Common use of Your Grievance and Appeals Rights Clause in Contracts

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. ◼ The plan’s overall deductible $1,000 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $1,000 ◼ Specialist copayment $30 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $1,000 ◼ Specialist copayment $30 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 20% Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Deductibles $1,000 Copayments $10 Coinsurance $2,300 Limits or exclusions $60 The total Peg would pay is $3,370 Deductibles $900 Copayments $800 Coinsurance $0 Limits or exclusions $20 The total Xxx would pay is $1,720 Deductibles $1,000 Copayments $100 Coinsurance $100 Limits or exclusions $0 The total Mia would pay is $1,200 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copy.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. ◼ The plan’s overall deductible $1,000 500 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $1,000 500 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $1,000 500 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 20% Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Deductibles $1,000 500 Copayments $10 Coinsurance $2,300 2,400 Limits or exclusions $60 The total Peg would pay is $3,370 2,970 Deductibles $900 500 Copayments $800 700 Coinsurance $0 80 Limits or exclusions $20 The total Xxx would pay is $1,720 1,300 Deductibles $1,000 500 Copayments $100 70 Coinsurance $100 200 Limits or exclusions $0 The total Mia would pay is $1,200 770 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copy.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. ◼ The plan’s overall deductible $1,000 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $1,000 ◼ Specialist copayment $30 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $1,000 ◼ Specialist copayment $30 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 20% Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Deductibles $1,000 Copayments $10 Coinsurance $2,300 Limits or exclusions $60 The total Peg would pay is $3,370 Deductibles $900 Copayments $800 Coinsurance $0 Limits or exclusions $20 The total Xxx would pay is $1,720 Deductibles $1,000 Copayments $100 Coinsurance $100 Limits or exclusions $0 The total Mia would pay is $1,200 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copy.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township Blue Cross® and Blue Shield® of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000Michigan by calling the number on the back of your BCBSM ID card. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan ) Department of Insurance and Financial Services (DIFS) at (000) 000Services, P. O. Xxx 00000, Xxxxxxx, XX 00000-0000. 0000 or xxxx://xxx.xxxxxxxx.xxx/difs or xxxx-XXXXX@xxxxxxxx.xxx Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Spanish (Español): Para obtener asistencia en EspañolIMPORTANT: Blue Cross Blue Shield of Michigan is assuming that your coverage provides for all Essential Health Benefit (EHB) categories as defined by the State of Michigan. The minimum value of your plan may be affected if your plan does not cover certain EHB categories, 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 ninisingosuch as prescription drugs, kwiijigo holne' 0-000-000-0000. or if your plan provides coverage of specific EHB categories, for example prescription drugs, through another carrier.) ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section. –––––––––––––––––––––– This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- self-only coverage. ◼ The plan’s overall deductible $1,000 100 ◼ Primary care physician coinsurance 0% Specialist copayment $10 ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% Primary care physician This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $1,000 100 ◼ Specialist copayment $30 10 ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% Specialist This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $1,000 100 ◼ Specialist copayment $30 10 ◼ Hospital (facility) coinsurance 010% ◼ Other coinsurance 2010% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test tests (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Deductibles $1,000 100 Copayments $10 Coinsurance $2,300 1,000 Limits or exclusions $60 The total Peg would pay is $3,370 Deductibles $900 100 Copayments $800 500 Coinsurance $0 80 Limits or exclusions $20 The total Xxx would pay is $1,720 Deductibles $1,000 100 Copayments $100 30 Coinsurance $100 200 Limits or exclusions $0 The total Mia would pay is $1,200 If you are also covered by an account-type plan such as an integrated health flexible spending arrangement (FSA), health reimbursement arrangement (HRA), and/or a health savings account (HSA), then you may have access to additional funds to help cover certain out-of-pocket expenses – like the deductible, copayments, or coinsurance, or benefits not otherwise covered. Community Blue PPOSM ASC Coverage for: Individual/Family | Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx visit xxx.xxxxx.xxx or call (000) 000-0000the number on the back of your BCBSM ID card. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx xxxxx://xxx.xxxxxxxxxx.xxx/sbc-glossary or call Care Coordinators at (000) 000-0000 the number on the back of your BCBSM ID card to request a copy.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township Blue Cross® and Blue Shield® of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000Michigan by calling the number on the back of your BCBSM ID card. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan ) Department of Insurance and Financial Services (DIFS) at (000) 000Services, P. O. Xxx 00000, Xxxxxxx, XX 00000-0000. 0000 or xxxx://xxx.xxxxxxxx.xxx/difs or xxxx-XXXXX@xxxxxxxx.xxx Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Spanish (Español): Para obtener asistencia en EspañolIMPORTANT: Blue Cross Blue Shield of Michigan is assuming that your coverage provides for all Essential Health Benefit (EHB) categories as defined by the State of Michigan. The minimum value of your plan may be affected if your plan does not cover certain EHB categories, 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 ninisingosuch as prescription drugs, kwiijigo holne' 0-000-000-0000. or if your plan provides coverage of specific EHB categories, for example prescription drugs, through another carrier.) ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section. –––––––––––––––––––––– This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- self-only coverage. ◼ The plan’s overall deductible $1,000 250 ◼ Primary care physician coinsurance 0% Specialist copayment $20 ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% Primary care physician This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $1,000 250 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% Specialist This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $1,000 250 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 010% ◼ Other coinsurance 2010% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test tests (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Deductibles $1,000 250 Copayments $10 Coinsurance $2,300 1,000 Limits or exclusions $60 The total Peg would pay is $3,370 Deductibles $900 250 Copayments $800 600 Coinsurance $0 70 Limits or exclusions $20 The total Xxx would pay is $1,720 Deductibles $1,000 250 Copayments $100 Coinsurance $100 Limits or exclusions $0 The total Mia would pay is $1,200 If you are also covered by an account-type plan such as an integrated health flexible spending arrangement (FSA), health reimbursement arrangement (HRA), and/or a health savings account (HSA), then you may have access to additional funds to help cover certain out-of-pocket expenses – like the deductible, copayments, or coinsurance, or benefits not otherwise covered. Community Blue PPOSM ASC Coverage for: Individual/Family | Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx visit xxx.xxxxx.xxx or call (000) 000-0000the number on the back of your BCBSM ID card. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx xxxxx://xxx.xxxxxxxxxx.xxx/sbc-glossary or call Care Coordinators at (000) 000-0000 the number on the back of your BCBSM ID card to request a copy.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township Blue Cross® and Blue Shield® of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000Michigan by calling the number on the back of your BCBSM ID card. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan ) Department of Insurance and Financial Services (DIFS) at (000) 000Services, P. O. Xxx 00000, Xxxxxxx, XX 00000-0000. 0000 or xxxx://xxx.xxxxxxxx.xxx/difs or xxxx-XXXXX@xxxxxxxx.xxx Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Spanish (Español): Para obtener asistencia en EspañolIMPORTANT: Blue Cross Blue Shield of Michigan is assuming that your coverage provides for all Essential Health Benefit (EHB) categories as defined by the State of Michigan. The minimum value of your plan may be affected if your plan does not cover certain EHB categories, 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 ninisingosuch as prescription drugs, kwiijigo holne' 0-000-000-0000. or if your plan provides coverage of specific EHB categories, for example prescription drugs, through another carrier.) ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section. –––––––––––––––––––––– This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- self-only coverage. ◼ The plan’s overall deductible $1,000 0 ◼ Primary care physician coinsurance 0% Specialist copayment $10 ◼ Hospital (facility) coinsurance 20% copayment $0 ◼ Other coinsurance 20% Primary care physician copayment $0 This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $1,000 0 ◼ Specialist copayment $30 10 ◼ Hospital (facility) coinsurance 20% copayment $0 ◼ Other coinsurance 20% Specialist copayment $0 This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $1,000 0 ◼ Specialist copayment $30 10 ◼ Hospital (facility) coinsurance 0% copayment $0 ◼ Other coinsurance 20% copayment $0 This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test tests (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Deductibles $1,000 0 Copayments $10 Coinsurance $2,300 0 Limits or exclusions $60 The total Peg would pay is $3,370 Deductibles $900 0 Copayments $800 300 Coinsurance $0 Limits or exclusions $20 The total Xxx would pay is $1,720 Deductibles $1,000 0 Copayments $100 30 Coinsurance $100 0 Limits or exclusions $0 The total Mia would pay is $1,200 If you are also covered by an account-type plan such as an integrated health flexible spending arrangement (FSA), health reimbursement arrangement (HRA), and/or a health savings account (HSA), then you may have access to additional funds to help cover certain out-of-pocket expenses – like the deductible, copayments, or coinsurance, or benefits not otherwise covered. Community Blue PPOSM ASC Coverage for: Individual/Family | Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx visit xxx.xxxxx.xxx or call (000) 000-0000the number on the back of your BCBSM ID card. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx xxxxx://xxx.xxxxxxxxxx.xxx/sbc-glossary or call Care Coordinators at (000) 000-0000 the number on the back of your BCBSM ID card to request a copy.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. ◼ The plan’s overall deductible $1,000 250 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $1,000 250 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $1,000 250 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 2010% Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Deductibles $1,000 250 Copayments $10 Coinsurance $2,300 1,200 Limits or exclusions $60 The total Peg would pay is $3,370 1,520 Deductibles $900 250 Copayments $800 Coinsurance $0 70 Limits or exclusions $20 The total Xxx would pay is $1,720 1,140 Deductibles $1,000 250 Copayments $100 70 Coinsurance $100 Limits or exclusions $0 The total Mia would pay is $1,200 The 420 This Summary of Dental Plan Benefits should be read along with your Certificate. Your Certificate provides additional information about your Delta Dental plan, including information about plan exclusions and Coverage limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the dentist's network participation.* Delta Dental PPO Dentist Delta Dental Premier Dentist Plan Pays Plan Pays Control Plan – Delta Dental of Michigan Benefit Year – January 1 through December 31 Covered Services – Nonparticipating Dentist Plan Pays* Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers 100% 85% 65% Emergency Palliative Treatment – to temporarily relieve pain 100% 85% 65% Brush Biopsy – to detect oral cancer 100% 85% 65% Radiographs – X-rays 100% 85% 65% Minor Restorative Services – fillings and crown repair 80% 65% 65% Endodontic Services – root canals 80% 65% 65% Periodontic Services – to treat gum disease 80% 65% 65% Oral Surgery Services – extractions and dental surgery 80% 65% 65% Other Basic Services – misc. services 80% 65% 65% Relines and Repairs – to prosthetic appliances 80% 65% 65% Major Restorative Services – crowns 75% 60% 60% Prosthodontic Services – bridges, implants, dentures, and crowns over implants 60% 60% 60% Orthodontic Services – braces 60% 60% 60% Orthodontic Age Limit – up to age 19 up to age 19 up to age 19 * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This amount may be less than what the Dentist charges or Delta Dental approves and you are responsible for that difference.  Oral exams (SBCincluding evaluations by a specialist) document will are payable twice in any period of 12 consecutive months.  Prophylaxes (cleanings) are payable twice in any period of 12 consecutive months.  People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment.  Fluoride treatments are payable twice in any period of 12 consecutive months for people age 18 and under.  Bitewing X-rays are payable once in any period of 12 consecutive months and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period.  Composite resin (white) restorations are optional treatment on posterior teeth.  Porcelain and resin facings on crowns are optional treatment on posterior teeth.  Implants are payable once per tooth in any five-year period. Implant related services are Covered Services.  Crowns over implants are payable once per tooth in any five-year period. Services related to crowns over implants are Covered Services. Having Delta Dental coverage makes it easy for you toAgppeetnddeixn"taHl"care almost everywhere in the world! You can now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a worldwide network of dentists and dental clinics. English-speaking operators are available around the clock to answer questions and help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summaryschedule care. For more information about information, check our Web site or contact your coverage, or benefits representative to get a copy of our Passport Dental information sheet. Maximum Payment – $2,000 per person total per Benefit Year on all services except orthodontic services. $2,000 per person total per lifetime on orthodontic services. Payment for Orthodontic Service – When orthodontic treatment begins, your Dentist will submit a payment plan to Delta Dental based upon your projected course of treatment. In accordance with the complete terms agreed upon payment plan, Delta Dental will make an initial payment to you or your Participating Dentist equal to Delta Dental's stated Copayment on 30% of coverage, go the Maximum Payment for Orthodontic Services as set forth in this Summary of Dental Plan Benefits. Delta Dental will make additional payments as follows: Delta Dental will pay 60% of the per monthly fee charged by your Dentist based upon the agreed upon payment plan provided by your Dentist to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000Delta Dental. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copyDeductible – None.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. Appendix "C" - Plan #048 - Ontario This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. ◼ The plan’s overall deductible $1,000 500 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $1,000 500 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $1,000 500 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 20% Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Deductibles $1,000 500 Copayments $10 Coinsurance $2,300 2,400 Limits or exclusions $60 The total Peg would pay is $3,370 2,970 Deductibles $900 500 Copayments $800 700 Coinsurance $0 80 Limits or exclusions $20 The total Xxx would pay is $1,720 1,300 Deductibles $1,000 500 Copayments $100 70 Coinsurance $100 200 Limits or exclusions $0 The total Mia would pay is $1,200 770 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copy.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. Appendix "C" This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. ◼ The plan’s overall deductible $1,000 500 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $1,000 500 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $1,000 500 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 20% Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Deductibles $1,000 500 Copayments $10 Coinsurance $2,300 2,400 Limits or exclusions $60 The total Peg would pay is $3,370 2,970 Deductibles $900 500 Copayments $800 700 Coinsurance $0 80 Limits or exclusions $20 The total Xxx would pay is $1,720 1,300 Deductibles $1,000 500 Copayments $100 70 Coinsurance $100 200 Limits or exclusions $0 The total Mia would pay is $1,200 770 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copy.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. Appendix "D" This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. ◼ The plan’s overall deductible $1,000 500 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $1,000 500 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $1,000 500 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 20% Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Deductibles $1,000 500 Copayments $10 Coinsurance $2,300 2,400 Limits or exclusions $60 The total Peg would pay is $3,370 2,970 Deductibles $900 500 Copayments $800 700 Coinsurance $0 80 Limits or exclusions $20 The total Xxx would pay is $1,720 1,300 Deductibles $1,000 500 Copayments $100 70 Coinsurance $100 200 Limits or exclusions $0 The total Mia would pay is $1,200 770 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copy.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. Appendix "F" This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. ◼ The plan’s overall deductible $1,000 250 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $1,000 250 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $1,000 250 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 2010% Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Deductibles $1,000 250 Copayments $10 Coinsurance $2,300 1,200 Limits or exclusions $60 The total Peg would pay is $3,370 1,520 Deductibles $900 250 Copayments $800 Coinsurance $0 70 Limits or exclusions $20 The total Xxx would pay is $1,720 1,140 Deductibles $1,000 250 Copayments $100 70 Coinsurance $100 Limits or exclusions $0 The total Mia would pay is $1,200 The 420 This Summary of Dental Plan Benefits should be read along with your Certificate. Your Certificate provides additional information about your Delta Dental plan, including information about plan exclusions and Coverage limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the dentist's network participation.* Delta Dental PPO Dentist Delta Dental Premier Dentist Plan Pays Plan Pays Control Plan – Delta Dental of Michigan Benefit Year – January 1 through December 31 Covered Services – Nonparticipating Dentist Plan Pays* Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers 100% 85% 65% Emergency Palliative Treatment – to temporarily relieve pain 100% 85% 65% Brush Biopsy – to detect oral cancer 100% 85% 65% Radiographs – X-rays 100% 85% 65% Minor Restorative Services – fillings and crown repair 80% 65% 65% Endodontic Services – root canals 80% 65% 65% Periodontic Services – to treat gum disease 80% 65% 65% Oral Surgery Services – extractions and dental surgery 80% 65% 65% Other Basic Services – misc. services 80% 65% 65% Relines and Repairs – to prosthetic appliances 80% 65% 65% Major Restorative Services – crowns 75% 60% 60% Prosthodontic Services – bridges, implants, dentures, and crowns over implants 60% 60% 60% Orthodontic Services – braces 60% 60% 60% Orthodontic Age Limit – up to age 19 up to age 19 up to age 19 * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This amount may be less than what the Dentist charges or Delta Dental approves and you are responsible for that difference.  Oral exams (SBCincluding evaluations by a specialist) document will are payable twice in any period of 12 consecutive months.  Prophylaxes (cleanings) are payable twice in any period of 12 consecutive months.  People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment.  Fluoride treatments are payable twice in any period of 12 consecutive months for people age 18 and under.  Bitewing X-rays are payable once in any period of 12 consecutive months and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period.  Composite resin (white) restorations are optional treatment on posterior teeth.  Porcelain and resin facings on crowns are optional treatment on posterior teeth.  Implants are payable once per tooth in any five-year period. Implant related services are Covered Services.  Crowns over implants are payable once per tooth in any five-year period. Services related to crowns over implants are Covered Services. Having Delta Dental coverage makes it easy for you toAgppeetnddeixn"taGl"care almost everywhere in the world! You can now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a worldwide network of dentists and dental clinics. English-speaking operators are available around the clock to answer questions and help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summaryschedule care. For more information about information, check our Web site or contact your coverage, or benefits representative to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000our Passport Dental information sheet. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the GlossaryMaximum Payment – $2,000 per person total per Benefit Year on all services except orthodontic services. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copy$2,000 per person total per lifetime on orthodontic services.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. Appendix "D" This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. ◼ The plan’s overall deductible $1,000 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $1,000 ◼ Specialist copayment $30 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $1,000 ◼ Specialist copayment $30 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 20% Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Deductibles $1,000 Copayments $10 Coinsurance $2,300 Limits or exclusions $60 The total Peg would pay is $3,370 Deductibles $900 Copayments $800 Coinsurance $0 Limits or exclusions $20 The total Xxx would pay is $1,720 Deductibles $1,000 Copayments $100 Coinsurance $100 Limits or exclusions $0 The total Mia would pay is $1,200 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copy.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. Appendix "E" - Plan #50 - Michigan This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. ◼ The plan’s overall deductible $1,000 250 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $1,000 250 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $1,000 250 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 2010% Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Deductibles $1,000 250 Copayments $10 Coinsurance $2,300 1,200 Limits or exclusions $60 The total Peg would pay is $3,370 1,520 Deductibles $900 250 Copayments $800 Coinsurance $0 70 Limits or exclusions $20 The total Xxx would pay is $1,720 1,140 Deductibles $1,000 250 Copayments $100 70 Coinsurance $100 Limits or exclusions $0 The total Mia would pay is $1,200 The 420 This Summary of Dental Plan Benefits should be read along with your Certificate. Your Certificate provides additional information about your Delta Dental plan, including information about plan exclusions and Coverage limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the dentist's network participation.* Delta Dental PPO Dentist Delta Dental Premier Dentist Plan Pays Plan Pays Control Plan – Delta Dental of Michigan Benefit Year – January 1 through December 31 Covered Services – Nonparticipating Dentist Plan Pays* Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers 100% 85% 65% Emergency Palliative Treatment – to temporarily relieve pain 100% 85% 65% Brush Biopsy – to detect oral cancer 100% 85% 65% Radiographs – X-rays 100% 85% 65% Minor Restorative Services – fillings and crown repair 80% 65% 65% Endodontic Services – root canals 80% 65% 65% Periodontic Services – to treat gum disease 80% 65% 65% Oral Surgery Services – extractions and dental surgery 80% 65% 65% Other Basic Services – misc. services 80% 65% 65% Relines and Repairs – to prosthetic appliances 80% 65% 65% Major Restorative Services – crowns 75% 60% 60% Prosthodontic Services – bridges, implants, dentures, and crowns over implants 60% 60% 60% Orthodontic Services – braces 60% 60% 60% Orthodontic Age Limit – up to age 19 up to age 19 up to age 19 * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This amount may be less than what the Dentist charges or Delta Dental approves and you are responsible for that difference.  Oral exams (SBCincluding evaluations by a specialist) document will are payable twice in any period of 12 consecutive months.  Prophylaxes (cleanings) are payable twice in any period of 12 consecutive months.  People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment.  Fluoride treatments are payable twice in any period of 12 consecutive months for people age 18 and under.  Bitewing X-rays are payable once in any period of 12 consecutive months and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period.  Composite resin (white) restorations are optional treatment on posterior teeth.  Porcelain and resin facings on crowns are optional treatment on posterior teeth.  Implants are payable once per tooth in any five-year period. Implant related services are Covered Services.  Crowns over implants are payable once per tooth in any five-year period. Services related to crowns over implants are Covered Services. Having Delta Dental coverage makes it easy for you toAgpepetnddeixnt"aFl"care almost everywhere in the world! You can now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a worldwide network of dentists and dental clinics. English-speaking operators are available around the clock to answer questions and help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summaryschedule care. For more information about information, check our Web site or contact your coverage, or benefits representative to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000our Passport Dental information sheet. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the GlossaryMaximum Payment – $2,000 per person total per Benefit Year on all services except orthodontic services. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copy$2,000 per person total per lifetime on orthodontic services.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. Appendix "H" This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. ◼ The plan’s overall deductible $1,000 250 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $1,000 250 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $1,000 250 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 2010% Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Deductibles $1,000 250 Copayments $10 Coinsurance $2,300 1,200 Limits or exclusions $60 The total Peg would pay is $3,370 1,520 Deductibles $900 250 Copayments $800 Coinsurance $0 70 Limits or exclusions $20 The total Xxx would pay is $1,720 1,140 Deductibles $1,000 250 Copayments $100 70 Coinsurance $100 Limits or exclusions $0 The total Mia would pay is $1,200 The 420 This Summary of Dental Plan Benefits should be read along with your Certificate. Your Certificate provides additional information about your Delta Dental plan, including information about plan exclusions and Coverage limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the dentist's network participation.* Delta Dental PPO Dentist Delta Dental Premier Dentist Plan Pays Plan Pays Control Plan – Delta Dental of Michigan Benefit Year – January 1 through December 31 Covered Services – Nonparticipating Dentist Plan Pays* Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers 100% 85% 65% Emergency Palliative Treatment – to temporarily relieve pain 100% 85% 65% Brush Biopsy – to detect oral cancer 100% 85% 65% Radiographs – X-rays 100% 85% 65% Minor Restorative Services – fillings and crown repair 80% 65% 65% Endodontic Services – root canals 80% 65% 65% Periodontic Services – to treat gum disease 80% 65% 65% Oral Surgery Services – extractions and dental surgery 80% 65% 65% Other Basic Services – misc. services 80% 65% 65% Relines and Repairs – to prosthetic appliances 80% 65% 65% Major Restorative Services – crowns 75% 60% 60% Prosthodontic Services – bridges, implants, dentures, and crowns over implants 60% 60% 60% Orthodontic Services – braces 60% 60% 60% Orthodontic Age Limit – up to age 19 up to age 19 up to age 19 * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This amount may be less than what the Dentist charges or Delta Dental approves and you are responsible for that difference.  Oral exams (SBCincluding evaluations by a specialist) document will are payable twice in any period of 12 consecutive months.  Prophylaxes (cleanings) are payable twice in any period of 12 consecutive months.  People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment.  Fluoride treatments are payable twice in any period of 12 consecutive months for people age 18 and under.  Bitewing X-rays are payable once in any period of 12 consecutive months and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period.  Composite resin (white) restorations are optional treatment on posterior teeth.  Porcelain and resin facings on crowns are optional treatment on posterior teeth.  Implants are payable once per tooth in any five-year period. Implant related services are Covered Services.  Crowns over implants are payable once per tooth in any five-year period. Services related to crowns over implants are Covered Services. Having Delta Dental coverage makes it easy for you toAgpeptenddeixnt"aI"l care almost everywhere in the world! You can now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a worldwide network of dentists and dental clinics. English-speaking operators are available around the clock to answer questions and help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summaryschedule care. For more information about information, check our Web site or contact your coverage, or benefits representative to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000our Passport Dental information sheet. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the GlossaryMaximum Payment – $2,000 per person total per Benefit Year on all services except orthodontic services. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copy$2,000 per person total per lifetime on orthodontic services.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. Appendix "F" This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. ◼ The plan’s overall deductible $1,000 500 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $1,000 500 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $1,000 500 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 20% Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Deductibles $1,000 500 Copayments $10 Coinsurance $2,300 2,400 Limits or exclusions $60 The total Peg would pay is $3,370 2,970 Deductibles $900 500 Copayments $800 700 Coinsurance $0 80 Limits or exclusions $20 The total Xxx would pay is $1,720 1,300 Deductibles $1,000 500 Copayments $100 70 Coinsurance $100 200 Limits or exclusions $0 The total Mia would pay is $1,200 770 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copy.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township Blue Cross® and Blue Shield® of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000Michigan by calling the number on the back of your BCBSM ID card. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan ) Department of Insurance and Financial Services (DIFS) at (000) 000Services, P. O. Xxx 00000, Xxxxxxx, XX 00000-0000. 0000 or xxxx://xxx.xxxxxxxx.xxx/difs or xxxx-XXXXX@xxxxxxxx.xxx Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Spanish (Español): Para obtener asistencia en EspañolIMPORTANT: Blue Cross Blue Shield of Michigan is assuming that your coverage provides for all Essential Health Benefit (EHB) categories as defined by the State of Michigan. The minimum value of your plan may be affected if your plan does not cover certain EHB categories, 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 ninisingosuch as prescription drugs, kwiijigo holne' 0-000-000-0000. or if your plan provides coverage of specific EHB categories, for example prescription drugs, through another carrier.) ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section. –––––––––––––––––––––– This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- self-only coverage. ◼ The plan’s overall deductible $1,000 0 ◼ Primary care physician coinsurance 0% Specialist copayment $20 ◼ Hospital (facility) coinsurance 20% copayment $0 ◼ Other coinsurance 20% Primary care physician copayment $0 This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $1,000 0 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 20% copayment $0 ◼ Other coinsurance 20% Specialist copayment $0 This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $1,000 0 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 0% copayment $0 ◼ Other coinsurance 20% copayment $0 This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test tests (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Deductibles $1,000 0 Copayments $10 Coinsurance $2,300 Limits or exclusions $60 The total Peg would pay is $3,370 Deductibles $900 Copayments $800 0 Coinsurance $0 Limits or exclusions $20 The total Xxx would pay is $1,720 70 Deductibles $1,000 0 Copayments $100 Coinsurance $100 0 Limits or exclusions $3,500 Deductibles $0 The total Mia would pay is Copayments $1,200 40 Coinsurance $0 Limits or exclusions $10 If you are also covered by an account-type plan such as an integrated health flexible spending arrangement (FSA), health reimbursement arrangement (HRA), and/or a health savings account (HSA), then you may have access to additional funds to help cover certain out-of-pocket expenses – like the deductible, copayments, or coinsurance, or benefits not otherwise covered. Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 10/01/2021 Simply Blue PPO HSASM ASC Coverage for: Individual/Family | Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx visit xxx.xxxxx.xxx or call (000) 000-0000the number on the back of your BCBSM ID card. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx xxxxx://xxx.xxxxxxxxxx.xxx/sbc-glossary or call Care Coordinators at (000) 000-0000 the number on the back of your BCBSM ID card to request a copy.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. ◼ The plan’s overall deductible $1,000 250 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $1,000 250 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $1,000 250 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 2010% Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Deductibles $1,000 250 Copayments $10 Coinsurance $2,300 1,200 Limits or exclusions $60 The total Peg would pay is $3,370 1,520 Deductibles $900 250 Copayments $800 Coinsurance $0 70 Limits or exclusions $20 The total Xxx would pay is $1,720 1,140 Deductibles $1,000 250 Copayments $100 70 Coinsurance $100 Limits or exclusions $0 The total Mia would pay is $1,200 The 420 This Summary of Dental Plan Benefits should be read along with your Certificate. Your Certificate provides additional information about your Delta Dental plan, including information about plan exclusions and Coverage limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the dentist's network participation.* Delta Dental PPO Dentist Delta Dental Premier Dentist Plan Pays Plan Pays Control Plan – Delta Dental of Michigan Benefit Year – January 1 through December 31 Covered Services – Nonparticipating Dentist Plan Pays* Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers 100% 85% 65% Emergency Palliative Treatment – to temporarily relieve pain 100% 85% 65% Brush Biopsy – to detect oral cancer 100% 85% 65% Radiographs – X-rays 100% 85% 65% Minor Restorative Services – fillings and crown repair 80% 65% 65% Endodontic Services – root canals 80% 65% 65% Periodontic Services – to treat gum disease 80% 65% 65% Oral Surgery Services – extractions and dental surgery 80% 65% 65% Other Basic Services – misc. services 80% 65% 65% Relines and Repairs – to prosthetic appliances 80% 65% 65% Major Restorative Services – crowns 75% 60% 60% Prosthodontic Services – bridges, implants, dentures, and crowns over implants 60% 60% 60% Orthodontic Services – braces 60% 60% 60% Orthodontic Age Limit – up to age 19 up to age 19 up to age 19 * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This amount may be less than what the Dentist charges or Delta Dental approves and you are responsible for that difference.  Oral exams (SBCincluding evaluations by a specialist) document will are payable twice in any period of 12 consecutive months.  Prophylaxes (cleanings) are payable twice in any period of 12 consecutive months.  People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment.  Fluoride treatments are payable twice in any period of 12 consecutive months for people age 18 and under.  Bitewing X-rays are payable once in any period of 12 consecutive months and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period.  Composite resin (white) restorations are optional treatment on posterior teeth.  Porcelain and resin facings on crowns are optional treatment on posterior teeth.  Implants are payable once per tooth in any five-year period. Implant related services are Covered Services.  Crowns over implants are payable once per tooth in any five-year period. Services related to crowns over implants are Covered Services. Having Delta Dental coverage makes it easy for you toAgppeetnddeixn"taGl"care almost everywhere in the world! You can now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a worldwide network of dentists and dental clinics. English-speaking operators are available around the clock to answer questions and help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summaryschedule care. For more information about information, check our Web site or contact your coverage, or benefits representative to get a copy of our Passport Dental information sheet. Maximum Payment – $2,000 per person total per Benefit Year on all services except orthodontic services. $2,000 per person total per lifetime on orthodontic services. Payment for Orthodontic Service – When orthodontic treatment begins, your Dentist will submit a payment plan to Delta Dental based upon your projected course of treatment. In accordance with the complete terms agreed upon payment plan, Delta Dental will make an initial payment to you or your Participating Dentist equal to Delta Dental's stated Copayment on 30% of coverage, go the Maximum Payment for Orthodontic Services as set forth in this Summary of Dental Plan Benefits. Delta Dental will make additional payments as follows: Delta Dental will pay 60% of the per monthly fee charged by your Dentist based upon the agreed upon payment plan provided by your Dentist to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000Delta Dental. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copyDeductible – None.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. Appendix "E" This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. ◼ The plan’s overall deductible $1,000 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $1,000 ◼ Specialist copayment $30 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $1,000 ◼ Specialist copayment $30 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 20% Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Deductibles $1,000 Copayments $10 Coinsurance $2,300 Limits or exclusions $60 The total Peg would pay is $3,370 Deductibles $900 Copayments $800 Coinsurance $0 Limits or exclusions $20 The total Xxx would pay is $1,720 Deductibles $1,000 Copayments $100 Coinsurance $100 Limits or exclusions $0 The total Mia would pay is $1,200 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copy.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. Appendix "E" This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. ◼ The plan’s overall deductible $1,000 250 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $1,000 250 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $1,000 250 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 2010% Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Deductibles $1,000 250 Copayments $10 Coinsurance $2,300 1,200 Limits or exclusions $60 The total Peg would pay is $3,370 1,520 Deductibles $900 250 Copayments $800 Coinsurance $0 70 Limits or exclusions $20 The total Xxx would pay is $1,720 1,140 Deductibles $1,000 250 Copayments $100 70 Coinsurance $100 Limits or exclusions $0 The total Mia would pay is $1,200 The 420 This Summary of Dental Plan Benefits should be read along with your Certificate. Your Certificate provides additional information about your Delta Dental plan, including information about plan exclusions and Coverage limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the dentist's network participation.* Delta Dental PPO Dentist Delta Dental Premier Dentist Plan Pays Plan Pays Control Plan – Delta Dental of Michigan Benefit Year – January 1 through December 31 Covered Services – Nonparticipating Dentist Plan Pays* Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers 100% 85% 65% Emergency Palliative Treatment – to temporarily relieve pain 100% 85% 65% Brush Biopsy – to detect oral cancer 100% 85% 65% Radiographs – X-rays 100% 85% 65% Minor Restorative Services – fillings and crown repair 80% 65% 65% Endodontic Services – root canals 80% 65% 65% Periodontic Services – to treat gum disease 80% 65% 65% Oral Surgery Services – extractions and dental surgery 80% 65% 65% Other Basic Services – misc. services 80% 65% 65% Relines and Repairs – to prosthetic appliances 80% 65% 65% Major Restorative Services – crowns 75% 60% 60% Prosthodontic Services – bridges, implants, dentures, and crowns over implants 60% 60% 60% Orthodontic Services – braces 60% 60% 60% Orthodontic Age Limit – up to age 19 up to age 19 up to age 19 * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This amount may be less than what the Dentist charges or Delta Dental approves and you are responsible for that difference.  Oral exams (SBCincluding evaluations by a specialist) document will are payable twice in any period of 12 consecutive months.  Prophylaxes (cleanings) are payable twice in any period of 12 consecutive months.  People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment.  Fluoride treatments are payable twice in any period of 12 consecutive months for people age 18 and under.  Bitewing X-rays are payable once in any period of 12 consecutive months and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period.  Composite resin (white) restorations are optional treatment on posterior teeth.  Porcelain and resin facings on crowns are optional treatment on posterior teeth.  Implants are payable once per tooth in any five-year period. Implant related services are Covered Services.  Crowns over implants are payable once per tooth in any five-year period. Services related to crowns over implants are Covered Services. Having Delta Dental coverage makes it easy for you toAgpepetnddeixnt"aFl"care almost everywhere in the world! You can now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a worldwide network of dentists and dental clinics. English-speaking operators are available around the clock to answer questions and help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summaryschedule care. For more information about information, check our Web site or contact your coverage, or benefits representative to get a copy of our Passport Dental information sheet. Maximum Payment – $2,000 per person total per Benefit Year on all services except orthodontic services. $2,000 per person total per lifetime on orthodontic services. Payment for Orthodontic Service – When orthodontic treatment begins, your Dentist will submit a payment plan to Delta Dental based upon your projected course of treatment. In accordance with the complete terms agreed upon payment plan, Delta Dental will make an initial payment to you or your Participating Dentist equal to Delta Dental's stated Copayment on 30% of coverage, go the Maximum Payment for Orthodontic Services as set forth in this Summary of Dental Plan Benefits. Delta Dental will make additional payments as follows: Delta Dental will pay 60% of the per monthly fee charged by your Dentist based upon the agreed upon payment plan provided by your Dentist to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000Delta Dental. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copyDeductible – None.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township contact: the Member Service number listed on the back of Clinton at (000) 000-0000 your ID card or Care Coordinators at (000) 000-0000xxxxx.xxx. Additionally, a consumer assistance program can may help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000xxx.xxx/xxxx/xxxxxxxxxxxx. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- self-only coverage. (9 months of in-network pre-natal care and a hospital delivery) (a year of routine in-network care of a well- controlled condition) (in-network emergency room visit and follow up care) ◼ The plan’s overall deductible $1,000 500 ◼ Primary care physician The plan’s overall deductible $500 ◼ The plan’s overall deductible $500 ◼ Specialist copay $50 ◼ Specialist copay $50 ◼ Specialist copay $50 ◼ Hospital (facility) coinsurance 020% ◼ Hospital (facility) coinsurance 20% ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% Primary care physician ◼ Other coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal pre-natal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $1,000 ◼ Specialist copayment $30 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% Specialist This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $1,000 ◼ Specialist copayment $30 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Deductibles $1,000 500 Copayments $10 0 Coinsurance $2,300 500 Limits or exclusions $60 The total Peg would pay is $3,370 Deductibles $900 200 Copayments $800 Coinsurance $0 20 Limits or exclusions $20 The total Xxx would pay is $1,720 30 Deductibles $1,000 500 Copayments $100 300 Coinsurance $100 60 Limits or exclusions $0 The total Mia would pay is $1,200 The This Summary of Dental Plan Benefits should be read along with your Certificate. Your Certificate provides additional information about your Delta Dental plan, including information about plan exclusions and Coverage limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the Dentist's network participation.* Control Plan – Delta Dental of Ohio Benefit Year – January 1 through December 31 Delta Dental PPO™ Dentist Covered Services – Delta Dental Premier® Dentist Nonparticipating Dentist Plan Pays Plan Pays Plan Pays* Diagnostic and Preventive Services – exams, cleanings, and fluoride 100% 100% 100% Emergency Palliative Treatment – to temporarily relieve pain 100% 100% 100% Sealants – to prevent decay of permanent teeth 100% 100% 100% Brush Biopsy – to detect oral cancer 100% 100% 100% Radiographs – X-rays 100% 100% 100% Space Maintainers – appliances to prevent tooth movement 80% 80% 80% Minor Restorative Services – fillings and crown repair 80% 80% 80% Endodontic Services – root canals 80% 80% 80% Periodontic Services – to treat gum disease 80% 80% 80% Oral Surgery Services – extractions and dental surgery 80% 80% 80% Other Basic Services – misc. services 80% 80% 80% Relines and Repairs – to prosthetic appliances 80% 80% 80% Major Restorative Services – crowns 50% 50% 50% Prosthodontic Services – bridges, implants, dentures, and crowns over implants 50% 50% 50% Orthodontic Services – braces 50% 50% 50% Orthodontic Age Limit – through age 18 and under through age 18 and under through age 18 and under * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This amount may be less than what the Dentist charges and you are responsible for that difference. ⮚ Oral exams (SBCincluding evaluations by a specialist) document will are payable twice per calendar year. ⮚ Prophylaxes (cleanings) are payable twice per calendar year. ⮚ People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her Dentist about treatment. ⮚ Fluoride treatments are payable once per calendar year with no age limit. ⮚ Space maintainers are payable once per area per lifetime for people age 17 and under. ⮚ Bitewing X-rays are payable twice per calendar year and full-mouth X-rays (which include bitewing X-rays) or a panorex are payable once in any five-year period. ⮚ Sealants are payable for first and second permanent molars for people age 18 and under. The surface must be free from decay and restorations. ⮚ Veneers are payable on incisors, cuspids, and bicuspids once per tooth per five-year period when necessary due to fracture or decay. ⮚ Composite resin (white) restorations are payable on posterior teeth. ⮚ Porcelain and resin facings on crowns are Covered Services on posterior teeth. ⮚ Implants are payable once per tooth in any five-year period. Implant related services are Covered Services. ⮚ Crowns over implants are payable once per tooth in any five-year period. Services related to crowns over implants are Covered Services. ⮚ People with special health care needs may be eligible for additional services including exams, hygiene visits, dental case management, and sedation/anesthesia. Special health care needs include any physical, developmental, mental, sensory, behavioral, cognitive, or emotional impairment or limiting condition that requires medical management, healthcare intervention, and/or use of specialized services or programs. The condition may be congenital, developmental, or acquired through disease, trauma, or environmental cause and may impose limitations in performing daily self-maintenance activities or substantial limitations in a major life activity. Having Delta Dental coverage makes it easy for you to get dental care almost everywhere in the world! You can now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a worldwide network of Dentists and dental clinics. English-speaking operators are available around the clock to answer questions and help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summaryschedule care. For more information about information, check our website or contact your coverage, or benefits representative to get a copy of our Passport Dental information sheet. Maximum Payment – $1,500 per Member total per Benefit Year on all services except orthodontic services. $1,500 per Member total per lifetime on orthodontic services. Payment for Orthodontic Service – When orthodontic treatment begins, your Dentist will submit a payment plan to Delta Dental based upon your projected course of treatment. In accordance with the complete terms agreed upon payment plan, Delta Dental will make an initial payment to you or your Participating Dentist equal to Delta Dental's stated Copayment on 30% of coverage, go the Maximum Payment for Orthodontic Services as set forth in this Summary of Dental Plan Benefits. Delta Dental will make additional payments as follows: Delta Dental will pay 50% of the per month fee charged by your Dentist based upon the agreed upon payment plan provided by Delta Dental to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000your Dentist. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copyDeductible – None.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. ◼ The plan’s overall deductible $1,000 250 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $1,000 250 ◼ Specialist copayment $30 10 ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $1,000 250 ◼ Specialist copayment $30 10 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 2010% Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Deductibles $1,000 250 Copayments $10 0 Coinsurance $2,300 500 Limits or exclusions $60 The total Peg would pay is $3,370 810 Deductibles $900 250 Copayments $800 500 Coinsurance $0 40 Limits or exclusions $20 The total Xxx would pay is $1,720 770 Deductibles $1,000 250 Copayments $100 40 Coinsurance $100 Limits or exclusions $0 The total Mia would pay is $1,200 The 390 This Summary of Dental Plan Benefits should be read along with your Certificate. Your Certificate provides additional information about your Delta Dental plan, including information about plan exclusions and Coverage limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the dentist's network participation.* Delta Dental PPO Dentist Delta Dental Premier Dentist Plan Pays Plan Pays Control Plan – Delta Dental of Michigan Benefit Year – January 1 through December 31 Covered Services – Nonparticipating Dentist Plan Pays* Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers 100% 85% 65% Emergency Palliative Treatment – to temporarily relieve pain 100% 85% 65% Brush Biopsy – to detect oral cancer 100% 85% 65% Radiographs – X-rays 100% 85% 65% Minor Restorative Services – fillings and crown repair 80% 65% 65% Endodontic Services – root canals 80% 65% 65% Periodontic Services – to treat gum disease 80% 65% 65% Oral Surgery Services – extractions and dental surgery 80% 65% 65% Other Basic Services – misc. services 80% 65% 65% Relines and Repairs – to prosthetic appliances 80% 65% 65% Major Restorative Services – crowns 75% 60% 60% Prosthodontic Services – bridges, implants, dentures, and crowns over implants 60% 60% 60% Orthodontic Services – braces 60% 60% 60% Orthodontic Age Limit – up to age 19 up to age 19 up to age 19 * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This amount may be less than what the Dentist charges or Delta Dental approves and you are responsible for that difference.  Oral exams (SBCincluding evaluations by a specialist) document will are payable twice in any period of 12 consecutive months.  Prophylaxes (cleanings) are payable twice in any period of 12 consecutive months.  People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment.  Fluoride treatments are payable twice in any period of 12 consecutive months for people age 18 and under.  Bitewing X-rays are payable once in any period of 12 consecutive months and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period.  Composite resin (white) restorations are optional treatment on posterior teeth.  Porcelain and resin facings on crowns are optional treatment on posterior teeth.  Implants are payable once per tooth in any five-year period. Implant related services are Covered Services.  Crowns over implants are payable once per tooth in any five-year period. Services related to crowns over implants are Covered Services. Having Delta Dental coverage makes it easy for you toAgppeetnddeixn"taHl"care almost everywhere in the world! You can now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a worldwide network of dentists and dental clinics. English-speaking operators are available around the clock to answer questions and help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summaryschedule care. For more information about information, check our Web site or contact your coverage, or benefits representative to get a copy of our Passport Dental information sheet. Maximum Payment – $2,000 per person total per Benefit Year on all services except orthodontic services. $2,000 per person total per lifetime on orthodontic services. Payment for Orthodontic Service – When orthodontic treatment begins, your Dentist will submit a payment plan to Delta Dental based upon your projected course of treatment. In accordance with the complete terms agreed upon payment plan, Delta Dental will make an initial payment to you or your Participating Dentist equal to Delta Dental's stated Copayment on 30% of coverage, go the Maximum Payment for Orthodontic Services as set forth in this Summary of Dental Plan Benefits. Delta Dental will make additional payments as follows: Delta Dental will pay 60% of the per monthly fee charged by your Dentist based upon the agreed upon payment plan provided by your Dentist to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000Delta Dental. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copyDeductible – None.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. ◼ The plan’s overall deductible $1,000 250 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $1,000 250 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 2010% ◼ Other coinsurance 2010% Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $1,000 250 ◼ Specialist copayment $30 20 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 2010% Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Deductibles $1,000 250 Copayments $10 Coinsurance $2,300 1,200 Limits or exclusions $60 The total Peg would pay is $3,370 1,520 Deductibles $900 250 Copayments $800 Coinsurance $0 70 Limits or exclusions $20 The total Xxx would pay is $1,720 1,140 Deductibles $1,000 250 Copayments $100 70 Coinsurance $100 Limits or exclusions $0 The total Mia would pay is $1,200 420 Charter Township of Clinton Employee and Retiree BeneAfipt pPelannd:ixH"UGR" O- PNla0n19#0019 Coverage for: Single + Family | Plan Type: POS The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copy.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. Appendix "G" This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. ◼ The plan’s overall deductible $1,000 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $1,000 ◼ Specialist copayment $30 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $1,000 ◼ Specialist copayment $30 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 20% Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Deductibles $1,000 Copayments $10 Coinsurance $2,300 Limits or exclusions $60 The total Peg would pay is $3,370 Deductibles $900 Copayments $800 Coinsurance $0 Limits or exclusions $20 The total Xxx would pay is $1,720 Deductibles $1,000 Copayments $100 Coinsurance $100 Limits or exclusions $0 The total Mia would pay is $1,200 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copy.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Charter Township of Clinton at (000) 000-0000 or Care Coordinators at (000) 000-0000. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP), Michigan Department of Insurance and Financial Services (DIFS) at (000) 000-0000. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 section. Appendix "D"- Plan #049 - Erie This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. ◼ The plan’s overall deductible $1,000 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $1,000 ◼ Specialist copayment $30 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $1,000 ◼ Specialist copayment $30 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 20% Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Deductibles $1,000 Copayments $10 Coinsurance $2,300 Limits or exclusions $60 The total Peg would pay is $3,370 Deductibles $900 Copayments $800 Coinsurance $0 Limits or exclusions $20 The total Xxx would pay is $1,720 Deductibles $1,000 Copayments $100 Coinsurance $100 Limits or exclusions $0 The total Mia would pay is $1,200 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copy.