HBS PPO Standard Plan B SJMHS Benefits-at-a-Glance Trinity Health

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1 HBS PPO Standard Plan B SJMHS Benefits-at-a-Glance Trinity Health Deductible, Copays/Coinsurance and Dollar Maximums Deductible - per calendar year Tier 1 $750 per member $1,500 per family $750 per member $1,500 per family $1,500 per member $3,000 per family Copays/Coinsurance Fixed Dollar Copays Percent Coinsurance $25 copay: Office Visits Outpatient Mental Health / Substance Abuse $35 copay: Urgent Care Services $50 copay: Outpatient surgery facility fee only $250 copay: 10% - 10%/20% - Trinity Health Professional Services $25 copay: Office Visits Outpatient Mental Health / Substance Abuse $35 copay: Urgent Care Services Outpatient surgeryfacility fee only $500 copay: $200 copay: Outpatient surgeryfacility fee only $1,000 copay: 20% 40% Note: Services without a network are covered at the in-network level. Out-of-Pocket Maximum Percent Coinsurance Includes deductible, coinsurance and copays for all covered services Preventive Services Health Maintenance Exam - one per calendar year (age 18 and over) Routine Physical Related Test X-Rays, EKG and lab procedures performed as part of the health maintenance exam Annual Gynecological Exam - one per calendar year, in addition to health maintenance exam Pap Smear Screening - one per calendar year Mammography Screening - one per calendar year (one baseline age then one annually age 40 and over) $2,500 per member $5,000 per family $5,500 per member $11,000 per family $11,000 per member $22,000 per family Covered - 100% Covered - 100% Covered - 60% Covered - 100% Covered - 100% Covered - 60% Covered - 100% Covered - 100% Covered - 60% Covered - 100% Covered - 100% Covered - 60% Covered - 100% Covered - 100% Covered - 60%

2 Tier 1 Prostate Specific Antigen (PSA) Covered - 100% Covered - 100% Covered - 60% Screening - one per calendar year Endoscopic Exams - one per calendar year Covered - 100% Covered - 100% Covered - 60% Well Child Care 7 visits, birth through 12 months Covered - 100% Covered - 100% Covered 60% 3 visits, 13 months through 36 months 2 visits, 37 months through 47 months 1 visit per year thereafter through age 17 Immunizations -Pediatric & Adult Covered - 100% Covered - 100% Covered - 60% Routine Hearing Exam Covered - 100% Covered - 100% Covered - 60% One per calendar year Physician Office Services Office Visits Includes: Primary care and specialist physicians Presurgical consultations Initial visit to determine pregnancy Covered 100% after $25 copay One copay applies to the office visit exam and all services performed during the office visit (e.g., lab, x-ray, etc.) Covered 100% after $25 copay One copay applies to the office visit exam and all services performed during the office visit (e.g., lab, x-ray, etc.) Covered - 60% Emergency Medical Care Hospital Emergency Room Qualified medical emergency Non-Emergency use of the Emergency Room Covered - $100 copay; then 90% Covered - $100 copay; then 80% Covered - $100 copay; then 60% Urgent Care Services Covered - 100% after $35 copay Covered - 100% after $35 copay Covered - 60% Ambulance Services - Medically Necessary Transport Covered - 90% Covered - 80% Covered - 60% Facility Diagnostic and Therapeutic Services MRI,MRA, PET and CAT Scans and Covered - 90% Covered - 80% Covered - 60% Nuclear Medicine Diagnostic Tests, X-rays, Laboratory & Covered - 90% Covered - 80% Covered - 60% Pathology Radiation Therapy and Chemotherapy Covered - 90% Covered - 80% Covered - 60% Professional Diagnostic and Therapeutic Services MRI,MRA, PET and CAT Scans and Covered - 80% Covered - 80% Covered - 60% Nuclear Medicine Diagnostic Tests, X-rays, Laboratory & Covered - 80% Covered - 80% Covered - 60% Pathology Radiation Therapy and Chemotherapy Covered - 80% Covered - 80% Covered - 60% Maternity Services Provided by a Physician Prenatal and Postnatal Care Visits Covered 100% Covered 100% Covered - 60% Delivery and Nursery Care Covered - 80% Covered - 80% Covered - 60% Hospital Care Semi-Private Room, General Nursing Covered 90% after $ 250 copay Covered - $500 copay, then 80% Covered - $1,000 copay, then Care, Hospital Services and Supplies 60% Inpatient Medical Care Covered - 80% Covered - 80% Covered - 60%

3 Tier 1 Alternatives to Hospital Care Hospice Care Covered - 100% Covered - 100% Covered - 60% Home Health Care Covered - 90% Covered - 80% Covered - 60% Skilled Nursing Limited to 120 days per calendar year Surgical Services (Outpatient) Surgery (includes related facility surgical services) Sterilization males only excludes reversal sterilization Sterilization female only excludes reversal sterilization Covered - 90% Covered - $500 copay, then 80% Covered - $1,000 copay, then 60% Covered - 90% after $50 copay Covered - $100 copay then; 80% Covered - $200 copay then; 60% Not Covered Not Covered Not Covered Covered - 100% Covered - 100% Not Covered Human Organ Transplants Specified Organ Transplants in designated Covered - 100% Covered - 100% Not covered facilities only, when coordinated through BCBSM Human Organ Transplant Program ( ) Kidney, Cornea, Bone Marrow and Skin Covered - 90% Covered - 80% Covered - 60% Behavioral Health and Substance Abuse Services Inpatient Behavioral Health and Inpatient Substance Abuse Care Covered 90% after $ 250 copay Covered - $500 copay, then 80% Covered - $1,000 copay, then 60% Outpatient Behavioral Health Care Covered - 100% after $25 copay Covered - 100% after $25 copay Covered - 60% Outpatient Substance Abuse Care Covered - 100% after $25 copay Covered - 100% after $25 copay Covered - 60% Other Services Cardiac Rehabilitation Covered - 90% Covered - 80% Covered - 60% Maximum 36 visits in a 12 week period Chiropractic Services Covered - 80% Covered - 80% Covered - 60% 20 visit maximum per calendar year Durable Medical Equipment Covered - 90% Covered - 80% Covered - 60% Prosthetic and Orthotic Devices Covered - 90% Covered - 80% Covered - 60% Private Duty Nursing Covered - 90% Covered - 80% Covered - 60% Allergy Testing Covered - 80% Covered - 80% Covered - 60% Allergy Therapy Covered - 80% Covered - 80% Covered - 60% Therapy Services Physical, Occupational and Speech Therapy Covered - 90% Covered - 80% Covered - 60% Limited to 60 visits maximum per calendar year Independent Physical Therapist Covered - 80% Covered - 80% Covered - 60% Limited to 60 visits maximum per calendar year combined with outpatient physical therapy Note: The following services require preapproval: Inpatient Care, select Radiology Services, Inpatient Mental Health and Substance Abuse Care and Skilled Nursing. 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 bec omes 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 Non-Surgical Weight Loss Therapy Along with the existing benefits for bariatric surgery, the plan will cover additional services for non-surgical weight loss treatment. Benefits are payable 100% up to an annual benefit maximum of $500 and include: Outpatient counseling or therapy, Office visits rendered by a licensed physician for the treatment of weight loss Lab services performed during a course of treatment, and Services for weight loss rendered by a Trinity Health Ministry Organization or national recognized programs such as Jenny Craig, Weight Watchers and LA Weight Loss. Weight-loss expenses that are not covered are: Services administered exclusively through an Internet-based forum, Medication or injection expenses for weight loss, unless otherwise covered for an unrelated medical condition Charges for food or nutritional supplements, unless included in the initial program fee, Charges for over-the counter diet aids, Health clubs or exercise equipment, Services or programs that are not approved in the United States, and Charges in connection with acupuncture, hypnotism or biofeedback training. Case Management / Disease Management Incentive Program If you and/or your covered spouse complete a disease management or case management program, you will receive $50 Visa gift c ard for each program completed.* Baby Steps Program If you agree to participate a BCBSM nurse case manager will administer an assessment and an individualized plan that includes condition and goals based on your assessment results. The nurse will work with you via telephone to address your specific health concerns and goals. Once you have completed the program you will receive a case closure letter via mail and a call explaining that you have completed your program. Upon your case being closed, you will be awarded a $50 Visa gift card that will be issued in the calendar quarter following the program completion date. If you (or your covered spouse) enroll in the Baby Steps program, you will be eligible for a $50 Visa gift card that will be issued in the calendar quarter following the date in which you enroll in the Baby Steps program.* The Baby Steps program connects you with a BCBSM registered nurse who provides information to support the health of your baby and to address your questions or concerns. The nurse can help by: Conducting a confidential health assessment questionnaire Offering suggestions on how to reduce risks during pregnancy Addressing any questions or concerns following the birth of your child Helping you get access to free online materials and self-help books *Please note that gift card incentives are considered taxable income.

5 Selecting a Provider When you use Trinity Health facilities and satellite locations, you receive the highest benefit payment level. A listing of eligible facilities is available online at bsbsm.com. Network Providers Network providers have signed agreements with BCBS, which means they agree to accept our approved payment for a covered benefit as payment in full. You will only pay for the deductibles, copayments and coinsurances required by your coverage. Ask your physician if he or she participates with the BCBS PPO network in your plan area. If you need help locating a network provider, please call the phone number to locate a BCBS network provider or visit the Web site listed on the inside front cover of this handbook. When you go to network providers, you do not have to send a claim to us. Network providers submit claims to BCBS for you, and they are paid directly by BCBS. Nonparticipating (Out-of-Network) Providers Nonparticipating providers have not signed agreements with BCBS. This means they may or may not choose to accept the BCBS approved amount as payment in full for your health care services. If your present providers do not participate with BCBS, ask if they will accept the amount we approve as payment in full for the services you need. This is called participating on a "per claim" basis and means that the providers will accept the approved amount as payment in full for the specific services. You are responsible for any deductibles, copayments, and coinsurances required by your plan along with charges for non-covered services. Prescription Drugs Administered directly by CVS Caremark Retail 34-day supply Ministry Organization on-site pharmacies 90-day supply Mail Order 90 day supply 100% after $10 copay 20% with $30 minimum and $80 maximum 40% with $60 minimum and $100 maximum 100% after $30 copay* 20% with $90 minimum and $240 maximum* 40% with $180 minimum and $300 maximum* * Not inclusive of associate discount 100% after $25 copay 20% with $75 minimum and $200 maximum 40% with $150 minimum and $250 maximum If the brand drug has a specific equivalent generic drug available and the plan participant receives the brand, then in addition to the copay, the plan participant must also pay the difference between the ingredient cost of the brand drug and the generic dr ug.