Medical Plan Comparison - Retirees Age 65 or Over

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1 * Plan Type Medicare Cost Plan with Prescription Coordinates with Medicare and includes Medicare prescription drug program Medicare Cost Plan with Prescription Medicare Advantage Plan with Prescription How Plan works with Medicare and Medicare Assignment Medicare pays primary Part A inpatient hospital, skilled nursing facility, and home health care expenses. Medica pays Medicare coinsurance and. Medica pays primary Medicare Part B provider expenses. to use Medica network providers, but you do not assign your Medicare benefits to Medica. You are allowed to use your Medicare the Medica network. pays after applying inpatient and coinsurance. You pay Medicare. to use BCBS network providers, but you do not assign your Medicare benefits to Blue Cross. You are allowed to use your the BCBS network. Medicare pays primary Part A inpatient hospital, skilled nursing facility, and home health care expenses. pays Medicare coinsurance and. pays primary Medicare Part B provider expenses. to use network providers, but you do not assign your Medicare benefits to. You are allowed to use your Medicare the network. administers benefits and claims payment of Medicare Parts A and B, as well as the additional benefits included in the plan, such as Prescription Drug coverage (Part D) and preventive care. Bills health care services are sent directly to by providers (not to Medicare) and are processed in the Claims Department. You cannot use your Medicare benefits outside of the network * See Page 15 how this plan works with Medicare. Medicare Part B Medicare Part D Benefits Enrollment Page 20

2 Office Visit $15 No $15 $15 Emergency Services worldwide coverage; $50 if not admitted after Medicare, $50 if not admitted worldwide coverage; $50 if not admitted Ambulance after Medicare Urgent Care Office Visit after Medicare after $20 Inpatient Hospital Plan pays 80% of first $2,900 of total allowed amount following the $100 annual inpatient ; thereafter through end of calendar year. Your outof-pocket expense is limited to $680 per year, including $100 annual inpatient. Skilled Nursing Facilities after 3-day hospitalization up to 100 days per benefit period after 3-day hospitalization up to 100 days per benefit period up to 100 days per benefit period (3-day hospital stay not required) Mental Health up to 365-day up to 190-day up to 190-day Chemical Dependency Benefits Enrollment Page 21

3 Health Care Services Preventive Care Physician after Medicare (no routine visits) Eye and Hearing Exams (routine) of allowed amount ; $75 annual allowance toward lenses and frames / Surgery after Medicare Mental Health after Medicare ; $7.50 group therapy Chemical Dependency after Medicare Chiropractic Care after Medicare Medicareapproved services at -affiliated chiropractor Physical and Occupational Therapy after Medicare Benefits Enrollment Page 22

4 Blue Cross Blue Shield Speech and Language Therapy after Medicare Home Health Care of Medicareapproved amount of Medicareapproved amount of Medicareapproved amount of Medicareapproved amount Prescription Drugs Note: Separate card provided pharmacy coverage through MedicareBlue Rx Generic Drugs - Retail $10 31-day supply $10 31-day supply $10 30-day supply Up to a $10 34-day supply Formulary Brand Drugs - Retail $30 31-day supply $30 Preferred Brand and Specialty Drugs 31-day supply $30 30-day supply $30 34-day supply Non-Preferred Formulary Brand Drugs - Retail $30 31-day supply $50 Non-Preferred Brand $30 30-day supply $30 34-day supply Supplemental Covered under 25% coinsurance Covered under Covered under Drug Benefit above s above s above s Drugs Purchased 3-month supply 3-month supply 3-month supply 3-month supply by Mail Order available 2 available 2 available 2 (102 day) available s through s through s through 2 s through mail order mail order or if using mail order mail order and at Preferred Extended participating (PXT) within pharmacies Group MedicareBlue RX network Non-Formulary Not applicable Prior authorization Not applicable Not applicable required Benefits Enrollment Page 23

5 Blue Cross Blue Shield Catastrophic Catastrophic 30-day supply $10 $30 brand/specialty expenses including drug manufacturer discounts exceed be the greater of: 5% of drug cost or $2.60 $6.50 brand/mulary $10 $30 brand/specialty $10 $30 brand/specialty Medical Equipment Prosthetics, Durable Medical Equipment, Hearing Aids, $500 hearing aids, 80% hearing aids every 3 years 90%, including diabetic supplies; 80% hearing aids every 3 years prosthetics and diabetic supplies; 80% durable medical equipment; $500 every 36 months hearing aids Travel Travel Coverage/ Extended Absence May be out of service area up to 9 consecutive months; benefits must be activated by calling Member Services No limitations May be out of service area up to 9 consecutive months; benefits must be activated by calling Member Services May be out of service area up to 6 consecutive months; then eligible emergency services with $50 if not admitted, and nonemergency service at 80%; no need to notify Member Services Maximums Maximum Annual Out-of- Pocket (including and coinsurance) $1,000 medical cost sharing; No cap on prescription cost sharing $842, $680 plus $132, Medicare B amounts may change 2012, (pharmacy ments do annual out-of-pocket maximum) $3,000 (pharmacy ments do annual out-of-pocket maximum) $3,400 (pharmacy s, hearing/ eyeware, and co-insurance non-emergency outof-network care do annual maximum) Lifetime Maximum Benefits Enrollment Page 24

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