2015HEALTH PLAN PROFILES

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1 2015HEALTH PLAN PROFILES PLAN TYPE MANAGED CARE PLANS TRADITIONAL PLAN TRADITIONAL PPO PLAN U-M Premier Care Health Alliance Plan Comprehensive Major Medical PPO Address 2311 Green Road Ann Arbor, MI Green Road Ann Arbor, MI West Grand Boulevard Detroit, MI Lafayette East Detroit, MI Lafayette East Detroit, MI Questions? Directory or Contact Information On the Web at: benefits.umich.edu/ or call: On the Web at: benefits.umich.edu/ or call: On the Web at: or call: PCP Select: On the Web at: www. or call: On the Web at: www. or call: Type of Plan Plan for U-M graduate students only Managed Care Plan HMO Traditional fee-for-service plan PPO Group Number Number of Members 6,953 68, ,550 Number of PCPs Network 1 1,089 Network 1 1,089 3,233 Number of Specialists 14,496 14,496 7,449 Number of Hospitals More than 4 million More than 4 million Percentage of Board Certified PCPs 91.4% 91.4% 92% Percentage of Board Certified Specialists 86.5% 86.5% 91% Policy for Selecting and Changing PCPs or Physicians Level 1, contact BCN Customer Service Contact BCN Customer Service Contact HAP Client Services at: Three Reasons You Should Choose this Plan (Provided by the Plan) 1. Excellent medical care for graduate students at a fair and reasonable price. 2. Worldwide access to care. 3. Access to outstanding provider network, great customer service, money saving programs, and award winning health management programs. 1. Dedicated customer service line. 2. Worldwide access to care. 3. Access to outstanding provider network, great customer service, money saving programs, and award winning health management programs. 1. Nine-county service area. Emergencies and urgent care covered worldwide. 50 years of financial stability 2. HAP s weight management programs include Weight Watchers and Online Health Risk Assessment. 3. University of Michigan Health System PCPs and Specialists. 1. Blue ID card access to all hospitals and doctors nationwide. 2. Valuable online resources, including Blue Health Connection and Blue Worldwide access to care. 1. Blue ID card access to all hospitals and doctors nationwide. 2. Valuable online resources, including Blue Health Connection and Blue Worldwide access to care.

2 General Information Service Area Residency Requirement Important Information About the Terms Used in This Chart Maximum Annual Out-of-Pocket Amount Lifetime Maximum Benefit Phone Number for Customer Service and Provider Directory Only available to GSIs, GSSAs, GSRAs, medical students, and sponsored graduate student groups at the University of Michigan Level 1 and continuance: U-M academic campus means your services must be provided or authorized by a Primary Care Physician (PCP). The plan co-insurance amount is 100% unless stated otherwise or unless a co-pay is indicated for the covered service. Co-pay means a set dollar amount you pay for a covered service. 2 (family) Genessee, Livingston, Macomb, Oakland, Washtenaw and Wayne counties; and portions of Ingham, Jackson, Lapeer, Monroe, and St. Clair counties Participants must reside in the state of Michigan means your services must be provided or authorized by a Primary Care Physician (PCP). The plan co-insurance amount is 100% unless stated otherwise or unless a co-pay is indicated for the covered service. Co-pay means a set dollar amount you pay for a covered service. 5 (family) for Network 1 and 2 providers combined Genesee, Lapeer, Livingston, Macomb, Monroe, Oakland, St. Clair, Washtenaw, and Wayne counties Participants must reside in the service area means your services must be provided or authorized by a Primary Care Physician (PCP). The plan co-insurance amount is 100% unless stated otherwise or unless a co-pay is indicated for the covered service. Co-pay means a set dollar amount you pay for a covered service. 5 (family) Nationwide/Worldwide means you pay a $500/$1,000 deductible, 20% co-insurance up to the annual outof-pocket maximums, and costs that exceed the BCBSM fee schedule or balance billing when non-participating providers are used. Co-insurance means the percentage amount of the provider s charge you pay for a covered service. Including the annual deductible, the maximum out-of-pocket amount is $3,000 per individual and $6,000 per family. 4 Nationwide/Worldwide means the plan payment amount for covered charges is 100% unless stated otherwise. You pay costs that exceed the BCBSM fee schedule or balance billing when non-participating providers are used. Co-pay means the set dollar amount you pay for a covered service. 5 (family). means the plan payment amount for covered charges is 100% unless stated otherwise. You pay costs that exceed the BCBSM fee schedule or balance billing when non-participating providers are used. Co-pay means the set dollar amount you pay for a covered service. 5 Out-of-pocket maximum is $5,000 per individual, $10,000 per family. 4 This chart is not intended to be a full description of coverage. The complete plan description is contained in the appropriate certificate of coverage or plan document issued by each plan. Every effort has been made to ensure the accuracy of this chart. If statements in this chart differ from applicable contracts, certificates, or riders, then the terms and of those documents prevail. This chart assumes all services are provided by a participating medical care provider when required. All benefits are subject to change. 2 Coverage described applies to Level 1. For details on outof-network services, call BCN. 4 The out-of-pocket maximum does not include non-covered charges, and costs that exceed the plan s fee allowance for a particular service for all plans. 5 Co-pays may differ for bargained-for groups. Web Site hap.org Hospital Services Inpatient Hospital Admissions at 50% Days of Care Room Type specialty care units if medically necessary private room not covered Hospital Physician Service at 50% Consultation Between Physicians at 50% Surgery at 50%

3 Preventive Services Routine Physical Exams Routine Pediatric Exams Pap Smears Lab and Pathology Routine Mammograms Physical, occupational, and speech therapies are covered for acute and subject to prior plan authorization. Administrative guidelines and interpretations may vary among plans. for specific coverage provisions before commencing treatment. PSA (Prostate) Test Inoculations for travel are not covered. Outpatient Services Office Visits Outpatient Physical, Occupational and Speech Therapy with a $25 co-pay if in-network PCP is used, except students pay no co-pay at University Health Service. with a $25 co-pay per visit; major diagnoses limited to 60 visits per calendar year; minor diagnoses limited to 15 visits per calendar year. Major and minor diagnoses are determined by the plan. 6 with a $25 co-pay with a $25 co-pay per visit; major diagnoses limited to 60 visits per calendar year; minor diagnoses limited to 15 visits per calendar year. Major and minor diagnoses are determined by the plan. 6 with a $25 co-pay ; up to 60 combined visits per benefit period, may be rendered at home for unlimited treatments 6 with a $25 co-pay with a $25 co-pay (co-pay applies to professional billed services only); limited to 60 visits per year (facility & professional services combined) 6 at 50% at 50%; limited to 60 visits per year (facility and professional services combined) 6 10 Your doctor may provide a preventive service, such as a cholesterol screening test, as part of an office visit. Be aware that your plan can require you to pay some costs of the office visit, if the preventive service is not the primary purpose of the visit, or if your doctor bills you for the preventive services separately for the office visit. Therapeutic Radiology at 50% Diagnostic Lab, X-Ray, EKGs at 50% Outpatient Surgery at 50% Routine Immunizations Coverd 10 7 Allergy Testing with a $30 co-pay with a $30 co-pay with a $30 co-pay ; a $30 co-pay may apply at 50% Allergy Injections ; a $30 co-pay may apply ; a $30 co-pay may apply ; a $30 co-pay may apply ; a $30 co-pay may apply at 50% Other Injections $30 office visit co-pay may apply $30 office visit co-pay may apply $30 office visit co-pay may apply ; a $30 co-pay may apply at 50%

4 Emergency Care In Area for accidental or acute for accidental or acute for accidental or acute hospital treatment covered with a $100 co-pay; co-pay waived if for accidental or acute a $100 co-pay; co-pay waived if patient admitted or due to accidental injury. for accidental or acute medical emergency. Outpatient hospital treatment covered with a $100 copay; co-pay waived if patient admitted or due to accidental injury. Out of Area for accidental or acute for accidental or acute for accidental or acute hospital treatment covered with a $100 co-pay; co-pay waived if for accidental or acute a $100 co-pay; co-pay waived if patient admitted or due to accidental injury. for accidental or acute medical emergency. Outpatient hospital treatment covered with a $100 copay; co-pay waived if patient admitted or due to accidental injury. Ambulance for emergencies when medically necessary for emergencies when medically necessary for emergencies when medically necessary for transfer to or from hospital; includes ground and air when medically necessary. for emergency transportation when medically necessary for emergency transportation when medically necessary Mental Health Care Preauthorization Required All mental health care services must have prior authorization from BCN. All mental health care services must have prior authorization from BCN. Call Coordinated Behavioral Health Management for authorization at: requirements before mental health care services are provided. These services must be obtained through an approved or participating provider or facility. requirements before mental health care services are provided. These services must be obtained through an approved or participating provider or facility. No Inpatient Days of Care for acute for acute for acute for acute at 50% for acute Outpatient Individual Psychiatric Care with a $25 co-pay for acute with a $25 co-pay for acute with a $25 co-pay with a $25 co-pay at 50% Group Therapy with a $25 co-pay for acute with a $25 co-pay for acute with a $25 co-pay with a $25 co-pay at 50% Psychological Testing with a $25 co-pay for acute with a $25 co-pay for acute with a $25 co-pay with a $25 co-pay at 50% Substance Abuse Care Preauthorization Required All substance abuse care services must have prior authorization from BCN. All substance abuse care services must have prior authorization from BCN. Call Coordinated Behavioral Health Management for authorization at: requirements before these services are provided. Inpatient care for these services is covered when care is received in a participating facility having an approved substance abuse program or an approved non-hospital residential program. requirements before these services are provided. Inpatient care for these services is covered when care is received in a participating facility having an approved substance abuse program or an approved non-hospital residential program. No

5 Substance Abuse Care (continued) Inpatient Days of Care at 50% Outpatient Individual Therapy Maternity Care Group Therapy with a $25 co-pay per visit with a $25 co-pay per visit with a $25 co-pay per visit with a $25 co-pay per visit with a $25 co-pay per visit with a $25 co-pay per visit with a $25 co-pay per visit with a $25 co-pay per visit at 50% at 50% 8 Hearing aid administration guidelines may differ by plan. for specific provisions before commencing treatment. 9 Includes ordering and fitting of hearing aids. Parental Care, Delivery, Postnatal Care at 50% Skilled Nursing Facility (Non-Custodial Care) up to 45 days per calendar year if preauthorized by BCN up to 120 days per calendar year when arranged and authorized by BCN up to 730 days, renewable after 60 days for authorized services up to 120 days per calendar year up to 120 days per calendar year Hearing Care Examinations with a $30 co-pay; once with a $30 co-pay; once with a $30 co-pay Office visit partially covered only if treated for a medical condition Tests with a $30 co-pay; once with a $30 co-pay; once with a $30 co-pay Hearing Aids ; monaural or binaural hearing aid 8, 9 ; monaural or binaural hearing aid 8, 9 for authorized conventional hearing aid 8, 9 ; monaural or binaural hearing aid 8, 9 ; monaural or binaural hearing aid 8, 9 Vision Care Eye Examinations at plan vision providers one exam per year; at non-plan providers, covered up to $40. at plan vision providers one exam per year; at non-plan providers, covered up to $40. with a $30 co-pay ; one exam per year. ; one exam per year. up to $40; one exam per year. Eyeglasses

6 Nursing Care Preauthorization Required 12 necessary and recommended by your Primary Care Physician or approved by your plan. U-M Premier Care1, 3, 12 necessary and recommended by your Primary Care Physician or approved by your plan. necessary and recommended by your Primary Care Physician or approved by your plan. Medical1, 4, 11, 12 necessary and recommended by the plan physician. Coverage for home health aide services must be provided by a BCBSM-approved agency. Contact BCBSM for specific coverage requirements before these services are provided. PPO In-Network1, 4, 11, 12 necessary and recommended by the plan physician. Coverage for home health aide services must be provided by a BCBSM approved agency. Contact BCBSM for specific coverage requirements before these services are provided. PPO Out-of-Network1, 4, 12 4 The out-of-pocket maximum does not include non-covered charges, and costs that exceed the plan s fee allowance for a particular service for all plans. Visiting Nurse Home Care Private Duty Nursing Home Health Aides Other Services Hospice Care with a $20 co-pay when medically necessary and approved by the plan. with a $20 co-pay when medically necessary and approved by the plan. when authorized by BCN when medically necessary and approved by the plan. when medically necessary and approved by the plan. when authorized by BCN for authorized services. when medically necessary and approved by the plan., 210 days lifetime under a BCBSMapproved Home Care Program; no visit limits with a 50% co-insurance for authorized services under an approved Home Care Program levels before these services are provided. at 50% 11 ; contact BCBSM for specific coverage levels before these services are provided. at 50% 11 Any expense paid at 50% does not apply to the out-of-pocket maximum for the CMM plan. Private duty nursing expenses do not apply to the out-ofpocket maximum under the BCBSM Community Blue PPO plan. 12 In Vitro Ferilization Services can be obtained only at University of Michigan Health System for women through age 42 who have been diagnosed with infertility. Individuals contribute a co-insurance of 20 percent of the cost, and the remainder by the plan up to a $20,000 lifetime maximum. HAP is excluded. Durable Medical Equipment, Prosthetic Appliance when authorized by BCN when authorized by BCN for authorized equipment based on HAP guidelines when medically necessary Voluntary Sterilization at 50% Chiropractic Spinal Manipulation ; maximum of 38 visits per calendar year with a $25 co-pay; limited to 24 visits per year at 50%; limited to 24 visits per year Reproductive Services

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