Common use of Community Blue PPO Clause in Contracts

Community Blue PPO. This plan is Blue Cross and Blue Shield of Michigan’s Community Blue PPO (A) with riders reducing annual maximum co-pay and co- pays for mental health care and emergency treatment. Additional riders provide hearing coverage as well as prescription drugs (including mail order) for a $10/$20 co-pay; a $50.00 co-pay for outpatient hospital emergency room visits; and a $15.00 co-pay for office visits in a network physician’s office. This PPO (Preferred Provider Organization) plan provides comparable benefits to the Plan described in paragraph 108, with reduced premium rates and with reduced out- of-pocket expenses for the participants. However, the participant is expected to choose the hospital or physician for health care from the Blue Preferred Plan Directory. When services are provided by a Blue Preferred Plan provider the participant pays only for services not covered under the Community Blue Plan or for liabilities such as co-pays required by the Plan. If eligible services are received from a provider who is not a member of the Blue Preferred Plan network, Community Blue pays eighty percent (80%) of the reasonable amount as determined by BC/BSM after deductibles, and the participant is responsible for the remaining charges. Specific policy terms are those in the executed insurance contract with Blue Cross/Blue Shield of Michigan. This plan will no longer be offered by Oakland as of January 1, 2018. Oakland offers participation in Blue Cross and Blue Shield of Michigan's Community Blue PPO (B) or an essentially similar plan. The True Out-if Pocket Maximum (which includes the deductible, coinsurance maximum and flat dollar copays, as required by the Affordable Care Act) is set by the Federal government. When services are provided by a Blue Preferred Plan provider, Community Blue pays eighty percent (80%) in accordance with a fee schedule as established by Blue Cross/Blue Shield of Michigan after deductibles, and the participant is responsible for the remaining charges. If services are received from a provider who is not a member of the Blue Preferred Plan network, Community Blue pays sixty percent (60%) in accordance with a fee schedule as established by Blue Cross/Blue Shield of Michigan after deductibles, and the participant is responsible for the remaining charges. Specific policy terms are those in the executed insurance contract with Blue Cross/Blue Shield of Michigan.

Community Blue PPO. This plan is Blue Cross and Blue Shield of Michigan’s Community Blue PPO (A) Option 1 with riders reducing annual maximum co-pay and co- co-pays for mental health care and emergency treatment. Additional riders provide hearing coverage as well as prescription drugs (including mail order) for a $10/$20 co-pay; a $50.00 co-pay for outpatient hospital emergency room visits; and a $15.00 co-pay for office visits in a network physician’s office. This PPO (Preferred Provider Organization) plan provides comparable benefits to the Plan described in paragraph 108, with reduced premium rates and with reduced out- of-pocket expenses for the participants. However, the participant is expected to choose the hospital or physician for health care from the Blue Preferred Plan Directory. When services are provided by a Blue Preferred Plan provider the participant pays only for services not covered under the Community Blue Plan or for liabilities such as co-pays required by the Plan. If eligible services are received from a provider who is not a member of the Blue Preferred Plan network, Community Blue pays eighty percent (80%) of the reasonable amount as determined by BC/BSM after deductibles, and the participant is responsible for the remaining charges. Specific policy terms are those in the executed insurance contract with Blue Cross/Blue Shield of Michigan. This plan will no longer be offered by Oakland as of Beginning January 1, 2018. 2010, Oakland offers participation in will also offer Blue Cross and Blue Shield of Michigan's Community Blue PPO (B) or an essentially Option 3. This PPO provides similar planbenefits to those under the Community Blue PPO Option 1 except for the following: $20 co-pay for office/urgent care visits in a network physician's office. The True Out-if Pocket Maximum (which includes the deductible, coinsurance maximum Calendar year deductibles of $250/$500 in network and flat dollar copays, as required by the Affordable Care Act) is set by the Federal government. $500/$1,000 non- network Annual out of pocket of $1,250/$2,500 in network and $3,500/$7,000 non- network When services are provided by a Blue Preferred Plan provider, Community Blue pays eighty percent (80%) in accordance with a fee schedule of the reasonable amount as established determined by Blue Cross/Blue Shield of Michigan after deductibles, and the participant is responsible for the remaining charges. If services are received from a provider who is not a member of the Blue Preferred Plan network, Community Blue pays sixty percent (60%) in accordance with a fee schedule of the reasonable amount as established determined by Blue Cross/Blue Shield of Michigan after deductibles, and the participant is responsible for the remaining charges. Specific policy terms are those in the executed insurance contract with Blue Cross/Blue Shield of Michigan.

Community Blue PPO. This plan is Blue Cross and Blue Shield of Michigan’s Community Blue PPO (A) Option 1 with riders reducing annual maximum co-pay and co- co-pays for mental health care and emergency treatment. Additional riders provide hearing coverage as well as prescription drugs (including mail order) for a $10/$20 co-pay; a $50.00 co-pay for outpatient hospital emergency room visits; and a $15.00 co-pay for office visits in a network physician’s office. This PPO (Preferred Provider Organization) plan provides comparable benefits to the Plan described in paragraph 108, with reduced premium rates and with reduced out- of-pocket expenses for the participants. However, the participant is expected to choose the hospital or physician for health care from the Blue Preferred Plan Directory. When services are provided by a Blue Preferred Plan provider the participant pays only for services not covered under the Community Blue Plan or for liabilities such as co-pays required by the Plan. If eligible services are received from a provider who is not a member of the Blue Preferred Plan network, Community Blue pays eighty percent (80%) of the reasonable amount as determined by BC/BSM after deductibles, and the participant is responsible for the remaining charges. Specific policy terms are those in the executed insurance contract with Blue Cross/Blue Shield of Michigan. This plan will no longer be offered by Oakland as of January 1, 2018. Oakland currently offers participation in the Blue Cross and Blue Shield of Michigan's Community Blue PPO (B) or an essentially Option 3. This PPO provides similar planbenefits to those under the Community Blue PPO Option 1 except for the following: $20 co-pay for office/urgent care visits in a network physician's office. The True Out-if Pocket Maximum (which includes the deductible, coinsurance maximum Calendar year deductibles of $250/$500 in network and flat dollar copays, as required by the Affordable Care Act) is set by the Federal government. $500/$1,000 non- network Annual out of pocket of $1,250/$2,500 in network and $3,500/$7,000 non- network When services are provided by a Blue Preferred Plan provider, Community Blue pays eighty percent (80%) in accordance with a fee schedule of the reasonable amount as established determined by Blue Cross/Blue Shield of Michigan after deductibles, and the participant is responsible for the remaining charges. If services are received from a provider who is not a member of the Blue Preferred Plan network, Community Blue pays sixty percent (60%) in accordance with a fee schedule of the reasonable amount as established determined by Blue Cross/Blue Shield of Michigan after deductibles, and the participant is responsible for the remaining charges. Specific policy terms are those in the executed insurance contract with Blue Cross/Blue Shield of Michigan.