Note to ASC groups: Before completing this template, please

Western Michigan Health Insurance Pool reference the disclaimer on the attached cover page.
Flexible Blue 2, RX5 Coverage Period: Beginning on or after 01/01/2020
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage for: Individual/Family | Plan Type: PPO

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share
the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 1-877-752-1233. For
general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You
can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 1-877-752-1233 to request a copy.
Answers
Important Questions Why This Matters:
In-Network Out-of-Network
Generally, you must pay all of the costs from providers up to the deductible amount before this
$1,400 Individual/ $2,800 Individual/
What is the overall deductible? plan begins to pay. If you have other family members on the policy, the overall family
$2,800 Family $5,600 Family
deductible must be met before the plan begins to pay.
This plan covers some items and services even if you haven’t yet met the deductible amount.
Are there services covered before Yes. Preventive care services are covered But a copayment or coinsurance may apply. For example, this plan covers certain preventive
you meet your deductible? before you meet your deductible. services without cost-sharing and before you meet your deductible. See a list of covered
preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other deductibles for
No. You don’t have to meet deductibles for specific services.
specific services?
What is the out-of-pocket limit for
this plan? $2,300 Individual/ $7,300 Individual/ The out-of-pocket limit is the most you could pay in a year for covered services. If you have
(May include a coinsurance $4,600 Family $14,600 Family other family members in this plan, the overall family out-of-pocket limit must be met.
maximum)
Premiums, balance-billing charges, any
What is not included in the out-of-
pharmacy penalty and health care this Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
pocket limit?
plan doesn’t cover.
This plan uses a provider network. You will pay less if you use a provider in the plan’s
network. You will pay the most if you use an out-of-network provider, and you might receive a
Will you pay less if you use a Yes. For a list of network providers see
bill from a provider for the difference between the provider’s charge and what your plan pays
network provider? www.bcbsm.com or call 1-877-752-1233
(balance billing). Be aware, your network provider might use an out-of-network provider for
some services (such as lab work). Check with your provider before you get services.
Do you need a referral to see a
No. You can see the specialist you choose without a referral.
specialist?

Group Number 71565-3000-034; 034, 035 SBC000008078379 1 of 8

 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

What You Will Pay

Limitations, Exceptions, & Other Important
Common Medical Event Services You May Need In-Network Provider Out-of-Network Provider Information
(You will pay the least) (You will pay the most)
Primary care visit to treat
No charge 20% coinsurance None
an injury or illness
Specialist visit No charge 20% coinsurance None
If you visit a health care
provider’s office or clinic You may have to pay for services that aren’t
Preventive care/
No charge; deductible does not preventive. Ask your provider if the services
screening/ Not Covered
apply needed are preventive. Then check what your plan
immunization
will pay for.
Diagnostic test (x-ray,
No charge 20% coinsurance None
blood work)
If you have a test
Imaging (CT/PET scans,
No charge 20% coinsurance May require preauthorization.
MRIs)
$5 copay/prescription for retail
$5 copay/prescription plus an
Generic or prescribed 30-day supply, $10
additional 20% of BCBSM
over-the-counter drugs copay/prescription for mail
If you need drugs to treat approved amount for the drug
order 90-day supply
your illness or condition
$30 copay/prescription for Preauthorization, step therapy and quantity limits
More information about $30 copay/prescription plus an
Preferred brand-name retail 30-day supply, $60 may apply to select drugs. Preventive drugs
prescription drug coverage additional 20% of BCBSM
drugs copay/prescription for mail covered in full. Mail order drugs are not covered
is available at approved amount for the drug
order 90-day supply out-of-network.
www.bcbsm.com/druglists
$30 copay/prescription for
$30 copay/prescription plus an
Non-Preferred brand- retail 30-day supply, $60
additional 20% of BCBSM
name drugs copay/prescription for mail
approved amount for the drug
order 90-day supply
Facility fee (e.g.,
If you have outpatient ambulatory surgery No charge 20% coinsurance None
surgery center)
Physician/surgeon fees No charge 20% coinsurance None
Emergency room care No charge No charge None

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 What You Will Pay
Limitations, Exceptions, & Other Important
Common Medical Event Services You May Need In-Network Provider Out-of-Network Provider Information
(You will pay the least) (You will pay the most)
Emergency medical
If you need immediate No charge No charge Mileage limits apply.
transportation
medical attention
Urgent care No charge 20% coinsurance None
Facility fee (e.g., hospital
No charge 20% coinsurance Preauthorization is required.
If you have a hospital stay room)
Physician/surgeon fee No charge 20% coinsurance None
If you need behavioral Your cost share may be different for services
Outpatient services No charge 20% coinsurance
health services (mental performed in an office setting.
health and substance use
disorder) Inpatient services No charge 20% coinsurance Preauthorization is required.
Maternity care may include services described
Prenatal: No charge;
Prenatal: 20% coinsurance elsewhere in the SBC (i.e. tests) and cost share
Office visits deductible does not apply
Postnatal: 20% coinsurance may apply. Cost sharing does not apply to certain
Postnatal: No charge
maternity services considered to be preventive.
If you are pregnant
Childbirth/delivery
No charge 20% coinsurance None
professional services
Childbirth/delivery facility
No charge 20% coinsurance None
services
Home health care No charge No charge Preauthorization is required.
Physical, Occupational, Speech therapy is limited
Rehabilitation services No charge 20% coinsurance to a combined maximum of 60 visits per member,
per calendar year.
Applied behavioral analysis (ABA) treatment for
Autism – when rendered by an approved board-
If you need help recovering Habilitation services No charge 20% coinsurance
certified analyst - is covered through age 18,
or have other special health subject to preauthorization.
needs
Preauthorization is required. Limited to a maximum
Skilled nursing care No charge No charge
of 90 days per member, per calendar year.
Excludes bath, exercise and deluxe equipment
Durable medical
No charge 20% coinsurance and comfort and convenience items. Prescription
equipment
required.
Hospice services No charge No charge Preauthorization is required. Unlimited visits.
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 What You Will Pay
Limitations, Exceptions, & Other Important
Common Medical Event Services You May Need In-Network Provider Out-of-Network Provider Information
(You will pay the least) (You will pay the most)
Children’s eye exam Not Covered Not Covered None
If your child needs dental or Children’s glasses Not Covered Not Covered None
eye care
Children’s dental check-
Not Covered Not Covered None
up

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Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
 Acupuncture  Hearing Aids  Routine eye care (Adult)
 Cosmetic surgery  Infertility treatment  Routine foot care
 Dental care (Adult)  Long-term care  Weight Loss programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
 Bariatric surgery  Coverage provided outside the United States.  Non-Emergency care when travelling outside the U.S.
See http://provider.bcbs.com
 Chiropractic care  Private-duty nursing
 If you are also covered by an account-type plan
such as an integrated health flexible spending
arrangement (FSA), health reimbursement
arrangement (HRA), and/or a health savings
account (HSA), then you may have access to
additional funds to help cover certain out-of-
pocket expenses – like the deductible,
copayments, or coinsurance, or benefits not
otherwise covered.

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Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is:
Department of Labor’s Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa/healthreform, or the Department of Health and Human Services,
Center for Consumer Information and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov or by
calling 1-877-752-1233. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For
more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance
or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete
information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Blue Cross ® and
Blue Shield® of Michigan by calling 1-877-752-1233.

Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP) Department of
Insurance and Financial Services, P. O. Box 30220, Lansing, MI 48909-7720 or http://www.michigan.gov/difs or difs-HICAP@michigan.gov
Does this plan provide Minimum Essential Coverage? Yes.
If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the
requirement that you have health coverage for that month.
Does this plan meet Minimum Value Standards? Yes.
If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
(IMPORTANT: Blue Cross Blue Shield of Michigan is assuming that your coverage provides for all Essential Health Benefit (EHB) categories as defined by the State of
Michigan. The minimum value of your plan may be affected if your plan does not cover certain EHB categories, such as prescription drugs, or if your plan provides coverage
of specific EHB categories, for example prescription drugs, through another carrier.)

Language Access Services: See Addendum

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section. ––––––––––––––––––––––

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About these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different
depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles,
copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different
health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby Managing Joe’s Type 2 Diabetes Mia’s Simple Fracture
(9 months of in-network pre-natal care (a year of routine in-network care of (in-network emergency room visit and
and a hospital delivery) a well-controlled condition) follow up care)

 The plan’s overall deductible $1,400  The plan’s overall deductible $1,400  The plan’s overall deductible $1,400
 Specialist copayment $0  Specialist copayment $0  Specialist copayment $0
 Hospital (facility) coinsurance 0%  Hospital (facility) coinsurance 0%  Hospital (facility) coinsurance 0%
 Other coinsurance 0%  Other coinsurance 0%  Other coinsurance 0%

This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:
Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical
Childbirth/Delivery Professional Services disease education) supplies)
Childbirth/Delivery Facility Services Diagnostic tests (blood work) Diagnostic tests (x-ray)
Diagnostic tests (ultrasounds and blood work) Prescription drugs Durable medical equipment (crutches)
Specialist visit (anesthesia) Durable medical equipment (glucose meter) Rehabilitation services (physical therapy)

Total Example Cost $12,700 Total Example Cost $7,400 Total Example Cost $1,900

In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:
Cost Sharing Cost Sharing Cost Sharing
Deductibles $1,400 Deductibles $1,400 Deductibles $1,400
Copayments $20 Copayments $500 Copayments $0
Coinsurance $0 Coinsurance $0 Coinsurance $0
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions $60 Limits or exclusions $60 Limits or exclusions $0
The total Peg would pay is $1,480 The total Joe would pay is $1,960 The total Mia would pay is $1,400

The plan would be responsible for the other costs of these EXAMPLE covered services. 7 of 8
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