Michigan Electrical Employees Health Plan Benefits & Eligibility-at-a Glance Supplement to Medicare - Medicare Enrollees

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1 Medicare Coverage BCBSM Supp Coverage Preventive Services 12 months, if age 50 and older Colonoscopy - one per calendar year 1 0 years (if at high risk every 24 months) approved amount**, once per flu Flu Shots season in the fall or whiter Prostate specific antigen (PSA) test Pneumococcal shot approved amount** Hepatitis B shots - for those at high or medium risk of contracting the disease approved amount** Shingles Vaccine - age 50 and over Mammography screening 12 months at age 40 and older (one baseline mammogram for women between ages 35 and 39) Covered at 50% after BCBSM Deductible Physician Office Services Office Visits Outpatient and home medical care visits Office Consultations Emergency Medical Care Hospital Emergency Room (professional services) - must be medically necessary Ambulance Services - must be medically necessary Covers Medicare and Covers Medicare and -2This is intended as an easy to read summary. It is not a contract. AdditionaJ limitations and exclusions may apply to covered services. For an official description of benefits,

2 Deductibles Fixed dollar copays Coinsurance/percent copay amounts Preventive Services Health maintenance exam - Welcome to Medicare Exam Wellness Exam Gynecological exam Pap smear screening - laboratory services only Fecal occult blood screening Flexible sigmoidoscopy exam Medicare Coverage 12 months Note: Your first yearly "Wellness" exam can't take place within 12 months of your "Welcome to Medicare" physical exam. 24 months 24 months (more frequently if high risk) 12 months, if age 50 and older 48 months, if age 50 and older BCBSM Supp Coverage $500 per person $1,000 per family, per calendar year N/A 50% up to $1,000 Individual or Family Medicare Part A $1,156* (for days 1-60) each benefit period Medicare Part B $140* per calendar year Hospitalization $289* per day (for days 61-90) $578* per day (for days ) Skilled nursing facility care (a limit of 100 days for each benefit period) $144.50* per day (for days ) 20% of Medicare approved amount for most general services 40%* of Medicare approved amount for outpatient mental health care 50% of Medicare approved amount for outpatient substance abuse -1- This is intended as an easy to read summary. It is not a contract. Additional limitations and exclusions may apply to covered services. For an official description of benefits, please see the applicable Summary Plan Description. Payment amounts are based on the Blue Cross Blue Shield of Michigan approved amount

3 Alternatives to Hospital Care Covered at Medicare approved amount less small co-payment for outpatient drugs and less Hospice Care small coinsurance for inpatient respite care Home health care - must be medically necessary approved amount Surgical Services provided by a physician Surgery - includes related surgical services Human Organ Transplants Heart and liver transplants Lung and heart-lung transplants Pancreas transplants Bone marrow transplants-under certain conditions Kidney, cornea and skin transplants Covers limited costs not covered by Medicare at 50% after BCBSM Covers Medicare and Covers Medicare and Covers Medicare and approved amount less Note: Pancreas transplants are Note: Covers Medicare covered under certain conditions. and coinsurance when covered by Please call Medicare for more Medicare at 50% after BCBSM information Covers Medicare and approved amount less (Please call Medicare for more information) Covers Medicare and approved amount less 50% after BCBSM (Please call Medicare for more information) approved amount less Mental health care In-patient mental health care in psychiatric facility -Days lifetime Additional days after 190 lifetime days are used are not covered See "Hospital care" benefits (Medicare pays the claim as part of your regular Part A hospital coverage, subject to Part A and coinsurance) Note: hi most cases, psychiatric care in general (as opposed to psychiatric hospitals) is not subject to the 190-day limit Covers Medicare and daily 50% after BCBSM -4This is intended as an easy to read summary. It is not a contract. Additional limitations and exclusions may apply to covered services. For an official description of benefits

4 Clinical laboratory services Laboratory & pathology tests - used in the diagnosis and treatment of an illness or injury Hospital Care Semiprivate room, inpatient physician care, general nursing care, hospital services and supplies Days 1-60 Supplement to Medicare Medicare Enrollees Medicare Coverage BCBSM Supp Coverage approved amount for most diagnostic laboratory and pathology services (covered at 80% of approved amount for certain laboratory services) approved amount less Part A (also includes inpatient mental health & residential substance abuse) Covers Medicare at 50% after BCBSM Days approved amount less Part A daily coinsurance Covers Medicare daily Lifetime reserve days (60 days) approved amount less Part A daily coinsurance Covers Medicare daily Additional days Chemotherapy Alternatives to Hospital Care Skilled Nursing Care - must be in a participating skilled nursing facility Days Days Days 101 and after approved amount for administration and drugs, must meet Medicare criteria approved amount approved amount less daily coinsurance Covered at BCBSM approved amount, up to an additional 30 days at 50% after BCBSM Covers Medicare and Covers Medicare coinsurance at 50% after BCBSM -3- This is intended as an easy to read summary. It is not a contract. Additional limitations and exclusions may apply to covered services. For an official description of benefits,

5

6 Mental health care Out-patient mental health care Other covered services Allergy testing and therapy - with approved diagnosis Chiropractic Spinal Manipulation - must be medically necessary Outpatient physical, speech and occupational therapy Durable medical equipment Prosthetic appliances Private duty nursing Prescription drugs Oral cancer drugs Other Benefits Vision -VSP Medicare Coverage Covered at 60% of Medicare (Diagnostic services are covered at 80% of Medicare ) Note: If you get your services in a hospital outpatient clinic, or hospital outpatient department, you may have to pay an additional copayment or coinsurance amount to the hospital Approved drugs are covered BCBSM Supp Coverage Covers Medicare and daily 50% after BCBSM Covers Medicare and coinsurance for 50% after BCBSM Covers Medicare and coinsurance or set 50% after BCBSM Covers Medicare and 50% after BCBSM Covers Medicare and 50% after BCBSM 20% discount on eye exam 20% discount on frames, lenses and lens options when a complete pair of prescription glasses is purchased 15% discount on contact lens exam, including evaluation and fitting Laser Eye Surgery (Lasik) - Discounts available only from a VSP Network doctor. -5- This is intended as an easy to read summary. It is not a contract Additional limitations and exclusions may apply to covered services. For an official description of benefits,

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