MyPrioritySM. Individual & family health insurance plans

MyPrioritySM Individual & family health insurance plans

2 For more information call 855.MyPriority (855.697.7467)

Just right for you Choosing the right health insurance is an important decision. With several plans to choose from, an accident rider and dental options, you can have coverage that s geared to your lifestyle and budget. Priority Health makes it easy, with health insurance designed especially for you. priorityhealth.com 3

How MyPriority works for you Start by choosing a PPO or HSA plan. * MyPriority PPO Before you meet your Preventive health visits and procedures are covered in full* You ll pay just $30 every time you see a doctor or go to urgent care (up to four visits per year) Two options for prescription drug coverage - We ll cover of brand or generic or of generics only Your costs will track to separate s for in-network and out-of-network care* Once you meet your You ll pay just a portion of the discounted cost of covered services. The percentage depends on which plan you select.* Accident rider (optional coverage) We waive the, and you pay only 20% or 30% for covered services within 60 days of the accident (depending on the option you choose). * For full details on PPO options and rates see page 6 and page 12.

MyPriority HSA Make deposits to your HSA at any time Benefit from tax-deferred investment account Withdraw the cash tax-free now or later for qualified medical expenses Save ahead for future medical expenses with no use it or lose it rules Before you meet your Preventive health visits and procedures are 100% covered* You ll pay for your prescriptions and other health services using funds from your tax-advantaged health savings account You ll take advantage of our in-network discounts on prescriptions and other health services Once you meet your In-network services and prescriptions are covered 100%, and you ll have coverage for most out-of-network services. Accident rider (optional coverage) We cover the first for all covered services within 60 days of the accident. Get Answers Get your free copy of our e-book, Health Savings Accounts for Dummies. It s full of easy-tounderstand facts about HSAs. Download your copy online at priorityhealth.com, keyword search HSA. * For full details on HSA options and rates see pages 8 and 16. Apply today It s easy to enjoy the affordable security of MyPriority. Just pick your plan and complete the application. To learn more: Get an instant quote at priorityhealth.com Call us for more information toll-free at 855.MyPriority (855.697.7467) Contact your local agent

Overview of benefits MyPriority PPO Medical Brand/generic drug Medical Brand/generic drug Medical Generic drugs only Annual single in-network 1 family $2,500 $3,500 $7,000 $7,500 $15,000 $20,000 $2,500 $3,000 $6,000 Annual single out-of-network family $4,000 $7,000 $14,000 $20,000 $15,000 $30,000 $20,000 $40,000 $4,000 $4,000 $6,000 $12,000 Coinsurance Plan Pays: (unless otherwise noted) in-network out-of-network in-network out-of-network in-network out-of-network Annual in-network single out-of-pocket maximum 2 family $3,000 $6,000 $4,500 $9,000 $5,500 $11,000 $7,000 $14,000 $9,500 $19,000 $12,000 $24,000 $4,000 $8,000 $6,500 $13,000 $3,000 $6,000 $9,000 $18,000 Annual out-of-network single out-of-pocket maximum 2 family $20,000 $13,000 $26,000 $15,000 $30,000 $18,000 $36,000 $23,000 $46,000 $28,000 $56,000 $12,000 $24,000 $15,000 $30,000 $12,000 $24,000 $16,000 $32,000 Annual benefit maximum (for in and out-of-network services combined) $2 million $2 million $2 million Benefit What you pay Preventive care 3 $0; 100% covered $0; 100% covered $0; 100% covered Doctor's office visits 4 $30 copay before $30 copay before $30 copay before Urgent care 4 Emergency room 5 $150 copay 30% coinsurance in-network after 30% coinsurance out-of-network after $150 copay 30% coinsurance in-network after 30% coinsurance out-ofnetwork after $150 copay 40% in-network coinsurance after 40% out-of-network coinsurance after Ambulance 30% coinsurance in-network after 30% coinsurance out-of-network after 30% coinsurance in-network after 30% coinsurance out-ofnetwork after 40% in-network coinsurance after 40% out-of-network coinsurance after Outpatient lab/x-ray 20% coinsurance in-network after Outpatient surgery 40% coinsurance out-of-network after Hospitalization Outpatient speech therapy 6 30% coinsurance in-network after coinsurance out-ofnetwork after 30% coinsurance in-network after coinsurance out-ofnetwork after Outpatient occupational therapy 6 Outpatient physical therapy/ spinal manipulation 6 Cardiac rehab 6 Skilled nursing; Subacute; Inpatient rehab; Hospice 7 Home health care 8 Substance abuse 9 Dietitian services 10 6 For more information call 855.MyPriority (855.697.7467)

DME; P&O 11 coinsurance after coinsurance after coinsurance after Prescription drug coverage 12 40% copay for generics and brand drugs before Includes oral contraceptives 40% copay for generics and brand drugs before Includes oral contraceptives Generic drugs covered at before Includes oral contraceptives Brands at Priority Health discounted price before Medical specialty drugs 13 20% coinsurance in-network after 40% coinsurance out-of network after 30% coinsurance in-network after coinsurance out-ofnetwork after coinsurance after Transplants 14 At designated transplant facility At designated transplant facility At designated transplant facility Optional coverage Accident rider 15 20% coinsurance in-network before 40% coinsurance out-of-network before 30% coinsurance in-network before coinsurance out-ofnetwork before 30% coinsurance in-network before coinsurance out-ofnetwork before MyPriority Dental MyPriority Dental Pro (see page 10 for details) No network required Annual : $50 per person, $150 per family up to three members Orthodontic services Not covered (for all options) Certain surgeries bariatric surgery, blepharoplasty of upper eyelids, breast reduction, panniculectomy, surgical treatment of male gynecomastia and procedures to correct obstructive sleep apnea. Family planning/infertility services vasectomy, tubal litigation, diaphragm, infertility counseling and treatment of underlying cause of infertility TMJ, port wine stains, orthognathic surgery 90-day waiting period (for all options) Surgeries subject to the 90 day waiting period include: Tonsillectomy, Adenoidectomy, Hemorrhoidectomy, Hysterectomy and Bunionectomy, Surgical treatment of the following conditions are also subject to the 90 day waiting period: Cystocele, Enterocele, Rectocele, Urethrocele, Uterine Prolapse, Inguinal Hernia (other than strangulated or incarcerated), Carpal Tunnel Syndrome and Varicose Veins. Pre-existing condition exclusion Benefits will be excluded for each Illness or Injury or condition not disclosed on the application, for which, during the six month period prior to the effective date, medical advice, diagnosis, care or treatment recommended by or received from a Health Professional. For purposes of this limitation, treatment includes the use of prescription drugs. This Pre-Existing Condition exclusion will apply until the end of the twelve month period beginning on the effective date under the policy. The Pre-Existing Condition exclusion does not apply to a newborn who becomes a Covered Dependent under this Policy within 31 days after the birth. 1 Family may be met collectively by 2 or more individuals in the family 2 Excludes copays, includes coinsurance and 3 Within Priority Health Preventive Health Care Guidelines 4 4 combined visits per member annually after the 4 visits, covered charges apply towards and coinsurance. 5 Copay waived if admitted within 24 hours 6 $3,000 combined annual max per member 7 60-day combined annual max per member 8 60 visits annual max per member 9 Up to the state-mandated benefit 10 6 visits per member per year 11 max per member each year for in-network services; max per member each year for out-of-network services 12 These expenses do not go towards your or out-of-pocket maximum. 13 $25,000 maximum per member each year for services received out-of-network 14,000 maximum 15 For services incurred within 60-days of the injury. After the 60-days the will be applied to any covered charges. *For complete plan details go to priorityhealth.com priorityhealth.com 7

Overview of benefits MyPriority HSA Annual single in-network 1 family $4,000 $4,000 $8,000 Annual single out-of-network 1 family $4,000 $8,000 $8,000 $16,000 Annual in-network single out-of-pocket maximum 2 family $4,000 $4,000 $8,000 Annual out-of-network single out-of-pocket maximum 2 family $9,000 $18,000 $13,000 $26,000 Annual benefit maximum (for in and out-of-network services combined) $2 million Benefit In-network Out-of-network Preventive care 3 $0; 100% covered Not covered After the is met the plan pays In-network Out-of-network Doctor's office visits 100% Urgent care 100% Emergency room 100% 100% Ambulance 100% 100% Outpatient lab/x-ray 100% Outpatient surgery Hospitalization Outpatient speech therapy 4 Outpatient occupational therapy 4 Outpatient physical therapy/ spinal manipulation 4 Cardiac rehab 4 Skilled nursing; Subacute; Inpatient rehab; Hospice 5 Home health care 6 Substance abuse Dietician services 7 DME; P&O 8 Prescription drug coverage 100% Includes oral contraceptives Not covered $20,000 $15,000 $30,000 8 For more information call 855.MyPriority (855.697.7467)

Medical specialty drugs 9 100% Transplants 10 100% Optional coverage Accident rider Priority Health will pay the first for all covered expenses incurred within 60 days of an injury. After the or 60 days (whichever comes first) covered charges will apply towards the. MyPriority Dental MyPriority Dental Pro (see page 10 for details) No network required Annual : $50 per person, $150 per family up to three members Orthodontic services Waiting period Pre-existing condition exclusion Benefits will be excluded for each Illness or Injury or condition not disclosed on the application, for which, during the six month period prior to the effective date, medical advice, diagnosis, care or treatment recommended by or received from a Health Professional. For purposes of this limitation, treatment includes the use of prescription drugs. This Pre-Existing Condition exclusion will apply until the end of the twelve month period beginning on the effective date under the policy. The Pre-Existing Condition exclusion does not apply to a newborn who becomes a Covered Dependent under this Policy within 31 days after the birth. Surgeries subject to the 90 day waiting period include: Tonsillectomy, Adenoidectomy, Hemorrhoidectomy, Hysterectomy and Bunionectomy, Surgical treatment of the following conditions are also subject to the 90 day waiting period: Cystocele, Enterocele, Rectocele, Urethrocele, Uterine Prolapse, Inguinal Hernia (other than strangulated or incarcerated), Carpal Tunnel Syndrome and Varicose Veins. Not covered Certain surgeries bariatric surgery, blepharoplasty of upper eyelids, breast reduction, panniculectomy, surgical treatment of male gynecomastia and procedures to correct obstructive sleep apnea Family planning/infertility services vasectomy, tubal ligation, diaphragm, infertility counseling and treatment of underlying cause of infertility TMJ, port wine stains, orthognathic surgery *For complete plan details go to priorityhealth.com 1 The family may be met by 1 or more individuals in the family 2 Includes and coinsurance 3 Within Priority Health Preventive Health Care Guidelines 4 30 visits combined for in and out-of-network services maximum per member each year 5 60-day combined for in and out-of-network services annual max per member 6 60-visits max per member each year 7 6 visits per member each year 8 max per member each year for in-network services; max per member each year for out-of-network services 9 $25,000 maximum per member each year for services received out-of-network 10 At designated transplant facility priorityhealth.com 9

Overview of benefits MyPriority Dental & Dental Pro MyPriority Dental $26.97 per person per month MyPriority Dental Pro $36.41 per person per month Deductibles and maximums Annual Annual benefit maximum $50 per person on the plan, $150 per family up to three members per person on the plan None $1,500 per person on the plan Benefit category Plan pays Member pays Plan pays Member pays Class I Preventive services Includes exams, cleanings, and fluoride treatments. (Cleanings, exams: limit two per year and fluoride treatment: limit one per year) 100% 0% 100% 0% Emergency palliative treatment used to temporarily relieve pain 20% 20% X-rays (limit one per year) 20% 20% Sealants dental sealants to prevent decay of permanent molars (to age nine on first molars and age 14 on second molars, limit one per lifetime). 20% 20% Class II Minor restorative services (six month waiting period) Oral surgery services extractions and dental surgery, including preoperative and postoperative care Minor restorative services used to repair teeth damaged by disease or injury (for example, amalgam [silver] fillings) Class III Major restorative services (six month waiting period) Endodontics used to treat teeth with diseased or damaged nerves (root canals for example) Periodontics used to treat diseases of the gums and supporting structures of the teeth. Bridges Dentures Implants Crowns Class IV Orthodontic services after after after after after after after after 75% 25% 75% 25% Orthodontic diagnostic procedures (to age 19) 0% 0% Orthodontic services benefit maximum $0 no separate benefit maximum for orthodontic services $1,500 per person per lifetime Each plan pays 85% for covered procedures based on the reasonable and customary fee schedule. Additional limitations may apply for certain services. 10 For more information call 855.MyPriority (855.697.7467)

6 insurance terms you should know Before, the trivial details of insurance didn t matter. Now you need to know. We make it easy. 1. Copayment: The amount you pay for specific medical services and prescriptions covered by the plan. 2. Coinsurance: The cost of treatment shared between you and Priority Health. This is usually calculated as a percentage of the total cost. Often coinsurance applies only after you meet your. 3. Coverage: With MyPriority, you re covered. Your coverage is what we ll pay for. 4. Deductible: The amount you pay per plan year before Priority Health starts paying. 5. In-network: MyPriority has doctors, hospitals, pharmacies and other care providers that charge Priority Health members a special discounted rate. You ll save, too, if you use our network. 6. Urgent care: If you can t see your regular doctor, urgent care centers and walk-in centers are usually your best choice. (You ll pay $30 for each visit up to four visits.) Save money You ll save on monthly premiums if you choose higher s. priorityhealth.com 11

Preferred premiums MyPriority PPO Medical Brand/generic drug Counties: Kalamazoo, Lenawee, Livingston, Macomb, Monroe, Oakland, Oceola, St. Clair, Washtenaw, Wayne Medical Brand/generic drug Medical Generic drugs only Deductibles Single (in-network) Family $2,500 $3,500 $7,000 $7,500 $15,000 $20,000 $2,500 $5,=00 $3,000 $6,000 Coinsurance in-network out-of-network Male 0-25 dependents $107.00 $84.00 $75.00 $65.00 $49.00 $43.00 $100.00 $78.00 $93.00 $67.00 0-18 110.00 86.00 77.00 67.00 50.00 44.00 103.00 80.00 96.00 69.00 19-24 116.00 91.00 81.00 70.00 53.00 46.00 109.00 84.00 101.00 72.00 25-29 131.00 103.00 92.00 79.00 59.00 52.00 123.00 95.00 108.00 77.00 30-34 149.00 118.00 105.00 91.00 68.00 59.00 140.00 108.00 117.00 84.00 35-39 177.00 139.00 124.00 107.00 80.00 70.00 166.00 128.00 138.00 99.00 40-44 204.00 161.00 143.00 124.00 93.00 81.00 192.00 148.00 160.00 115.00 45-49 252.00 198.00 176.00 152.00 114.00 100.00 236.00 182.00 197.00 141.00 50-54 319.00 251.00 224.00 193.00 145.00 127.00 299.00 231.00 250.00 179.00 55-59 394.00 310.00 276.00 239.00 179.00 157.00 370.00 285.00 309.00 221.00 60-64 482.00 379.00 338.00 292.00 219.00 191.00 452.00 349.00 378.00 271.00 Accident rider $4.00 $8.00 $10.00 $12.00 $14.00 $16.00 $4.00 $8.00 $4.00 $6.00 MyPriority Dental $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 MyPriority Dental Pro $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 Female 0-25 dependents $107.00 $84.00 $75.00 $65.00 $49.00 $43.00 $100.00 $78.00 $93.00 $67.00 0-18 110.00 86.00 77.00 67.00 50.00 44.00 103.00 80.00 96.00 69.00 19-24 116.00 91.00 81.00 70.00 53.00 46.00 109.00 84.00 101.00 72.00 25-29 143.00 112.00 100.00 86.00 65.00 57.00 134.00 103.00 118.00 84.00 30-34 172.00 135.00 120.00 104.00 78.00 68.00 161.00 124.00 135.00 96.00 35-39 227.00 178.00 159.00 137.00 103.00 90.00 212.00 164.00 178.00 127.00 40-44 269.00 212.00 188.00 163.00 122.00 107.00 252.00 195.00 211.00 151.00 45-49 314.00 247.00 220.00 190.00 143.00 125.00 295.00 228.00 246.00 176.00 50-54 361.00 284.00 253.00 218.00 164.00 143.00 338.00 261.00 283.00 203.00 55-59 422.00 332.00 295.00 255.00 192.00 168.00 395.00 305.00 330.00 237.00 60-64 496.00 391.00 348.00 301.00 226.00 197.00 465.00 359.00 389.00 279.00 Accident rider $6.00 $10.00 $12.00 $16.00 $18.00 $20.00 $6.00 $10.00 $4.00 $8.00 MyPriority Dental $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 MyPriority Dental Pro $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 * When you age into the next age bracket, your premiums will be adjusted at your annual renewal. * If you move to a county that is in a different premium table, your premiums will be adjusted on the next billing cycle after you have notified us of your address change. 12 For more information call 855.MyPriority (855.697.7467)

Preferred premiums MyPriority PPO Medical Brand/generic drug Medical Brand/generic drug Counties: Jackson, Hillsdale Medical Generic drugs only Deductibles Single (in-network) Family $2,500 $3,500 $7,000 $7,500 $15,000 $20,000 $2,500 $3,000 $6,000 Coinsurance in-network out-of-network Male 0-25 dependents $102.00 $81.00 $72.00 $62.00 $46.00 $41.00 $96.00 $74.00 $89.00 $64.00 0-18 105.00 83.00 73.00 63.00 48.00 42.00 98.00 76.00 91.00 65.00 19-24 111.00 87.00 78.00 67.00 50.00 44.00 104.00 80.00 96.00 69.00 25-29 125.00 98.00 87.00 76.00 57.00 50.00 117.00 90.00 103.00 74.00 30-34 143.00 112.00 100.00 86.00 65.00 57.00 134.00 103.00 112.00 80.00 35-39 169.00 133.00 118.00 102.00 77.00 67.00 158.00 122.00 132.00 95.00 40-44 195.00 153.00 137.00 118.00 89.00 77.00 183.00 141.00 153.00 109.00 45-49 240.00 189.00 168.00 146.00 109.00 95.00 225.00 174.00 188.00 135.00 50-54 305.00 240.00 213.00 185.00 139.00 121.00 286.00 221.00 239.00 171.00 55-59 376.00 296.00 264.00 228.00 171.00 149.00 353.00 272.00 295.00 211.00 60-64 460.00 362.00 322.00 279.00 209.00 183.00 431.00 333.00 360.00 258.00 Accident rider $4.00 $8.00 $10.00 $12.00 $14.00 $16.00 $4.00 $8.00 $4.00 $6.00 MyPriority Dental $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 MyPriority Dental Pro $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 Female 0-25 dependents $102.00 $81.00 $72.00 $62.00 $46.00 $41.00 $96.00 $74.00 $89.00 $64.00 0-18 105.00 83.00 73.00 63.00 48.00 42.00 98.00 76.00 91.00 65.00 19-24 111.00 87.00 78.00 67.00 50.00 44.00 104.00 80.00 96.00 69.00 25-29 136.00 107.00 95.00 82.00 62.00 54.00 128.00 99.00 112.00 80.00 30-34 164.00 129.00 115.00 99.00 75.00 65.00 154.00 119.00 129.00 92.00 35-39 216.00 170.00 152.00 131.00 98.00 86.00 203.00 157.00 169.00 121.00 40-44 257.00 202.00 180.00 155.00 117.00 102.00 241.00 186.00 201.00 144.00 45-49 300.00 236.00 210.00 182.00 136.00 119.00 281.00 217.00 235.00 168.00 50-54 344.00 271.00 241.00 209.00 157.00 137.00 323.00 249.00 270.00 193.00 55-59 403.00 317.00 282.00 244.00 183.00 160.00 378.00 292.00 315.00 226.00 60-64 474.00 373.00 332.00 287.00 215.00 188.00 444.00 343.00 371.00 266.00 Accident rider $6.00 $10.00 $12.00 $14.00 $16.00 $18.00 $4.00 $8.00 $4.00 $8.00 MyPriority Dental $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 MyPriority Dental Pro $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 * When you age into the next age bracket, your premiums will be adjusted at your annual renewal. * If you move to a county that is in a different premium table, your premiums will be adjusted on the next billing cycle after you have notified us of your address change. priorityhealth.com 13

Preferred premiums MyPriority PPO Medical Brand/generic drug Counties: Allegan, Arenac, Barry, Bay, Berrien, Branch, Calhoun, Cass, Clare, Clinton, Eaton, Genesee, Gladwin, Gratiot, Huron, Ingham, Ionia, Isabella, Kent, Lake, Lapeer, Mason, Mecosta, Midland, Montcalm, Muskegon, Newaygo, Oceana, Oceola, Ottawa, Saginaw, St. Joseph, Sanilac, Shiawasee, Tuscola, Van Buren Medical Brand/generic drug Medical Generic drugs only Deductibles Single (in-network) Family $2,500 $3,500 $7,000 $7,500 $15,000 $20,000 $2,500 $3,000 $6,000 Coinsurance in-network out-of-network Male 0-25 dependents $98.00 $77.00 $69.00 $59.00 $44.00 $39.00 $92.00 $71.00 $85.00 $61.00 0-18 100.00 79.00 70.00 61.00 46.00 40.00 94.00 73.00 87.00 63.00 19-24 106.00 83.00 74.00 64.00 48.00 42.00 99.00 77.00 92.00 66.00 25-29 120.00 94.00 84.00 72.00 54.00 47.00 112.00 87.00 99.00 71.00 30-34 137.00 107.00 96.00 83.00 62.00 54.00 128.00 99.00 107.00 77.00 35-39 161.00 127.00 113.00 98.00 73.00 64.00 151.00 117.00 126.00 91.00 40-44 187.00 147.00 131.00 113.00 85.00 74.00 175.00 135.00 146.00 105.00 45-49 230.00 181.00 161.00 139.00 105.00 91.00 216.00 167.00 180.00 129.00 50-54 292.00 230.00 204.00 177.00 133.00 116.00 273.00 211.00 228.00 164.00 55-59 360.00 284.00 252.00 218.00 164.00 143.00 338.00 261.00 282.00 202.00 60-64 440.00 347.00 308.00 267.00 200.00 175.00 413.00 319.00 345.00 247.00 Accident rider $4.00 $8.00 $10.00 $10.00 $12.00 $14.00 $4.00 $6.00 $4.00 $6.00 MyPriority Dental $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 MyPriority Dental Pro $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 Female 0-25 dependents $98.00 $77.00 $69.00 $59.00 $44.00 $39.00 $92.00 $71.00 $85.00 $61.00 0-18 100.00 79.00 70.00 61.00 46.00 40.00 94.00 73.00 87.00 63.00 19-24 106.00 83.00 74.00 64.00 48.00 42.00 99.00 77.00 92.00 66.00 25-29 130.00 103.00 91.00 79.00 59.00 52.00 122.00 94.00 107.00 77.00 30-34 157.00 124.00 110.00 95.00 71.00 62.00 147.00 114.00 123.00 88.00 35-39 207.00 163.00 145.00 125.00 94.00 82.00 194.00 150.00 162.00 116.00 40-44 246.00 193.00 172.00 149.00 112.00 98.00 230.00 178.00 192.00 138.00 45-49 287.00 226.00 201.00 174.00 130.00 114.00 269.00 208.00 225.00 161.00 50-54 330.00 259.00 231.00 200.00 150.00 131.00 309.00 239.00 258.00 185.00 55-59 385.00 303.00 270.00 233.00 175.00 153.00 361.00 279.00 302.00 216.00 60-64 454.00 357.00 318.00 275.00 206.00 180.00 425.00 328.00 355.00 255.00 Accident rider $4.00 $10.00 $12.00 $14.00 $16.00 $18.00 $4.00 $8.00 $4.00 $8.00 MyPriority Dental $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 MyPriority Dental Pro $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 * When you age into the next age bracket, your premiums will be adjusted at your annual renewal. * If you move to a county that is in a different premium table, your premiums will be adjusted on the next billing cycle after you have notified us of your address change. 14 For more information call 855.MyPriority (855.697.7467)

Preferred premiums MyPriority PPO Deductibles Single (in-network) Family Medical Brand/generic drug $2,500 $3,500 $7,000 Counties: Alcona, Alger, Alpena, Antrim, Baraga, Benzie, Charlevoix, Cheboygan, Chippewa, Crawford, Delta, Dickinson, Emmet, Gogebic, Grand Traverse, Houghton, Iosco, Iron, Kalkaska, Keweenaw, Leelanau, Luce, Mackinac, Manistee, Marquette, Menominee, Missaukee, Montmorency, Ogemaw, Ontonagon, Oscoda, Otsego, Presque Isle, Roscommon, Schoolcraft, Wexford $7,500 $15,000 $20,000 Medical Brand/generic drug $2,500 Medical Generic drugs only $3,000 $6,000 Coinsurance in-network out-of-network Male 0-25 dependents $93.00 $73.00 $65.00 $56.00 $42.00 $37.00 $87.00 $67.00 $81.00 $58.00 0-18 95.00 75.00 66.00 57.00 43.00 38.00 89.00 69.00 83.00 59.00 19-24 100.00 79.00 70.00 61.00 46.00 40.00 94.00 73.00 87.00 62.00 25-29 113.00 89.00 79.00 68.00 51.00 45.00 106.00 82.00 93.00 67.00 30-34 129.00 102.00 90.00 78.00 59.00 51.00 121.00 93.00 101.00 72.00 35-39 153.00 120.00 107.00 92.00 69.00 61.00 143.00 110.00 119.00 86.00 40-44 176.00 139.00 124.00 107.00 80.00 70.00 165.00 128.00 138.00 99.00 45-49 217.00 171.00 152.00 132.00 99.00 86.00 204.00 157.00 170.00 122.00 50-54 276.00 217.00 193.00 167.00 125.00 110.00 259.00 200.00 216.00 155.00 55-59 340.00 268.00 238.00 206.00 155.00 135.00 319.00 246.00 267.00 191.00 60-64 416.00 328.00 292.00 252.00 189.00 165.00 390.00 301.00 326.00 234.00 Accident rider $4.00 $8.00 $8.00 $10.00 $12.00 $14.00 $4.00 $6.00 $4.00 $6.00 MyPriority Dental $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 MyPriority Dental Pro $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 Female 0-25 dependents $93.00 $73.00 $65.00 $56.00 $42.00 $37.00 $87.00 $67.00 $81.00 $58.00 0-18 95.00 75.00 66.00 57.00 43.00 38.00 89.00 69.00 83.00 59.00 19-24 100.00 79.00 70.00 61.00 46.00 40.00 94.00 73.00 87.00 62.00 25-29 123.00 97.00 86.00 75.00 56.00 49.00 115.00 89.00 102.00 73.00 30-34 148.00 117.00 104.00 90.00 67.00 59.00 139.00 107.00 116.00 83.00 35-39 196.00 154.00 137.00 119.00 89.00 78.00 184.00 142.00 153.00 110.00 40-44 232.00 183.00 163.00 141.00 106.00 92.00 218.00 168.00 182.00 130.00 45-49 271.00 214.00 190.00 164.00 123.00 108.00 254.00 196.00 213.00 152.00 50-54 312.00 245.00 218.00 189.00 142.00 124.00 292.00 226.00 244.00 175.00 55-59 364.00 287.00 255.00 221.00 166.00 145.00 342.00 264.00 285.00 205.00 60-64 429.00 338.00 300.00 260.00 195.00 170.00 402.00 310.00 336.00 241.00 Accident rider $4.00 $8.00 $10.00 $14.00 $16.00 $18.00 $4.00 $8.00 $4.00 $8.00 MyPriority Dental $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 $26.97 MyPriority Dental Pro $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 $36.41 * When you age into the next age bracket, your premiums will be adjusted at your annual renewal. * If you move to a county that is in a different premium table, your premiums will be adjusted on the next billing cycle after you have notified us of your address change. priorityhealth.com 15

Preferred premiums MyPriority HSA Counties: Kalamazoo, Lenawee, Livingston, Macomb, Monroe, Oakland, St. Clair, Washtenaw, Wayne Counties: Jackson, Hillsdale Deductible In-network Single $4,000 Family $4,000 Single $8,000 Family Single Family Deductible In-network Single $4,000 Family $4,000 Single $8,000 Family Single Family Male Male 0-25 dependents $83.00 $64.00 $58.00 0-25 dependents $79.00 $61.00 $56.00 0-18 85.00 65.00 60.00 0-18 81.00 62.00 57.00 19-24 90.00 69.00 63.00 19-24 86.00 66.00 60.00 25-29 101.00 78.00 71.00 25-29 97.00 74.00 68.00 30-34 116.00 89.00 82.00 30-34 110.00 85.00 78.00 35-39 137.00 105.00 96.00 35-39 131.00 100.00 92.00 40-44 158.00 121.00 111.00 40-44 151.00 116.00 106.00 45-49 195.00 149.00 137.00 45-49 186.00 143.00 131.00 50-54 247.00 190.00 174.00 50-54 236.00 181.00 166.00 55-59 305.00 234.00 215.00 55-59 291.00 223.00 205.00 60-64 373.00 286.00 263.00 60-64 356.00 273.00 251.00 Accident rider $4.00 $2.00 $2.00 Accident rider $4.00 $2.00 $2.00 MyPriority Dental $26.97 $26.97 $26.97 MyPriority Dental Pro $36.41 $36.41 $36.41 Female MyPriority Dental $26.97 $26.97 $26.97 MyPriority Dental Pro $36.41 $36.41 $36.41 Female 0-25 dependents $83.00 $64.00 $58.00 0-25 dependents $79.00 $61.00 $56.00 0-18 85.00 65.00 60.00 0-18 81.00 62.00 57.00 19-24 90.00 69.00 63.00 19-24 86.00 66.00 60.00 25-29 110.00 85.00 78.00 25-29 105.00 81.00 74.00 30-34 133.00 102.00 94.00 30-34 127.00 97.00 90.00 35-39 175.00 135.00 124.00 35-39 168.00 128.00 118.00 40-44 208.00 160.00 147.00 40-44 199.00 152.00 140.00 45-49 243.00 187.00 171.00 45-49 232.00 178.00 164.00 50-54 279.00 214.00 197.00 50-54 267.00 204.00 188.00 55-59 327.00 250.00 230.00 55-59 312.00 239.00 220.00 60-64 384.00 295.00 271.00 60-64 367.00 281.00 259.00 Accident rider $4.00 $4.00 $4.00 Accident rider $4.00 $4.00 $4.00 MyPriority Dental $26.97 $26.97 $26.97 MyPriority Dental Pro $36.41 $36.41 $36.41 MyPriority Dental $26.97 $26.97 $26.97 MyPriority Dental Pro $36.41 $36.41 $36.41 * When you age into the next age bracket, your premiums will be adjusted at your annual renewal. * If you move to a county that is in a different premium table, your premiums will be adjusted on the next billing cycle after you have notified us of your address change. 16 For more information call 855.MyPriority (855.697.7467)

Preferred premiums MyPriority HSA Counties: Allegan, Arenac, Barry, Bay, Berrien, Branch, Calhoun, Cass, Clare, Clinton, Eaton, Genesee, Gladwin, Gratiot, Huron, Ingham, Ionia, Isabella, Kent, Lake, Lapeer, Mason, Mecosta, Midland, Montcalm, Muskegon, Newaygo, Oceana, Oceola, Ottawa, Saginaw, St. Joseph, Sanilac, Shiawasee, Tuscola, Van Buren Counties: Alcona, Alger, Alpena, Antrim, Baraga, Benzie, Charlevoix, Cheboygan, Chippewa, Crawford, Delta, Dickinson, Emmet, Gogebic, Grand Traverse, Houghton, Iosco, Iron, Kalkaska, Keweenaw, Leelanau, Luce, Mackinac, Manistee, Marquette, Menominee, Missaukee, Montmorency, Ogemaw, Ontonagon, Oceola, Oscoda, Otsego, Presque Isle, Roscommon, Schoolcraft, Wexford Deductible In-network Single $4,000 Family $4,000 Single $8,000 Family Single Family Deductible In-network Single $4,000 Family $4,000 Single $8,000 Family Single Family Male Male 0-25 dependents $76.00 $58.00 $53.00 0-25 dependents $72.00 $55.00 $50.00 0-18 78.00 60.00 55.00 0-18 73.00 56.00 52.00 19-24 82.00 63.00 58.00 19-24 78.00 59.00 55.00 25-29 93.00 71.00 65.00 25-29 87.00 67.00 62.00 30-34 106.00 81.00 74.00 30-34 100.00 77.00 70.00 35-39 125.00 96.00 88.00 35-39 118.00 91.00 83.00 40-44 145.00 111.00 102.00 40-44 137.00 105.00 96.00 45-49 178.00 137.00 126.00 45-49 168.00 129.00 119.00 50-54 226.00 173.00 159.00 50-54 213.00 164.00 150.00 55-59 279.00 214.00 196.00 55-59 264.00 202.00 186.00 60-64 341.00 261.00 240.00 60-64 322.00 247.00 227.00 Accident rider $4.00 $2.00 $2.00 Accident rider $4.00 $2.00 $2.00 MyPriority Dental $26.97 $26.97 $26.97 MyPriority Dental Pro $36.41 $36.41 $36.41 Female MyPriority Dental $26.97 $26.97 $26.97 MyPriority Dental Pro $36.41 $36.41 $36.41 Female 0-25 dependents $76.00 $58.00 $53.00 0-25 dependents $72.00 $55.00 $50.00 0-18 78.00 60.00 55.00 0-18 73.00 56.00 52.00 19-24 82.00 63.00 58.00 19-24 78.00 59.00 55.00 25-29 101.00 77.00 71.00 25-29 95.00 73.00 67.00 30-34 122.00 93.00 86.00 30-34 115.00 88.00 81.00 35-39 160.00 123.00 113.00 35-39 152.00 116.00 107.00 40-44 190.00 146.00 134.00 40-44 180.00 138.00 127.00 45-49 222.00 170.00 157.00 45-49 210.00 161.00 148.00 50-54 255.00 196.00 180.00 50-54 241.00 185.00 170.00 55-59 298.00 229.00 210.00 55-59 282.00 216.00 199.00 60-64 351.00 269.00 247.00 60-64 332.00 255.00 234.00 Accident rider $4.00 $4.00 $4.00 Accident rider $4.00 $4.00 $4.00 MyPriority Dental $26.97 $26.97 $26.97 MyPriority Dental Pro $36.41 $36.41 $36.41 MyPriority Dental $26.97 $26.97 $26.97 MyPriority Dental Pro $36.41 $36.41 $36.41 * When you age into the next age bracket, your premiums will be adjusted at your annual renewal. * If you move to a county that is in a different premium table, your premiums will be adjusted on the next billing cycle after you have notified us of your address change. priorityhealth.com 17

18 For more information call 855.MyPriority (855.697.7467)

We have plans for everyone Priority Health provides you with health insurance choices to meet your needs the easy, affordable way. MyPriority PPO & MyPriority HSA Comprehensive, affordable coverage for individuals and families. Includes preventive coverage. An accident rider or dental may be purchased separately. MyPriority Short-term Basic one-six month coverage that protects you and your family when you re changing jobs or recently unemployed. To learn more: Get an instant quote at priorityhealth.com Call us for more information toll-free at 855.MyPriority (855.697.7467) Contact your local agent priorityhealth.com 19

Priority Health is a nationally recognized, health benefits company that has been providing access to affordable health care for more than 20 years. Visit us online at priorityhealth.com. 2012 Priority Health PH763 6777R 08/12