BLUE CROSS® PHYSICIAN CHOICE PPO GROUP BENEFITS CERTIFICATE SG (For Small, Insured Group Customers)

BLUE CROSS® PHYSICIAN CHOICE PPO GROUP BENEFITS CERTIFICATE SG (for small, insured group customers) © 2018 Blue Cross Blue Shield of Michigan PREFERRED RX PROGRAM CERTIFICATE SG This contract is between you and Blue Cross Blue Shield of Michigan. Because we are an independent corporation licensed by the Blue Cross and Blue Shield Association - an association of independent Blue Cross and Blue Shield plans - we are allowed to use the Blue Cross and Blue Shield names and service marks in the state of Michigan. However, we are not an agent of BCBSA and, by accepting this contract, you agree that you made this contract based only on what you were told by BCBSM or its agents. Only BCBSM has an obligation to provide benefits under this certificate and no other obligations are created or implied by this language. © 2018 Blue Cross Blue Shield of Michigan © 2018 Blue Cross Blue Shield of Michigan BLUE CROSS® PHYSICIAN CHOICE PPO GROUP BENEFITS CERTIFICATE SG Dear Subscriber: We are pleased you have selected Blue Cross Blue Shield of Michigan for your health care coverage under the Blue Cross® Physician Choice PPO. Through this program, we have established a network of physicians, facilities and other health care professionals to provide your medical care through organized systems of care. To have the lowest out-of-pocket expenses under this program, members will select and use a primary care physician within a high-performing organized system of care. If you do not choose a primary care physician, yet continue to access services through our extensive PPO network of providers, your out-of- pocket expenses will be slightly higher. Health care services you obtain from providers who are not in our PPO network are referred to as "out-of-network" providers. Services obtained from out-of-network providers are subject to the largest out-of-pocket expenses. Other sections of this book, which is your Certificate, explain the Blue Cross® Physician Choice PPO in more detail, describe the program's benefits and limitations and outline other aspects of the program. These will help you understand your benefits and financial responsibilities before you require services. Your certificate, your signed application and your BCBSM identification card are your contract with us. You may also have riders. Riders make changes to your certificate and are an important part of your coverage. When you receive riders, keep them with this book. Please read it carefully. If you have any questions about your coverage, call us at the customer service telephone numbers listed in the "How to Reach Us" section of this book. Every Blue Cross Blue Shield employee is dedicated to giving you the finest service. We look forward to serving you for many years. Sincerely, Daniel J. Loepp President and Chief Executive Officer Blue Cross Blue Shield of Michigan © 2018 Blue Cross Blue Shield of Michigan BLUE CROSS® PHYSICIAN CHOICE PREFERRED RX PROGRAM PPO GROUP BENEFITS CERTIFICATE SG CERTIFICATE SG About Your Certificate This certificate is arranged to help you locate information easily. You will find: • A Table of Contents — for quick reference • Information About Your Contract • Blue Cross® Physician Choice PPO • What You Must Pay • What BCBSM Pays For • How Providers Are Paid • General Services That Are Not Payable • General Conditions of Your Contract • Definitions — explanations of the terms used in your certificate • Additional Information You Need to Know • How to Reach Us • Index This certificate provides you with the information you need to get the most from your BCBSM health care coverage. Please call us if you have any questions. © 2018 Blue Cross Blue Shield of Michigan BLUE CROSS® PHYSICIAN CHOICE PPO GROUP BENEFITS CERTIFICATE SG TABLE OF CONTENTS About Your Certificate ...................................................................................................................................... i Section 1: Information About Your Contract ................................................................................................ 1 ELIGIBILITY ....................................................................................................................................................... 2 Who is Eligible to Receive Benefits .................................................................................................. 2 Changing Your Coverage .................................................................................................................. 4 End Stage Renal Disease (ESRD) ................................................................................................... 4 TERMINATION ................................................................................................................................................... 7 How to Terminate Your Coverage .................................................................................................... 7 How We Terminate Your Coverage .................................................................................................. 7 Rescission ......................................................................................................................................... 8 CONTINUATION OF BENEFITS ....................................................................................................................... 8 Consolidated Omnibus Budget Reconciliation Act (COBRA) ........................................................... 8 Individual Coverage ........................................................................................................................... 9 Section 2: Blue Cross® Physician Choice PPO ......................................................................................... 10 Section 3: What You Must Pay ..................................................................................................................... 12 Level 1 and Level 2 (In-Network) Providers .................................................................................... 16 Level 3 (Out-of-Network) Providers ................................................................................................ 21 Benefit-Specific Cost-Sharing Requirements ................................................................................. 25 Maximums for Days of Care or Visits .............................................................................................. 26 Section 4: What BCBSM Pays For ................................................................................................................ 27 Allergy Testing and Therapy ........................................................................................................... 28 Ambulance Services........................................................................................................................ 29 Anesthesiology Services ................................................................................................................. 31 Audiologist Services ........................................................................................................................ 32 Autism Disorders ............................................................................................................................. 33 Cardiac Rehabilitation ..................................................................................................................... 37 Chemotherapy ................................................................................................................................. 38 Chiropractic Services and Osteopathic Manipulative Therapy ....................................................... 39 Chronic Disease Management ........................................................................................................ 40 Clinical Trials (Routine Patient Costs) ............................................................................................ 41 Contraceptive Services ................................................................................................................... 42 Dental Services ............................................................................................................................... 43 Diagnostic Services ......................................................................................................................... 45 Dialysis Services ............................................................................................................................. 47 Durable Medical Equipment ............................................................................................................ 50 Emergency Treatment ..................................................................................................................... 52 Gender Dysphoria Treatment.......................................................................................................... 53 Home Health Care Services ............................................................................................................ 54 Hospice Care Services .................................................................................................................... 56 Hospital Services ............................................................................................................................. 60 Infertility Treatment .......................................................................................................................... 61 Infusion Therapy .............................................................................................................................

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