Medical Plan Comparison - Retirees Age 65 or Over

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1 l Plan Comparison - Retirees Age 65 or Over Program Name U of M Retiree Plan with Group reblue SM Rx Group Platinum Blue SM Plan C withgroup reblue SM Rx Freedom Plan & Retiree National Choice Freedom Plan & Retiree National Choice Type of Policy Coordinates with re and includes re prescription drug program re Cost Plan with re Prescription Drug Coverage re Cost Plan with re Prescription Drug Coverage re Cost Plan with re Prescription Drug Coverage Monthly Premium $ $ $ $ How Plan Works with re and re Assignment U of M Retiree Plan pays after applying U of M Retiree Plan inpatient deductible and coinsurance. You pay re Part B s re pays primary for home health care expenses. For most in-network claims, Blue Cross pays re Part B provider expenses re pays primary for home health care expenses. pays re Part B provider expenses re pays primary for home health care expenses. pays re Part B provider expenses.. re Assignment Outpatient Hospital BCBS network providers, but you do not assign your re benefits to Blue Cross. re benefits outside of the BCBS network BCBS network providers, but you do not assign your re benefits to Blue Cross. You are allowed to use your re benefits outside of the BCBS network network providers, but you do not assign your re benefits to. re benefits outside of the network. network providers, but you do not assign your re benefits to. re benefits outside of the network Outpatient Surgery after re Part B after $75 after $75 MRIs, CT scans, Other Outpatient Testing Emergency Services after re Part B after $50 after $50 after $100 Ambulance after re Part B after $75 80%

2 l Plan Comparison - Retirees Age 65 or Over Program Name Group Prime Solution Group Prime Solution for Seniors for Seniors Type of Policy re Cost Plan with re Prescription Drug Coverage re Cost Plan with re Prescription Drug Coverage re Advantage Plan including Prescription Drug Coverage re Advantage Plan including Prescription Drug Coverage Monthly Premium $ $ $ $ How Plan Works with re and re Assignment re pays primary for home health care expenses. pays re Part B provider expenses re pays primary for home health care expenses. pays re Part B provider expenses administers benefits and claims payment of re Parts A and B, as well as additional benefits included in plan, such as Prescription Drug coverage (Part D) and preventive care. Bills for health care services are sent directly to by providers (not to re) and are processed in Claims department administers benefits and claims payment of re Parts A and B, as well as additional benefits included in plan, such as Prescription Drug coverage (Part D) and preventive care. Bills for health care services are sent directly to by providers (not to re) and are processed in Claims department re Assignment network providers, but you do not assign your re benefits to. re benefits outside of the network network providers, but you do not assign your re benefits to. re benefits outside of the network You cannot use your re benefits outside of network You cannot use your re benefits outside of network Outpatient Hospital Outpatient Surgery after $50 after $100 MRIs, CT Scans, Other Outpatient testing after $50 after $25 after $25 Emergency Services after $50 after $65 (20% coinsurance outside the U.S. Expenses do not apply to Out-of-Pocket Maximum) after $50 after $50 Ambulance 80% coinsurance

3 l Plan Comparison - Retirees Age 65 or Over Urgent Care Visit after re Part B after $20 after $15 after Inpatient Hospital Plan pays 80% of first $2,900 of total allowed amount following $100 annual inpatient deductible; then through end of calendar year. Out-of-pocket expense limited to $680 per year including $100 deductible after $200 for each re-covered stay. limit on number of days covered by plan after $200 per visit Skilled Nursing Plan pays 80% of first $2,900 of total allowed amount following $100 annual inpatient deductible; then through end of calendar year. Out-of-pocket expense limited to $680 per year including $100 deductible. 3-day hospital stay requirement after 3-day after 3-day after 3-day Mental Health Plan pays 80% of first $2,900 of total allowed amount following $100 annual inpatient deductible; then through end of calendar year. Out-of-pocket expense limited to $680 per year including $100 deductible after $200 up to 190 days of inpatient psychiatric hospital care in a lifetime. This limitation does not apply to inpatient psychiatric services furnished in a general hospital after $200 per visit Chemical Dependency Plan pays 80% of first $2,900 of total allowed amount following $100 annual inpatient deductible; then through end of calendar year. Out-of-pocket expense limited to $680 per year including $100 deductible after $200 after $200 per visit Outpatient l Preventive Physician Office Visit after re Part B after $20 after $15 after: Primary Care $20 / Specialist

4 l Plan Comparison - Retirees Age 65 or Over Urgent Care Visit after $15 after after $20 after $20 Inpatient Hospital after $200 after $200 Skilled Nursing after 3-day after 3-day coverage for up to ; no 3-day hospital stay requirement coverage for up to ; no 3-day hospital stay requirement Mental Health after $200 after $200 Chemical Dependency after $200 after $200 Outpatient l Preventive Physician Office Visit after $15 after: Primary Care $20 / Specialist after $15 after $20

5 l Plan Comparison - Retirees Age 65 or Over tions Delivered in Physician Office Setting and Paid under re Part B after re Part B after $20 after Primary Care $20 /Specialist $30 (If Part B drugs are billed separately,coverage is 80%) Routine Eye and Hearing Exams Outpatient Mental Health after re Part B after $20 after $15 individual/ $7.50 group after $30 individual/ $15 group Outpatient Chemical Dependency after re Part B after $20 after $15 after Chiropractic Care after re Part B after $20 after Podiatry after re Part B after $20 after $15 after Physical & Occupational Therapy after re Part B after $20 after $15 after Speech & Language Therapy after re Part B after $20 after $15 after Home Health Care after re Part B l Equipment DME Prosthetics after re Part B (amount may change in % 90% 80% Hearing Aids 80% for hearing aids every 3 years $450 plan coverage limit for hearing aids every year 80% coverage for 1 selected hearing aid for each ear every 3 years. implantable devices coverage. Discounts available

6 l Plan Comparison - Retirees Age 65 or Over tions Delivered in Physician Office setting and Paid under re Part B after $15 (If Part B drugs billed separately, coverage is 80%) after Primary Care $20 /Specialist $30 (If Part B drugs billed separately, coverage is 80%) after $50 after $50 Routine Eye and Hearing Exams Outpatient Mental Health after $15 after after $15 after $20 Outpatient Chemical Dependency after $15 after after $15 after $20 Chiropractic Care after $15 after $20 Podiatry after $15 after after $15 after $20 Physical & Occupational Therapy after $15 after after $15 after $20 Speech & Language Therapy after $15 after after $15 after $20 Home Health Care l Equipment DME Prosthetics 80% coinsurance 80% DME/ Prosthetics 80% DME/ Prosthetics Hearing Aids $500 allowance per year coverage $500 allowance every 36 months $500 allowance every 36 months

7 l Plan Comparison - Retirees Age 65 or Over Prescription Drugs Generic Drugs Retail Formulary Brand Drugs Retail $25 $35 n-preferred Formulary Brand Retail $50 $60 $70 Specialty Drugs Supplemental Drugs Covered at generic and brand s shown above Covered at generic and brand s shown above Mail Order 3-month supply for 2 s through mail order or if using Preferred Extended Network (PXT) within Group re- Blue Rx pharmacy network 3-month supply for 2 s through mail order or if using Preferred Extended Network (PXT) within Group re- Blue Rx pharmacy network 3-month supply for 2 s 3-month supply for 2 s Benefits in the re Coverage Gap (Between $2,850 total prescription costs and $4,450 total out-of-pocket expenses) coverage after $10 or specialty. 75% coverage for supplemental drugs coverage after $10 generic or $25 brand. for supplemental drugs coverage after $10 coverage after $10 generic. coverage for brand drugs but 50% reimbursement from brand drug manufacturer at the pharmacy Catastrophic Level (after $4,450 in total out-of- pocket expenses) the member cost will be the greater of $2.55 for covered generic or multisource preferred brand drugs, and $6.35 for all other covered drugs, or 5% of the cost of the drug, and not to exceed $10/$30/$50/$30 the member cost will be the greater of 5% of drug cost or $2.55 for generic drugs and $6.35 for brand/ formulary drugs The lesser of 5% or the above s the member cost will be the greater of 5% of drug cost or $2.55 for generic drugs and $6.35 for brand/formulary drugs Wellness Benefits Fitness Club Membership Fitness discount that credits your fitness center account $20 a month for membership fees when you work out 12 times a month Fitness Program that provides a fitness club membership at participating facilities or home exercise kits Fitness club memberships at most major clubs for just $25 per year Nurseline 24-hour Nurse Advice Line 24-hour Nurse Advice Line Free access to registered nurses 24/7 through the CareLine SM nurse line Other Wellness Benefits Stop Smoking Program Stop Smoking support Free, unlimited number of virtuwell visits for Freedom Plan members Weight Watchers discount Weight Watchers discount Healthy discounts on hearing aids, eating services, delivery services, fitness equipment and much more Discounts available with participating providers Up to $125 limit for non- re covered eyewear every year Up to 35% discount off eyewear

8 l Plan Comparison - Retirees Age 65 or Over Prescription Drugs Generic Drugs Retail Formulary Brand Drugs Retail n-preferred Formulary brand Retail $70 $60 Specialty Drugs. (Expenses don t count for Out-of-Pocket Maximum.) Supplemental Drugs Covered at generic and brand s shown above t covered Covered at generic and brand s shown above t covered Mail Order 93 days x 3 s 93 days x 3 s Maintenance medications available through Mail Order or at retail locations 2 s for 102-day supply Maintenance medications available through Mail Order or at retail locations 2 s for 102-day supply Benefits in the re Coverage Gap (Between $2,850 total prescription costs and $4,450 total out-of-pocket expenses) coverage after $10 coverage after $10 generic. coverage for brand drugs but 50% reimbursement from brand drug manufacturer at the pharmacy coverage after $10 coverage after $10 generic. coverage for brand drugs but 50% reimbursement from brand drug manufacturer at the pharmacy Catastrophic Level (after $4,450 in total out-of- pocket expenses) coverage after $10 the member cost will be the greater of 5% of drug cost or $2.55 for generic drugs and $6.35 for brand/formulary drugs coverage after $10 member cost will be the greater of 5% of drug cost or $2.55 for generic drugs and $6.35 for brand/formulary drugs Wellness Benefits Fitness Club Membership s partnered fitness program provides a health club membership to all members Silver Sneakers Fitness Program Nurseline and Other Programs Personal Health Advocate can help navigate the healthcare system as well as provide access to registered nurses for guidance and support 24 hours a day/7 days a week Health Connections 24-Hour Nurse Line, Community Education Class reimbursement, My Health Decisions Online Tool Other Wellness Benefits offers a free tobacco treatment program that helps members quit using all forms of tobacco A survey for senior members that is reviewed by nurses in s Care Management area to assess additional needs tion Therapy Management (MTM) program provides information and resources to improve medication use and patient care Quit Smoking, plus Disease and Case Management Programs Weight Loss Mammogram Incentive Programs

9 l Plan Comparison - Retirees Age 65 or Over Plan features Travel and Out-of-Area Benefits Travel benefits limitations May travel out of the service area and within the United States for 9 months, no activation of benefit required May be out of the service area for up to 9 consecutive months annually; benefits are activated by calling Member Services May be out of the service area for up to 9 consecutive months annually; benefits are activated by calling Member Services Option to live outside of service area Yes Yes, but only through Retiree National Choice Yes, but only through Retiree National Choice Maximums Annual Out-of-Pocket $847 that includes $680 plus $147 (for 2013) Part B deductible (Pharmacy s do not apply) $3,000. This amount does not include re (Pharmacy s do not apply) $3,000 (Pharmacy s do not apply) $3,000 (Pharmacy s do not apply) Lifetime Plan features Travel and Out-of-Area Benefits Travel benefits Extended Absence Option allows members to use medical and prescription drug coverage when traveling away from the service area for up to 9 consecutive months Extended Absence Option allows members to use medical and prescription drug coverage when traveling away from the service area for up to 9 consecutive months Members may be out of service area for up to 6 consecutive months. Members do not need to notify when they leave or return. Emergency benefits are worldwide: $50 for ER visits; waived if admitted to the hospital. 80% coverage for non-emergency services anywhere in the US. $100,000 plan benefit maximum Members may be out of service area for up to 6 consecutive months. Members do not need to notify when they leave or return. Emergency benefits are worldwide: $50 for ER visits; waived if admitted to the hospital. 80% coverage for non-emergency services anywhere in the US. $100,000 plan benefit maximum Option to live outside of service area Maximums Annual Out-of-Pocket $1,000 on l (Pharmacy s do not apply) $3,000 on l (Pharmacy s do not apply) $3,400 l Out-of- Pocket Maximum / $4,750 Pharmacy Out-of- Pocket Maximum $3,400 l Out-of- Pocket Maximum / $4,750 Pharmacy Out-of- Pocket Maximum Lifetime

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