getaways. General: Shopping for a home? Looking for a home security system? Healthy Blue Xtras has savings for you. Recreation: Save on family activities and outings like golf and kayaking. Blue365 Find it online Visit bcbsm.com/xtras to view all of our offers and find out how to redeem them. Check back often for new deals. Through the Healthy Blue Xtras website, members can also find out about deals through Blue365, our national savings program. Blue365 features special weekly deals from national companies. A partnership with Healthways TM Fitness Your Way brings members exciting new offers on fitness and alternative medicine options nationwide. Members can access more than 8,000 fitness centers for only $25 a month plus a $25 enrollment fee and a three-month commitment. good for you. good for michigan. Daily coupons increase savings Healthy BlueXtras now offers daily online coupons that will help you save even more money. Go to bcbsm.cm/xtras and click on Daily Coupons to find coupons for healthy products from national companies like Dole, Gerber, Nature s Bounty, StarKist and more*. Click on the coupons you like, print them out** and redeem them at your local retailer. *Offers subject to change **Members need to download the coupon print activator the first time they print coupons.

20 Benefits at a Glance

21 The following section provides you with details of what your plan covers. Refer to this section for specifics about: Annual deductible Coinsurance or copayment Annual coinsurance or copayment maximum Annual out-of-pocket maximum Preventive services Physician office services Emergency and urgent care services Diagnostic and radiation services Maternity services Inpatient hospital care Surgical care Outpatient services and other benefits Organ transplantation Mental health and substance abuse treatment Prescription drugs (if applicable to your plan) Dental (if applicable to your plan) Vision (if applicable to your plan) Find it online You can view your specific benefits online. Go to bcbsm.com. Sign into your account click the My Coverage tab at the top of the screen.

22 Core PPO Plan Benefits-at-a-Glance Benteler In-Network Deductible, Copays, Coinsurance and Dollar Maximums Deductible - per calendar year $500 per member $1,000 per family Copays $30 copay for: Fixed Dollar Copays Office visits Chiropractic spinal manipulations $40 copay for: Urgent care services $125 copay for: Facility medical emergency Out-of-Network $1,000 per member $2,000 per family $125 copay for: Facility medical emergency Coinsurance Percent Coinsurance 10% 30% Note: Services without a network are covered at the in-network level. Out-of-Pocket Maximum Lifetime Maximum $2,500 per member $5,000 per family Includes Deductible, Coinsurance and Copays Benteler_ Group Number: Package Code(s):010 Section Code(s):1000, 1010, 1020, 1030, 1040, 1050 Unlimited $4,500 per member $9,000 per family Includes Coinsurance Preventive Services Health Maintenance Exam - one per calendar year Covered - 100% Not Covered Routine Physical Related Test Covered - 100% Not Covered X-Rays, EKG and lab procedures performed as part of the health maintenance exam Annual Gynecological Exam - two per calendar year, Covered - 100% Not Covered in addition to health maintenance exam Pap Smear Screening - one per calendar year Covered - 100% Not Covered Mammography Screening - one per calendar year Covered - 100% Not Covered Contraceptive Methods and Counseling Covered - 100% Prostate Specific Antigen (PSA) Screening - one per Covered - 100% Not Covered calendar year Endoscopic Exams - one per calendar year Covered - 100% Not Covered Well Child Care Covered - 100% Not Covered 6 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. Immunizations -pediatric and adult Covered - 100% Not Covered Physician Office Services Office Visits Covered - 100% after $30 copay R101314

23 In-Network Out-of-Network Emergency Medical Care Hospital Emergency Room Covered - 100% after $125 copay Covered - 100% after $125 copay Qualified medical emergency Non-Emergency use of the Emergency Room Not Covered Not Covered Urgent Care Services Covered - 100% after $40 copay Ambulance Services - Medically Necessary Transport Covered - 90% after deductible Covered - 90% after deductible Diagnostic Services MRI,MRA, PET and CAT Scans and Nuclear Covered - 90% after deductible Medicine Diagnostic Tests, X-rays, Laboratory & Pathology Covered - 90% after deductible Radiation Therapy and Chemotherapy Covered - 90% after deductible Maternity Services Provided by a Physician Prenatal and Postnatal Care Visits Covered - 100% Delivery and Nursery Care Covered - 90% after deductible Hospital Care Semi-Private Room, Inpatient Physician Care, General Covered - 90% after deductible Nursing Care, Hospital Services and Supplies Inpatient Medical Care Covered - 90% after deductible Alternatives to Hospital Care Hospice Care Covered - 90% after deductible Home Health Care Covered - 90% after deductible Skilled Nursing Limited to 90 days per calendar year Covered - 90% after deductible Surgical Services Surgery (includes related surgical services) Covered - 90% after deductible Sterilization - males only; excludes reversal sterilization Covered - 90% after deductible Sterilization - females only; Covered - 100% excludes reversal sterilization Human Organ Transplants Specified Organ Transplants in designated facilities Covered - 100% Not covered except in designated facilities only, when coordinated through BCBSM Human Organ Transplant Program ( ) Kidney, Cornea, Bone Marrow and Skin Covered - 90% after deductible Behavioral Health Care and Substance Abuse Treatment Services Inpatient Behavioral Health Care and Substance Abuse Covered - 90% after deductible Treatment Outpatient Behavioral Health Care and Substance Covered - 90% after deductible Abuse Treatment Other Services Cardiac Rehabilitation Covered - 90% after deductible Chiropractic Services Covered - 100% after $30 copay Limited to 24 visits per calendar year Durable Medical Equipment Covered - 90% after deductible Prosthetic and Orthotic Devices Covered - 90% after deductible Private Duty Nursing Covered - 90% after deductible Allergy Therapy and Testing Covered - 90% after deductible Benteler_ Group Number: Package Code(s):010 Section Code(s):1000, 1010, 1020, 1030, 1040, 1050 R101314

24 In-Network Out-of-Network Therapy Services Physical, Occupational and Speech Therapy Limited to 60 visits combined per calendar year Covered - 90% after deductible Note: The following services require preapproval: Inpatient Care, select Radiology Services, Inpatient Behavioral Health Care and Substance Abuse Treatment, and Skilled Nursing. Benteler_ Group Number: Package Code(s):010 Section Code(s):1000, 1010, 1020, 1030, 1040, 1050 R101314

25 Prescription Drugs Your prescription drug copays, including mail order copays, may be subject to the same annual out-of-pocket maximum required under your medical coverage. Retail- 30 day supply Retail and Mail Order - 90 day supply Oral and Injectable Contraceptives Retail and Mail Order Additional Services Smoking Cessation Drugs Weight Loss Drugs Impotency Drugs Infertility Drugs Diabetic Supplies $10 copay Generic drugs $40 copay Formulary brand name drugs $80 copay Non-Formulary brand name drugs Prescriptions and refills obtained from a non-network pharmacy are reimbursed at 75% of the approved amount, less the member s copay. $20 copay Generic drugs $80 copay Formulary brand name drugs $160 copay Non-Formulary brand name drugs Covered - 100% for Generic drugs; Brand name drugs are subject to the applicable copay/coinsurance Covered Covered Covered Covered Includes: Needles/Syringes and Insulin - $40 copay at retail; $80 copay at mail order Test Strips - $40 copay at retail; $80 copay at mail order Lancets - $40 copay at retail; $80 copay at mail order 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. If there is a discrepancy between this Benefits-at-a-Glance and any applicable plan document, the plan document will control. Benteler_ Group Number: Package Code(s):010 Section Code(s):1000, 1010, 1020, 1030, 1040, 1050 R101314

26 Enhanced PPO Plan Benefits-at-a-Glance Benteler In-Network Deductible, Copays, Coinsurance and Dollar Maximums Deductible - per calendar year $250 per member $500 per family Copays $20 copay for: Fixed Dollar Copays Office visits Chiropractic spinal manipulations $40 copay for: Urgent care services $125 copay for: Facility medical emergency Out-of-Network $500 per member $1,000 per family $125 copay for: Facility medical emergency Coinsurance Percent Coinsurance 10% 30% Note: Services without a network are covered at the in-network level. Out-of-Pocket Maximum Lifetime Maximum $1,500 per member $3,000 per family Includes Deductible, Coinsurance and Copays Benteler_ Group Number: Package Code(s):020 Section Code(s):1000, 1010, 1020, 1030, 1040, 1050 Unlimited $2,500 per member $5,000 per family Includes Coinsurance Preventive Services Health Maintenance Exam - one per calendar year Covered - 100% Not Covered Routine Physical Related Test Covered - 100% Not Covered X-Rays, EKG and lab procedures performed as part of the health maintenance exam Annual Gynecological Exam - two per calendar year, Covered - 100% Not Covered in addition to health maintenance exam Pap Smear Screening - one per calendar year Covered - 100% Not Covered Mammography Screening - one per calendar year Covered - 100% Not Covered Contraceptive Methods and Counseling Covered - 100% Prostate Specific Antigen (PSA) Screening - one per Covered - 100% Not Covered calendar year Endoscopic Exams - one per calendar year Covered - 100% Not Covered Well Child Care Covered - 100% Not Covered 6 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. Immunizations -pediatric and adult Covered - 100% Not Covered Physician Office Services Office Visits Covered - 100% after $20 copay R101314

27 In-Network Out-of-Network Emergency Medical Care Hospital Emergency Room Covered - 100% after $125 copay Covered - 100% after $125 copay Qualified medical emergency Non-Emergency use of the Emergency Room Not Covered Not Covered Urgent Care Services Covered - 100% after $40 copay Ambulance Services - Medically Necessary Transport Covered - 90% after deductible Covered - 90% after deductible Diagnostic Services MRI,MRA, PET and CAT Scans and Nuclear Covered - 90% after deductible Medicine Diagnostic Tests, X-rays, Laboratory & Pathology Covered - 90% after deductible Radiation Therapy and Chemotherapy Covered - 90% after deductible Maternity Services Provided by a Physician Prenatal and Postnatal Care Visits Covered - 100% Delivery and Nursery Care Covered - 90% after deductible Hospital Care Semi-Private Room, Inpatient Physician Care, General Covered - 90% after deductible Nursing Care, Hospital Services and Supplies No Maximum Inpatient Medical Care Covered - 90% after deductible Alternatives to Hospital Care Hospice Care Covered - 90% after deductible Home Health Care Covered - 90% after deductible Skilled Nursing Limited to 90 days per calendar year Covered - 90% after deductible Surgical Services Surgery (includes related surgical services) Covered - 90% after deductible Sterilization - males only; excludes reversal sterilization Covered - 90% after deductible Sterilization - females only; Covered - 100% excludes reversal sterilization Human Organ Transplants Specified Organ Transplants in designated facilities Covered - 100% Not covered except in designated facilities only, when coordinated through BCBSM Human Organ Transplant Program ( ) Kidney, Cornea, Bone Marrow and Skin Covered - 90% after deductible Behavioral Health Care and Substance Abuse Treatment Services Inpatient Behavioral Health Care and Substance Abuse Covered - 90% after deductible Treatment Outpatient Behavioral Health Care and Substance Covered - 90% after deductible Abuse Treatment Other Services Cardiac Rehabilitation Covered - 90% after deductible Chiropractic Services Covered - 100% after $20 copay Limited to 24 visits per calendar year Durable Medical Equipment Covered - 90% after deductible Prosthetic and Orthotic Devices Covered - 90% after deductible Private Duty Nursing Covered - 90% after deductible Allergy Therapy and Testing Covered - 90% after deductible Benteler_ Group Number: Package Code(s):020 Section Code(s):1000, 1010, 1020, 1030, 1040, 1050 R101314

28 In-Network Out-of-Network Therapy Services Physical, Occupational and Speech Therapy Limited to 60 visits combined per calendar year Covered - 90% after deductible Note: The following services require preapproval: Inpatient Care, select Radiology Services, Inpatient Behavioral Health Care and Substance Abuse Treatment, and Skilled Nursing. Benteler_ Group Number: Package Code(s):020 Section Code(s):1000, 1010, 1020, 1030, 1040, 1050 R101314

29 Prescription Drugs Your prescription drug copays, including mail order copays, may be subject to the same annual out-of-pocket maximum required under your medical coverage. Retail- 30 day supply Retail and Mail Order - 90 day supply Oral and Injectable Contraceptives Retail and Mail Order Additional Services Smoking Cessation Drugs Weight Loss Drugs Impotency Drugs Infertility Drugs Diabetic Supplies $10 copay Generic drugs $40 copay Formulary brand name drugs $80 copay Non-Formulary brand name drugs Prescriptions and refills obtained from a non-network pharmacy are reimbursed at 75% of the approved amount, less the member s copay. $20 copay Generic drugs $80 copay Formulary brand name drugs $160 copay Non-Formulary brand name drugs Covered - 100% for Generic drugs; Brand name drugs are subject to the applicable copay/coinsurance Covered Covered Covered Covered Includes: Needles/Syringes and Insulin - $40 copay at retail; $80 copay at mail order Test Strips - $40 copay at retail; $80 copay at mail order Lancets - $40 copay at retail; $80 copay at mail order 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. If there is a discrepancy between this Benefits-at-a-Glance and any applicable plan document, the plan document will control. Benteler_ Group Number: Package Code(s):020 Section Code(s):1000, 1010, 1020, 1030, 1040, 1050 R101314

30 HDHP PPO Plan Benefits-at-a-Glance Benteler In-Network Deductible, Copays, Coinsurance and Dollar Maximums Deductible - per calendar year $1,300 per member $2,600 per family Copays Fixed Dollar Copays $2,600 per member $5,200 per family Out-of-Network Coinsurance Percent Coinsurance 20% 40% Note: Services without a network are covered at the in-network level. Out-of-Pocket Maximum Lifetime Maximum $2,300 per member $4,600 per family Includes Deductible, Coinsurance and Copays Unlimited $4,600 per member $9,200 per family Includes Coinsurance Preventive Services Health Maintenance Exam - one per calendar year Covered - 100% Not Covered Routine Physical Related Test Covered - 100% Not Covered X-Rays, EKG and lab procedures performed as part of the health maintenance exam Annual Gynecological Exam - two per calendar year, Covered - 100% Not Covered in addition to health maintenance exam Pap Smear Screening - one per calendar year Covered - 100% Not Covered Mammography Screening - one per calendar year Covered - 100% Not Covered Contraceptive Methods and Counseling Covered - 100% Covered - 60% after deductible Prostate Specific Antigen (PSA) Screening - one per Covered - 100% Not Covered calendar year Endoscopic Exams - one per calendar year Covered - 100% Not Covered Well Child Care Covered - 100% Not Covered 6 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. Immunizations -pediatric and adult Covered - 100% Not Covered Physician Office Services Office Visits Covered - 80% after deductible Covered - 60% after deductible Benteler_ Group Number: Package Code(s):040, 050 Section Code(s):4000, 4010, 4020, 4030, 4040, 4050 R101314

31 Emergency Medical Care Hospital Emergency Room Covered - 80% after deductible Covered - 80% after deductible Qualified medical emergency Non-Emergency use of the Emergency Room Not Covered Not Covered Urgent Care Services Covered - 80% after deductible Covered - 60% after deductible Ambulance Services - Medically Necessary Transport Covered - 80% after deductible Covered - 80% after deductible Diagnostic Services MRI,MRA, PET and CAT Scans and Nuclear Covered - 80% after deductible Covered - 60% after deductible Medicine Diagnostic Tests, X-rays, Laboratory & Pathology Covered - 80% after deductible Covered - 60% after deductible Radiation Therapy and Chemotherapy Covered - 80% after deductible Covered - 60% after deductible Maternity Services Provided by a Physician Prenatal and Postnatal Care Visits Covered - 100% Covered - 60% after deductible Delivery and Nursery Care Covered - 80% after deductible Covered - 60% after deductible Hospital Care Semi-Private Room, Inpatient Physician Care, General Covered - 80% after deductible Covered - 60% after deductible Nursing Care, Hospital Services and Supplies No Maximum Inpatient Medical Care Covered - 80% after deductible Covered - 60% after deductible Alternatives to Hospital Care Hospice Care Covered - 80% after deductible Covered - 60% after deductible Home Health Care Covered - 80% after deductible Covered - 60% after deductible Skilled Nursing Limited to 90 days per calendar year Covered - 80% after deductible Covered - 60% after deductible Surgical Services Surgery (includes related surgical services) Covered - 80% after deductible Covered - 60% after deductible Sterilization - males only; excludes reversal sterilization Covered - 80% after deductible Covered - 60% after deductible Sterilization - females only; Covered - 100% Covered - 60% after deductible excludes reversal sterilization Human Organ Transplants Specified Organ Transplants in designated facilities Covered - 100% Not covered except in designated facilities only, when coordinated through BCBSM Human Organ Transplant Program ( ) Kidney, Cornea, Bone Marrow and Skin Covered - 80% after deductible Covered - 60% after deductible Behavioral Health Care and Substance Abuse Treatment Services Inpatient Behavioral Health Care and Substance Abuse Covered - 80% after deductible Treatment Outpatient Behavioral Health Care and Substance Covered - 80% after deductible Abuse Treatment Covered - 60% after deductible Covered - 60% after deductible Other Services Cardiac Rehabilitation Covered - 80% after deductible Covered - 60% after deductible Chiropractic Services Covered - 80% after deductible Covered - 60% after deductible Limited to 24 visits per calendar year Durable Medical Equipment Covered - 80% after deductible Covered - 60% after deductible Prosthetic and Orthotic Devices Covered - 80% after deductible Covered - 60% after deductible Private Duty Nursing Covered - 80% after deductible Covered - 60% after deductible Allergy Therapy and Testing Covered - 80% after deductible Covered - 60% after deductible Benteler_ Group Number: Package Code(s):040, 050 Section Code(s):4000, 4010, 4020, 4030, 4040, 4050 R101314

32 Therapy Services Physical, Occupational and Speech Therapy Limited to 60 visits combined per calendar year Covered - 80% after deductible Covered - 60% after deductible Note: The following services require preapproval: Inpatient Care, select Radiology Services, Inpatient Behavioral Health Care and Substance Abuse Treatment, and Skilled Nursing. Benteler_ Group Number: Package Code(s):040, 050 Section Code(s):4000, 4010, 4020, 4030, 4040, 4050 R101314

33 Prescription Drugs Your prescription drug copays, including mail order copays, may be subject to the same annual out-of-pocket maximum required under your medical coverage. Deductible Retail- 30 day supply Retail and Mail Order - 90 day supply Oral and Injectable Contraceptives Retail and Mail Order Additional Services Smoking Cessation Drugs Weight Loss Drugs Impotency Drugs Infertility Drugs Diabetic Supplies $1,300 per individual $2,600 per family 20% coinsurance for both generic and brand name drugs Prescriptions and refills obtained from a non-network pharmacy are reimbursed at 75% of the approved amount, less the member s copay. 20% coinsurance for both generic and brand name drugs Covered - 100% for Generic drugs; Brand name drugs are subject to the applicable copay/coinsurance Covered Covered Covered Covered Includes: Needles/Syringes and Insulin - 20% copay at retail; 20% copay at mail order Test Strips - 20% copay at retail; 20% copay at mail order Lancets - 20% copay at retail; 20% copay at mail order 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. If there is a discrepancy between this Benefits-at-a-Glance and any applicable plan document, the plan document will control. Benteler_ Group Number: Package Code(s):040, 050 Section Code(s):4000, 4010, 4020, 4030, 4040, 4050 R101314