Common use of Language Access Services Clause in Contracts

Language Access Services. Spanish (Español): Para obtener asistencia en Español, llame al 0-000-000-0000. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. Chinese (中文): 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– About these Coverage Examples: This is not a cost estimator. Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. Having a baby (normal delivery) ■ Amount owed to providers: $7,540 ■ Plan pays $4,935 ■ Patient pays $2,605 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Managing type 2 diabetes (routine maintenance of a well-controlled condition) ■ Amount owed to providers: $5,400 ■ Plan pays $3,545 ■ Patient pays $1,855 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Deductibles $1,000 Copays $775 Coinsurance $80 Limits or exclusions $0 Total $1,855 Patient pays: Note: These numbers assume the patient is filling scripts at a participating pharmacy. Deductibles $1,900 Copays $45 Coinsurance $660 Limits or exclusions $0 Total $2,605 Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? • Costs don’t include premiums. • Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan. • The patient’s condition was not an excluded or preexisting condition. • All services and treatments started and ended in the same coverage period. • There are no other medical expenses for any member covered under this plan. • Out-of-pocket expenses are based only on treating the condition in the example. • The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited. Does the Coverage Example predict my own care needs?

Language Access Services. Spanish (Español): Para obtener asistencia en Español, llame al 0-000-000-0000. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. Chinese (中文): 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– About these Coverage Examples: This is not a cost estimator. Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. Having a baby (normal delivery) ■ Amount owed to providers: $7,540 ■ Plan pays $4,935 6,550 ■ Patient pays $2,605 1,845 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Managing type 2 diabetes (routine maintenance of a well-controlled condition) ■ Amount owed to providers: $5,400 ■ Plan pays $3,545 3,945 ■ Patient pays $1,855 1,455 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Deductibles $1,000 500 Copays $775 Coinsurance $80 180 Limits or exclusions $0 Total $1,855 1,455 Patient pays: Note: These numbers assume the patient is filling scripts at a participating pharmacy. Deductibles $1,900 1,000 Copays $45 Coinsurance $660 800 Limits or exclusions $0 Total $2,605 1,845 Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? • Costs don’t include premiums. • Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan. • The patient’s condition was not an excluded or preexisting condition. • All services and treatments started and ended in the same coverage period. • There are no other medical expenses for any member covered under this plan. • Out-of-pocket expenses are based only on treating the condition in the example. • The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited. Does the Coverage Example predict my own care needs?

Language Access Services. Spanish (Español): Para obtener asistencia en Español, llame al 0-000-000-0000. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. Chinese (中文): 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– About these Coverage Examples: This is not a cost estimator. Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. Having a baby (normal delivery) ■ Amount owed to providers: $7,540 ■ Plan pays $4,935 6,374 ■ Patient pays $2,605 1,166 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Managing type 2 diabetes (routine maintenance of a well-controlled condition) ■ Amount owed to providers: $5,400 ■ Plan pays $3,545 4,300 ■ Patient pays $1,855 1,100 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Deductibles $1,000 250 Copays $775 735 Coinsurance $80 115 Limits or exclusions $0 Total $1,855 1,100 Patient pays: Note: These numbers assume the patient is filling scripts at a participating pharmacy. Deductibles $1,900 500 Copays $45 21 Coinsurance $660 645 Limits or exclusions $0 Total $2,605 1,166 Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? • Costs don’t include premiums. • Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan. • The patient’s condition was not an excluded or preexisting condition. • All services and treatments started and ended in the same coverage period. • There are no other medical expenses for any member covered under this plan. • Out-of-pocket expenses are based only on treating the condition in the example. • The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited. Does the Coverage Example predict my own care needs?

Language Access Services. Spanish (Español): Para obtener asistencia en Español, llame al 0-000-000-0000. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. Chinese (中文): 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– About these Coverage Examples: This is not a cost estimator. Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. Having a baby (normal delivery) ■ Amount owed to providers: $7,540 ■ Plan pays $4,935 6,550 ■ Patient pays $2,605 990 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Managing type 2 diabetes (routine maintenance of a well-controlled condition) ■ Amount owed to providers: $5,400 ■ Plan pays $3,545 4,260 ■ Patient pays $1,855 1,140 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Deductibles $1,000 250 Copays $775 Coinsurance $80 115 Limits or exclusions $0 Total $1,855 1,140 Patient pays: Note: These numbers assume the patient is filling scripts at a participating pharmacy. Deductibles $1,900 500 Copays $45 Coinsurance $660 445 Limits or exclusions $0 Total $2,605 990 Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? • Costs don’t include premiums. • Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan. • The patient’s condition was not an excluded or preexisting condition. • All services and treatments started and ended in the same coverage period. • There are no other medical expenses for any member covered under this plan. • Out-of-pocket expenses are based only on treating the condition in the example. • The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited. Does the Coverage Example predict my own care needs?

Language Access Services. Spanish (Español): Para obtener asistencia en Español, llame al 0-000-000-0000. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. Chinese (中文): 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– About these Coverage Examples: This is not a cost estimator. Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. Having a baby (normal delivery) ■ ◼ Amount owed to providers: $7,540 ■ ◼ Plan pays $4,935 ■ ◼ Patient pays $2,605 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Managing type 2 diabetes (routine maintenance of a well-controlled condition) ■ ◼ Amount owed to providers: $5,400 ■ ◼ Plan pays $3,545 ■ ◼ Patient pays $1,855 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Deductibles $1,000 Copays $775 Coinsurance $80 Limits or exclusions $0 Total $1,855 Patient pays: Note: These numbers assume the patient is filling scripts at a participating pharmacy. Deductibles $1,900 Copays $45 Coinsurance $660 Limits or exclusions $0 Total $2,605 Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? • Costs don’t include premiums. • Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan. • The patient’s condition was not an excluded or preexisting condition. • All services and treatments started and ended in the same coverage period. • There are no other medical expenses for any member covered under this plan. • Out-of-pocket expenses are based only on treating the condition in the example. • The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited. Does the Coverage Example predict my own care needs?

Language Access Services. Spanish (Español): Para obtener asistencia en Español, llame al 0-000-000-0000. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. Chinese (中文): 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– About these Coverage Examples: This is not a cost estimator. Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. Having a baby (normal delivery) ■ ◼ Amount owed to providers: $7,540 ■ ◼ Plan pays $4,935 ■ 6,550 ◼ Patient pays $2,605 1,845 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Managing type 2 diabetes (routine maintenance of a well-controlled condition) ■ ◼ Amount owed to providers: $5,400 ■ ◼ Plan pays $3,545 ■ 3,945 ◼ Patient pays $1,855 1,455 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Deductibles $1,000 500 Copays $775 Coinsurance $80 180 Limits or exclusions $0 Total $1,855 1,455 Patient pays: Note: These numbers assume the patient is filling scripts at a participating pharmacy. Deductibles $1,900 1,000 Copays $45 Coinsurance $660 800 Limits or exclusions $0 Total $2,605 1,845 Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? • Costs don’t include premiums. • Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan. • The patient’s condition was not an excluded or preexisting condition. • All services and treatments started and ended in the same coverage period. • There are no other medical expenses for any member covered under this plan. • Out-of-pocket expenses are based only on treating the condition in the example. • The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited. Does the Coverage Example predict my own care needs?

Language Access Services. Spanish (Español): Para obtener asistencia en Español, llame al 0-000-000-0000. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. Chinese (中文): 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– About these Coverage Examples: This is not a cost estimator. Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. Having a baby (normal delivery) ■ ◼ Amount owed to providers: $7,540 ■ ◼ Plan pays $4,935 ■ 6,550 ◼ Patient pays $2,605 990 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Managing type 2 diabetes (routine maintenance of a well-controlled condition) ■ ◼ Amount owed to providers: $5,400 ■ ◼ Plan pays $3,545 ■ 4,260 ◼ Patient pays $1,855 1,140 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Deductibles $1,000 250 Copays $775 Coinsurance $80 115 Limits or exclusions $0 Total $1,855 1,140 Patient pays: Note: These numbers assume the patient is filling scripts at a participating pharmacy. Deductibles $1,900 500 Copays $45 Coinsurance $660 445 Limits or exclusions $0 Total $2,605 990 Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? • Costs don’t include premiums. • Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan. • The patient’s condition was not an excluded or preexisting condition. • All services and treatments started and ended in the same coverage period. • There are no other medical expenses for any member covered under this plan. • Out-of-pocket expenses are based only on treating the condition in the example. • The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited. Does the Coverage Example predict my own care needs?

Language Access Services. Spanish (Español): Para obtener asistencia en Español, llame al 0-000-000-0000. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. Chinese (中文): 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– About these Coverage Examples: This is not a cost estimator. Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. Having a baby (normal delivery) ■ ◼ Amount owed to providers: $7,540 ■ ◼ Plan pays $4,935 ■ 6,374 ◼ Patient pays $2,605 1,166 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Managing type 2 diabetes (routine maintenance of a well-controlled condition) ■ ◼ Amount owed to providers: $5,400 ■ ◼ Plan pays $3,545 ■ 4,300 ◼ Patient pays $1,855 1,100 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Deductibles $1,000 250 Copays $775 735 Coinsurance $80 115 Limits or exclusions $0 Total $1,855 1,100 Patient pays: Note: These numbers assume the patient is filling scripts at a participating pharmacy. Deductibles $1,900 500 Copays $45 21 Coinsurance $660 645 Limits or exclusions $0 Total $2,605 1,166 Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? • Costs don’t include premiums. • Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan. • The patient’s condition was not an excluded or preexisting condition. • All services and treatments started and ended in the same coverage period. • There are no other medical expenses for any member covered under this plan. • Out-of-pocket expenses are based only on treating the condition in the example. • The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited. Does the Coverage Example predict my own care needs?

Language Access Services. Spanish (Español): Para obtener asistencia en Español, llame al 0-000-000-0000. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. Chinese (中文): 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– Blue Cross Blue Shield Michigan: Division 0049 Coverage Period: 01/01/2016 – 12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Covered Individuals | Plan Type: PPO About these Coverage Examples: This is not a cost estimator. Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. Having a baby (normal delivery) ■ ◼ Amount owed to providers: $7,540 ■ ◼ Plan pays $4,935 ■ ◼ Patient pays $2,605 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Managing type 2 diabetes (routine maintenance of a well-controlled condition) ■ ◼ Amount owed to providers: $5,400 ■ ◼ Plan pays $3,545 ■ ◼ Patient pays $1,855 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Deductibles $1,000 Copays $775 Coinsurance $80 Limits or exclusions $0 Total $1,855 Patient pays: Note: These numbers assume the patient is filling scripts at a participating pharmacy. Deductibles $1,900 Copays $45 Coinsurance $660 Limits or exclusions $0 Total $2,605 Blue Cross Blue Shield Michigan: Division 0049 Coverage Period: 01/01/2016 – 12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Covered Individuals | Plan Type: PPO Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? • Costs don’t include premiums. • Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan. • The patient’s condition was not an excluded or preexisting condition. • All services and treatments started and ended in the same coverage period. • There are no other medical expenses for any member covered under this plan. • Out-of-pocket expenses are based only on treating the condition in the example. • The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited. Does the Coverage Example predict my own care needs?

Language Access Services. Spanish (Español): Para obtener asistencia en Español, llame al 0-000-000-0000. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. Chinese (中文): 如果需要中文的帮助，请拨打这个号码 如果需要中文的帮助,请拨打这个号码 0-000-000-0000. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To ----------------------To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– page.----------- Having a baby (normal delivery)  Amount owed to providers: $7,540  Plan pays: $5,360  Patient pays: $2,180 Sample care costs: Hospital charges (mother) $2,700 Routine Obstetric Care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductible $800 Co-pays $60 Co-insurance $1,290 Limits or exclusions $30 Total $2,180 Managing type 2 diabetes (routine maintenance of a well-controlled condition)  Amount owed to providers: $5,400  Plan pays: $3,610  Patient pays: $1,790 Sample care costs: Prescriptions $2,900 Medical equipment and supplies $1,300 Office visits & procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductible $800 Co-pays $670 Co-insurance $40 Limits or exclusions $280 Total $1,790 Coverage Examples About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. estimator Don’t n't use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. Having a baby (normal delivery) ■ Amount owed to providers: $7,540 ■ Plan pays $4,935 ■ Patient pays $2,605 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Managing type 2 diabetes (routine maintenance of a well-controlled condition) ■ Amount owed to providers: $5,400 ■ Plan pays $3,545 ■ Patient pays $1,855 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Deductibles $1,000 Copays $775 Coinsurance $80 Limits or exclusions $0 Total $1,855 Patient pays: Note: These numbers assume the patient is filling scripts at a participating pharmacyenrollment in individual-only coverage. Deductibles $1,900 Copays $45 Coinsurance $660 Limits or exclusions $0 Total $2,605 Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? •  Costs don’t n't include premiums. •  Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t n't specific to a particular geographic area or health plan. •  The patient’s 's condition was not an excluded or preexisting pre existing condition. •  All services and treatments started and ended in the same coverage period. •  There are no other medical expenses for any member covered under this plan. •  Out-of-pocket expenses are based only on treating the condition in the example. •  The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copaymentsco-payments, and coinsurance co-insurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t n't covered or payment is limited. Does the Coverage Example predict my own care needs?? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor's advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can't use the examples 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 providers charge, and the reimbursement your health plan allows. 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 in 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 premium, the more you'll pay in out-of-pocket costs, such as co-payments, deductibles, and co-insurance. You also should consider 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. Plan ID: 5330038 BenefitVersion: 8Plan Name: 2017 OAP Base PlanKitTrack#SBM25189 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 xxx.xxxxx.xxx/xx/ or by calling 1-800-Cigna24 Important Questions Answers Why this Matters: What is the overall deductible? For in-network providers $4,000 person / $8,000 family For out-of-network providers $4,000 person / $8,000 family Combined medical/behavioral and pharmacy deductible Does not apply to in-network preventive care & immunizations. You must pay all the costs up to the deductible amount before this plan 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, 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 deductibles for specific services? No. You don't have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. Is there an out-of-pocket limit on my expenses? Yes. For in-network providers $4,000 person / $8,000 family For out-of-network providers $8,000 person / $16,000 family Combined medical/behavioral and pharmacy out-of-pocket limit. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. What is not included in the out-of-pocket limit? Premium, balance-billed charges, and health care this plan doesn't cover. Even though you pay these expenses, they don't count toward the out-of- pocket limit. Is there an overall annual limit on what the plan pays? No. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. Does this plan use a network of providers? Yes. For a list of participating providers, see xxx.xxXxxxx.xxx or call 1-800-Cigna24 If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use 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 see a specialist? No. You don't need a referral to see a specialist. You can see the specialist you choose without permission from this plan. Are there services this plan doesn't cover? 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 services.  Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount of the service. For example, if the health 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 charge is $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 an Limitations & Exceptions Common Medical Event Services You May Need In-Network Provider Out-of-Network Provider If you visit a health care provider's office or clinic Primary care visit to treat an injury or illness No charge 30% co-insurance ---------- none -------- Specialist visit No charge 30% co-insurance ---------- none -------- Other practitioner office visit No charge for chiropractor 30% co-insurance Coverage for Chiropractic care is limited to 12 days annual max. Preventive care/screening/ immunization No charge 30% co-insurance ------------none---------- If you have a test Diagnostic test (x-ray, blood work) No charge 30% co-insurance ---------- none -------- Imaging (CT/PET scans, MRIs) No charge 30% co-insurance ------------none---------- Your Cost if you use an Limitations & Exceptions Common Medical Event Services You May Need In-Network Provider Out-of-Network Provider If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.xxXxxxx.xxx Generic drugs 0% co-insurance/prescription (retail 30 days) 0% co-insurance/prescription (retail and home delivery 90 days) 30% co-insurance (30 day retail) Not Covered (home delivery) Coverage is limited up to a 90-day supply (retail and home delivery); up to a 30-day supply (retail) and a 90- day supply (home delivery) for Specialty drugs. Certain limitations may apply, including, for example: prior authorization, step therapy, quantity limits. Preferred brand drugs 0% co-insurance/prescription (retail 30 days) 0% co-insurance/prescription (retail and home delivery 90 days) 30% co-insurance (30 day retail) Not Covered (home delivery) Non-preferred brand drugs 0% co-insurance/prescription (retail 30 days) 0% co-insurance/prescription (retail and home delivery 90 days) 30% co-insurance (30 day retail) Not Covered (home delivery) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 30% co-insurance ------------none---------- Physician/surgeon fees No charge 30% co-insurance ----------- none -------- If you need immediate medical attention Emergency room services No charge No charge ------------none---------- Emergency medical transportation No charge No charge ----------- none -------- Urgent care No charge No charge ------------none---------- If you have a hospital stay Facility fee (e.g., hospital room) No charge 30% co-insurance ----------- none -------- Physician/surgeon fees No charge 30% co-insurance ----------- none -------- If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services No charge 30% co-insurance ------------none---------- Mental/Behavioral health inpatient services No charge 30% co-insurance ------------none---------- Substance use disorder outpatient services No charge 30% co-insurance ------------none---------- Substance use disorder inpatient services No charge 30% co-insurance ------------none---------- If you are pregnant Prenatal and postnatal care No charge 30% co-insurance ------------none---------- Delivery and all inpatient services No charge 30% co-insurance ------------none---------- Common Medical Event Services You May Need Your Cost if you use an Limitations & Exceptions Home health care No charge 30% co-insurance ------------none---------- If you need help recovering or have other special health needs Rehabilitation services No charge 30% co-insurance Coverage for Physical Therapy services is limited to 40 days annual max. Speech Therapy is 20 days annual max. Occupational therapy, Pulmonary Rehab and Cognitive therapy are limited to 20 days annual max. Cardiac Rehabilitation services are limited to 36 days annual max, Chiropractic Therapy is limited to 12 days max per Calendar Year. Habilitation services Not Covered Not Covered ------------none---------- Skilled nursing care No charge 30% co-insurance Coverage is limited to 120 days annual max Durable medical equipment No charge 30% co-insurance ------------none---------- Hospice services No charge 30% co-insurance ------------none---------- If your child needs dental or eye care Eye Exam Not Covered Not Covered ------------none---------- Glasses Not Covered Not Covered ------------none---------- Dental check-up Not Covered Not Covered ------------none---------- 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  Acupuncture  Hearing aids  Cosmetic surgery  Infertility treatment  Dental care (Adult)  Long-term care  Routine foot care  Dental care (Children)  Non-emergency care when traveling outside the U.S.  Weight loss programs  Eye care (Children)  Private-duty nursing  Habilitation services  Routine eye care (Adult) 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  Bariatric surgery

Language Access Services. Spanish (Español): Para obtener asistencia en Español, llame al 0-000-000-0000. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. Chinese (中文): 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– Blue Cross Blue Shield Michigan: Division 0048 Coverage Period: 01/01/2016 – 12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Covered Individuals | Plan Type: PPO About these Coverage Examples: This is not a cost estimator. Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. Having a baby (normal delivery) ■ ◼ Amount owed to providers: $7,540 ■ ◼ Plan pays $4,935 ■ 6,550 ◼ Patient pays $2,605 1,845 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Managing type 2 diabetes (routine maintenance of a well-controlled condition) ■ ◼ Amount owed to providers: $5,400 ■ ◼ Plan pays $3,545 ■ 3,945 ◼ Patient pays $1,855 1,455 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Deductibles $1,000 500 Copays $775 Coinsurance $80 180 Limits or exclusions $0 Total $1,855 1,455 Patient pays: Note: These numbers assume the patient is filling scripts at a participating pharmacy. Deductibles $1,900 1,000 Copays $45 Coinsurance $660 800 Limits or exclusions $0 Total $2,605 1,845 Blue Cross Blue Shield Michigan: Division 0048 Coverage Period: 01/01/2016 – 12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Covered Individuals | Plan Type: PPO Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? • Costs don’t include premiums. • Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan. • The patient’s condition was not an excluded or preexisting condition. • All services and treatments started and ended in the same coverage period. • There are no other medical expenses for any member covered under this plan. • Out-of-pocket expenses are based only on treating the condition in the example. • The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited. Does the Coverage Example predict my own care needs?

Language Access Services. Spanish (Español): Para obtener asistencia en Español, llame al 0-000-000-0000. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. Chinese (中文): 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– About these Coverage Examples: This is not a cost estimator. Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. Managing type 2 diabetes (routine maintenance of a well-controlled condition) Having a baby (normal delivery) ■ Amount owed to providers: $7,540 ■ Plan pays $4,935 ■ 6,550 Patient pays $2,605 Sample 1,845 ample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient atient pays: Managing type 2 diabetes (routine maintenance of a well-controlled condition) ■ ■ Amount owed to providers: $5,400 ■ ■ Plan pays $3,545 3,945 ■ ■ Patient pays $1,855 1,455 S Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Deductibles $1,000 500 Copays $775 Coinsurance $80 180 Limits or exclusions $0 Total $1,855 1,455 Patient pays: P Note: These numbers assume the patient is filling scripts at a participating pharmacy. Deductibles $1,900 1,000 Copays $45 Coinsurance $660 800 Limits or exclusions $0 Total $2,605 1,845 Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? • Costs don’t include premiums. • Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan. • The patient’s condition was not an excluded or preexisting condition. • All services and treatments started and ended in the same coverage period. • There are no other medical expenses for any member covered under this plan. • Out-of-pocket expenses are based only on treating the condition in the example. • The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited. Does the Coverage Example predict my own care needs?

Language Access Services. Spanish (Español): Para obtener asistencia en Español, llame al 0-000-000-0000. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. Chinese (中文): 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– Blue Cross Blue Shield Michigan: Division 0050 Coverage Period: 01/01/2016 – 12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Covered Individuals | Plan Type: PPO About these Coverage Examples: This is not a cost estimator. Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. Having a baby (normal delivery) ■  Amount owed to providers: $7,540 ■  Plan pays $4,935 ■ 6,374  Patient pays $2,605 1,166 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Managing type 2 diabetes (routine maintenance of a well-controlled condition) ■  Amount owed to providers: $5,400 ■  Plan pays $3,545 ■ 4,300  Patient pays $1,855 1,100 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Deductibles $1,000 250 Copays $775 735 Coinsurance $80 115 Limits or exclusions $0 Total $1,855 1,100 Patient pays: Note: These numbers assume the patient is filling scripts at a participating pharmacy. Deductibles $1,900 500 Copays $45 21 Coinsurance $660 645 Limits or exclusions $0 Total $2,605 1,166 Blue Cross Blue Shield Michigan: Division 0050 Coverage Period: 01/01/2016 – 12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Covered Individuals | Plan Type: PPO Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? •  Costs don’t include premiums. •  Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan. •  The patient’s condition was not an excluded or preexisting condition. •  All services and treatments started and ended in the same coverage period. •  There are no other medical expenses for any member covered under this plan. •  Out-of-pocket expenses are based only on treating the condition in the example. •  The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited. Does the Coverage Example predict my own care needs?

Language Access Services. Spanish (Español): Para obtener asistencia en Español, llame al 0-000-000-0000. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. Chinese (中文): 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– About these Coverage Examples: This is not a cost estimator. Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. Managing type 2 diabetes (routine maintenance of a well-controlled condition) Having a baby (normal delivery) ■ Amount owed to providers: $7,540 ■ Plan pays $4,935 ■ Patient pays $2,605 Sample ample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient atient pays: Managing type 2 diabetes (routine maintenance of a well-controlled condition) ■ ■ Amount owed to providers: $5,400 ■ ■ Plan pays $3,545 ■ ■ Patient pays $1,855 S Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Deductibles $1,000 Copays $775 Coinsurance $80 Limits or exclusions $0 Total $1,855 Patient pays: P Note: These numbers assume the patient is filling scripts at a participating pharmacy. Deductibles $1,900 Copays $45 Coinsurance $660 Limits or exclusions $0 Total $2,605 Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? • Costs don’t include premiums. • Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan. • The patient’s condition was not an excluded or preexisting condition. • All services and treatments started and ended in the same coverage period. • There are no other medical expenses for any member covered under this plan. • Out-of-pocket expenses are based only on treating the condition in the example. • The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited. Does the Coverage Example predict my own care needs?

Language Access Services. Spanish (Español): Para obtener asistencia en Español, llame al 0-000-000-0000. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. Chinese (中文): 如果需要中文的帮助，请拨打这个号码 如果需要中文的帮助,请拨打这个号码 0-000-000-0000. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To ----------------------To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– page.----------- Having a baby (normal delivery) • Amount owed to providers: $7,540 • Plan pays: $5,360 • Patient pays: $2,180 Sample care costs: Hospital charges (mother) $2,700 Routine Obstetric Care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductible $800 Co-pays $60 Co-insurance $1,290 Limits or exclusions $30 Total $2,180 Managing type 2 diabetes (routine maintenance of a well-controlled condition) • Amount owed to providers: $5,400 • Plan pays: $3,610 • Patient pays: $1,790 Sample care costs: Prescriptions $2,900 Medical equipment and supplies $1,300 Office visits & procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductible $800 Co-pays $670 Co-insurance $40 Limits or exclusions $280 Total $1,790 Coverage Examples About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. estimator Don’t n't use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. Having a baby (normal delivery) ■ Amount owed to providers: $7,540 ■ Plan pays $4,935 ■ Patient pays $2,605 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Managing type 2 diabetes (routine maintenance of a well-controlled condition) ■ Amount owed to providers: $5,400 ■ Plan pays $3,545 ■ Patient pays $1,855 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Deductibles $1,000 Copays $775 Coinsurance $80 Limits or exclusions $0 Total $1,855 Patient pays: Note: These numbers assume the patient is filling scripts at a participating pharmacyenrollment in individual-only coverage. Deductibles $1,900 Copays $45 Coinsurance $660 Limits or exclusions $0 Total $2,605 Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? • Costs don’t n't include premiums. • Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t n't specific to a particular geographic area or health plan. • The patient’s 's condition was not an excluded or preexisting pre existing condition. • All services and treatments started and ended in the same coverage period. • There are no other medical expenses for any member covered under this plan. • Out-of-pocket expenses are based only on treating the condition in the example. • The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copaymentsco-payments, and coinsurance co-insurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t n't covered or payment is limited. Does the Coverage Example predict my own care needs?? 🗶No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor's advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? 🗶No. Coverage Examples are not cost estimators. You can't use the examples 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 providers charge, and the reimbursement your health plan allows. 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 in 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 premium, the more you'll pay in out-of-pocket costs, such as co-payments, deductibles, and co-insurance. You also should consider 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. Plan ID: 5330038 BenefitVersion: 8Plan Name: 2017 OAP Base PlanKitTrack#SBM25189 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 xxx.xxxxx.xxx/xx/ or by calling 1-800-Cigna24 Important Questions Answers Why this Matters: What is the overall deductible? For in-network providers $4,000 person / $8,000 family For out-of-network providers $4,000 person / $8,000 family Combined medical/behavioral and pharmacy deductible Does not apply to in-network preventive care & immunizations. You must pay all the costs up to the deductible amount before this plan 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, 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 deductibles for specific services? No. You don't have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. Is there an out-of-pocket limit on my expenses? Yes. For in-network providers $4,000 person / $8,000 family For out-of-network providers $8,000 person / $16,000 family Combined medical/behavioral and pharmacy out-of-pocket limit. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. What is not included in the out-of-pocket limit? Premium, balance-billed charges, and health care this plan doesn't cover. Even though you pay these expenses, they don't count toward the out-of- pocket limit. Is there an overall annual limit on what the plan pays? No. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. Does this plan use a network of providers? Yes. For a list of participating providers, see xxx.xxXxxxx.xxx or call 1-800-Cigna24 If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use 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 see a specialist? No. You don't need a referral to see a specialist. You can see the specialist you choose without permission from this plan. Are there services this plan doesn't cover? 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 services. • Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount of the service. For example, if the health 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 charge is $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 an Limitations & Exceptions Common Medical Event Services You May Need In-Network Provider Out-of-Network Provider If you visit a health care provider's office or clinic Primary care visit to treat an injury or illness No charge 30% co-insurance ---------- none -------- Specialist visit No charge 30% co-insurance ---------- none -------- Other practitioner office visit No charge for chiropractor 30% co-insurance Coverage for Chiropractic care is limited to 12 days annual max. Preventive care/screening/ immunization No charge 30% co-insurance ------------none---------- If you have a test Diagnostic test (x-ray, blood work) No charge 30% co-insurance ---------- none -------- Imaging (CT/PET scans, MRIs) No charge 30% co-insurance ------------none---------- Your Cost if you use an Limitations & Exceptions Common Medical Event Services You May Need In-Network Provider Out-of-Network Provider If you need drugs to treat your illness or condition More information about prescription drug coverage is available at xxx.xxXxxxx.xxx Generic drugs 0% co-insurance/prescription (retail 30 days) 0% co-insurance/prescription (retail and home delivery 90 days) 30% co-insurance (30 day retail) Not Covered (home delivery) Coverage is limited up to a 90-day supply (retail and home delivery); up to a 30-day supply (retail) and a 90- day supply (home delivery) for Specialty drugs. Certain limitations may apply, including, for example: prior authorization, step therapy, quantity limits. Preferred brand drugs 0% co-insurance/prescription (retail 30 days) 0% co-insurance/prescription (retail and home delivery 90 days) 30% co-insurance (30 day retail) Not Covered (home delivery) Non-preferred brand drugs 0% co-insurance/prescription (retail 30 days) 0% co-insurance/prescription (retail and home delivery 90 days) 30% co-insurance (30 day retail) Not Covered (home delivery) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 30% co-insurance ------------none---------- Physician/surgeon fees No charge 30% co-insurance ----------- none -------- If you need immediate medical attention Emergency room services No charge No charge ------------none---------- Emergency medical transportation No charge No charge ----------- none -------- Urgent care No charge No charge ------------none---------- If you have a hospital stay Facility fee (e.g., hospital room) No charge 30% co-insurance ----------- none -------- Physician/surgeon fees No charge 30% co-insurance ----------- none -------- If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services No charge 30% co-insurance ------------none---------- Mental/Behavioral health inpatient services No charge 30% co-insurance ------------none---------- Substance use disorder outpatient services No charge 30% co-insurance ------------none---------- Substance use disorder inpatient services No charge 30% co-insurance ------------none---------- If you are pregnant Prenatal and postnatal care No charge 30% co-insurance ------------none---------- Delivery and all inpatient services No charge 30% co-insurance ------------none---------- Common Medical Event Services You May Need Your Cost if you use an Limitations & Exceptions Home health care No charge 30% co-insurance ------------none---------- If you need help recovering or have other special health needs Rehabilitation services No charge 30% co-insurance Coverage for Physical Therapy services is limited to 40 days annual max. Speech Therapy is 20 days annual max. Occupational therapy, Pulmonary Rehab and Cognitive therapy are limited to 20 days annual max. Cardiac Rehabilitation services are limited to 36 days annual max, Chiropractic Therapy is limited to 12 days max per Calendar Year. Habilitation services Not Covered Not Covered ------------none---------- Skilled nursing care No charge 30% co-insurance Coverage is limited to 120 days annual max Durable medical equipment No charge 30% co-insurance ------------none---------- Hospice services No charge 30% co-insurance ------------none---------- If your child needs dental or eye care Eye Exam Not Covered Not Covered ------------none---------- Glasses Not Covered Not Covered ------------none---------- Dental check-up Not Covered Not Covered ------------none---------- 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 • Acupuncture • Hearing aids • Cosmetic surgery • Infertility treatment • Dental care (Adult) • Long-term care • Routine foot care • Dental care (Children) • Non-emergency care when traveling outside the U.S. • Weight loss programs • Eye care (Children) • Private-duty nursing • Habilitation services • Routine eye care (Adult) 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 • Bariatric surgery

Language Access Services. Spanish (Español): Para obtener asistencia en Español, llame al 0-000-000-0000. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. Chinese (中文): 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– Blue Cross Blue Shield Michigan: Division 0050 Coverage Period: 01/01/2016 – 12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Covered Individuals | Plan Type: PPO About these Coverage Examples: This is not a cost estimator. Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. Having a baby (normal delivery) ■ ◼ Amount owed to providers: $7,540 ■ ◼ Plan pays $4,935 ■ 6,374 ◼ Patient pays $2,605 1,166 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Managing type 2 diabetes (routine maintenance of a well-controlled condition) ■ ◼ Amount owed to providers: $5,400 ■ ◼ Plan pays $3,545 ■ 4,300 ◼ Patient pays $1,855 1,100 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Deductibles $1,000 250 Copays $775 735 Coinsurance $80 115 Limits or exclusions $0 Total $1,855 1,100 Patient pays: Note: These numbers assume the patient is filling scripts at a participating pharmacy. Deductibles $1,900 500 Copays $45 21 Coinsurance $660 645 Limits or exclusions $0 Total $2,605 1,166 Blue Cross Blue Shield Michigan: Division 0050 Coverage Period: 01/01/2016 – 12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Covered Individuals | Plan Type: PPO Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? • Costs don’t include premiums. • Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan. • The patient’s condition was not an excluded or preexisting condition. • All services and treatments started and ended in the same coverage period. • There are no other medical expenses for any member covered under this plan. • Out-of-pocket expenses are based only on treating the condition in the example. • The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited. Does the Coverage Example predict my own care needs?

Language Access Services. Spanish (Español): Para obtener asistencia en Español, llame al 0-000-000-0000. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. Chinese (中文): 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– Blue Cross Blue Shield Michigan: Division 0049 Coverage Period: 01/01/2018 – 12/31/2018 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Covered Individuals | Plan Type: PPO About these Coverage Examples: This is not a cost estimator. Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. Having a baby (normal delivery) ■ Amount owed to providers: $7,540 ■ Plan pays $4,935 ■ Patient pays $2,605 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Managing type 2 diabetes (routine maintenance of a well-controlled condition) ■ Amount owed to providers: $5,400 ■ Plan pays $3,545 ■ Patient pays $1,855 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Deductibles $1,000 Copays $775 Coinsurance $80 Limits or exclusions $0 Total $1,855 Patient pays: Note: These numbers assume the patient is filling scripts at a participating pharmacy. Deductibles $1,900 Copays $45 Coinsurance $660 Limits or exclusions $0 Total $2,605 Blue Cross Blue Shield Michigan: Division 0049 Coverage Period: 01/01/2018 – 12/31/2018 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Covered Individuals | Plan Type: PPO Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? • Costs don’t include premiums. • Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan. • The patient’s condition was not an excluded or preexisting condition. • All services and treatments started and ended in the same coverage period. • There are no other medical expenses for any member covered under this plan. • Out-of-pocket expenses are based only on treating the condition in the example. • The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited. Does the Coverage Example predict my own care needs?

Language Access Services. Spanish (Español): Para obtener asistencia en Español, llame al 0-000-000-0000. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. Chinese (中文): 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– About these Coverage Examples: This is not a cost estimator. Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. Managing type 2 diabetes (routine maintenance of a well-controlled condition) Having a baby (normal delivery) ■ Amount owed to providers: $7,540 ■ Plan pays $4,935 ■ 6,374 Patient pays $2,605 Sample 1,166 ample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient atient pays: Managing type 2 diabetes (routine maintenance of a well-controlled condition) ■ ■ Amount owed to providers: $5,400 ■ ■ Plan pays $3,545 4,300 ■ ■ Patient pays $1,855 1,100 S Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Deductibles $1,000 250 Copays $775 735 Coinsurance $80 115 Limits or exclusions $0 Total $1,855 1,100 Patient pays: P Note: These numbers assume the patient is filling scripts at a participating pharmacy. Deductibles $1,900 500 Copays $45 21 Coinsurance $660 645 Limits or exclusions $0 Total $2,605 1,166 Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? • Costs don’t include premiums. • Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan. • The patient’s condition was not an excluded or preexisting condition. • All services and treatments started and ended in the same coverage period. • There are no other medical expenses for any member covered under this plan. • Out-of-pocket expenses are based only on treating the condition in the example. • The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited. Does the Coverage Example predict my own care needs?

Language Access Services. Spanish (Español): Para obtener asistencia en Español, llame al 0-000-000-0000. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. Chinese (中文): 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– Blue Cross Blue Shield Michigan: Division 0048 Coverage Period: 01/01/2018 – 12/31/2018 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Covered Individuals | Plan Type: PPO About these Coverage Examples: This is not a cost estimator. Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. Having a baby (normal delivery) ■ Amount owed to providers: $7,540 ■ Plan pays $4,935 6,550 ■ Patient pays $2,605 1,845 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Managing type 2 diabetes (routine maintenance of a well-controlled condition) ■ Amount owed to providers: $5,400 ■ Plan pays $3,545 3,945 ■ Patient pays $1,855 1,455 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Deductibles $1,000 500 Copays $775 Coinsurance $80 180 Limits or exclusions $0 Total $1,855 1,455 Patient pays: Note: These numbers assume the patient is filling scripts at a participating pharmacy. Deductibles $1,900 1,000 Copays $45 Coinsurance $660 800 Limits or exclusions $0 Total $2,605 1,845 Blue Cross Blue Shield Michigan: Division 0048 Coverage Period: 01/01/2018 – 12/31/2018 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Covered Individuals | Plan Type: PPO Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? • Costs don’t include premiums. • Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan. • The patient’s condition was not an excluded or preexisting condition. • All services and treatments started and ended in the same coverage period. • There are no other medical expenses for any member covered under this plan. • Out-of-pocket expenses are based only on treating the condition in the example. • The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited. Does the Coverage Example predict my own care needs?

Language Access Services. Spanish (Español): Para obtener asistencia en Español, llame al 0-000-000-0000. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. Chinese (中文): 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– Blue Cross Blue Shield Michigan: Division 0048 Coverage Period: 01/01/2016 – 12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Covered Individuals | Plan Type: PPO About these Coverage Examples: This is not a cost estimator. Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. Having a baby (normal delivery) ■  Amount owed to providers: $7,540 ■  Plan pays $4,935 ■ 6,550  Patient pays $2,605 1,845 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Managing type 2 diabetes (routine maintenance of a well-controlled condition) ■  Amount owed to providers: $5,400 ■  Plan pays $3,545 ■ 3,945  Patient pays $1,855 1,455 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Deductibles $1,000 500 Copays $775 Coinsurance $80 180 Limits or exclusions $0 Total $1,855 1,455 Patient pays: Note: These numbers assume the patient is filling scripts at a participating pharmacy. Deductibles $1,900 1,000 Copays $45 Coinsurance $660 800 Limits or exclusions $0 Total $2,605 1,845 Blue Cross Blue Shield Michigan: Division 0048 Coverage Period: 01/01/2016 – 12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Covered Individuals | Plan Type: PPO Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? •  Costs don’t include premiums. •  Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan. •  The patient’s condition was not an excluded or preexisting condition. •  All services and treatments started and ended in the same coverage period. •  There are no other medical expenses for any member covered under this plan. •  Out-of-pocket expenses are based only on treating the condition in the example. •  The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited. Does the Coverage Example predict my own care needs?

Language Access Services. Spanish (Español): Para obtener asistencia en Español, llame al 0-000-000-0000. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. Chinese (中文): 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– Blue Cross Blue Shield Michigan: Division 0019 Coverage Period: 01/01/2018 – 12/31/2018 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Covered Individuals | Plan Type: PPO About these Coverage Examples: This is not a cost estimator. Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. Having a baby (normal delivery) ■ Amount owed to providers: $7,540 ■ Plan pays $4,935 6,550 ■ Patient pays $2,605 990 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Managing type 2 diabetes (routine maintenance of a well-controlled condition) ■ Amount owed to providers: $5,400 ■ Plan pays $3,545 4,260 ■ Patient pays $1,855 1,140 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Deductibles $1,000 250 Copays $775 Coinsurance $80 115 Limits or exclusions $0 Total $1,855 1,140 Patient pays: Note: These numbers assume the patient is filling scripts at a participating pharmacy. Deductibles $1,900 500 Copays $45 Coinsurance $660 445 Limits or exclusions $0 Total $2,605 990 Blue Cross Blue Shield Michigan: Division 0019 Coverage Period: 01/01/2018 – 12/31/2018 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Covered Individuals | Plan Type: PPO Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? • Costs don’t include premiums. • Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan. • The patient’s condition was not an excluded or preexisting condition. • All services and treatments started and ended in the same coverage period. • There are no other medical expenses for any member covered under this plan. • Out-of-pocket expenses are based only on treating the condition in the example. • The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited. Does the Coverage Example predict my own care needs?

Language Access Services. Spanish (Español): Para obtener asistencia en Español, llame al 0-000-000-0000. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. Chinese (中文): 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– Blue Cross Blue Shield Michigan: Division 0049 Coverage Period: 01/01/2016 – 12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Covered Individuals | Plan Type: PPO About these Coverage Examples: This is not a cost estimator. Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. Having a baby (normal delivery) ■ Amount owed to providers: $7,540 ■ Plan pays $4,935 ■ Patient pays $2,605 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Managing type 2 diabetes (routine maintenance of a well-controlled condition) ■ Amount owed to providers: $5,400 ■ Plan pays $3,545 ■ Patient pays $1,855 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Deductibles $1,000 Copays $775 Coinsurance $80 Limits or exclusions $0 Total $1,855 Patient pays: Note: These numbers assume the patient is filling scripts at a participating pharmacy. Deductibles $1,900 Copays $45 Coinsurance $660 Limits or exclusions $0 Total $2,605 Blue Cross Blue Shield Michigan: Division 0049 Coverage Period: 01/01/2016 – 12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Covered Individuals | Plan Type: PPO Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? • Costs don’t include premiums. • Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan. • The patient’s condition was not an excluded or preexisting condition. • All services and treatments started and ended in the same coverage period. • There are no other medical expenses for any member covered under this plan. • Out-of-pocket expenses are based only on treating the condition in the example. • The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited. Does the Coverage Example predict my own care needs?