Wake County Government: PPO 85 (High Plan) Retiree Coverage Period: 01/01/2013 - 12/31/2013

Wake County Government: PPO 85 (High Plan) Retiree Coverage Period: 01/01/2013 - 12/31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family Plan Type: PPO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at http://www.bcbsnc.com or by calling 877-275-9787. Important Questions Answers Why this Matters: $500 person/$1,000 family for in-network; $1,000 person/$2,000 You must pay all the costs up to the deductible amount before this plan begins to What is the overall family for out-of-network; Doesn't pay for covered services you use. The deductible for this plan runs from January deductible? apply to In-Network preventive through December. See the chart starting on page 2 for how much you pay for care. Coinsurance and copayments covered services after you meet the deductible . do not apply to the deductible. Are there other You don’t have to meet deductibles for specific services, but see the chart starting deductibles for specific No. on page 2 for other costs for services this plan covers. services? Is there an out-of- $2,000 person/$4,000 family for The out-of-pocket limit is the most you could pay during a coverage period pocket limit on my in-network; $4,000 person/$8,000 (usually one year) for your share of the cost of covered services. This limit expenses? family for out-of-network helps you plan for health care expenses. Penalties for failure to obtain pre- authorizations for services, What is not included in Even though you pay these expenses, they don’t count toward the out–of–pocket Premiums, balance-billed charges, the out-of-pocket limit? limit. copayments, deductibles, and health care this plan doesn't cover Is there an overall The chart starting on page 2 describes any limits on what the plan will pay for annual limit on what No. specific covered services, such as office visits. the plan pays? If you use an in-network doctor or other health care provider, this plan will pay Does this plan use a some or all of the costs of covered services. Be aware, your in-network doctor network of Yes. or hospital may use an out-of-network provider for some services. Plans use pr oviders? the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. Do I need a referral to No. You can see the specialist you choose without permission from this plan. see a specialist? Some of the services this plan doesn’t cover are listed on a later page. See Are there services this Yes. your policy or plan document for additional information about excluded plan doesn't cover? services. Questions: Call 877-275-9787 or visit us at http://www.bcbsnc.com . If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at http://cciio.cms.gov/programs/consumer/summaryandglossary/index.html or call 877-275-9787 to request a copy. 1 of 8 Wake County Government: PPO 85 (High Plan) Retiree Coverage Period: 01/01/2013 - 12/31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family Plan Type: PPO

 Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.

 Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your co insurance payment of 20% would be $200. This may change if you haven’t met your deductible.  The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)  This plan may encourage you to use participating providers by charging you lower deductibles, copayments and coinsurance amounts.

Your cost if you use an Common Services You May Need In-Network Out-of-Network Limitations & Exceptions Medical Event Provider Provider Primary care visit to treat an injury or $20 Copay/visit 35% Coinsurance ---None--- illness Specialist visit $35 Copay/visit 35% Coinsurance ---None--- If you visit a health care provider’s Chiropractic services are limited to 24 Other practitioner office visit $35 Copay/visit 35% Coinsurance office or clinic visits per coverage period. Preventive care/screening/immunization No Charge 35% Coinsurance Age and frequency limits may apply

Diagnostic test (x-ray, blood work) 15% Coinsurance 35% Coinsurance No coverage for tests not ordered by a doctor. If you have a test Prior authorization required or Imaging (CT/PET scans, MRIs) 15% Coinsurance 35% Coinsurance services will not be covered.

Questions: Call 877-275-9787 or visit us at http://www.bcbsnc.com . If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at http://cciio.cms.gov/programs/consumer/summaryandglossary/index.html or call 877-275-9787 to request a copy. 2 of 8 Wake County Government: PPO 85 (High Plan) Retiree Coverage Period: 01/01/2013 - 12/31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family Plan Type: PPO

Your cost if you use an Common Services You May Need In-Network Out-of-Network Limitations & Exceptions Medical Event Provider Provider Retail: 30 day supply/$100 maximum If you need drugs Generic drugs 20% Coinsurance Not Covered to treat your illness Mail: 90 day supply/ $250 maximum or condition Retail: 30 day supply/$100 maximum Preferred brand drugs 35% Coinsurance Not Covered Mail: 90 day supply/ $250 maximum More information about prescription Retail: 30 day supply/$50 minimum & 50% Coinsurance Not Covered $100 maximum drug coverage is Non-preferred brand drugs available at Mail: 90 day supply/ $250 maximum http://www. Based on tier Walgreens.com Specialty drugs (generic, preferred, Not Covered non-preferred) If you have Facility fee (e.g., ambulatory surgery 15% Coinsurance 35% Coinsurance ---None--- center) outpatient surgery Physician/surgeon fees 15% Coinsurance 35% Coinsurance ---None--- $100 Copay/visit Emergency room services $100 Copay/visit Copay waived if admitted then coinsurance then coinsurance If you need immediate medical Emergency medical transportation 15% Coinsurance 15% Coinsurance ---None--- attention Urgent care $35 Copay/visit $35 Copay/visit ---None---

If you have a Facility fee (e.g., hospital room) 15% Coinsurance 35% Coinsurance Precertification Required. hospital stay Physician/surgeon fee 15% Coinsurance 35% Coinsurance ---None---

Your cost if you use an Questions:Common Call 877-275-9787Services or visit Yusou at May http://www.bcbsnc.com Need . Limitations & Exceptions If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at http://cciio.cms.gov/programs/consumer/summaryandglossary/index.html or call 877-275-9787 to request a copy. 3 of 8 Wake County Government: PPO 85 (High Plan) Retiree Coverage Period: 01/01/2013 - 12/31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family Plan Type: PPO Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)  Acupuncture  Infertility treatment  Weight loss programs  Bariatric surgery  Long-term care  Benefits paid as a result of injuries caused by another party may need to be  Cosmetic surgery  Routine foot care repaid to the health plan or paid for by  Dental care (Adult or child) another party under certain circumstances

Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)

 Chiropractic care  Non-emergency care when traveling outside  Routine eye care (Adult and child) the U.S.  Hearing aids (limited to participants under age 22)  Private Duty Nursing Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a p r emium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at the number listed on your ID card. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa , or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.” Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: BCBSNC at 1-877-258-3334 or mybcbsnc.com. Language Access Services: Spanish (Español): Para obtener asistencia en español, llame al número que aparece al respaldo de su tarjeta del seguro.

------To see examples how this plan might cover costs for a sample medical situation, see the next Questions: Call 877-275-9787 or visit us at http://www.bcbsnc.com . If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at http://cciio.cms.gov/programs/consumer/summaryandglossary/index.html or call 877-275-9787 to request a copy. 4 of 8 Wake County Government: PPO 85 (High Plan) Retiree Coverage Period: 01/01/2013 - 12/31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family Plan Type: PPO page ------

Questions: Call 877-275-9787 or visit us at http://www.bcbsnc.com . If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at http://cciio.cms.gov/programs/consumer/summaryandglossary/index.html or call 877-275-9787 to request a copy. 5 of 8 Wake County Government: PPO 85 (High Plan) Retiree Coverage Period: 01/01/2013 - 12/31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family Plan Type: PPO

About these Coverage Having a baby Managing type 2 diabetes Examples: (normal delivery) (routine maintenance of a well-controlled condition) These examples show how this plan might ■ Amount owed to providers: cover medical care in given situations. Use $7,540 ■ Amount owed to providers: $5,400 these examples to see, in general, how ■ Plan pays $5,870 ■ Plan pays $3,780 much financial protection a sample patient ■ You pay $1,670 ■ You pay $1,620 might get if they are covered under different plans. Sample care costs: Sample care costs: Hospital charges (mother) $2,700 Prescriptions $2,900 Routine obstetric care $2,100 Medical Equipment and Supplies $1,300 Hospital charges (baby) $900 Office Visits and Procedures $700 Anesthesia $900 Education $300 This is Laboratory tests $500 Laboratory tests $100 not a cost Prescriptions $200 Vaccines, other preventive $100 estimator. Radiology $200 Total $5,400 Vaccines, other preventive $40 Total $7,540 Don't use these examples to Patient pays: estimate your actual costs Deductibles $500 under this plan. The actual Patient pays: Co-pays $350 care you receive will be Deductibles $500 Co-insurance $690 different from these examples, Co-pays $0 Limits or exclusions $80 and the cost of that care also Co-insurance $1,020 Total $1,620 will be different. Limits or exclusions $150 Total $1,670 See the next page for important information about these examples. The examples above assume the Wake Co. Medical Plan is the primary payer. However, as a retiree plan, this plan will pay secondary to Medicare.

Questions: Call 877-275-9787 or visit us at http://www.bcbsnc.com . If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at http://cciio.cms.gov/programs/consumer/summaryandglossary/index.html or call 877-275-9787 to request a copy. 6 of 8 Wake County Government: PPO 85 (High Plan) Retiree Coverage Period: 01/01/2013 - 12/31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family Plan Type: PPO Questions and answers about Coverage Examples:

What are some of the What does a Coverage Example health plan allows. assumptions behind the show? Coverage Examples? For each treatment situation, the Coverage Example helps you see how deductibles,  Costs don't include premiums. copayments, and coinsurance can add  Sample care costs are based on up. It also helps you see what expenses national averages supplied by the U.S. might be left up to you to pay because the Department of Health and Human service or treatment isn’t covered or Services, and aren't specific to a payment is limited. particular geographic area or health plan. Does the Coverage Example  Patient's condition was not an excluded predict my own care needs? or preexisting condition  All services and treatments started and No. Treatments shown are just examples. ended in the same coverage period. The care you would receive for this  There are no other medical expenses condition could be different based on for any member covered under this your doctor’s advice, your age, how plan. serious your condition is, and many  Out-of-pocket expenses are based only other factors. on treating the condition in the example. Does the Coverage Example  The patient received all care from in- predict my future expenses? network p r oviders. If the patient had received care from out-of-network No. Coverage Examples are not cost p r oviders, costs would have been estimators. You can’t use the examples higher. to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your p r oviders charge, and the reimbursement your Questions: Call 877-275-9787 or visit us at http://www.bcbsnc.com . If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at http://cciio.cms.gov/programs/consumer/summaryandglossary/index.html or call 877-275-9787 to request a copy. 7 of 8 Wake County Government: PPO 85 (High Plan) Retiree Coverage Period: 01/01/2013 - 12/31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family Plan Type: PPO Can I use Coverage Examples to compare plans? ✔ Yes. When you look at the Summary of Benefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “Patient Pays” box for each example. The smaller that number, the more coverage the plan provides.

Are there other costs I should consider when comparing plans?

✔ Yes. An important cost is the premium you pay. Generally, the lower your p r emium, the more you’ll pay in out-of- pocket costs, such as co-payments, deductibles, and co-insurance. You should consider also contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses.

Questions: Call 877-275-9787 or visit us at http://www.bcbsnc.com . If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at http://cciio.cms.gov/programs/consumer/summaryandglossary/index.html or call 877-275-9787 to request a copy. 8 of 8