Western Michigan Health Insurance Pool

Western Michigan Health Insurance Pool: Comstock Park Flexible Blue 2, RX6 Coverage Period: Beginning on or after 01/01/2013 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 www.bcbsm.com or by calling 877 752-1233. Answers Important Questions Why this Matters: In-Network Out-of-Network $1,250 Individual/ $2,500 Individual/ You must pay all the costs up to the deductible amount before this plan What is the overall $2,500 Family $5,000 Family begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, deductible? January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible Are there other No No You don't have to meet deductibles for specific services, but see the deductibles for specific Common Medical Event chart starting on page 2 for other costs for services? services this plan covers. Is there an out–of–pocket $2,250 Individual/ $4,500 Individual/ The out-of-pocket limit is the most you could pay during a coverage $4,500 Family $9,000 Family period (usually one year) for your share of the cost of covered services. limit on my expenses? This limit helps you plan for health care expenses. What is not included in Co-pays, premiums, balance-billed Even though you pay these expenses, they don’t count toward the out-of- charges, and health care this plan doesn’t pocket limit. the out–of–pocket limit? cover. No. The Common Medical Events chart starting on page 2 describes any Is there an overall annual limits on what the plan will pay for specific covered services, such as limit on what the plan office visits. pays? Yes. For a list of in-network providers, see If you use an in-network doctor or other health care provider, this plan www.bcbsm.com or call the number on the will pay some or all of the costs of covered services. Be aware, your in- Does this plan use a back of your BCBSM ID card. network doctor or hospital may use an out-of-network provider for some network of providers? services. Plans use the term in-network, preferred, or participating for providers in their network. See the Common Medical Events Chart starting on page 2 for how this plan pays different kinds of providers. Do I need a referral to see No. You can see the specialist you choose without permission from this plan. a specialist?

Group Number 71565 036, 037, 038, 039 Questions: Call the number on the back of your BCBSM ID card or visit us at www.bcbsm.com. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at http://www.dol.gov/ebsa/healthreform or call the number on the back of your BCBSM ID card to request a copy. 1 of 8 Western Michigan Health Insurance Pool: Comstock Park Flexible Blue 2, RX6 Coverage Period: Beginning on or after 01/01/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual / Family | Plan Type: PPO Are there services this Yes. Some of the services this plan doesn’t cover are listed on page 5. See your policy or plan document for additional information about excluded plan doesn’t cover? services.

Group Number 71565 036, 037, 038, 039 Questions: Call the number on the back of your BCBSM ID card or visit us at www.bcbsm.com. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at http://www.dol.gov/ebsa/healthreform or call the number on the back of your BCBSM ID card to request a copy. 2 of 8  Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.  Co-insurance 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 in-network providers by charging you lower deductibles, co-payments and co-insurance amounts. Your cost if you use a Common Services You May Need In-Network Out-of-Network Limitations & Exceptions Medical Event Provider Provider Primary care visit to treat No charge after 20% co-insurance ---none--- an injury or illness deductible after deductible No charge after 20% co-insurance ---none--- Specialist visit deductible after deductible If you visit a health care provider’s office or clinic Other practitioner office No charge after 20% co-insurance Limited to a maximum of 24 visits per deductible for after deductible for member per calendar year visit Chiropractor Chiropractor Preventive care/screening/ No charge Not Covered ---none--- immunization

Diagnostic test (x-ray, No charge after 20% co-insurance ---none--- blood work) deductible after deductible If you have a test Imaging (CT/PET scans, No charge after 20% co-insurance ---none--- deductible after deductible MRIs) If you need drugs to treat $10 co-pay after $10 co-pay after For information on women's contraceptive your illness or condition deductible for deductible plus an coverage, contact your employer. Mail order retail 30-day additional 25% of drugs are not covered out-of-network. For more information about Generic or prescribed over- supply, $20 co- BCBSM approved prescription drug the-counter drugs pay after amount deductible for coverage (if applicable), mail order 90- contact your employer. day supply Formulary (preferred) $40 co-pay after $40 co-pay after Mail order drugs are not covered out-of- brand-name drugs deductible for deductible plus an network. retail 30-day additional 25% of supply, $80 co- BCBSM approved 3 of 8 Your cost if you use a Common Services You May Need In-Network Out-of-Network Limitations & Exceptions Medical Event Provider Provider pay after amount deductible for mail order 90- day supply $40 co-pay after $40 co-pay after Mail order drugs are not covered out-of- deductible for deductible plus an network. Nonformulary retail 30-day additional 25% of supply, $80 co- BCBSM approved (nonpreferred) brand-name pay after amount drugs deductible for mail order 90- day supply Facility fee (e.g., No charge after 20% co-insurance ---none--- If you have outpatient ambulatory surgery center) deductible after deductible surgery No charge after 20% co-insurance ---none--- Physician/surgeon fees deductible after deductible No charge after No charge after ---none--- Emergency room services deductible deductible If you need immediate Emergency medical No charge after No charge after ---none--- medical attention transportation deductible deductible No charge after 20% co-insurance ---none--- Urgent care deductible after deductible Facility fee (e.g., hospital No charge after 20% co-insurance ---none--- room) deductible after deductible If you have a hospital stay No charge after 20% co-insurance ---none--- Physician/surgeon fee deductible after deductible

If you have mental health, Mental/Behavioral health No charge after 20% co-insurance ---none--- behavioral health, or outpatient services deductible after deductible substance abuse needs No charge after 20% co-insurance ---none--- Mental/Behavioral health deductible after deductible inpatient services Substance use disorder No charge after 20% co-insurance ---none--- outpatient services deductible after deductible

4 of 8 Your cost if you use a Common Services You May Need In-Network Out-of-Network Limitations & Exceptions Medical Event Provider Provider Substance use disorder No charge after 20% co-insurance ---none--- inpatient services deductible after deductible No charge after 20% co-insurance ---none--- Prenatal and postnatal care deductible after deductible

If you are pregnant No charge after 20% co-insurance ---none--- Delivery and all inpatient deductible after deductible services

No charge after No charge after ---none--- Home health care deductible deductible No charge after 20% co-insurance Physical, Occupational, and Speech therapy deductible after deductible are limited to a combined maximum of 60 Rehabilitation services visits per member, per calendar year.

If you need help Habilitation services Not Covered Not Covered ---none--- recovering or have other No charge after No charge after Limited to a maximum of 90 days per special health needs Skilled nursing care deductible deductible member per calendar year. No charge after 20% co-insurance ---none--- Durable medical equipment deductible after deductible No charge after No charge after ---none--- Hospice service deductible deductible

Eye exam Not Covered Not Covered ---none--- If your child needs dental Glasses Not Covered Not Covered ---none--- or eye care Dental check-up Not Covered Not Covered ---none---

5 of 8 Excluded Services & Other Covered Services:

6 of 8 Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.) • Acupuncture • Routine eye care • Cosmetic surgery • Routine foot care • Hearing aids • Weight loss programs • Infertility treatment • Long-term care

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.) • Bariatric surgery • Chiropractic care • Coverage provided outside the United States. See http://provider.bcbs.com • Dental care (Adult) • If you are also covered by an account-type plan such as an integrated health flexible spending arrangement (FSA), health reimbursement arrangement (HRA), and/or a health savings account (HSA), then you may have access to additional funds to help cover certain out-of-pocket expenses – like the deductible, co-payments, or co-insurance, or benefits not otherwise covered. • Private-duty nursing

7 of 8 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 premium, 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 877 752-1233. 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 Blue Cross® and Blue Shield® of Michigan, a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association, by calling 877 752-1233. Or, you can contact Michigan Office of Financial and Insurance Regulation at www.michigan.gov/ofir or 1-877-999-6442. For group health coverage subject to ERISA, you may also contact Employee Benefits Security Administration at 1-866-444-EBSA (3272).

Language Access Services For assistance in a language below, please call (Group would insert the number they want members to call here).

SPANISH (Español): Para ayuda en español, llame al número de servicio al cliente [customer service] que se encuentra en este aviso ó en el reverso de su tarjeta de identificación.

TAGALOG (Tagalog): Para sa tulong sa wikang Tagalog, mangyaring tumawag sa numero ng serbisyo sa mamimili [customer service] na nakalagay sa likod ng iyong pagkakakilanlan kard o sa paunawang ito.

CHINESE (中文): 要获取中文帮助，请致电您的身份识别卡背面或本通知提供的客户服务 [customer service] 号码。

NAVAJO (Dine): Taa’dineji’keego shii’kaa’ahdool’wool ninizin’goo [customer service], beesh behane’e naal’tsoos bikii sin’dahiigii binii’deehgo eeh’doodago di’naaltsoo bikaiigii bichi’hoodillnii.

8 of 8 About these Coverage Examples:  Amount owed to providers: $7,540  Amount owed to providers: $5,400 These examples show how this plan might  Plan pays $5,440  Plan pays $3,690 cover medical care in given situations. Use  You pay $2100  You pay $1,710 these examples to see, in general, how much insurance protection a sample patient might get Sample care costs: Sample care costs: if they are covered under different plans. Hospital charges (mother) $2,700 Prescriptions $2,900 Routine obstetric care $2,100 Medical Equipment & Supplies $1,300 Hospital charges (baby) $900 Office Visits & Procedures $700 Anesthesia $900 Education $300 Laboratory tests $500 Laboratory tests $100 Prescriptions $200 Vaccines, other preventive $100 Radiology $200 Total $5,400 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $1,250 Patient pays: Co-pays $240 Deductibles $1250 Co-insurance $0 Co-pays $0 Limits or exclusions $220 Co-insurance $0 Total $1,710 Limits or exclusions $850 Total $2100

Please note: Coverage Examples are calculated based on individual coverage.

9 of 8 Questions and answers about the Coverage Examples:

What are some of the assumptions What does a Coverage Example No. Coverage Examples are not cost behind the Coverage Examples? show? estimators. You can’t use the examples to estimate costs for an actual condition. For each treatment situation, the Coverage  Costs don’t include premiums. They are for comparative purposes only. Example helps you see how deductibles, Your own costs will be different  Sample care costs are based on co-payments, and co-insurance can add up. depending on the care you receive, the national averages supplied by the U.S. It also helps you see what expenses might be prices your providers charge, and the Department of Health and Human left up to you to pay because the service or reimbursement your health plan allows. Services, and aren’t specific to a treatment isn’t covered or payment is particular geographic area or health limited. plan.  The patient’s condition was not an excluded or preexisting condition. Does the Coverage Example predict  All services and treatments started my own care needs? and ended in the same coverage period.  No. Treatments shown are just examples.  There are no other medical expenses for any member covered under this The care you would receive for this plan. condition could be different, based on your doctor’s advice, your age, how  Out-of-pocket expenses are based serious your condition is, and many other only on treating the condition in the factors. example.  The patient received all care from in- network providers. If the patient had Does the Coverage Example predict received care from out-of-network my future expenses? providers, costs would have been higher.

Questions: Call the number on the back of your BCBSM ID card or visit us at www.bcbsm.com. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at http://www.dol.gov/ebsa/healthreform or call the number on the back of your BCBSM ID card to request a copy. 10 of 8 Can I use Coverage Examples to smaller that number, the more coverage premium, the more you’ll pay in out-of- the plan provides. pocket costs, such as co-payments, compare plans? deductibles, and co-insurance. You should also consider contributions to Yes. When you look at the Summary of  Are there other costs I should accounts such as health savings accounts Benefits and Coverage for other plans, consider when comparing plans? (HSAs), flexible spending arrangements you’ll find the same Coverage Examples. (FSAs) or health reimbursement accounts When you compare plans, check the Yes. An important cost is the premium (HRAs) that help you pay out-of-pocket “Patient Pays” box in each example. The you pay. Generally, the lower your expenses.

Questions: Call the number on the back of your BCBSM ID card or visit us at www.bcbsm.com. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at http://www.dol.gov/ebsa/healthreform or call the number on the back of your BCBSM ID card to request a copy. 11 of 8