Final. $2,500 per member $5,000 per family

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1 Final PPO PPO Medical, Rx, Dental Core, Dental Buy Up Benefits-at-a-Glance City of Pontiac Group Number: Deductible, Copays/Coinsurance and Dollar Maximums Deductible - per calendar year Copays/Coinsurance Fixed Dollar Copays In-Network $750 per member $1,500 per family $5 copay for Allergy Injections $30 copay for PCP office visits $45 copay for Specialist office visits $60 copay for Urgent Care visits $60 copay for Chiropractic visits $250 copay for Emergency Room Out-of-Network $1,500 per member $3,000 per family $60 copay for Urgent Care visits $60 copay for Chiropractic visits $250 copay Emergency Room Percent Coinsurance 20% 50% Note: Services without a network are covered at the in-network level. Out-of-Pocket Maximum per calendar year Percent Coinsurance deductible and copays do not apply Lifetime Maximum $2,500 per member $5,000 per family Unlimited $5,000 per member $10,000 per family Preventive Services Health Maintenance Exam - one per calendar year - 100% Routine Physical Related Test - X-Rays, EKG and lab - 100% procedures performed as part of the health maintenance exam Annual Gynecological Exam - one per calendar year, in - 100% addition to health maintenance exam Pap Smear Screening - one per calendar year - 100% Mammography Screening - one per calendar year - 100% Prostate Specific Antigen (PSA) Screening - one per - 100% calendar year Endoscopic Exams - one per calendar year - 100% Well Child Care - 100% 6 visits, birth through 12 months 6 visits, 13 months through 23 months 6 visits, 24 months through 35 months 2 visits, 36 months through 47 months Visits beyond 47 months are limited to one per member per calendar year under the health maintenance exam benefit. Immunizations %

2 In-Network Out-of-Network Physician Office Services Office Visits - 100% after $30 pcp copay $45 specialist copay Emergency Medical Care Hospital Emergency Room Qualified medical emergency - 100% after $250 copay, copay waived if admitted Non-Emergency use of the Emergency Room Urgent Care Services - 100% after $60 copay - 50% after $60 copay Ambulance Services - Medically Necessary Transport - 80% after deductible - 80% after deductible Diagnostic and Therapeutic Services MRI,MRA, PET and CAT Scans and Nuclear Medicine - 80% after deductible Diagnostic Tests, X-rays, Laboratory & Pathology - 80% after deductible Radiation Therapy and Chemotherapy - 80% after deductible Maternity Services Provided by a Physician - 100% after $250 copay, copay waived if admitted Prenatal and Postnatal Care - 100% Delivery and Nursery Care - 80% after deductible Hospital Care Semi-Private Room, Inpatient Physician Care, General - 80% after deductible Nursing Care, Hospital Services and Supplies Note: Nonemergency services must be rendered in a participating hospital. Unlimited days Inpatient Medical Care - 80% after deductible Alternatives to Hospital Care Hospice Care - 80% after deductible Home Health Care - 80% after deductible Limited to 100 visits per calendar year Skilled Nursing - 80% after deductible Limited to 60 days per calendar year Surgical Services Surgery (includes related surgical services) - 80% after deductible Sterilization - excludes reversal sterilization - 80% after deductible Human Organ Transplants Specified Organ Transplants in designated facilities - 100% Not covered except in designated facilities only, when coordinated through BCBSM Human Organ Transplant Program ( ) Kidney, Cornea, Bone Marrow and Skin - 80% after deductible Mental Health and Substance Abuse Services Inpatient Mental Health and Substance Abuse Care - 80% after deductible Outpatient Mental Health and Substance Abuse Care Approved facilities only - 100% after $45 copay

3 In-Network Out-of-Network Other Services Cardiac Rehabilitation - 80% after deductible Chiropractic spinal manipulation, adjustments and - 100% after $60 copay - 50% after $60 copay modalities Limited to a combined maximum of 20 visits per member per calendar year Durable Medical Equipment - 80% after deductible Prosthetic and Orthotic Devices - 80% after deductible Private Duty Nursing - 80% after deductible Allergy Testing - 100% Allergy Therapy (injections) - 100% after $5 copay Therapy Services Physical, Occupational and Speech Therapy Combined - limited to 30 visits per calendar year - 80% after deductible Note: Services at nonparticipating outpatient physical therapy facilities are not covered. Prescription Drugs Retail - 30 day supply $15 copay Generic drugs $40 copay Formulary brand name drugs $80 copay Non-Formulary brand name drugs Prescriptions and refills obtained from a non-network pharmacy are reimbursed at 75% of the approved amount, less the member s copay. Mail Order - 90 day supply $30 copay Generic drugs $80 copay Formulary brand name drugs $160 copay Non-Formulary brand name drugs Specialty Drugs - 30 day supply only 25% copay subject to annual $2,500 specialty drug maximum then paid at 100% Additional Services Oral and Injectable Contraceptive Smoking Cessation Drugs Weight Loss Drugs Impotency Drugs Infertility Drugs Diabetic Supplies Includes: Needles/Syringes and Insulin - $40 copay at retail; $80 copay at mail order Test Strips - $40 copay at retail; $80 copay at mail order Lancets - $40 copay at retail; $80 copay at mail order The information in this document is based on BCBSM s current interpretation of the Patient Protection and Affordable Care Act (PPACA). Interpretations of PPACA vary and the federal government continues to issue guidance on how PPACA should be interpreted and applied. Efforts will be made to update this document as more information about PPACA becomes available. This document is only an educational tool and should not be relied upon as legal or compliance advice. Additionally, some PPACA requirements may differ for particular members enrolled in certain programs, and those members should consult with their plan administrators for specific details. This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and exclusions may apply. Payment amounts are based on BCBSM s approved amount, less any applicable deductible and/or copay. For a complete description of benefits please see the applicable BCBSM certificates and riders, if your group is underwritten or any other plan documents your group uses, if your group is self-funded. If there is a discrepancy between this Benefits-At-A-Glance and any applicable plan document, the plan document will control.

4 Traditional Plus Dental Coverage City of Pontiac Dental Core Plan Class I Services Periodic Oral Exams - 50%, twice per calendar year Prophylaxis (Teeth Cleaning) - 50%, twice per calendar year Bitewing X-Rays - 50%, twice per calendar year Brush Biopsy - 50% Full-mouth and Panoramic X-Rays - 50%, once every 60 months Fluoride Treatment - 50%, twice per calendar year, through age 18 Space Maintainers - 50%, once per quadrant per lifetime, through age 18 Palliative Emergency Treatment - 50% Sealants - 50%, once per tooth every 36 months, through age 19 Class II Services Benefits-at-a-Glance Fillings - permanent teeth - 50%, once every 24 months Fillings - primary teeth - 50%, once every 12 months Inlays, Onlays, and Crowns - permanent teeth - 50%, once every 60 months, payable for members age 12 and older Recementing of Crowns, Inlays, Onlays and Bridges - 50%, three per calendar year Root Canal Therapy - 50%, once per tooth, per lifetime Periodontal Scaling and Planing - 50%, once per quadrant every 24 months Occlusal Adjustment - 50%, up to five times in a 60-month period Occlusal Guards/Biteguards - 50%, once every 12 months General Anesthesia or IV Sedation - 50%, when medically necessary and with oral or dental surgery Oral Surgery including extractions - 50% Relining or Rebasing of Partials or Dentures - 50%, once every 36 months per arch Tissuing Conditioning - 50%, once every 36 months per arch Repair to Existing Partials or Dentures - 50% Class III Services Removable Dentures - Complete and Partials - 50%, once every 60 months Fixed Bridges - 50%, once every 60 months for age 16 and older Implants - 50%, one per tooth in any five-year period Class IV Services Orthodontic services for dependents Habit Breaking Appliances Minor Tooth Guidance Appliances Full Banding Treatment Other Benefit Period, Copays and Dollar Maximums Benefit Period Calendar Year Deductible No Deductible Member Coinsurance 50% for Class I, II, & III services Dollar Maximums - Annual Maximum $600 for covered Class I, II, & III services Lifetime Orthodontic Maximum Not Applicable This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and exclusions may apply. Payment amounts are based on BCBSM s approved amount, less any applicable deductible and/or copay. For a complete description of benefits please see the applicable BCBSM certificates and riders, if your group is underwritten or any other plan documents your group uses, if your group is self-funded. If there is a discrepancy between this Benefits-at-a-Glance and any applicable plan document, the plan document will control. With Traditional Plus Dental, members can choose any licensed dentist anywhere. However, they ll save the most money when they choose a dentist who is a member of the Dental Network of America (DNoA) Preferred Network of PPO dentists. DNoA Preferred Network Blue Dental members have unmatched access to PPO dentists through the DNoA Preferred Network, which offers nearly 200,000 dentist access points* nationwide. DNoA Preferred Network dentists agree to accept our approved amount as payment in full and participate on all claims. Members also receive discounts on noncovered services when they use PPO dentists. To find a DNoA Preferred Network dentist near you, please visit BCBSM.com/bluedental or call

5 * A dentist access point is any place a member can see a dentist to receive high-quality dental care. For example, one dentist practicing in two locations would be two access points. Blue Par Select SM arrangement Most dentists accept our Blue Par Select arrangement, which means they participate with the Blues on a per claim basis. Members should ask their dentists if they participate with BCBSM before every treatment. Blue Par Select dentists accept our approved amount as full payment for covered services members pay only applicable copays and deductibles, along with any fees for noncovered services. To find a dentist who may participate with BCBSM, please visit BCBSM.com/bluedental. Note: Members who go to nonparticipating dentists may be billed for any difference between our approved amount and the dentist s charge The information in this document is based on BCBSM s current interpretation of the Patient Protection and Affordable Care Act (PPACA). Interpretations of PPACA vary and the federal government continues to issue guidance on how PPACA should be interpreted and applied. Efforts will be made to update this document as more information about PPACA becomes available. This document is only an educational tool and should not be relied upon as legal or compliance advice. Additionally, some PPACA requirements may differ for particular members enrolled in certain programs, and those members should consult with their plan administrators for specific details.

6 Traditional Plus Dental Coverage City of Pontiac Dental Buy Up Class I Services Periodic Oral Exams - 100%, twice per calendar year Prophylaxis (Teeth Cleaning) - 100%, twice per calendar year Brush Biopsy - 100%, Fluoride Treatment - 100%, twice per calendar year, through age 18 Space Maintainers - 100%, once per quadrant per lifetime, through age 18 Palliative Emergency Treatment - 100% Sealants - 100%, once per tooth every 36 months, through age 19 Class II Services Benefits-at-a-Glance Fillings - permanent teeth - 80%, once every 24 months Fillings - primary teeth - 80%, once every 12 months Bitewing X-Rays - 80%, twice per calendar year Full-mouth and Panoramic X-Rays - 80%, once every 60 months Recementing of Crowns, Inlays, Onlays and Bridges - 80%, three per calendar year Root Canal Therapy - 80%, once per tooth, per lifetime Periodontal Scaling and Planing - 80%, once per quadrant every 24 months Occlusal Adjustment - 80%, up to five times in a 60-month period Occlusal Guards/Biteguards - 80%, once every 12 months General Anesthesia or IV Sedation - 80%, when medically necessary and with oral or dental surgery Oral Surgery including extractions - 80% Relining or Rebasing of Partials or Dentures - 80%, once every 36 months per arch Tissuing Conditioning - 80%, once every 36 months per arch Repair to Existing Partials or Dentures - 80% Class III Services Removable Dentures - Complete and Partials - 50%, once every 60 months Inlays, onlays and crowns - permanent teeth - 50%, once every 60 months Fixed Bridges - 50%, once every 60 months for age 16 and older Implants - 50%, once per tooth per lifetime Class IV Services Orthodontic services for dependents up to and including age 19 Habit Breaking Appliances - 50% Minor Tooth Guidance Appliances - 50% Full Banding Treatment - 50% Benefit Period,Copays and Dollar Maximums Benefit Period Deductible Member Coinsurance Dollar Maximums - Annual Maximum Lifetime Orthodontic Maximum Calendar Year No Deductible 0% for Class I services, 20% for Class II services, 50% for Class III & IV services $1000 Class II & III services per member for covered services $1000 per member This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and exclusions may apply. Payment amounts are based on BCBSM s approved amount, less any applicable deductible and/or copay. For a complete description of benefits please see the applicable BCBSM certificates and riders, if your group is underwritten or any other plan documents your group uses, if your group is self-funded. If there is a discrepancy between this Benefits-at-a-Glance and any applicable plan document, the plan document will control. With Traditional Plus Dental, members can choose any licensed dentist anywhere. However, they ll save the most money when they choose a dentist who is a member of the Dental Network of America (DNoA) Preferred Network of PPO dentists. DNoA Preferred Network Blue Dental members have unmatched access to PPO dentists through the DNoA Preferred Network, which offers nearly 200,000 dentist access points* nationwide. DNoA Preferred Network dentists agree to accept our approved amount as payment in full and participate on all claims. Members also receive discounts on noncovered services when they use PPO dentists. To find a DNoA Preferred Network dentist near you, please visit BCBSM.com/bluedental or call

7 * A dentist access point is any place a member can see a dentist to receive high-quality dental care. For example, one dentist practicing in two locations would be two access points. Blue Par Select SM arrangement Most dentists accept our Blue Par Select arrangement, which means they participate with the Blues on a per claim basis. Members should ask their dentists if they participate with BCBSM before every treatment. Blue Par Select dentists accept our approved amount as full payment for covered services members pay only applicable copays and deductibles, along with any fees for noncovered services. To find a dentist who may participate with BCBSM, please visit BCBSM.com/bluedental. Note: Members who go to nonparticipating dentists may be billed for any difference between our approved amount and the dentist s charge The information in this document is based on BCBSM s current interpretation of the Patient Protection and Affordable Care Act (PPACA). Interpretations of PPACA vary and the federal government continues to issue guidance on how PPACA should be interpreted and applied. Efforts will be made to update this document as more information about PPACA becomes available. This document is only an educational tool and should not be relied upon as legal or compliance advice. Additionally, some PPACA requirements may differ for particular members enrolled in certain programs, and those members should consult with their plan administrators for specific details.

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