Common use of Your Grievance and Appeals Rights Clause in Contracts

Your Grievance and Appeals Rights. If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able toappealor file agrievance. For questions about your rights, this notice, or assistance, you can contact: [insert applicable contact information from instructions]. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. These examples show how this plan might cover medical care in given situations.Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. Amount owed to providers: $7,540 Plan pays $4,935 Patient pays $2,605 Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Amount owed to providers: $5,400 Plan pays $3,545 Patient pays $1,855 Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits andProcedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Deductibles $1,000 Copays $775 Coinsurance $80 Limits or exclusions $0 Deductibles $1,900 Copays $45 Coinsurance $660 Limits or exclusions $0 Note: These numbers assume the patient is filling scriptsat a participating pharmacy.  Costs don’t include premiums.  Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan.  The patient’s condition was not an excluded or preexisting condition.  All services and treatments started and For each treatment situation, the Coverage Example helps you see how deductibles,copayments, and coinsurancecan add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited. providerscharge, and the reimbursement Yes. When you look at the Summaryof Benefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “PatientPays” boxineach example. The smaller that number, the more coverage the plan provides. ended in the same coverage period.  There are no other medical expenses for any member covered under this plan.  Out-of-pocket expenses are based only on treating the condition in the example.  The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. No.Treatments shown are just examples. The care you would receivefor thiscondition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors. No.Coverage Examplesare not cost estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your Yes.An important cost is the premium you pay. Generally, the lower your premium, the more you’ll pay in out-of- pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document by calling Human Resources at1-586-723-8072 Important Questions Answers Why this Matters: What is the overall deductible? $500person / $1,000 family Doesn’t apply to preventive care You must pay all the costs up to the deductibleamount before thisplan begins to pay for covered services you use. Check your policy or plan document to see when the deductiblestarts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. Are there other deductibles for specific services? There are deductibles for services received by out-of- network providers. $1,000person / $2,000family You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. Is there an out–of– pocket limit on my expenses? Yes. $2,000person / $4,000family for services received by in-network providers. The out-of-pocket limitis the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Higher out-of-pocket limits exist for services received by out-of-network providers. What is not included in theout–of–pocket limit? Premiums, balance-billed charges, and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Is there an overall annual limit on what theplan pays? No. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. Does this plan use a network of providers? Yes. See xxx.xxxxx.xxx for a list of participating providers. If you use an in-network doctor or other health care provider, thisplan will pay some or all of the costs of covered xxxxxxxx.Xx aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participatingfor providersin their network. See the chart starting on page 2 for how this plan pays different kinds of providers. Do I need a referral to see a specialist? No. You don’t need a referral to see a specialist. You can see the specialistyou choose without permission from this plan. Are there services this plan doesn’t cover? Yes. Some of the services thisplan doesn’t cover are listed on page 4. See your policy or plan document for additional information about excluded services.  Copaymentsare fixed dollar amounts (for example, $10) you pay for covered health care, usually when you receive the service.  Coinsuranceis your share of the costs of a covered service, calculated as a percent of the allowed amountfor the service. For example, if the plan’s allowed amountfor an overnight hospital stay is $1,000, your coinsurancepayment of 20% would be $200. This may change if you haven’t met your deductible.  The amount the plan pays for covered services is based on the allowed amount. If an out-of-networkprovidercharges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amountis $1,000, you may have to pay the $500 difference. (This is called balance billing.)  This plan may encourage you to use participating providersby charging you lower deductibles, copaymentsand coinsuranceamounts. Common Medical Event Services You May Need Your Cost If You Use a Participating Provider Your Cost If You Use a Non- Participating Provider Limitations & Exceptions If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $20copay/visit 40% coinsurance Specialist visit $20copay/visit 40% coinsurance Other practitioner office visit $20 copay/visit 40% coinsurance Preventive care/screening/immunization No charge Not covered Not covered for non-BCBSM If you have a test Diagnostic test (x-ray, blood work) 20% coinsurance 40% coinsurance Payment increases for non-BCBSM Imaging (CT/PET scans, MRIs) 20% coinsurance 40% coinsurance Payment increases for non-BCBSM If you need drugs to treat your illness or condition More information about prescription drug coverageis available at xxx.xxxxx.xxx Generic drugs $15 copay $15 copay + 25% Covers up to a 30-day supply (retail prescription); 31-90 day supply (mail order prescription) 2x copay Preferred brand drugs $30 copay $30 copay + 25% Covers up to a 30-day supply (retail prescription); 31-90 day supply (mail order prescription) 2x copay Non-preferred brand drugs $60 copay $60 copay + 25% Covers up to a 30-day supply (retail prescription); 31-90 day supply (mail order prescription) 2x copay Specialty drugs $60 copay Not covered Covers up to a 30-day supply (retail prescription); 31-90 day supply (mail order prescription) 2x copay If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 20% coinsurance 40% coinsurance Payment increases for non-BCBSM Physician/surgeon fees 20% coinsurance 40% coinsurance Payment increases for non-BCBSM If you need immediate medical attention Emergency room services $100 copay/visit $100 copay/visit Waived if admitted to hospital Emergency medical transportation 20% coinsurance 40% coinsurance Payment increases for non-BCBSM Urgent care $20 copay/visit 40% coinsurance Payment increases for non-BCBSM If you have a hospital stay Facility fee (e.g., hospital room) 20% coinsurance 40% coinsurance Payment increases for non-BCBSM Physician/surgeon fee 20% coinsurance 40%coinsurance Payment increases for non-BCBSM If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services 20% coinsurance 40% coinsurance Payment increases for non-BCBSM Mental/Behavioral health inpatient services 20% coinsurance 40% coinsurance Payment increases for non-BCBSM Substance use disorder outpatient services 20% coinsurance 40% coinsurance Payment increases for non-BCBSM Substance use disorder inpatient services 20% coinsurance 40% coinsurance Payment increases for non-BCBSM If you are pregnant Prenatal and postnatal care 100% covered 40% coinsurance Payment increases for non-BCBSM Delivery and all inpatient services 20% coinsurance 40% coinsurance Payment increases for non-BCBSM If you need help recovering or have other special health needs Home health care 20% coinsurance 20% coinsurance Payment increases for non-BCBSM Rehabilitation services 20% coinsurance 40% coinsurance 60 visits per calendar year Habilitation services 20% coinsurance 40% coinsurance Payment increases for non-BCBSM Skilled nursing care 20% coinsurance 20% coinsurance 120 days per calendar year Durable medical equipment 20% coinsurance 20% coinsurance Hospice service 100% covered 100% covered Four 90-day periods If your child needs dental or eye care Eye exam Not covered Not Covered Glasses Not covered Not Covered Dental check-up Not covered Not Covered Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for otherexcluded services.)  Cosmetic surgery  Long-term care  Routine eye care (Adult)  Certain Experimental Medicine  Non-emergency care when traveling outside the U.S.  Elective procedures that are not medically necessary  Organ transplants  Chiropractic care  Voluntary sterilization Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are exceptions, however, such as if:  You commit fraud  The insurer stops offering services in the State  You move outside the coverage area For more information on your rights to continue coverage, contact the insurer at [contact number]. You may also contact your state insurance department at [insert applicable State Department of Insurance contact information]. If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be OR limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at [contact number]. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 0-000-000-0000 or xxx.xxx.xxx/xxxx, or the U.S. Department of Health and Human Services at 0-000-000-0000 x00000 or xxx.xxxxx.xxx.xxx.

Your Grievance and Appeals Rights. If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able toappealor file agrievance. For questions about your rights, this notice, or assistance, you can contact: [insert applicable contact information from instructions]. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. These examples show how this plan might cover medical care in given situations.Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. Amount owed to providers: $7,540 Plan pays $4,935 6,550 Patient pays $2,605 1,845 Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Amount owed to providers: $5,400 Plan pays $3,545 3,945 Patient pays $1,855 1,455 Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits andProcedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Deductibles $1,000 500 Copays $775 Coinsurance $80 180 Limits or exclusions $0 Deductibles $1,900 1,000 Copays $45 Coinsurance $660 800 Limits or exclusions $0 Note: These numbers assume the patient is filling scriptsat a participating pharmacy.  Costs don’t include premiums.  Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan.  The patient’s condition was not an excluded or preexisting condition.  All services and treatments started and For each treatment situation, the Coverage Example helps you see how deductibles,copayments, and coinsurancecan add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited. providerscharge, and the reimbursement Yes. When you look at the Summaryof Benefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “PatientPays” boxineach example. The smaller that number, the more coverage the plan provides. ended in the same coverage period.  There are no other medical expenses for any member covered under this plan.  Out-of-pocket expenses are based only on treating the condition in the example.  The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. No.Treatments shown are just examples. The care you would receivefor thiscondition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors. No.Coverage Examplesare not cost estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your Yes.An important cost is the premium you pay. Generally, the lower your premium, the more you’ll pay in out-of- pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document by calling Human Resources at1-586-723-8072 Important Questions Answers Why this Matters: What is the overall deductible? $500person 250person / $1,000 500 family Doesn’t apply to preventive care You must pay all the costs up to the deductibleamount before thisplan begins to pay for covered services you use. Check your policy or plan document to see when the deductiblestarts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. Are there other deductibles for specific services? There are deductibles for services received by out-of- network providers. $1,000person 500person / $2,000family 1,000family You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. Is there an out–of– pocket limit on my expenses? Yes. $2,000person 750person / $4,000family 1,500family for services received by in-network providers. The out-of-pocket limitis the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Higher out-of-pocket limits exist for services received by out-of-network providers. What is not included in theout–of–pocket limit? Premiums, balance-billed charges, and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Is there an overall annual limit on what theplan pays? No. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. Does this plan use a network of providers? Yes. See xxx.xxxxx.xxx for a list of participating providers. If you use an in-network doctor or other health care provider, thisplan will pay some or all of the costs of covered xxxxxxxx.Xx aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participatingfor providersin their network. See the chart starting on page 2 for how this plan pays different kinds of providers. Do I need a referral to see a specialist? No. You don’t need a referral to see a specialist. You can see the specialistyou choose without permission from this plan. Are there services this plan doesn’t cover? Yes. Some of the services thisplan doesn’t cover are listed on page 4. See your policy or plan document for additional information about excluded services.  Copaymentsare fixed dollar amounts (for example, $10) you pay for covered health care, usually when you receive the service.  Coinsuranceis your share of the costs of a covered service, calculated as a percent of the allowed amountfor the service. For example, if the plan’s allowed amountfor an overnight hospital stay is $1,000, your coinsurancepayment of 20% would be $200. This may change if you haven’t met your deductible.  The amount the plan pays for covered services is based on the allowed amount. If an out-of-networkprovidercharges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amountis $1,000, you may have to pay the $500 difference. (This is called balance billing.)  This plan may encourage you to use participating providersby charging you lower deductibles, copaymentsand coinsuranceamounts. Common Medical Event Services You May Need Your Cost If You Use a Participating Provider Your Cost If You Use a Non- Participating Provider Limitations & Exceptions If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $20copay/visit 40% coinsurance Specialist visit $20copay/visit 40% coinsurance Other practitioner office visit $20 copay/visit 40% coinsurance Preventive care/screening/immunization No charge Not covered Not covered for non-BCBSM If you have a test Diagnostic test (x-ray, blood work) 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM Imaging (CT/PET scans, MRIs) 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM If you need drugs to treat your illness or condition More information about prescription drug coverageis available at xxx.xxxxx.xxx Generic drugs $15 7 copay $15 7 copay + 25% Covers up to a 30-day supply (retail prescription); 2x copay for 31-90 day supply (mail order prescription) 2x copay Preferred brand drugs $30 35 copay $30 35 copay + 25% Covers up to a 30-day supply (retail prescription); 2x copay for 31-90 day supply (mail order prescription) 2x copay Non-preferred brand drugs $60 70 copay $60 70 copay + 25% Covers up to a 30-day supply (retail prescription); 2x copay for 31-90 day supply (mail order prescription) 2x copay Specialty drugs $60 70 copay Not covered Covers up to a 30-day supply (retail prescription); 2x copay for 31-90 day supply (mail order prescription) 2x copay If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM Physician/surgeon fees 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM If you need immediate medical attention Emergency room services $100 50 copay/visit $100 50 copay/visit Waived if admitted to hospital Emergency medical transportation 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM Urgent care $20 10 copay/visit 40% coinsurance Payment increases for non-BCBSM If you have a hospital stay Facility fee (e.g., hospital room) 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM Physician/surgeon fee 2010% coinsurance 40%coinsurance Payment increases for non-BCBSM If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM Mental/Behavioral health inpatient services 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM Substance use disorder outpatient services 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM Substance use disorder inpatient services 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM If you are pregnant Prenatal and postnatal care 100% covered 40% coinsurance Payment increases for non-BCBSM Delivery and all inpatient services 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM If you need help recovering or have other special health needs Home health care 2010% coinsurance 2010% coinsurance Payment increases for non-BCBSM Rehabilitation services 2010% coinsurance 40% coinsurance 60 visits per calendar year Habilitation services 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM Skilled nursing care 2010% coinsurance 2010% coinsurance 120 days per calendar year Durable medical equipment 2010% coinsurance 2010% coinsurance Hospice service 100% covered 100% covered Four 90-day periods If your child needs dental or eye care Eye exam Not covered Not Covered Glasses Not covered Not Covered Dental check-up Not covered Not Covered Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for otherexcluded services.)  Cosmetic surgery  Long-term care  Routine eye care (Adult)  Certain Experimental Medicine  Non-emergency care when traveling outside the U.S.  Elective procedures that are not medically necessary  Organ transplants  Chiropractic care  Voluntary sterilization Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are exceptions, however, such as if:  You commit fraud  The insurer stops offering services in the State  You move outside the coverage area For more information on your rights to continue coverage, contact the insurer at [contact number]. You may also contact your state insurance department at [insert applicable State Department of Insurance contact information]. If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be OR limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at [contact number]. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 0-000-000-0000 or xxx.xxx.xxx/xxxx, or the U.S. Department of Health and Human Services at 0-000-000-0000 x00000 or xxx.xxxxx.xxx.xxx.

Your Grievance and Appeals Rights. If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able toappealor file agrievance. For questions about your rights, this notice, or assistance, you can contact: [insert applicable contact information from instructions]. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. These examples show how this plan might cover medical care in given situations.Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. Amount owed to providers: $7,540 Plan pays $4,935 6,550 Patient pays $2,605 1,845 Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Amount owed to providers: $5,400 Plan pays $3,545 3,945 Patient pays $1,855 1,455 Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits andProcedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Deductibles $1,000 500 Copays $775 Coinsurance $80 180 Limits or exclusions $0 Deductibles $1,900 1,000 Copays $45 Coinsurance $660 800 Limits or exclusions $0 Note: These numbers assume the patient is filling scriptsat a participating pharmacy.  Costs don’t include premiums.  Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan.  The patient’s condition was not an excluded or preexisting condition.  All services and treatments started and For each treatment situation, the Coverage Example helps you see how deductibles,copayments, and coinsurancecan add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited. providerscharge, and the reimbursement Yes. When you look at the Summaryof Benefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “PatientPays” boxineach example. The smaller that number, the more coverage the plan provides. ended in the same coverage period.  There are no other medical expenses for any member covered under this plan.  Out-of-pocket expenses are based only on treating the condition in the example.  The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. No.Treatments shown are just examples. The care you would receivefor thiscondition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors. No.Coverage Examplesare not cost estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your Yes.An important cost is the premium you pay. Generally, the lower your premium, the more you’ll pay in out-of- pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document by calling Human Resources at1-586-723-8072 Important Questions Answers Why this Matters: What is the overall deductible? $500person 250person / $1,000 500 family Doesn’t apply to preventive care You must pay all the costs up to the deductibleamount before thisplan begins to pay for covered services you use. Check your policy or plan document to see when the deductiblestarts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. Are there other deductibles for specific services? There are deductibles for services received by out-of- network providers. $1,000person 500person / $2,000family 1,000family You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. Is there an out–of– pocket limit on my expenses? Yes. $2,000person 750person / $4,000family 1,500family for services received by in-network providers. The out-of-pocket limitis the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Higher out-of-pocket limits exist for services received by out-of-network providers. What is not included in theout–of–pocket limit? Premiums, balance-billed charges, and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Is there an overall annual limit on what theplan pays? No. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. Does this plan use a network of providers? Yes. See xxx.xxxxx.xxx for a list of participating providers. If you use an in-network doctor or other health care provider, thisplan will pay some or all of the costs of covered xxxxxxxx.Xx aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participatingfor providersin their network. See the chart starting on page 2 for how this plan pays different kinds of providers. Do I need a referral to see a specialist? No. You don’t need a referral to see a specialist. You can see the specialistyou choose without permission from this plan. Are there services this plan doesn’t cover? Yes. Some of the services thisplan doesn’t cover are listed on page 4. See your policy or plan document for additional information about excluded services.  Copaymentsare fixed dollar amounts (for example, $10) you pay for covered health care, usually when you receive the service.  Coinsuranceis your share of the costs of a covered service, calculated as a percent of the allowed amountfor the service. For example, if the plan’s allowed amountfor an overnight hospital stay is $1,000, your coinsurancepayment of 20% would be $200. This may change if you haven’t met your deductible.  The amount the plan pays for covered services is based on the allowed amount. If an out-of-networkprovidercharges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amountis $1,000, you may have to pay the $500 difference. (This is called balance billing.)  This plan may encourage you to use participating providersby charging you lower deductibles, copaymentsand coinsuranceamounts. Common Medical Event Services You May Need Your Cost If You Use a Participating Provider Your Cost If You Use a Non- Participating Provider Limitations & Exceptions If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $20copay10copay/visit 40% coinsurance Specialist visit $20copay10copay/visit 40% coinsurance Other practitioner office visit $20 10 copay/visit 40% coinsurance Preventive care/screening/immunization No charge Not covered Not covered for non-BCBSM If you have a test Diagnostic test (x-ray, blood work) 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM Imaging (CT/PET scans, MRIs) 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM If you need drugs to treat your illness or condition More information about prescription drug coverageis available at xxx.xxxxx.xxx Generic drugs $15 copay $15 copay + 25% Covers up to a 30-day supply (retail prescription); 31-90 day supply (mail order prescription) 2x copay Preferred brand drugs $30 copay $30 copay + 25% Covers up to a 30-day supply (retail prescription); 31-90 day supply (mail order prescription) 2x copay Non-preferred brand drugs $60 30 copay $60 30 copay + 25% Covers up to a 30-day supply (retail prescription); 31-90 day supply (mail order prescription) 2x copay Specialty drugs $60 30 copay Not covered Covers up to a 30-day supply (retail prescription); 31-90 day supply (mail order prescription) 2x copay If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 2010% coinsurance 4020% coinsurance Payment increases for non-BCBSM Physician/surgeon fees 2010% coinsurance 4020% coinsurance Payment increases for non-BCBSM If you need immediate medical attention Emergency room services $100 50 copay/visit $100 50 copay/visit Waived if admitted to hospital Emergency medical transportation 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM Urgent care $20 10 copay/visit 40% coinsurance Payment increases for non-BCBSM If you have a hospital stay Facility fee (e.g., hospital room) 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM Physician/surgeon fee 2010% coinsurance 40%coinsurance Payment increases for non-BCBSM If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM Mental/Behavioral health inpatient services 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM Substance use disorder outpatient services 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM Substance use disorder inpatient services 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM If you are pregnant Prenatal and postnatal care 100% covered 40% coinsurance Payment increases for non-BCBSM Delivery and all inpatient services 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM If you need help recovering or have other special health needs Home health care 2010% coinsurance 2010% coinsurance Payment increases for non-BCBSM Rehabilitation services 2010% coinsurance 40% coinsurance 60 visits per calendar year Habilitation services 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM Skilled nursing care 2010% coinsurance 2010% coinsurance 120 days per calendar year Durable medical equipment 2010% coinsurance 2010% coinsurance Hospice service 100% covered 100% covered Four 90-day periods If your child needs dental or eye care Eye exam Not covered Not Covered Glasses Not covered Not Covered Dental check-up Not covered Not Covered Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for otherexcluded services.)  Cosmetic surgery  Long-term care  Routine eye care (Adult)  Certain Experimental Medicine  Non-emergency care when traveling outside the U.S.  Elective procedures that are not medically necessary  Organ transplants  Chiropractic care  Voluntary sterilization Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are exceptions, however, such as if:  You commit fraud  The insurer stops offering services in the State  You move outside the coverage area For more information on your rights to continue coverage, contact the insurer at [contact number]. You may also contact your state insurance department at [insert applicable State Department of Insurance contact information]. If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be OR limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at [contact number]. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 0-000-000-0000 or xxx.xxx.xxx/xxxx, or the U.S. Department of Health and Human Services at 0-000-000-0000 x00000 or xxx.xxxxx.xxx.xxx.

Your Grievance and Appeals Rights. If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able toappealor to appeal or file agrievancea grievance. For questions about your rights, this notice, or assistance, you can contact: [insert applicable contact information from instructions]CIGNA, X.X. Xxx 0000, Xxxxxxxx, XX 00000-0000 or call 0-000-XXXXX (1-800- 244-6224) or go to: xxx.xxXXXXX.xxx. –For appeals on a prescription drug claim, your Physician needs to fax a letter of medical necessity to Caremark at 0-000-000-0000. The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Para obtener asistencia en Español, llame al 1-866-847-1300-Opcion 3. –––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Please consider any contributions you may receive in an HRA, HSA or FSA. These examples show how this plan might cover medical care in given situations.. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. Amount  Amount owed to providers: $7,540 Plan  Plan pays $ 5,330  Patient pays $4,935 Patient pays $2,605 2,210 Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Amount  Amount owed to providers: $5,400 Plan  Plan pays $3,545 Patient $ 3,980  Patient pays $1,855 $ 1,420 Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits andProcedures and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Deductibles $1,000 750 Copays $775 200 Coinsurance $80 390 Limits or exclusions $0 80 Deductibles $1,900 750 Copays $45 10 Coinsurance $660 1,330 Limits or exclusions $0 Note: These numbers assume the patient is filling scriptsat a participating pharmacy.  150 • Costs don’t include premiums.  • Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan.  • The patient’s condition was not an excluded or preexisting condition.  • All services and treatments started and ended in the same coverage period. • There are no other medical expenses for any member covered under this plan. • Out-of-pocket expenses are based only on treating the condition in the example. • The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. For each treatment situation, the Coverage Example helps you see how deductibles,, copayments, and coinsurancecan coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited. providerscharge, and the reimbursement Yes. When you look at the Summaryof Benefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “PatientPays” boxineach example. The smaller that number, the more coverage the plan provides. ended in the same coverage period.  There are no other medical expenses for any member covered under this plan.  Out-of-pocket expenses are based only on treating the condition in the example.  The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. No.Treatments shown are just examples. The care you would receivefor thiscondition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors. No.Coverage Examplesare not cost estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your Yes.An important cost is the premium you pay. Generally, the lower your premium, the more you’ll pay in out-of- pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document by calling Human Resources at1-586-723-8072 Important Questions Answers Why this Matters: What is the overall deductible? $500person / $1,000 family Doesn’t apply to preventive care You must pay all the costs up to the deductibleamount before thisplan begins to pay for covered services you use. Check your policy or plan document to see when the deductiblestarts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. Are there other deductibles for specific services? There are deductibles for services received by out-of- network providers. $1,000person / $2,000family You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. Is there an out–of– pocket limit on my expenses? Yes. $2,000person / $4,000family for services received by in-network providers. The out-of-pocket limitis the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Higher out-of-pocket limits exist for services received by out-of-network providers. What is not included in theout–of–pocket limit? Premiums, balance-billed charges, and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Is there an overall annual limit on what theplan pays? No. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. Does this plan use a network of providers? Yes. See xxx.xxxxx.xxx for a list of participating providers. If you use an in-network doctor or other health care provider, thisplan will pay some or all of the costs of covered xxxxxxxx.Xx aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participatingfor providersin their network. See the chart starting on page 2 for how this plan pays different kinds of providers. Do I need a referral to see a specialist? No. You don’t need a referral to see a specialist. You can see the specialistyou choose without permission from this plan. Are there services this plan doesn’t cover? Yes. Some of the services thisplan doesn’t cover are listed on page 4. See your policy or plan document for additional information about excluded services.  Copaymentsare fixed dollar amounts (for example, $10) you pay for covered health care, usually when you receive the service.  Coinsuranceis your share of the costs of a covered service, calculated as a percent of the allowed amountfor the service. For example, if the plan’s allowed amountfor an overnight hospital stay is $1,000, your coinsurancepayment of 20% would be $200. This may change if you haven’t met your deductible.  The amount the plan pays for covered services is based on the allowed amount. If an out-of-networkprovidercharges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amountis $1,000, you may have to pay the $500 difference. (This is called balance billing.)  This plan may encourage you to use participating providersby charging you lower deductibles, copaymentsand coinsuranceamounts. Common Medical Event Services You May Need Your Cost If You Use a Participating Provider Your Cost If You Use a Non- Participating Provider Limitations & Exceptions If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $20copay/visit 40% coinsurance Specialist visit $20copay/visit 40% coinsurance Other practitioner office visit $20 copay/visit 40% coinsurance Preventive care/screening/immunization No charge Not covered Not covered for non-BCBSM If you have a test Diagnostic test (x-ray, blood work) 20% coinsurance 40% coinsurance Payment increases for non-BCBSM Imaging (CT/PET scans, MRIs) 20% coinsurance 40% coinsurance Payment increases for non-BCBSM If you need drugs to treat your illness or condition More information about prescription drug coverageis available at xxx.xxxxx.xxx Generic drugs $15 copay $15 copay + 25% Covers up to a 30-day supply (retail prescription); 31-90 day supply (mail order prescription) 2x copay Preferred brand drugs $30 copay $30 copay + 25% Covers up to a 30-day supply (retail prescription); 31-90 day supply (mail order prescription) 2x copay Non-preferred brand drugs $60 copay $60 copay + 25% Covers up to a 30-day supply (retail prescription); 31-90 day supply (mail order prescription) 2x copay Specialty drugs $60 copay Not covered Covers up to a 30-day supply (retail prescription); 31-90 day supply (mail order prescription) 2x copay If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 20% coinsurance 40% coinsurance Payment increases for non-BCBSM Physician/surgeon fees 20% coinsurance 40% coinsurance Payment increases for non-BCBSM If you need immediate medical attention Emergency room services $100 copay/visit $100 copay/visit Waived if admitted to hospital Emergency medical transportation 20% coinsurance 40% coinsurance Payment increases for non-BCBSM Urgent care $20 copay/visit 40% coinsurance Payment increases for non-BCBSM If you have a hospital stay Facility fee (e.g., hospital room) 20% coinsurance 40% coinsurance Payment increases for non-BCBSM Physician/surgeon fee 20% coinsurance 40%coinsurance Payment increases for non-BCBSM If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services 20% coinsurance 40% coinsurance Payment increases for non-BCBSM Mental/Behavioral health inpatient services 20% coinsurance 40% coinsurance Payment increases for non-BCBSM Substance use disorder outpatient services 20% coinsurance 40% coinsurance Payment increases for non-BCBSM Substance use disorder inpatient services 20% coinsurance 40% coinsurance Payment increases for non-BCBSM If you are pregnant Prenatal and postnatal care 100% covered 40% coinsurance Payment increases for non-BCBSM Delivery and all inpatient services 20% coinsurance 40% coinsurance Payment increases for non-BCBSM If you need help recovering or have other special health needs Home health care 20% coinsurance 20% coinsurance Payment increases for non-BCBSM Rehabilitation services 20% coinsurance 40% coinsurance 60 visits per calendar year Habilitation services 20% coinsurance 40% coinsurance Payment increases for non-BCBSM Skilled nursing care 20% coinsurance 20% coinsurance 120 days per calendar year Durable medical equipment 20% coinsurance 20% coinsurance Hospice service 100% covered 100% covered Four 90-day periods If your child needs dental or eye care Eye exam Not covered Not Covered Glasses Not covered Not Covered Dental check-up Not covered Not Covered Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for otherexcluded services.)  Cosmetic surgery  Long-term care  Routine eye care (Adult)  Certain Experimental Medicine  Non-emergency care when traveling outside the U.S.  Elective procedures that are not medically necessary  Organ transplants  Chiropractic care  Voluntary sterilization Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are exceptions, however, such as if:  You commit fraud  The insurer stops offering services in the State  You move outside the coverage area For more information on your rights to continue coverage, contact the insurer at [contact number]. You may also contact your state insurance department at [insert applicable State Department of Insurance contact information]. If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be OR limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at [contact number]. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 0-000-000-0000 or xxx.xxx.xxx/xxxx, or the U.S. Department of Health and Human Services at 0-000-000-0000 x00000 or xxx.xxxxx.xxx.xxx.

Your Grievance and Appeals Rights. If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able toappealor file agrievance. For questions about your rights, this notice, or assistance, you can contact: [insert applicable contact information from instructions]. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. These examples show how this plan might cover medical care in given situations.Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. Amount owed to providers: $7,540 Plan pays $4,935 6,374 Patient pays $2,605 1,166 Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Amount owed to providers: $5,400 Plan pays $3,545 4,300 Patient pays $1,855 1,100 Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits andProcedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Deductibles $1,000 250 Copays $775 735 Coinsurance $80 115 Limits or exclusions $0 Deductibles $1,900 500 Copays $45 21 Coinsurance $660 645 Limits or exclusions $0 Note: These numbers assume the patient is filling scriptsat a participating pharmacy.  Costs don’t include premiums.  Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan.  The patient’s condition was not an excluded or preexisting condition.  All services and treatments started and For each treatment situation, the Coverage Example helps you see how deductibles,copayments, and coinsurancecan add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited. providerscharge, and the reimbursement Yes. When you look at the Summaryof Benefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “PatientPays” boxineach example. The smaller that number, the more coverage the plan provides. ended in the same coverage period.  There are no other medical expenses for any member covered under this plan.  Out-of-pocket expenses are based only on treating the condition in the example.  The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. No.Treatments shown are just examples. The care you would receivefor thiscondition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors. No.Coverage Examplesare not cost estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your Yes.An important cost is the premium you pay. Generally, the lower your premium, the more you’ll pay in out-of- pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document by calling Human Resources at1-586-723-8072 Important Questions Answers Why this Matters: What is the overall deductible? $500person 250person / $1,000 500 family Doesn’t apply to preventive care You must pay all the costs up to the deductibleamount before thisplan begins to pay for covered services you use. Check your policy or plan document to see when the deductiblestarts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. Are there other deductibles for specific services? There are deductibles for services received by out-of- network providers. $1,000person 500person / $2,000family 1,000family You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. Is there an out–of– pocket limit on my expenses? Yes. $2,000person 750person / $4,000family 1,500family for services received by in-network providers. The out-of-pocket limitis the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Higher out-of-pocket limits exist for services received by out-of-network providers. What is not included in theout–of–pocket limit? Premiums, balance-billed charges, and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Is there an overall annual limit on what theplan pays? No. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. Does this plan use a network of providers? Yes. See xxx.xxxxx.xxx for a list of participating providers. If you use an in-network doctor or other health care provider, thisplan will pay some or all of the costs of covered xxxxxxxx.Xx aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participatingfor providersin their network. See the chart starting on page 2 for how this plan pays different kinds of providers. Do I need a referral to see a specialist? No. You don’t need a referral to see a specialist. You can see the specialistyou choose without permission from this plan. Are there services this plan doesn’t cover? Yes. Some of the services thisplan doesn’t cover are listed on page 4. See your policy or plan document for additional information about excluded services.  Copaymentsare fixed dollar amounts (for example, $10) you pay for covered health care, usually when you receive the service.  Coinsuranceis your share of the costs of a covered service, calculated as a percent of the allowed amountfor the service. For example, if the plan’s allowed amountfor an overnight hospital stay is $1,000, your coinsurancepayment of 20% would be $200. This may change if you haven’t met your deductible.  The amount the plan pays for covered services is based on the allowed amount. If an out-of-networkprovidercharges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amountis $1,000, you may have to pay the $500 difference. (This is called balance billing.)  This plan may encourage you to use participating providersby charging you lower deductibles, copaymentsand coinsuranceamounts. Common Medical Event Services You May Need Your Cost If You Use a Participating Provider Your Cost If You Use a Non- Participating Provider Limitations & Exceptions If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $20copay10copay/visit 40% coinsurance Specialist visit $20copay10copay/visit 40% coinsurance Other practitioner office visit $20 10 copay/visit 40% coinsurance Preventive care/screening/immunization No charge Not covered Not covered for non-BCBSM If you have a test Diagnostic test (x-ray, blood work) 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM Imaging (CT/PET scans, MRIs) 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM If you need drugs to treat your illness or condition More information about prescription drug coverageis available at xxx.xxxxx.xxx Generic drugs $15 10 copay $15 10 copay + 25% Covers up to a 30-day supply (retail prescription); 31-90 day supply (mail order prescription) 2x copay Preferred brand drugs $30 20 copay $30 20 copay + 25% Covers up to a 30-day supply (retail prescription); 31-90 day supply (mail order prescription) 2x copay Non-preferred brand drugs $60 40 copay $60 40 copay + 25% Covers up to a 30-day supply (retail prescription); 31-90 day supply (mail order prescription) 2x copay Specialty drugs $60 40 copay Not covered Covers up to a 30-day supply (retail prescription); 31-90 day supply (mail order prescription) 2x copay If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 2010% coinsurance 4020% coinsurance Payment increases for non-BCBSM Physician/surgeon fees 2010% coinsurance 4020% coinsurance Payment increases for non-BCBSM If you need immediate medical attention Emergency room services $100 50 copay/visit $100 50 copay/visit Waived if admitted to hospital Emergency medical transportation 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM Urgent care $20 10 copay/visit 40% coinsurance Payment increases for non-BCBSM If you have a hospital stay Facility fee (e.g., hospital room) 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM Physician/surgeon fee 2010% coinsurance 40%coinsurance Payment increases for non-BCBSM If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM Mental/Behavioral health inpatient services 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM Substance use disorder outpatient services 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM Substance use disorder inpatient services 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM If you are pregnant Prenatal and postnatal care 100% covered 40% coinsurance Payment increases for non-BCBSM Delivery and all inpatient services 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM If you need help recovering or have other special health needs Home health care 2010% coinsurance 2010% coinsurance Payment increases for non-BCBSM Rehabilitation services 2010% coinsurance 40% coinsurance 60 visits per calendar year Habilitation services 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM Skilled nursing care 2010% coinsurance 2010% coinsurance 120 days per calendar year Durable medical equipment 2010% coinsurance 2010% coinsurance Hospice service 100% covered 100% covered Four 90-day periods If your child needs dental or eye care Eye exam Not covered Not Covered Glasses Not covered Not Covered Dental check-up Not covered Not Covered Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for otherexcluded services.)  Cosmetic surgery  Long-term care  Routine eye care (Adult)  Certain Experimental Medicine  Non-emergency care when traveling outside the U.S.  Elective procedures that are not medically necessary  Organ transplants  Chiropractic care  Voluntary sterilization Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are exceptions, however, such as if:  You commit fraud  The insurer stops offering services in the State  You move outside the coverage area For more information on your rights to continue coverage, contact the insurer at [contact number]. You may also contact your state insurance department at [insert applicable State Department of Insurance contact information]. If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be OR limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at [contact number]. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 0-000-000-0000 or xxx.xxx.xxx/xxxx, or the U.S. Department of Health and Human Services at 0-000-000-0000 x00000 or xxx.xxxxx.xxx.xxx.

Your Grievance and Appeals Rights. If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able toappealor file agrievance. For questions about your rights, this notice, or assistance, you can contact: [insert applicable contact information from instructions]. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. These examples show how this plan might cover medical care in given situations.Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. Amount owed to providers: $7,540 Plan pays $4,935 6,550 Patient pays $2,605 990 Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Amount owed to providers: $5,400 Plan pays $3,545 4,260 Patient pays $1,855 1,140 Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits andProcedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Deductibles $1,000 250 Copays $775 Coinsurance $80 115 Limits or exclusions $0 Deductibles $1,900 500 Copays $45 Coinsurance $660 445 Limits or exclusions $0 Note: These numbers assume the patient is filling scriptsat a participating pharmacy.  Costs don’t include premiums.  Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan.  The patient’s condition was not an excluded or preexisting condition.  All services and treatments started and For each treatment situation, the Coverage Example helps you see how deductibles,copayments, and coinsurancecan add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited. providerscharge, and the reimbursement Yes. When you look at the Summaryof Benefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “PatientPays” boxineach example. The smaller that number, the more coverage the plan provides. ended in the same coverage period.  There are no other medical expenses for any member covered under this plan.  Out-of-pocket expenses are based only on treating the condition in the example.  The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. No.Treatments shown are just examples. The care you would receivefor thiscondition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors. No.Coverage Examplesare not cost estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your Yes.An important cost is the premium you pay. Generally, the lower your premium, the more you’ll pay in out-of- pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document by calling Human Resources at1-586-723-8072 Important Questions Answers Why this Matters: What is the overall deductible? $500person 250person / $1,000 500 family Doesn’t apply to preventive care You must pay all the costs up to the deductibleamount before thisplan begins to pay for covered services you use. Check your policy or plan document to see when the deductiblestarts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. Are there other deductibles for specific services? There are deductibles for services received by out-of- network providers. $1,000person 500person / $2,000family 1,000family You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. Is there an out–of– pocket limit on my expenses? Yes. $2,000person 750person / $4,000family 1,500family for services received by in-network providers. The out-of-pocket limitis the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Higher out-of-pocket limits exist for services received by out-of-network providers. What is not included in theout–of–pocket limit? Premiums, balance-billed charges, and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Is there an overall annual limit on what theplan pays? No. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. Does this plan use a network of providers? Yes. See xxx.xxxxx.xxx for a list of participating providers. If you use an in-network doctor or other health care provider, thisplan will pay some or all of the costs of covered xxxxxxxx.Xx aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participatingfor providersin their network. See the chart starting on page 2 for how this plan pays different kinds of providers. Do I need a referral to see a specialist? No. You don’t need a referral to see a specialist. You can see the specialistyou choose without permission from this plan. Are there services this plan doesn’t cover? Yes. Some of the services thisplan doesn’t cover are listed on page 4. See your policy or plan document for additional information about excluded services.  Copaymentsare fixed dollar amounts (for example, $10) you pay for covered health care, usually when you receive the service.  Coinsuranceis your share of the costs of a covered service, calculated as a percent of the allowed amountfor the service. For example, if the plan’s allowed amountfor an overnight hospital stay is $1,000, your coinsurancepayment of 20% would be $200. This may change if you haven’t met your deductible.  The amount the plan pays for covered services is based on the allowed amount. If an out-of-networkprovidercharges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amountis $1,000, you may have to pay the $500 difference. (This is called balance billing.)  This plan may encourage you to use participating providersby charging you lower deductibles, copaymentsand coinsuranceamounts. Common Medical Event Services You May Need Your Cost If You Use a Participating Provider Your Cost If You Use a Non- Participating Provider Limitations & Exceptions If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $20copay/visit 40% coinsurance Specialist visit $20copay/visit 40% coinsurance Other practitioner office visit $20 copay/visit 40% coinsurance Preventive care/screening/immunization No charge Not covered Not covered for non-BCBSM If you have a test Diagnostic test (x-ray, blood work) 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM Imaging (CT/PET scans, MRIs) 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM If you need drugs to treat your illness or condition More information about prescription drug coverageis available at xxx.xxxxx.xxx Generic drugs $15 7 copay $15 7 copay + 25% Covers up to a 30-day supply (retail prescription); 2x copay for 31-90 day supply (mail order prescription) 2x copay Preferred brand drugs $30 35 copay $30 35 copay + 25% Covers up to a 30-day supply (retail prescription); 2x copay for 31-90 day supply (mail order prescription) 2x copay Non-preferred brand drugs $60 70 copay $60 70 copay + 25% Covers up to a 30-day supply (retail prescription); 2x copay for 31-90 day supply (mail order prescription) 2x copay Specialty drugs $60 70 copay Not covered Covers up to a 30-day supply (retail prescription); 2x copay for 31-90 day supply (mail order prescription) 2x copay If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM Physician/surgeon fees 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM If you need immediate medical attention Emergency room services $100 50 copay/visit $100 50 copay/visit Waived if admitted to hospital Emergency medical transportation 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM Urgent care $20 10 copay/visit 40% coinsurance Payment increases for non-BCBSM If you have a hospital stay Facility fee (e.g., hospital room) 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM Physician/surgeon fee 2010% coinsurance 40%coinsurance Payment increases for non-BCBSM If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM Mental/Behavioral health inpatient services 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM Substance use disorder outpatient services 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM Substance use disorder inpatient services 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM If you are pregnant Prenatal and postnatal care 100% covered 40% coinsurance Payment increases for non-BCBSM Delivery and all inpatient services 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM If you need help recovering or have other special health needs Home health care 2010% coinsurance 2010% coinsurance Payment increases for non-BCBSM Rehabilitation services 2010% coinsurance 40% coinsurance 60 visits per calendar year Habilitation services 2010% coinsurance 40% coinsurance Payment increases for non-BCBSM Skilled nursing care 2010% coinsurance 2010% coinsurance 120 days per calendar year Durable medical equipment 2010% coinsurance 2010% coinsurance Hospice service 100% covered 100% covered Four 90-day periods If your child needs dental or eye care Eye exam Not covered Not Covered Glasses Not covered Not Covered Dental check-up Not covered Not Covered Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for otherexcluded services.)  Cosmetic surgery  Long-term care  Routine eye care (Adult)  Certain Experimental Medicine  Non-emergency care when traveling outside the U.S.  Elective procedures that are not medically necessary  Organ transplants  Chiropractic care  Voluntary sterilization Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are exceptions, however, such as if:  You commit fraud  The insurer stops offering services in the State  You move outside the coverage area For more information on your rights to continue coverage, contact the insurer at [contact number]. You may also contact your state insurance department at [insert applicable State Department of Insurance contact information]. If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be OR limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at [contact number]. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 0-000-000-0000 or xxx.xxx.xxx/xxxx, or the U.S. Department of Health and Human Services at 0-000-000-0000 x00000 or xxx.xxxxx.xxx.xxx.