2017 Summary of Benefits and Coverage (SBC) Documents

1 2017 Summary of Benefits and Coverage (SBC) Documents PPO1 ASR Health Benefits PPO2 Blue Cross/Blue Shield of Michigan PPO3 ASR Health Benefits HMO Health Alliance Plan TRADITIONAL Blue Cross/Blue Shield of Michigan The Summary of Benefits and Coverage (SBC) Documents for the medical plans offered through Oakland County Natural Select are included in this document for your review as part of the 2017 Natural Select Open Enrollment packet. These are only a Summary . If you want more detail about your Coverage and costs, you can get the complete terms in the policy or plan document at the website or by calling 1-248-858-0465 or faxing a request to 1-248-858-1511. If you have questions regarding any of the SBCs visit the website or call 1-248-858-0465 or faxing a request to 1-248-858-1511. If you aren t clear about any of the bolded terms used in this form, you can view the Glossary on the website or call 1-248-858-0465 to request a copy.

2 Questions: Call 616-957-1751 or 1-800-968-2449 or visit If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at the website above or by calling the phone numbers above to request a copy. ASR PPO1 1 of 8 Rev. 06/30/16 Oakland County, G-962 PPO1 PLAN Summary of Benefits and Coverage : What this PlanCovers & What it CostsCoverage Period: Beginning on or after 1/1/ 2017 Coverage for: Covered Person or FamilyPlan Type: PPO This is only a Summary . If you want more detail about your Coverage and costs, you can get the complete terms in the policy or plandocument at or by calling 616-957-1751 or 1-800-968-2449. Important Questions Answers Why this Matters: What is the overall deductible? $0 per covered person and $0 per family for most covered services. $200 per covered person and $400 per family for the limited number of covered services identified throughout this Summary as Master Medical Coverage .

3 Copayments, coinsurance, penalties, charges that exceed the plan s usual and customary fee allowance or are in excess of stated maximums, premiums, balance-billed charges (unless balance billing is prohibited), and health care this plan doesn t cover don t count toward the deductible. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. This plan s deductible starts over on January 1st. See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. Are there other deductibles for specific services? No. You don t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services that this plan covers. Is there an out of pocket limit on my expenses? Yes. The out-of-pocket limit for coinsurance only is $1,000 per covered person or family.

4 However, the total out of pocket limits, which include coinsurance, deductibles (if any), and in-network medical copayments, for covered services are $3,750 per covered person and $9,500 per family. The out of pocket limit is the most you could pay during a Coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. What is not included in the out of pocket limit? Deductibles and copayments are not included in the out of pocket limit applicable to only coinsurance (but could be included in the total out of pocket limits as specified above) . In general, the out of pocket limits specified in this Summary do not include out-of-network medical copayments, prescription drug copayments (however, these expenses will c ount towards a separate out of pocket limit that is not specified in this Summary ), penalties, charges that exceed the plan s usual and customary fee allowance or are in excess of stated maximums, premiums, balance-billed charges (unless balance billing is prohibited), and health care this plan doesn t cover.

5 Even though you pay these expenses, they don t count toward the out of pocket limit. ASR PPO1 2 of 8 Important Questions Answers Why this Matters: Is there an overall annual limit on what the plan pays? No. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services. Does this plan use a network of providers? Yes. For more information, visit the website or call one of the phone numbers shown at the bottom of page 1. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays for different kinds of providers.

6 Do I need a referral to see a specialist? No. You can see the specialist you choose without permission from this plan. Are there services this plan doesn t cover? Yes. Some of the services this plan doesn t cover are listed on page 5. See your policy or plan document for additional information about excluded services. Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, ifthe plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change ifyou haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than theallowed amount, you may have to pay the difference.

7 For example, if an out-of-network hospital charges $1,500 for an overnight stay andthe allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower deductibles, copayments and coinsurance Medical Event Services You May Need Your Cost If You Use an In-Network Provider Your Cost If You Use an Out-of-Network Provider Limitations & Exceptions If you visit a health care provider s office or clinic Primary care visit to treat an injury or illness $20 copay/visit $20 copay/visit and 15% coinsurance -- none-- Specialist visit $20 copay/visit $20 copay/visit and 15% coinsurance -- none-- ASR PPO1 3 of 8 Common Medical Event Services You May Need Your Cost If You Use an In-Network Provider Your Cost If You Use an Out-of-Network Provider Limitations & Exceptions If you visit a health care provider s office or clinic, cont.

8 Other practitioner office visit $20 copay/day for chiropractic services; otherwise $20 copay/visit or no charge $20 copay/day and 15% coinsurance for chiropractic services; otherwise $20 copay/visit and/or 15% coinsurance Covers up to 38 chiropractic visits annually. Preventive care/screening/ immunization No charge Not covered for most preventive services; otherwise 15% coinsurance may apply Coverage for a breast pump purchased from an out-of-network provider is limited to $250 for each birth. Certification is recommended for the rental and purchase of breast pumps. Preventive care, including well-baby and routine child care visits, are subject to various frequency limitations. This benefit includes one routine mammogram and one routine/ diagnostic colonoscopy (and any mammogram- and colonoscopy-related services) per year. All diagnostic mammograms or any subsequent routine mammograms and routine/diagnostic colonoscopies performed in that year will be subject to coinsurance and deductible.

9 If you have a test Diagnostic test (x-ray, blood work) No charge 15% coinsurance -- none-- Imaging (CT/PET scans, MRIs) No charge 15% coinsurance -- none-- If you need drugs to treat your illness or condition More information about prescription drug Coverage is available at or the Medical Option Comparison chart in your Natural Select workbook. Generic drugs Not covered Not covered No Coverage for prescription drugs purchased through a pharmacy or mail order program under the medical plan. Preferred brand drugs Not covered Not covered Non-preferred brand drugs Not covered Not covered Specialty drugs Not covered Not covered ASR PPO1 4 of 8 Common Medical Event Services You May Need Your Cost If You Use an In-Network Provider Your Cost If You Use an Out-of-Network Provider Limitations & Exceptions If you have outpatient surgery Facility fee ( ,ambulatory surgery center) No charge15% coinsurance -- none-- Physician/surgeon fees No charge 15% coinsurance --none-- If you need immediate medical attention Emergency room services $100 copay/visit $100 copay/visit Copay is waived if admitted inpatient or treated for an accidental injury.

10 Emergency medical transportation 10% coinsurance after Master Medical Coverage deductible 10% coinsurance after Master Medical Coverage deductible -- none-- Urgent care $20 copay/visit $20 copay/visit and 15% coinsurance -- none-- If you have a hospital stay Facility fee ( , hospital room) No charge 15% coinsurance Certification is recommended. Physician/surgeon fee No charge 15% coinsurance --none-- If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services No charge for autism spectrum disorder services; otherwise $20 copay/visit No charge for Applied Behavioral Analysis (ABA) treatment; otherwise 15% coinsurance ($20 copay/visit may also apply) Coverage for Applied Behavioral Analysis (ABA) treatment is limited to $50,000 annually. Mental/Behavioral health inpatient services No charge No charge for Applied Behavioral Analysis (ABA) treatment; otherwise 15% coinsurance Certification is recommended.