Plans. Who is eligible to enroll in the Plan? Blue Care Network (BCN) Health Alliance Plan (HAP) Health Plus. McLaren Health Plan

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1 Who is eligible to enroll in the Plan? All State of Michigan Employees who reside in the coverage area determined by zip code. All State of Michigan Employees who reside in the coverage area determined by zip code. All State of Michigan Employees who reside in the coverage area determined by zip code. All State of Michigan Employees who reside in the coverage area determined by zip code. All State of Michigan Employees who reside in the coverage area determined by zip code. All State of Michigan Employees who reside in the coverage area determined by zip code.

2 Deductibles, Co-ments and Maximums Deductibles Fixed dollar and percent Co-ments Out-of-Pocket Maximum (OOPM) $125 - Per Member $250 - Per Family $20 - Office visits, referral physician visits and urgent care center services. $200 - Emergency room services (waived if admitted) $2,000 - Per Member $4,000 - Per Family $125 - Per Member $250 - Per Family $20 - Office visits and urgent care center services. $200 - Emergency room services (waived if admitted) $2,000 - Per Member $4,000 - Per Family $125 - Per Member $250 - Per Family $20 - Office visits and urgent care center services. $200 - Emergency room services (waived if admitted) $2,000 - Per Member $4,000 - Per Family $125 - Per Member $250 - Per Family $20 - Office visits and urgent care center services. $200 - Emergency room services (waived if admitted) $2,000 - Per Member $4,000 - Per Family $125 - Per Member $250 - Per Family $20 - Office visits and urgent care center services. $200 - Emergency room services (waived if admitted) $2,000 - Per Member $4,000 - Per Family $125 - Per Member $250 - Per Family $20 - Office visits and urgent care center services. $200 - Emergency room services (waived if admitted) $2,000 - Per Member $4,000 - Per Family

3 Physician Office Services Office Visits Specialist Care

4 Preventive Services Health Maintenance Exam Annual Gynecological Exam Pap Smear Screening Immunizations Well-Baby and Child Care (lab only) (up to 24 months of age) Please see summary for number of allowed well child visits with no Co-.

5 Number of days of care Semi-private room, intensive care, surgery, general nursing care, hospital services and supplies Surgery & All Related Surgical Services Services in Hospital Anesthesia Laboratory Tests & X- Rays Inpatient consultation Chemotherapy Radiation Therapy Hemodialysis Covered - Covered - After, Unlimited - after Covered - Covered - After, Unlimited Covered - Covered - After, Unlimited Covered - Covered - After, including Antineoplastic Drugs Unlimited Covered - Covered - After, Unlimited Covered - Covered - After,

6 Surgical Services Inpatient - includes related surgical services Outpatient - includes Certain Surgeries & Treatments related surgical Sterilization LASIK Surgery services Human Organ Transplant Procedures Covered - after in designated facilities and/or subject to medical criteria Covered - $1,000 Co- - Bariatric Surgery & Related Services. One procedure per lifetime. Covered - Covered Female sterilizations Covered -. Male sterilizations covered at after. - Bariatric, Reduction Mammoplasty, Blepharoplasty of Upper Eyelids, Panniculectomy, Surgical Treatment of Male Gynecomastia, Sleep apnea treatment procedures. Prior approval required for some. Female sterilizations Covered -. Male sterilizations covered at after. MSEA Group Only Bariatric Surgery - Covered 10% coinsurance up to $1,000 Co- Female sterilizations Covered -. Male sterilizations covered at after. MSEA ONLY - Covered - Limited to $755 for both eyes per lifetime after in designated facilities, Deductible applies - Prior approval required for certain radiology examinations., Deductible applies - Bariatric, Skin Disorder Treatments, Reconstructive surgery, Varicose veins treatments, Sleep apnea treatment procedures. Prior approval required for some. Vasectomy in provider's office Or in connection with other covered inpatient/outpatient surgery, Deductible applies. Tubal Ligation - See preventive care services for benefit and coverage level., Deductible applies. Prior authorization required.

7 Emergency Care - Medical and Accidental Injury Hospital Emergency Room Physician's Office Urgent Care Facility Ambulance - medically necessary Covered - $200 - Co- (waived if admitted) after Covered - $200 - Co- (waived if admitted) after Covered - $200 - Co- (waived if admitted) after Covered - $200 - Co- (waived if admitted) Covered - (ground and air) Covered - $200 - Co- (waived if admitted) after Covered - $200 - Co- (waived if admitted) Covered - (ground and air)

8 Maternity Services Pre-Natal and Post-Natal Care Delivery in Hospital Newborn Baby Care in Hospital - Pre-Natal/$20 Co- per visit - Post-Natal after after - Pre-Natal/$20 Co- per visit - Post-Natal after - first visit may have Co- Pre-Natal. Post-Natal covered - $20 copay after after after after after

9 Diagnostic Services Laboratory and pathology tests Radiology Examinations and Laboratory Procedures (In a nonhospital facility) Diagnostic tests and X-rays Covered - Covered - after after Coverage. Deductible Applies. Prior approval is required for certain radiology examinations. after

10 Prescription Drugs Retail Pharmacy (30 days supply) Mail Order Pharmacy (90-day supply) $10 Tier 1 Generic/$30 - Tier 2 formulary preferred/$60- Tier 3 non-formulary. Includes contraceptives; Tier 1 contraceptives covered in full $10 Generic/$30 - Brand-name formulary/$60- Brand-name non-formulary 30 day supply for non maintenance drugs at 1 copay - 90 day supply for eligible maintenance drugs at 2 copays $20 Tier 1 Generic/$60 - Tier 2 formulary preferred/$120- Tier 3 non-formulary. Includes contraceptives; Tier 1 contraceptives covered in full $20 Generic/$60 - Brand-name formulary/$120 - Brand-name non-formulary 90 day supply for both eligible maintenance and non maintenance drugs at 2 copays $0 select generic maintenance/preventive/$10 Generic/$30 - Brand-name formulary/$60- Brandname non-formulary (includes birth control pills) $0 select generic maintenance/preventive/$10 Generic/$30 - Brand-name formulary/$60- Brand-name non-formulary (includes birth control pills) $10 Generic/$30 - Brand-name formulary/$60- Brand-name non-formulary (includes contraceptives) $20 Generic/$60 - Brand-name formulary/$120 - Brand-name non-formulary (includes contraceptives) $10 Generic/$30 - Brand-name formulary/$60- Brand-name non-formulary (includes contraceptives) $20 Generic/$60 - Brand-name formulary/$120 - Brand-name non-formulary (includes contraceptives) $10 Generic/$30 - Brand-name formulary/$60- Brand-name non-formulary (generic contraceptives ) $20 Generic/$60 - Brand-name formulary/$120 - Brand-name non-formulary (generic contraceptives )

11 Alternatives to Hospital Care Skilled Nursing Care in a nursing home Home Health Care Hospice Care Covered - after days per benefit period Covered - $20 copay after after for authorized services 120 days per confinement (Does not include PT/OT/ST) - after. Limited to 210 days per lifetime $20 copay $20 copay after Covered - $20 copay after - Limit of 60 visits per PY after, Deductible applies (limited to 120 days per confinement) ; $20 Copayment per visit, Deductible applies (including Hospice Services, excluding Rehabilitative Medicine), Deductible applies (limited to 120 days per confinement)

12 Mental Health Care Outpatient Psychiatric Services Inpatient Psychiatric Hospital Services Covered - Covered - per visit Covered - per visit Covered - Covered - $20 copay after ; $20 Co-ment per visit, Deductible applies. prior approval required.

13 Substance Abuse (Alcohol and Drug Abuse) Outpatient Substance Abuse Care Inpatient Alcoholism and Drug Abuse Care per visit per visit Covered - $20 copay after ; $20 Co-ment per visit, Deductible applies. prior approval required.

14 Appliances & Prosthetic Devices (Leg Braces, Artificial Prosthetics & Orthotics Durable Medical Equipment (Wheelchairs, Hospital Bends, Crutches, etc.) - approved equipment based on HAP's guidelines - approved equipment based on HAP's guidelines

15 Vision Services Vision screening Eyeglasses When performed in physician's office - - $20 Co- may apply ($20 office Co- may apply) Covered - $20 copay Not covered - Limit 1 exam per calendar year

16 Hearing Services Hearing Screening / Examination Hearing Aids When performed in physician's office - - $20 Co- may apply Covered - limited to one every 36 months (including binaural) ($20 office Co- may apply) Covered - After. Authorized conventional hearing aids Covered - $20 copay, one every 36 months Preventive for newborns only; Covered - limited to either one monaural to max benefit of $880 or one binaural to a max of $1600; every 36 months One hearing exam, one audiometric exam every 36 months. Exams covered One basic hearing aid per ear every 36 months. Covered to a max. of $500 per hearing aid

17 Chiropractic Services (Manipulations or adjustments; diagnostic radiological services; evaluation and treatment) Chiropractic spinal manipulation when referred by PCP - after after per visit, after, referral required $20 copay Covered - $20 co-pay after - Limit 20 visits per PY $20 Copayment up to a combined benefit maximum of 30 visits (combined with Therapy) per Contract Year, Deductible applies.

18 Other Services Allergy testing and therapy Nutritional & Health education and counseling Mammography Screening Temporomandibular Joint Syndrome (TMJS) Orthognathic Surgery Oral Surgery Outpatient Physical, Speech and Occupational Therapy Cardiac Rehabilitation and Pulmonary Rehabilitation Infertility counseling and treatment Private Duty Nursing - After - $20 Co- may apply after after after ; limited to 90 visits per plan year ; limited to 90 visits per plan year after Covered after when authorized - $20 Co- may apply Covered Covered - after Covered - after Covered for accidental injury after up to 60 combined visits per benefit period. May be rendered at home. Covered after Covered - after $20 Co- may apply after prior to age 21 for congenital defects after following accident or injury per day after $20 Co- per day after - after $20 Co- may apply - (Surgical Fees) Covered - - (Surgical Fees) - (Surgical Fees) $20 copay up to combined max of 90 visits per year Testing: after Injections/Therapy: Covered - Dependent on where services are received. Please see Certificate of Coverage. Dependent on where services are received. Must meet criteria and medical necessity. Please see Certificate of Coverage. Dependent on where services are received. Must meet criteria and medical necessity. Please see Certificate of Coverage. As medically necessary such as injury from an accident. Removal of wisdom teeth is excluded. Please see Certificate of Coverage. per visit limited to combined (with pulmonary) 60 visits per calendar year per visit limited to 36 visits per calendar year after - Limit 5 office visits & 3 diagnostic/surgical procedures per PY $20 Co-ment Coverage for testing, per visit - Up to six injections and serum. $20 Co- visits per may apply. Contract Year. Covered - 50%, Deductible applies if performed in hospital Covered - 50%, Deductible applies if performed in hospital for medical treatment, office copayment may apply, Deductible applies if performed in hospital - see Certificate of Coverage for details $20 Copayment up to a combined benefit maximum of 90 visits per Contract Year. $20 Co-ment up to a combined benefit maximum of 30 visits per Contract Year., Deductible applies

19 Plan Year Miscellaneous Conversion Option Pre-existing Condition Worldwide Coverage (Emergency care only) $200 Co- (waived if admitted) Yes Yes Not Offered Not Available Covered - $200 Co- (waived if admitted)

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