2016 - Cornerstone Schools · 2017. 2. 9. · Cornerstone Educa on Group partners with Group...
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2016 BENEFIT PLANS AND CONTRIBUTIONS EFFECTIVE OCTOBER 1, 2016 ‐ SEPTEMBER 30, 2017
Transcript of 2016 - Cornerstone Schools · 2017. 2. 9. · Cornerstone Educa on Group partners with Group...
2016
BENEFIT PLANS AND CONTRIBUTIONS EFFECTIVE
OCTOBER 1, 2016 ‐ SEPTEMBER 30, 2017
Table of Contents
The actual terms of the your benefit program are described in the appropriate carrier’s benefit book. Please refer to the appropriate benefit book when making any final benefit related decisions.
The carrier’s benefit book, as interpreted by the Plan Administrator, and not this summary, will control your benefits.
Introduc on to your employee benefits ....................................................................................... 2
Who is eligible for benefits? .......................................................................................................... 2
When do my benefits begin? ........................................................................................................ 2
Who can I cover? ........................................................................................................................... 3
New Hire and Open Enrollment Instruc ons ................................................................................ 3
Mid‐year status changes ............................................................................................................... 4
Ac vely at work requirement ....................................................................................................... 4
When Coverage Ends .................................................................................................................... 4
Medical Plan Waiver Op on ......................................................................................................... 4
Blue Care Network Healthy Blue Living …………………………………………………………………………………. 5
Employee Contribu ons ……………………………………………………………………………………………….……..... 6
Medical Opt‐Out Bonus Program ………………………………………………………………………………………….. 6
“New” Voluntary Life Op ons & Your Cost ………………..……………………………………….…………….……. 7
Sec on 125 Premium Only Plan (POP) …………………………………………………………………………………… 8
On‐Line Web Enrollment Instruc ons ……………………………………………………………………………………. 9
CHIPRA No ce ………………………………………………………………………………………………………...……………..11
Newborns’ and Mothers’ Health Protec on Act (NMHPA ) No ce ………………………………………...14
Women’s Health and Cancer Rights Act (WHCRA) No ce ......................................................... 14
No ce of Privacy Prac ces …………………………………………………………………………………….……………...15
Medicare Creditable Coverage No ce …………………………………………………………………………………..18
Important Benefits Contact Informa on .......................................................................Back Cover
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Introduc on to Your Employee Benefits
Eligibility, Instruc ons and Informa on to consider when choosing your benefits
In support of our philosophy to provide our eligible Salary Team Members and their families with a complete compensa on
package, Cornerstone Educa on Group is pleased to offer you the opportunity to par cipate in a quality benefits program.
What are my Benefit Op ons?
BCBSM/BCN Medical & Prescrip on Drugs—Two Plan Op ons
BCN‐Blue Care Network (HMO) ‐Healthy Blue Living
BCBSM‐Blue Cross and Blue Shield (PPO)
Guardian
Dental (orthodon a now included)
Short Term Disability
Long Term Disability
Employee Life and AD&D coverage
“New” Voluntary Life and AD&D Coverage
Short Term and Long Term Disability
Eyemed Vision *
*Please note that the Vision Plan is not a stand alone benefit and you must be enrolled in the Guardian Dental Plan to par cipate.
Who is Eligible?
All Salary Team Members working 30+ hours per week are eligible to enroll in Medical, Dental, Vision, Voluntary Life plans. Employee Life/AD&D, Short Term and Long Term Disability benefits are automa cally provided to all Salary Team Members.
When Benefits Begin (New Hires)
Benefits begin 1st of the Month following 30 days of ac ve employment
What’s New This Year ?
You have the op on to purchase addi onal Guardian Voluntary Life and AD&D coverage for yourself, spouse and children at this open enrollment. To guarantee your acceptance, you must elect coverage at this me.
The Guardian Dental benefits will now include Orthodon a coverage for children, under the age of 19.
Both BCN & BCBSM Medical plans now include online health care, 24 hours a day, 7 days a week, in the U.S. through American Well (Amwell). This afforda‐ble service provides easy‐to‐use online “Virtual Doctor Visits” for minor, nonemergency illnesses.
See the Benefit Summaries in the back of this book for further informa on
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Introduc on to Your Employee Benefits
Who You Can Cover
You can cover any “eligible dependents”. Eligible dependents include:
Your legally recognized spouse .
For BCN and BCBSM legal children, up un l the end of the calendar year in which they turn age 26. (No othercriteria applies due to federal law changes.)
For Guardian Dental & Eyemed Vision legal children are covered to end of month in which they turn age 20, 26 iffull me student. Full me schedule is required each semester.
New Hire Enrollment Instruc ons
Enrollment must be completed within 30 days of your eligibility date.
Open Enrollment Instruc ons
The open enrollment period will occur annually, this year 2016 your open enrollment will be:
During the open enrollment period, it is your responsibility to complete the on‐line enrollment process to re‐elect your
benefit plans. If the on‐line enrollment is not completed, your current coverage elec ons will remain in effect. Please see
informa on below for further details.
The elec ons and changes you make during open enrollment will be effec ve for the period October 1, 2016 through
September 30, 2017.
How Do I Enroll?
Cornerstone Educa on Group partners with Group Associates, Inc. (A Maestro Health Company) to host and process our benefit plans annual enrollment and changes using their web based pla orm Employee Management System (EMS). The system is encrypted and uses technology that keeps your protected health informa on private as required by HIPAA privacy regula ons. The system is available 24/7 and allows you to enroll and make changes as your benefit needs change. Follow the steps on the instruc ons included in this book on pages 9‐10. You will automa cally be enrolled for company‐paid core benefits (Employee Life, Short‐term and Long‐term Disability), but you must log in to the web site to designate your beneficiary.
If you do not enroll at this me, your next opportunity to enroll will be at annual open enrollment October 1st each year, unless you have a qualifying life event.
OPEN ENROLLMENT DATES
Monday, August 29, 2016 through Friday, September 9, 2016
NEED ASSISTANCE? Please contact the Customer Service Team
Group Associates Inc./Maestro Health Company‐ 1-877-858-0828
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Mid‐Year Status Changes (Can I change coverage in the middle of the year?)
Once you make your elec ons for coverage, you can not change them un l the next open enrollment period with changes
effec ve October 1, 2017.
Your benefit elec on is generally irrevocable for the period of coverage unless you experience a qualified change in status event
that affects your eligibility for coverage and you request a benefit change that is consistent with and on account of the qualified
event.
Events may include:
a change in marital status
change in number of dependents
change in employment status
significant plan cost or coverage changes
Loss of coverage under a Government plan
A judgment, degree or order
Medicare or Medicaid en tlement
A qualified Family Leave of Absence
Or HIPAA special enrollment event
Coverage changes must be consistent with you or your dependents’ “status change” that affects eligibility under an
employer’s plan.
Ac vely at Work Requirement
If an employee is not in ac ve employment because of injury, sickness, temporary layoff or leave of absence on the date that
coverage would otherwise become effec ve, some benefits may be delayed.
If a family member is totally disabled on the date coverage would otherwise begin, some benefits may not begin un l he or she
is no longer totally disabled. Generally, your family member is totally disabled if he or she is confined in a hospital or similar
ins tu on; is unable to perform two or more ac vi es of daily living because of a physical or mental incapacity resul ng from an
injury or a sickness; is cogni vely impaired; or has a life threatening condi on.
When Coverage Ends
Your coverage will end when you are no longer an eligible employee of Cornerstone Educa on Group. Dependent coverage will
end when your coverage ends, or earlier if the individual is no longer an eligible dependent (i.e., divorce or child reaches limi ng
age).
Certain coverage may con nue a er your termina on date through a Conversion, COBRA or Portability op on. Premiums are
fully paid by the employee in each of these op ons.
Medical Plan Waiver Op on
If you are waiving this coverage because you are currently covered by another medical plan, you will not lose future eligibility for
this plan. However, you must enroll in this plan within 31 days of your current plan benefits ending. This provision applies to
both you and your dependents.
In addi on, if you acquire a new dependent as a result of marriage, birth, adop on, or placement for adop on, you will be able
to enroll yourself and your dependent, provided you elect coverage within 31 days of the qualifying event.
Employees have 30 days a er a status change to make a change in benefits.
Changes not made within 30 days must wait for the next open enrollment period.
Introduc on to Your Employee Benefits
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Special Note about the Blue Care Network Plan
For those Salary Team Members choosing medical benefits provided by Blue Care Network (BCN) Healthy Blue Living plan. This
health care plan rewards people who commit to making be er health choices.
When enrolled in Healthy Blue Living, you have access to two benefits levels, enhanced and standard. Enhanced benefits have a
lower or no deduc ble and lower copayments so you save money when you use health plan services.
To receive enhanced benefits, you and your covered spouse must choose to meet requirements. If you choose not to meet the
requirements, you’ll s ll have health care coverage, but you’ll receive the standard benefit level, with higher copays and
deduc bles.
The health plan concentrates on six high‐impact health measures:
Tobacco Cholesterol
Depression Weight
Blood sugar Blood pressure
Why these? They are things you can manage. They have a huge impact on illness and fitness and the likelihood an individual will
develop one or more chronic or disabling diseases. This plan gives individuals the knowledge, skills and support to achieve their
goals to be er health.
All Salary Team Members who enroll with Healthy Blue Living coverage ini ally receive the enhanced benefit package. However, to
retain the enhanced benefits, you and your spouse must first complete a Blue Health Connec on health risk appraisal on the BCN
website www.bcbsm.com.
Then within the first 90 days of coverage, you and your spouse will need to see your Primary Care Physician (PCP) and ask him/
her to complete the Healthy Blue Living Qualifica on form.
If you and your spouse's PCP affirm your healthy status or create a healthy lifestyle plan that you ac vely commit to, you will
automa cally stay in the enhanced benefits plan.
Remember you and your spouse must ac vely commit to follow the wellness plan you develop with your PCP and must be
consistent with BCN guidelines for you to con nue to receive the enhanced benefits.
Once you enroll in coverage you will receive a Healthy Blue Living Welcome Package in the mail explaining in detail the further steps
you need to take to remain in the enhanced plan.
Blue Care Network Healthy Blue Living
To find a PCP (Primary Care Physician) near you go to the BCBSM website:
www.bcbsm.com Click: Find A Doctor Click: Get Started Click: I want to Find a Primary Care Physician Step 1 Enter: Your Home Address or Zip Code Step 2: Choose Your Plan ‐ (Blue Care Network HMO‐Group Enrollees) Step 3: You can choose the criteria or enter your doctor’s name TO FIND THE NPI # FOR YOUR CHOSEN PCP, GO TO: h p://www.npinumberlookup.org/
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Employee Contribu ons
About Salary Team Member contribu ons
Cornerstone Educa on Group will pay the majority of the cost of the Salary Team Member coverage for most par cipants. For
dependents, Cornerstone Educa on Group will pay 50% of the cost of the insurance coverage. The amount you are responsible to
pay is automa cally deducted from your paycheck. This does not include any addi onal costs for copayments, medicines or other
out of pocket expenses that are your responsibility. See each carrier’s booklet for addi onal informa on about medical expenses.
Deduc ons will be taken from all 26 payroll periods.
Medical Deduc ons Dental and Vision Deduc ons
BCN
Healthy
Blue
Living
HMO
Plan
Paycheck Deduc ons
Employee $ 17.28
Two Person $ 129.61
Family $ 181.46
BCBSM
PPO
Plan
Paycheck Deduc ons
Employee $ 160.45
Two Person $ 473.22
Family $ 610.97
Dental
And
Vision
Total
Paycheck Deduc ons
Employee $ 1.75
Employee +
Dependent(s) $ 19.70
Medicare par cipants may have slightly different
deduc ons based upon actual costs.
Medical Opt‐Out Bonus Program
Cornerstone Educa on Group will increase the pay of any Salary Team Member that is (1) covered by another medical plan
and (2) wishes to waive medical coverage. The annual bonus will equal $1,250 and will be paid in installments as part of
your regular compensa on. If you lose your other medical coverage you may enroll in the Cornerstone Educa on Group
plan within 30 days and the bonus program will be discon nued for the remainder of the year. If a husband and wife are
both employees at Cornerstone Educa on Group, they are not eligible for the Opt‐Out Bonus.
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Voluntary Life Op ons & Your Cost
8
Overview of Employee Benefits
Sec on 125 Premium Only Plan (POP)
This benefit allows you to make your medical, dental, and vision contribu ons with pre‐tax dollars. This benefit
will save you valuable tax dollars and put more money in your “take home” check.
The Sec on 125 Premium Only Plan lets you pay your por on of group medical/dental and vision premiums with
pre‐tax dollars. With Sec on 125, premium payments are deducted from your paycheck before Federal and Social
Security taxes (and, in some cases, before State taxes).
By paying premiums with pre‐tax dollars, you reduce taxable income and take home a larger por on of your
income. For an employee who pays $2,922 per year toward medical, vision and dental premium, the increases
in take‐home pay could be up to $876. The exact amount will depend on your personal tax situa on.
Here are a few facts you should know about the Sec on 125 Premium Only Plan:
Par cipa on in the plan does not affect benefits or the amount of premium for these benefits ‐ it simply allows
you to pay for these benefits on a pre‐tax basis.
Your future W‐2 (tax withholding) statements will reflect your reduced taxable income (gross income minus your
pre‐tax premium payments).
You cannot change this elec on during the plan year unless there has been a significant change in cost of coverage
on account of and consistent with a change in status (such as marriage or divorce, birth or adop on of a child,
death of a spouse or child, termina on or commencement of employment of a spouse, taking an unpaid leave of
absence or switching from part‐ me to full‐ me status or vice versa by you or your spouse).
Your por on of the premium paid with before‐tax dollars will automa cally increase or decrease, as the case may
be, to reflect the changes in the medical, vision and dental benefit premiums.
Because you’ll be paying less in Social Security taxes, par cipa on in the Sec on 125 Plan may reduce your future
Social Security benefits.
Because the Sec on 125 Premium Only Plan is an important part of eligible employee benefit program you will
automa cally be included in the Premium Only Plan. If you do not wish to par cipate you must request in
wri ng that you do not want to par cipate and provide it with your Open Enrollment Elec on form to your Human
Resources Manager.
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On‐Line Web Enrollment Instruc ons
Paperless On‐Line Web Enrollment……….Both Simple and Secure!
Cornerstone Educa on Group has contracted with Group Associates, a Maestro Health Company to host and process our benefits enrollment and life event status changes using their web‐based pla orm Employee Management System (EMS).
EMS is encrypted and uses technology that keeps your health informa on protected and private as required by HIPAA privacy regula ons. The system is available 24/7 and allows you to enroll and make changes as your family’s benefit needs change. Please take the me to review the informa on included in this Benefits Guide and select the benefits that will best meet your family’s healthcare and financial needs. You will be able to complete your enrollment via the Group Associates/Maestro Health website. Enrollment process instruc ons provided on the next page.
PLEASE NOTE: Healthcare Reform regula ons will now require detailed iden fying informa on for all members. Please begin by upda ng names, dates of birth and Social Security Numbers for you and your dependents.
Go online to enroll and/or submit changes at: h ps://client.groupassociates.com. Changes must be submi ed online within 30 days of your qualified status change.
Login creden als:
User ID: Employee’s Social Security Number PIN: Date of Birth (MMYYYY)
For security purposes, first me users will be prompted to create a secret ques on and answer. Choose a unique ques on that only you would know the answer. Once you have logged into the website, you will be able to complete the following:
Making Changes or Adding Eligible Dependents
You are responsible for no fying Group Associates/Maestro Health of changes in your status and your family’s status that affect coverage, such as:
Note: If you are currently enrolled and are not making any benefit changes, you do not need to make any elec ons.
Your benefits will remain the same.
Marriage Adop on or placement for adop on
Divorce Dependent no longer eligible for coverage
Birth Death of someone covered under the benefits
▪ Spouse and dependent informa on ▪ Elect or waive Vision Benefits
▪ Elect or waive in Medical benefits ▪ Elect or waive Op onal Life benefits
▪ Elect or waive in Dental benefits ▪ Beneficiary informa on
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On‐Line Web Enrollment Instruc ons
Paperless On‐Line Web Enrollment ‐ Basic Naviga on
Where to Enroll... h ps://client.groupassociates.com
How to Enroll... simply follow these instruc ons…
Step 1‐ Enter your User ID. It is your Social Security Number ...You can change your User ID by following the
direc ons on the Login page.
Step 2 ‐ Enter your PIN. It is your birth month & year.
(Example: MMYYYY… if born August 1961… 081961)
...You can change your PIN by selec ng the My Profile tab and complete Login Informa on.
Step 3 ‐ If this is your first me on the system, you will be asked to create a secret ques on/answer. This is used
in the event you lose your PIN.
Step 4 ‐ At the Home page, click “Ge ng Started” if you would view the tutorial on how to enroll in the
automated system.
Step 5 ‐ Back on the Home page, choose “Click Here For Op ons” or, “Quick Links” and choose the applicable
link: Annual Enrollment, New Hire, Life Event, or Update Dependent SSN.
Step 6 ‐ You must either Verify or Change each item listed under Elec ve Coverage por on of the Coverage
Screen.
Step 7 ‐ Review Elec ons Made on the Review Benefits page. Use the Previous bu on to return to any necessary
screen to make changes. Once you are sa sfied with your elec ons, click the Confirm Changes bu on.
Step 8 ‐ Click the Printer Friendly link to print a copy of your elec ons for your records.
What to Expect A er Enrollment
A Benefit Elec on Statement from Group Associates/Maestro Health
A Blue Cross Blue Shield ID or Blue Care Network card if you elect medical coverage
Need assistance? Call the Customer Service Team at (877) 858‐0828 Hours: Monday‐Friday: 8:00 AM to 5:00 PM (EST)
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CHIP No ces
Premium Assistance Under Medicaid and the
Children’s Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your
employer, your state may have a premium assistance program that can help pay for coverage, using funds from
their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be
eligible for these premium assistance programs but you may be able to buy individual insurance coverage
through the Health Insurance Marketplace. For more informa on, visit www.healthcare.gov.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact
your State Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your
dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1‐
877‐KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a
program that might help you pay the premiums for an employer‐sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under
your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled.
This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being
determined eligible for premium assistance. If you have ques ons about enrolling in your employer plan, contact
the Department of Labor at www.askebsa.dol.gov or call 1‐866‐444‐EBSA (3272).
If you live in one of the following states, you may be eligible for assistance paying your employer health plan
premiums. The following list of states is current as of January 31, 2016. Contact your State for more
informa on on eligibility.
ALABAMA – Medicaid GEORGIA – Medicaid
Website: h p://myalhipp.com/ Phone: 1‐855‐692‐5447
Website: h p://dch.georgia.gov/medicaid ‐ Click on Health Insurance Premium Payment (HIPP) Phone: 1‐404‐656‐4507
ALASKA – Medicaid INDIANA – Medicaid
Website: h p://health.hss.state.ak.us/dpa/programs/medicaid/ Phone (Outside of Anchorage): 1‐888‐318‐8890 Phone (Anchorage): 907‐269‐6529
Healthy Indiana Plan for low‐income adults 19‐64: Website: h p://www.hip.in.gov Phone: 1‐877‐438‐4479 All other Medicaid: Website: h p://www.indianamedicaid.com Phone: 1‐800‐403‐0864
COLORADO – Medicaid IOWA – Medicaid
Medicaid Website: h p://www.colorado.gov/hcpf Medicaid Customer Contact Center: 1‐800‐221‐3943
Website: h p://www.dhs.state.ia.us/hipp/ Phone: 1‐888‐346‐9562
FLORIDA – Medicaid KANSAS – Medicaid
Website: h ps://www.flmedicaidtplrecovery.com/hipp/ Phone: 1‐877‐357‐3268
Website: h p://www.kdheks.gov/hcf/ Phone: 1‐785‐296‐3512
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CHIP No ces
KENTUCKY – Medicaid NEW HAMPSHIRE – Medicaid
Website: h p://chfs.ky.gov/dms/default.htm Phone: 1‐800‐635‐2570
Website: h p://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603‐271‐5218
LOUISIANA – Medicaid NEW JERSEY – Medicaid and CHIP
Website: h p://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 1‐888‐695‐2447
Medicaid Website: h p://www.state.nj.us/humanservices/dmahs/clients/medicaid/ Medicaid Phone: 609‐631‐2392 CHIP Website: h p://www.njfamilycare.org/index.html CHIP Phone: 1‐800‐701‐0710
MAINE – Medicaid NEW YORK – Medicaid
Website: h p://www.maine.gov/dhhs/ofi/public‐assistance/index.html Phone: 1‐800‐442‐6003 TTY: Maine relay 711
Website: h p://www.nyhealth.gov/health_care/medicaid/ Phone: 1‐800‐541‐2831
MASSACHUSETTS – Medicaid and CHIP NORTH CAROLINA – Medicaid
Website: h p://www.mass.gov/MassHealth Phone: 1‐800‐462‐1120
Website: h p://www.ncdhhs.gov/dma Phone: 919‐855‐4100
MINNESOTA – Medicaid NORTH DAKOTA – Medicaid
Website: h p://www.mn.gov/dhs/ma/ Phone: 1‐800‐657‐3739
Website: h p://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1‐844‐854‐4825
MISSOURI – Medicaid OKLAHOMA – Medicaid and CHIP
Website: h p://www.dss.mo.gov/mhd/par cipants/pages/hipp.htm Phone: 573‐751‐2005
Website: h p://www.insureoklahoma.org Phone: 1‐888‐365‐3742
MONTANA – Medicaid OREGON – Medicaid
Website: h p://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1‐800‐694‐3084
Website: h p://www.oregonhealthykids.gov h p://www.hijossaludablesoregon.gov Phone: 1‐800‐699‐9075
NEBRASKA – Medicaid PENNSYLVANIA – Medicaid
Website: h p://dhhs.ne.gov/Children_Family_Services/AccessNebraska/Pages/accessnebraska_index.aspx Phone: 1‐855‐632‐7633
Website: h p://www.dhs.pa.gov/hipp Phone: 1‐800‐692‐7462
NEVADA – Medicaid RHODE ISLAND – Medicaid
Medicaid Website: h p://dwss.nv.gov/ Medicaid Phone: 1‐800‐992‐0900
Website: h p://www.eohhs.ri.gov/ Phone: 401‐462‐5300
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CHIP No ces
SOUTH CAROLINA – Medicaid VIRGINIA – Medicaid and CHIP
Website: h p://www.scdhhs.gov Phone: 1‐888‐549‐0820
Medicaid Website: h p://www.coverva.org/programs_premium_assistance.cfm Medicaid Phone: 1‐800‐432‐5924 CHIP Website: h p://www.coverva.org/programs_premium_assistance.cfm CHIP Phone: 1‐855‐242‐8282
SOUTH DAKOTA ‐ Medicaid WASHINGTON – Medicaid
Website: h p://dss.sd.gov Phone: 1‐888‐828‐0059
Website: h p://www.hca.wa.gov/medicaid/premiumpymt/pages/ index.aspx Phone: 1‐800‐562‐3022 ext. 15473
TEXAS – Medicaid WEST VIRGINIA – Medicaid
Website: h ps://www.gethipptexas.com/ Phone: 1‐800‐440‐0493
Website: www.dhhr.wv.gov/bms/Medicaid%20Expansion/Pages/default.aspx Phone: 1‐877‐598‐5820, HMS Third Party Liabil‐ity
UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIP
Website: Medicaid: h p://health.utah.gov/medicaid CHIP: h p://health.utah.gov/chip Phone: 1‐877‐543‐7669
Website: h ps://www.dhs.wisconsin.gov/publica ons/p1/p10095/pdf Phone: 1‐800‐362‐3002
VERMONT– Medicaid WYOMING – Medicaid
Website: h p://www.greenmountaincare.org/ Phone: 1‐800‐250‐8427
Website: h p://wyequalitycare.acs‐inc.com/ Phone: 307‐777‐7531
To see if any other states have added a premium assistance program since January 31, 2016, or for more informa on on special enrollment rights, contact either U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administra on Centers for Medicare & Medicaid Services www.dol.gov/ebsa www.cms.hhs.gov 1‐866‐444‐EBSA (3272) 1‐877‐267‐2323, Menu Op on 4, Ext. 61565
OMB Control Number 1210‐0137 (expires 10/31/2016)
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Important No fica ons
Newborns’ and Mothers’ Health Protec on Act Statement of Rights
Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any
hospital length of stay in connec on with childbirth for the mother or newborn child to less than 48 hours follow‐
ing a vaginal delivery, or less than 96 hours following a cesarean sec on.
However, Federal law generally does not prohibit the mother’s or newborn’s a ending provider, a er consul ng
with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours, as applicable).
In any case, plans and insurers may not, under Federal law, require that a provider obtain authoriza on from the
plan or the insurer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
Women’s Health and Cancer Rights Act (WHCRA) No ce
If you have had or are going to have a mastectomy, you may be en tled to certain benefits under the Women's
Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy‐related benefits, coverage
will be provided in a manner determined in consulta on with the a ending physician and the pa ent, for:
all stages of reconstruc on of the breast on which the mastectomy was per‐
formed;
surgery and reconstruc on of the other breast to produce a symmetrical appear‐
ance;
prostheses; and
treatment of physical complica ons of the mastectomy, including lymphedema.
These benefits will be provided subject to the same deduc bles and coinsurance applicable to other medical and
surgical benefits provided under this plan.
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THIS NOTICE OF PRIVACY PRACTICES DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This No ce of Privacy Prac ces (the “No ce”) describes the legal obliga ons of Cornerstone Educa on Group group health plan (the “Plan”) and your legal rights regarding your protected health informa on held by the Plan under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). Among other things, this No ce describes how your protected health informa on may be used or disclosed to carry out treatment, payment, or health care opera ons, or for any other purposes that are permi ed or required by law. We are required to provide this No ce of Privacy Prac ces to you pursuant to HIPAA. The HIPAA Privacy Rule protects only certain medical informa on known as “protected health informa on”. Generally, protected health informa on is individually iden fiable health informa on, including demographic informa on, collected from you or created or received by a health care provider, a health care clearinghouse, a health plan, or your employer on behalf of a group health plan, that relates to: (1) your past, present or future physical or mental health or condi on; (2) The provision of health care to you; or (3) The past, present or future payment for the provision of health care to
you. If you have any ques ons about this No ce or about our privacy prac ces, please contact Alicia Ganaway, HR Manager. Effec ve Date… This No ce is effec ve 10‐1‐2016. Our Responsibili es… We are required by law to:
Maintain the privacy of your protected health informa on;
Provide you with certain rights with respect to your protected health informa on;
Provide you with a copy of this No ce of our legal du es and privacy prac ces with respect to your protected health informa on; and
Follow the terms of the No ce that is currently in effect. We reserve the right to change the terms of this No ce and to make new provisions regarding your protected health informa on that we maintain, as allowed or required by law. If we make any material change to this No ce, we will provide you with a copy of our revised No ce of Privacy Prac ces by mail to the employees last known address on file. How We May Use & Disclose Your Protected Health Informa on… Under the law, we may use or disclose your protected health informa on under certain circumstances without your permission. The following categories describe the different ways that we may use and disclose your protected health informa on. For each category of uses or disclosures we will explain what we mean and present some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permi ed to use and disclose informa on will fall within one of the categories. For Treatment. We may use or disclose your protected health informa on to facilitate medical treatment or services by providers. We may disclose medical informa on about you to providers, including doctors, nurses, technicians, medical students or other hospital personnel who are involved in taking care of you. For example, we might disclose informa on about your prior prescrip ons to a pharmacist to determine if prior prescrip ons contraindicate a pending prescrip on. For Payment. We may use or disclose your protected health informa on to determine your eligibility for Plan benefits, to facilitate payment for the
treatment and services you receive from health care providers, to determine benefit responsibility under the Plan, or to coordinate Plan coverage. For example, we may tell your health care provider about your medical history to determine whether a par cular treatment is experimental, inves ga onal, or medically necessary, or to determine whether the Plan will cover the treatment. We may also share your protected health informa on with a u liza on review or precer fica on service provider. Likewise, we may share your protected health informa on with another en ty to assist with the adjudica on or subroga on of health claims or to another health plan to coordinate benefit payments. For Health Care Opera ons. We may use and disclose your protected health informa on for other Plan opera ons. These uses and disclosures are necessary to run the Plan. For example, we may use medical informa on in connec on with conduc ng quality assessment and improvement ac vi es; underwri ng, premium ra ng, and other ac vi es rela ng to Plan coverage; submi ng claims for stop‐loss (or excess‐loss) coverage; conduc ng or arranging for medical review, legal services, audit services, and fraud & abuse detec on programs; business planning and development such as cost management; and business management and general Plan administra ve ac vi es. To Business Associates. We may contract with individuals or en es known as Business Associates to perform various func ons on our behalf or to provide certain types of services. In order to perform these func ons or to provide these services, Business Associates will receive, create, maintain, use and/or disclose your protected health informa on, but only a er they agree in wri ng with us to implement appropriate safeguards regarding your protected health informa on. For example, we may disclosure your protected health informa on to a Business Associate to administer claims or to provide support services, such as u liza on management, pharmacy benefit management or subroga on, but only a er the Business Associate enters into a Business Associate contract with us. As Required by Law. We will disclose your protected health informa on when required to do so by federal, state or local law. For example, we may disclose your protected health informa on when required by na onal security laws or public health disclosure laws. To Avert a Serious Threat to Health or Safety. We may use and disclose your protected health informa on when necessary to prevent a serious threat to your health and safety, or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat. For example, we may disclose your protected health informa on in a proceeding regarding the licensure of a physician. To Plan Sponsors. For the purpose of administering the plan, we may disclose to certain employees of the Employer protected health informa on. However, those employees will only use or disclose that informa on as necessary to perform plan administra on func ons or as otherwise required by HIPAA, unless you have authorized further disclosures. Your protected health informa on cannot be used for employment purposes without your specific authoriza on. Special Situa ons… In addi on to the above, the following categories describe other possible ways that we may use and disclose your protected health informa on. For each category of uses or disclosures, we will explain what we mean and present some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permi ed to use and disclose informa on will fall within one of the categories. Organ and Tissue Dona on. If you are an organ donor, we may release your protected health informa on to organiza ons that handle organ procurement or organ, eye, or ssue transplanta on or to an organ dona on bank, as necessary to facilitate organ or ssue dona on and transplanta on.
No ce of Privacy Prac ces
Your rights and responsibili es regarding your personal informa on
16
No ce of Privacy Prac ces Your rights and responsibili es regarding your personal informa on
Military and Veterans. If you are a member of the armed forces, we may release your protected health informa on as required by military command authori es. We may also release protected health informa on about foreign military personnel to the appropriate foreign military authority. Workers’ Compensa on. We may release your protected health informa on for workers’ compensa on or similar programs. These programs provide benefits for work‐related injuries or illness. Public Health Risks. We may disclose your protected health informa on for public health ac ons. These ac ons generally include the following.
To prevent or control disease, injury, or disability;
To report births and deaths;
To report child abuse or neglect;
To report reac ons to medica ons or problems with products;
To no fy people of recalls of products they may be using;
To no fy a person who may have been exposed to a disease or may be at risk for contrac ng or spreading a disease or condi on;
To no fy the appropriate government authority if we believe that a pa ent has been the vic m of abuse, neglect, or domes c violence. We will only make this disclosure if you agree, or when required or authorized by law.
Health Oversight Ac vi es. We may disclose your protected health informa on to a health oversight agency for ac vi es authorized by law. These oversight ac vi es include, for example, audits, inves ga ons, inspec ons, and licensure. These ac vi es are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws. Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose your protected health informa on in response to a court or administra ve order. We may also disclose your protected health informa on in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protec ng the informa on requested. Law Enforcement. We may disclose your protected health informa on if asked to do so by a law enforcement official:
in response to a court order, subpoena, warrant, summons or similar process;
to iden fy or locate a suspect, fugi ve, material witness, or missing person;
about the vic m of a crime if, under certain limited circumstances, we are unable to obtain the vic m’s agreement;
about a death that we believe may be the result of criminal conduct; and
about criminal conduct. Coroners, Medical Examiners and Funeral Directors. We may release protected health informa on to a coroner or medical examiner. This may be necessary, for example, to iden fy a deceased person or determine the cause of death. We may also release medical informa on about pa ents to funeral directors, as necessary to carry out their du es. Na onal Security and Intelligence Ac vi es. We may release your protected health informa on to authorized federal officials for intelligence, counterintelligence, and other na onal security ac vi es authorized by law. Inmates. If you are an inmate of a correc onal ins tu on or are in the custody of a law enforcement official, we may disclose your protected health informa on to the correc onal ins tu on or law enforcement official if necessary:
(1) for the ins tu on to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correc onal ins tu on. Research. We may disclose your protected health informa on to researches when: (1) the individual iden fiers have been removed; or (2) when an ins tu onal review board or privacy board has reviewed the
research proposal and established protocols to ensure the privacy of the requested informa on, and approves the research.
Required Disclosures…
The following is a descrip on of disclosures of your protected health informa on we are required to make.
Government Audits. We are required to disclose your protected health informa on to the Secretary of the United States Department of Health and Human Services when the Secretary is inves ga ng or determining our compliance with the HIPAA privacy rule.
Disclosures to You. When you request, we are required to disclose to you the por on of your protected health informa on that contains medical records, billing records, and any other records used to make decisions regarding your health care benefits. We are also required, when requested, to provide you with an accoun ng of most disclosures of your protected health informa on if the disclosure was for reasons other than for payment, treatment, or health care opera ons, and if the protected health informa on was not disclosed pursuant to your individual authoriza on.
Other Disclosures…
Personal Representa ves. We will disclose your protected health informa on to individuals authorized by you, or to an individual designated as your personal representa ve, a orney‐in‐fact, etc., so long as you provide us with a wri en no ce/authoriza on and any suppor ng documents (i.e., power of a orney). Note: Under the HIPAA privacy rule, we do not have to disclose informa on to a personal representa ve if we have reasonable belief that:
(1) you have been, or may be, subjected to domes c violence, abuse or neglect by such person; or
(2) trea ng such person as your personal representa ve could endanger you; and
(3) in the exercise of professional judgment, it is not in your best interest to treat the person as your personal representa ve.
A Spouses and Other Family Members. With only limited excep ons, we will send all mail to the employee. This includes mail rela ng to the employee’s spouse and other family members who are covered under the Plan, and includes mail with informa on on the use of Plan benefits by the employee’s spouse and other family members and informa on on the denial of any Plan benefits to the employee’s spouse and other family members. If a person covered under the Plan has requested Restric ons or Confiden al Communica ons (see below under “Your Rights”), and if we have agreed to the request, we will send mail as provided by the request for Restric ons or Confiden al Communica ons.
17
No ce of Privacy Prac ces
Your rights and responsibili es regarding your personal informa on
Authoriza ons. Other uses or disclosures of your protected health informa on not described above will only be made with your wri en authoriza on. You may revoke wri en authoriza on at any me, so long as the revoca on is in wri ng. Once we receive your wri en revoca on, it will only be effec ve for future uses and disclosures. It will not be effec ve for any informa on that may have been used or disclosed in reliance upon the wri en authoriza on and prior to receiving your wri en revoca on. Your Rights… You have the following rights with respect to your protected health informa on: Right to Inspect and Copy. You have the right to inspect and copy certain protected health informa on that may be used to make decisions about your health care benefits. To inspect and copy your protected health informa on, you must submit your request in wri ng to your Human Resources Manager. If you request a copy of the informa on, we may charge a reasonable fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to your medical informa on, you may request that the denial be reviewed by submi ng a wri en request to your Human Resources Manager . Right to Amend. If you feel that the protected health informa on we have about you is incorrect or incomplete, you may ask us to amend the informa on. You have the right to request an amendment for as long as the informa on is kept by or for the Plan. To request an amendment, your request must be made in wri ng and submi ed to your Human Resources Manager. In addi on, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in wri ng or does not include a reason to support the request. In addi on, we may deny your request if you ask us to amend informa on that:
is not part of the medical informa on kept by or for the Plan;
was not created by us, unless the person or en ty that created the informa on is no longer available to make the amendment;
is not part of the informa on that you would be permi ed to inspect and copy; or
is already accurate and complete If we deny your request, you have the right to file a statement of disagreement with us and any future disclosures of the disputed informa on will include your statement. Right to an Accoun ng of Disclosures. You have the right to request an “accoun ng” of certain disclosures of your protected health informa on. The accoun ng will not include: (1) disclosures for purposes of treatment, payment, or health care
opera ons; (2) disclosures made to you; (3) disclosures made pursuant to your authoriza on; (4) disclosures made to friends or family in your presence or because of
an emergency; (5) disclosures for na onal security purposes; and (6) disclosures incidental to otherwise permissible disclosures. To request this list or accoun ng of disclosures, you must submit your request in wri ng to your Human Resources Manager . Your request must state a me period of not longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, paper or electronic). The first list you request within a 12‐month period will be provided free of charge. For addi onal lists, we may
charge you for the costs of providing the list. We will no fy you of the cost involved and you may choose to withdraw or modify your request at that
me before any costs are incurred. Right to Request Restric ons. You have the right to request a restric on or limita on on your protected health informa on that we use or disclose for treatment, payment, or health care opera ons. You also have the right to request a limit on your protected health informa on we disclose to someone who is involved in your care or the payment for your care, such as a family member or friend. For example, you could ask that we not use or disclose informa on about a surgery that you had. Except as provided in the next paragraph, we are not required to agree to your request. However, if we do agree to the request, we will honor the restric on un l you revoke it or we no fy you. Effec ve February 17, 2010 (or such other date specified as the effec ve date under applicable law), we comply with any restric on request if: (1) except as otherwise required by law, the disclosure is to health plan
purposes of carrying out payment or health care opera ons (and is not for purposes of carrying out treatment); and
(2) the protected health informa on pertains solely to a health care item or service for which the health care provider involved has been paid out‐of‐pocket in full.
To request restric ons, you must make your request in wri ng to the Human Resources Manager. In your request, you must tell us: (1) what informa on you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply ‐ for example, disclosures to your
spouse. Right to Request Confiden al Communica ons. You have the right to request that we communicate with you about medical ma ers in a certain way or at a certain loca on. For example, you can ask that we only contact you at work or by mail. To request confiden al communica ons, you must make your request in wri ng to the Human Resources Manager. We will not ask you the reason for your request. Your request must specify how or where you wish to be contacted. We will accommodate all reasonable requests if you clearly provide informa on that the disclosure of all or part of your protected informa on could endanger you. Right to be No fied of a Breach. You have the right to be no fied in the event that we (or a Business Associate) discover a breach of unsecured protected health informa on. Right to a Paper Copy of This No ce. You have the right to a paper copy of this no ce. You may ask us to give you a copy of this no ce at any me. Even if you have agreed to receive this no ce electronically, you are s ll en tled to a paper copy of this no ce. To obtain a paper copy of this no ce, contact your Human Resources Manager. Complaints… If you believe that your privacy rights have been violated, you may file a complaint with the Plan or with the Office for Civil Rights of the United States Department of Health and Human Services. To file a complaint with the Plan, contact your Human Resources Manager. All complaints must be submi ed in wri ng. You will not be penalized, or in any other way retaliated against, for filing a complaint with the Office for Civil Rights or with us.
18
Important No ce from Cornerstone Educa on Group About Your Prescrip on Drug Coverage and Medicare
Please read this no ce carefully and keep it where you can find it. This no ce has informa on about your current prescrip on drug coverage with Cornerstone Educa on Group and about your op ons under Medi‐care’s prescrip on drug coverage. This informa on can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescrip‐
on drug coverage in your area. Informa on about where you can get help to make decisions about your prescrip on drug coverage is at the end of this no ce. There are two important things you need to know about your current coverage and Medicare’s prescrip on drug coverage: Medicare prescrip on drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescrip on Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescrip on drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premi‐um. Cornerstone Educa on Group has determined that the prescrip on drug coverage offered by BCBSM/BCN is, on average for all plan par cipants, expected to pay out as much as standard Medicare prescrip‐
on drug coverage pays and is therefore considered Creditable Coverage. Because your exis ng cover‐age is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. Addi onal Informa on
When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from Octo‐ber 15th through December 7th. However, if you lose your current creditable prescrip on drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current Cornerstone Educa on Group coverage will be affected. If you elect Part D, this plan will coordinate with Part D coverage. When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with Cornerstone Educa on Group and don’t join a Medicare drug plan within 63 con nuous days a er your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 con nuous days or longer without creditable prescrip on drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescrip on drug coverage. In addi on, you may have to wait un l the following October to join. Where Can You Get For More Informa on About Your Op ons Under Medicare Prescrip on Drug Cover‐age?
About Your Prescrip on Drug Coverage and Medicare
19
More detailed informa on about Medicare plans that offer prescrip on drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more informa on about Medicare prescrip on drug coverage: Visit www.medicare.gov Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the
“Medicare & You” handbook for their telephone number) for personalized help. Call 1‐800‐MEDICARE (1‐800‐633‐4227). TTY users should call 1‐877‐486‐2048. If you have limited income and resources, extra help paying for Medicare prescrip on drug coverage is available. For informa on about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1‐800‐772‐1213 (TTY 1‐800‐325‐0778). Where Can You Get More Informa on About This No ce Or Your Current Prescrip on Drug Cover‐age? You will get this no ce each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Cornerstone Educa on Group changes. You may also request a copy of this no ce at any me. Contact the person listed below for further informa on. Name of En ty: Gallagher Benefit Services Inc. Contact: Daniel S. Ward, RHU Address: 30150 Telegraph Rd. Suite 408 Bingham Farms, MI 48025 Phone Number: (248) 502‐1100
Keep this Creditable Coverage no ce. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this no ce when you join to show whether or not you have main‐tained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).
About Your Prescrip on Drug Coverage and Medicare
En
han
ced
Hea
lth
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lue
Liv
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HM
O $
250
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osts
Co
vera
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for:
All
Con
trac
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lan
Typ
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MO
Qu
esti
ons:
Call
(800
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7 or
visi
t us a
t ww
w.B
CBSM
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. If y
ou a
ren’
t clea
r abo
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ny o
f the
und
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rms u
sed
in th
is fo
rm, s
ee th
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loss
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You
can
view
the
Glo
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y at
http
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ww
.dol
.gov
/ebs
a/pd
f/SB
CUni
form
Glo
ssar
y.pdf
or c
all (8
00) 6
62-6
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to re
ques
t a c
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SBC8
334
1 of
8
Th
is is
on
ly a
su
mm
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If y
ou w
ant m
ore
deta
il ab
out y
our c
over
age
and
cost
s, yo
u ca
n ge
t the
com
plet
e te
rms i
n th
e po
licy
or p
lan d
ocum
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at w
ww
.BC
BSM
.com
or b
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lling
(800
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2-66
67.
Imp
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ant
Qu
esti
on
s A
nsw
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Mem
ber
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hy
this
Mat
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:
Wh
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th
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edu
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$250
/$50
0 D
oesn
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to la
b, p
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offi
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aller
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jectio
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You
mus
t pay
all
the
cost
s up
to th
e d
edu
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le a
mou
nt b
efor
e th
is pl
an b
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s to
pay
for c
over
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s you
use
. Che
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our p
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o se
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the
ded
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ts o
ver (
usua
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t). S
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tarti
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on p
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2 fo
r how
muc
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u pa
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r cov
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serv
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fter y
ou m
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he d
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Are
th
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serv
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? N
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ou d
on’t
have
to m
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edu
ctib
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for s
pecif
ic se
rvice
s, bu
t see
the
char
t sta
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on
pag
e 2
for o
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cos
ts fo
r ser
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s thi
s plan
cov
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per
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year
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you
r sha
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f the
cos
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s. Th
is lim
it he
lps y
ou p
lan fo
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alth
care
exp
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s.
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at is
not
incl
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th
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t–of
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limit
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hea
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this
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Eve
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pay
s?
No.
Th
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tarti
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n pa
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des
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ny li
mits
on
wha
t the
plan
will
pay
for s
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ch a
s offi
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Doe
s th
is p
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use
a
net
wor
k of
pro
vid
ers?
Y
es. F
or a
list
of B
CN p
rovi
ders
, see
w
ww
.BCB
SM.co
m o
r call
(800
) 662
-666
7
If y
ou u
se a
n in
-net
wor
k do
ctor
or o
ther
hea
lth c
are
pro
vid
er, t
his p
lan w
ill p
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som
e or
all
of th
e co
sts o
f cov
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serv
ices.
Be a
war
e, yo
ur in
-net
wor
k do
ctor
or
hosp
ital m
ay u
se a
n ou
t-of-n
etw
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pro
vid
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r som
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rvice
s. P
lans u
se th
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rm
in-n
etw
ork,
pre
ferr
ed, o
r par
ticip
atin
g fo
r pro
vid
ers
in th
eir n
etw
ork.
See
the
char
t st
artin
g on
pag
e 2
for h
ow th
is pl
an p
ays d
iffer
ent k
inds
of p
rovi
der
s.
Do
I n
eed
a r
efer
ral t
o se
e a
spec
ialis
t?
Yes
, in-
netw
ork
only.
Pap
er o
r elec
troni
c.
This
plan
will
pay
som
e or
all
of th
e co
sts t
o se
e a
spec
ialis
t for
cov
ered
serv
ices b
ut
only
if yo
u ha
ve th
e pl
an’s
perm
issio
n be
fore
you
see
the
spec
ialis
t.
Are
th
ere
serv
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th
is
pla
n d
oesn
’t c
over
? Y
es
Som
e of
the
serv
ices t
his p
lan d
oesn
’t co
ver a
re li
sted
on
page
5. S
ee y
our p
olicy
or
plan
doc
umen
t for
add
ition
al in
form
atio
n ab
out e
xclu
ded
ser
vice
s.
Cor
ners
tone
Edu
catio
n G
roup
2
of 8
C
o-p
aym
ents
are
fixe
d do
llar a
mou
nts (
for e
xam
ple,
$15)
you
pay
for c
over
ed h
ealth
car
e, us
ually
whe
n yo
u re
ceiv
e th
e se
rvice
.
Co-
insu
ran
ce is
your
shar
e of
the
cost
s of a
cov
ered
serv
ice, c
alcul
ated
as a
per
cent
of t
he a
llow
ed a
mou
nt f
or th
e se
rvice
. For
exa
mpl
e, if
the
plan
’s al
low
ed a
mou
nt
for a
n ov
erni
ght h
ospi
tal s
tay
is $1
,000
, you
r co-
insu
ran
ce p
aym
ent o
f 20%
wou
ld b
e $2
00.
This
may
cha
nge
if yo
u ha
ven’
t met
yo
ur d
edu
ctib
le.
Th
e am
ount
the
plan
pay
s for
cov
ered
serv
ices i
s bas
ed o
n th
e al
low
ed a
mou
nt.
If a
n ou
t-of-n
etw
ork
pro
vid
er c
harg
es m
ore
than
the
allo
wed
am
oun
t, yo
u m
ay h
ave
to p
ay th
e di
ffer
ence
. For
exa
mpl
e, if
an o
ut-o
f-net
wor
k ho
spita
l cha
rges
$1,
500
for a
n ov
erni
ght s
tay
and
the
allo
wed
am
oun
t is
$1,0
00, y
ou m
ay h
ave
to p
ay th
e $5
00 d
iffer
ence
. (Th
is is
calle
d b
alan
ce b
illin
g.)
Th
is pl
an m
ay e
ncou
rage
you
to u
se In
Net
wor
k p
rovi
der
s by
cha
rgin
g yo
u lo
wer
ded
uct
ible
s, co
-pay
men
ts a
nd c
o-in
sura
nce
am
ount
s. Co
mm
on
M
edic
al E
ven
t S
ervi
ces
Yo
u M
ay N
eed
Yo
ur
cost
if
you
use
Pro
vid
ers:
Lim
itat
ion
s &
Exc
epti
on
s In
Net
wo
rk
Ou
t o
f N
etw
ork
If y
ou v
isit
a h
ealt
h
care
pro
vid
er’s
off
ice
or c
linic
Prim
ary
care
visi
t to
treat
an
inju
ry o
r illn
ess
$20
co-p
ay/v
isit
Not
cov
ered
––
––––
––––
–non
e–––
––––
––––
Spec
ialist
visi
t $3
0 co
-pay
/visi
t N
ot c
over
ed
Requ
ires r
efer
ral.
50%
co-
insu
ranc
e fo
r alle
rgy
offic
e vi
sit/$
5 co
-pay
for a
llerg
y in
jectio
ns
Oth
er p
ract
ition
er o
ffice
visi
t $3
0 co
-pay
/visi
t N
ot c
over
ed
Requ
ires r
efer
ral /
30
com
bine
d vi
sits f
or
spin
al m
anip
ulat
ions
per
form
ed b
y a
chiro
prac
tor o
r ost
eopa
thic
phys
ician
Prev
entiv
e ca
re/s
cree
ning
/im
mun
izat
ion
No
char
ge
Not
cov
ered
––
––––
––––
–non
e–––
––––
––––
If y
ou h
ave
a te
st
Diag
nost
ic te
st (x
-ray,
bloo
d w
ork)
20
% c
o-in
sura
nce
N
ot c
over
ed
May
requ
ire p
rior a
utho
rizat
ion/
Ded
uctib
le ap
plies
exc
ept f
or la
b se
rvice
s
Imag
ing
(CT/
PET
scan
s, M
RIs)
$1
50 c
o-pa
y
Not
cov
ered
Re
quire
s prio
r aut
horiz
atio
n/D
educ
tible
appl
ies
If y
ou n
eed
dru
gs t
o tr
eat
you
r ill
nes
s or
co
nd
itio
n
Mor
e in
form
atio
n ab
out
pre
scri
pti
on d
rug
cove
rage
is a
vaila
ble
ww
w.B
CBSM
.com
Tier
1A
- V
alue
Gen
erics
$4
/30
days
N
ot C
over
ed
•Prio
r-aut
horiz
atio
n an
d st
ep-th
erap
y ap
ply
to
selec
t dru
gs
•50%
co-
insu
ranc
e fo
r Sex
ual D
ysfu
nctio
n dr
ugs
•Ove
rall
out-o
f-poc
ket m
ax a
pplie
s •9
0 da
y m
ail o
rder
and
reta
il co
-pay
s are
3x
the
stan
dard
reta
il co
-pay
s min
us $
10
•Pre
vent
ive
Dru
gs c
over
ed in
full
Tier
1B
- Gen
erics
$1
5/30
day
s N
ot C
over
ed
Tier
2 -
Pref
erre
d Br
and
$40/
30 d
ays
Not
Cov
ered
Tier
3 -
Non
-Pre
ferr
ed B
rand
$8
0/30
day
s N
ot C
over
ed
Tier
4 -
Pref
erre
d Sp
ecial
ty
20%
co-
insu
ranc
e $2
00 m
ax/3
0 da
ys
Not
Cov
ered
•L
imite
d to
a 3
0 da
y su
pply
Tier
5 -
Non
-Pre
ferr
ed S
pecia
lty
20%
co-
insu
ranc
e $3
00 m
ax/3
0 da
ys
Not
Cov
ered
3
of 8
Co
mm
on
M
edic
al E
ven
t S
ervi
ces
Yo
u M
ay N
eed
Yo
ur
cost
if
you
use
Pro
vid
ers:
Lim
itat
ion
s &
Exc
epti
on
s In
Net
wo
rk
Ou
t o
f N
etw
ork
If y
ou h
ave
outp
atie
nt
surg
ery
Facil
ity fe
e (e
.g.,
ambu
lator
y su
rger
y ce
nter
) 20
% c
o-in
sura
nce
N
ot c
over
ed
May
requ
ire p
rior a
utho
rizat
ion/
50%
co-
insu
ranc
e fo
r weig
ht re
duct
ion
proc
edur
es,
TMJ,
orth
ogna
thic
surg
ery,
redu
ctio
n m
amm
oplas
ty, m
ale m
aste
ctom
y/D
educ
tible
appl
ies
Phys
ician
/sur
geon
fees
20
% c
o-in
sura
nce
N
ot c
over
ed
See
"Out
patie
nt su
rger
y fa
cility
fee"
If y
ou n
eed
imm
edia
te
med
ical
att
enti
on
Em
erge
ncy
room
serv
ices
$150
co-
pay/
visit
$1
50 c
o-pa
y/vi
sit
Copa
y w
aived
if a
dmitt
ed/D
educ
tible
appl
ies
Em
erge
ncy
med
ical t
rans
porta
tion
20%
co-
insu
ranc
e
20%
co-
insu
ranc
e
Non
-em
erge
nt tr
ansp
ort i
s not
co
vere
d/D
educ
tible
appl
ies
Urg
ent c
are
$35
co-p
ay/v
isit
$35
co-p
ay/v
isit
––––
––––
–––n
one–
––––
––––
––
If y
ou h
ave
a h
osp
ital
st
ay
Facil
ity fe
e (e
.g.,
hosp
ital r
oom
) 20
% c
o-in
sura
nce
N
ot c
over
ed
Requ
ires p
rior a
utho
rizat
ion/
50%
co-
insu
ranc
e fo
r weig
ht re
duct
ion
proc
edur
es,
TMJ,
orth
ogna
thic
surg
ery,
redu
ctio
n m
amm
oplas
ty, m
ale m
aste
ctom
y/D
educ
tible
appl
ies
Phys
ician
/sur
geon
fee
No
char
ge
Not
cov
ered
Se
e "H
ospi
tal s
tay
facil
ity fe
e"
If y
ou h
ave
men
tal
hea
lth
, beh
avio
ral
hea
lth
, or
sub
stan
ce
abu
se n
eed
s
Men
tal/
Beha
vior
al he
alth
outp
atien
t ser
vice
s$2
0 co
-pay
/visi
t N
ot c
over
ed
Requ
ires p
rior a
utho
rizat
ion
Men
tal/
Beha
vior
al he
alth
inpa
tient
serv
ices
20%
co-
insu
ranc
e
Not
cov
ered
Re
quire
s prio
r aut
horiz
atio
n/D
educ
tible
appl
ies
Subs
tanc
e us
e di
sord
er o
utpa
tient
serv
ices
$20
co-p
ay/v
isit
Not
cov
ered
Re
quire
s prio
r aut
horiz
atio
n
Subs
tanc
e us
e di
sord
er in
patie
nt se
rvic
es
20%
co-
insu
ranc
e
Not
cov
ered
Re
quire
s prio
r aut
horiz
atio
n/D
educ
tible
appl
ies
If y
ou a
re p
regn
ant
Pren
atal
and
post
nata
l car
e N
o ch
arge
N
ot c
over
ed
Post
nata
l and
non
-rout
ine
pren
atal
offic
e vi
sits-
$20
copa
y D
elive
ry a
nd a
ll in
patie
nt se
rvice
s 20
% c
o-in
sura
nce
N
ot c
over
ed
Ded
uctib
le ap
plies
If y
ou n
eed
hel
p
reco
veri
ng
or h
ave
oth
er s
pec
ial h
ealt
h
nee
ds
Hom
e he
alth
care
$3
0 co
-pay
/visi
t N
ot c
over
ed
Ded
uctib
le ap
plies
Reha
bilit
atio
n se
rvice
s $3
0 co
-pay
/visi
t N
ot c
over
ed
Requ
ires p
rior a
utho
rizat
ion/
One
per
iod
of
treat
men
t for
any
com
bina
tion
of th
erap
ies
with
in 6
0 co
nsec
utiv
e da
ys p
er C
alend
ar Y
ear.
Ded
uctib
le ap
plies
4
of 8
Co
mm
on
M
edic
al E
ven
t S
ervi
ces
Yo
u M
ay N
eed
Yo
ur
cost
if
you
use
Pro
vid
ers:
Lim
itat
ion
s &
Exc
epti
on
s In
Net
wo
rk
Ou
t o
f N
etw
ork
Hab
ilita
tion
serv
ices
$30
co-p
ay/v
isit
/ABA
- $2
0 co
-pa
y/vi
sit
Not
cov
ered
Lim
ited
to A
BA o
nly-
25
hour
s of l
ine
ther
apy
per w
eek
thro
ugh
age
18. P
T/O
T/ST
for
autis
m sp
ectru
m d
isord
er h
as u
nlim
ited
visit
s. Re
quire
s prio
r aut
horiz
atio
n
Skill
ed n
ursin
g ca
re
20%
co-
insu
ranc
e
Not
cov
ered
Re
quire
s prio
r aut
horiz
atio
n/Li
mite
d to
45
days
per
cale
ndar
yea
r/D
educ
tible
appl
ies
Dur
able
med
ical
equi
pmen
t 50
% c
o-in
sura
nce
N
ot c
over
ed
Mus
t be
auth
oriz
ed a
nd o
btain
ed fr
om a
BCN
su
pplie
r/20
% c
oins
uran
ce fo
r diab
etic
supp
lies
Hos
pice
serv
ice
No
char
ge
Not
cov
ered
In
patie
nt c
are
requ
ires
auth
oriz
atio
n/D
educ
tible
app
lies
If y
our
child
nee
ds
den
tal o
r ey
e ca
re
Eye
exa
m
Not
cov
ered
N
ot c
over
ed
See
plan
adm
inist
rato
r for
cov
erag
e in
form
atio
n
Glas
ses
Not
cov
ered
N
ot c
over
ed
See
plan
adm
inist
rato
r for
cov
erag
e in
form
atio
n
Den
tal c
heck
-up
Not
cov
ered
N
ot c
over
ed
See
plan
adm
inist
rato
r for
cov
erag
e in
form
atio
n
5
of 8
E
xclu
ded
Ser
vice
s &
Oth
er C
ove
red
Ser
vice
s:
Ser
vice
s Y
ou
r P
lan
Do
es N
OT
Co
ver
(Th
is is
n’t
a c
omp
lete
list
. Ch
eck
you
r p
olic
y or
pla
n d
ocu
men
t fo
r ot
her
exc
lud
ed s
ervi
ces.
)
A
cupu
nctu
re
Co
smet
ic su
rger
y
D
enta
l Car
e (A
dult)
E
lectiv
e A
borti
on
H
earin
g aid
s
Lo
ng-te
rm c
are
N
on-e
mer
genc
y ca
re w
hen
trave
ling
outs
ide
the
U.S
.
Pr
ivat
e-du
ty n
ursin
g
Ro
utin
e ey
e ca
re (A
dult)
Ro
utin
e fo
ot c
are
W
eight
loss
pro
gram
s
Oth
er C
ove
red
Ser
vice
s (T
his
isn
’t a
com
ple
te li
st. C
hec
k yo
ur
pol
icy
or p
lan
doc
um
ent
for
oth
er c
over
ed s
ervi
ces
and
you
r co
sts
for
thes
e se
rvic
es.)
Ba
riatri
c su
rger
y
Chiro
prac
tic c
are
In
ferti
lity
treat
men
t
6
of 8
Y
ou
r R
igh
ts t
o C
on
tin
ue
Co
vera
ge:
If
you
lose
cov
erag
e un
der t
he p
lan, t
hen,
dep
endi
ng u
pon
the
circu
mst
ance
s, Fe
dera
l and
Sta
te la
ws m
ay p
rovi
de p
rote
ctio
ns th
at a
llow
you
to k
eep
healt
h co
vera
ge. A
ny su
ch ri
ghts
may
be
limite
d in
dur
atio
n an
d w
ill re
quire
you
to p
ay a
pre
miu
m, w
hich
may
be
signi
fican
tly h
ighe
r tha
n th
e pr
emiu
m y
ou p
ay w
hile
cove
red
unde
r the
plan
. Oth
er li
mita
tions
on
your
righ
ts to
con
tinue
cov
erag
e m
ay a
lso a
pply.
Fo
r mor
e in
form
atio
n on
you
r rig
hts t
o co
ntin
ue c
over
age,
cont
act t
he p
lan a
t (80
0) 6
62-6
667.
You
may
also
con
tact
you
r sta
te in
sura
nce
depa
rtmen
t, th
e U
.S.
Dep
artm
ent o
f Lab
or, E
mpl
oyee
Ben
efits
Sec
urity
Adm
inist
ratio
n at
1-8
66-4
44-3
272
or w
ww
.dol
.gov
/ebs
a, or
the
U.S
. Dep
artm
ent o
f Hea
lth a
nd H
uman
Se
rvic
es a
t 1-8
77-2
67-2
323
x615
65 o
r ww
w.cc
iio.cm
s.gov
.
Yo
ur
Gri
evan
ce a
nd
Ap
pea
ls R
igh
ts:
If y
ou h
ave
a co
mpl
aint o
r are
diss
atisf
ied w
ith a
den
ial o
f cov
erag
e fo
r clai
ms u
nder
you
r plan
, you
may
be
able
to a
pp
eal o
r file
a g
riev
ance
. Fo
r que
stio
ns
abou
t you
r rig
hts,
this
notic
e, or
ass
istan
ce, y
ou c
an c
onta
ct: B
lue
Care
Net
wor
k, A
ppea
ls an
d G
rieva
nce
Uni
t, M
C C2
48, P
.O. B
ox 2
84, S
outh
field
, MI 4
8086
or
fax
1-88
8-45
8-07
16.
For s
tate
of M
ichig
an a
ssist
ance
con
tact
the
Dep
artm
ent o
f Ins
uran
ce a
nd F
inan
cial S
ervi
ces,
Hea
lthca
re A
ppea
ls Se
ctio
n, O
ffice
of G
ener
al Co
unse
l, 61
1 O
ttaw
a,
3rd F
loor
, P. O
. Box
302
20, L
ansin
g, M
I 489
09-7
720,
mic
higa
n.go
v/di
fs; c
all 1
-877
-999
-644
2 or
fax:
517
-241
-416
8.
For D
epar
tmen
t of L
abor
ass
istan
ce c
onta
ct th
e E
mpl
oyee
Ben
efits
Sec
urity
Adm
inist
ratio
n at
1-8
66-4
44-E
BSA
(327
2) o
r ww
w.d
ol.g
ov/e
bsa/
healt
href
orm
. A
dditi
onall
y, a
cons
umer
ass
istan
ce p
rogr
am c
an h
elp y
ou fi
le yo
ur a
ppea
l. Co
ntac
t the
Mich
igan
Hea
lth In
sura
nce
Cons
umer
Ass
istan
ce P
rogr
am (H
ICA
P),
Dep
artm
ent o
f Ins
uran
ce a
nd F
inan
cial S
ervi
ces,
P. O
. Box
302
20, L
ansin
g, M
I 489
09-7
720,
mic
higa
n.go
v/di
fs; O
fir-h
icap
@m
ichi
gan.
gov.
Do
es t
his
Co
vera
ge
Pro
vid
e M
inim
um
Ess
enti
al C
ove
rag
e?
The
Affo
rdab
le Ca
re A
ct re
quire
s mos
t peo
ple
to h
ave
healt
h ca
re c
over
age
that
qua
lifies
as “
min
imum
ess
entia
l cov
erag
e.” T
his p
lan o
r pol
icy d
oes p
rovi
de
min
imum
ess
entia
l cov
erag
e.
Do
es t
his
Co
vera
ge
Mee
t th
e M
inim
um
Val
ue
Sta
nd
ard
?
In o
rder
for c
erta
in ty
pes o
f hea
lth c
over
age
(for e
xam
ple,
indi
vidu
ally
purc
hase
d in
sura
nce
or jo
b-ba
sed
cove
rage
) to
quali
fy a
s min
imum
ess
entia
l cov
erag
e, th
e pl
an m
ust p
ay, o
n av
erag
e, at
leas
t 60
perc
ent o
f allo
wed
cha
rges
for c
over
ed se
rvic
es. T
his i
s call
ed th
e “m
inim
um v
alue
stan
dard
.” T
his h
ealth
cov
erag
e do
es
mee
t the
min
imum
valu
e st
anda
rd fo
r the
ben
efits
it p
rovi
des.
(IMPO
RTA
NT:
Blu
e Ca
re N
etw
ork
of M
ichig
an is
ass
umin
g th
at y
our c
over
age
prov
ides
for a
ll E
ssen
tial H
ealth
Ben
efit
(EH
B) c
ateg
ories
as d
efin
ed b
y th
e St
ate
of M
ichig
an.
The
min
imum
valu
e of
you
r plan
may
be
affe
cted
if y
our p
lan d
oes n
ot c
over
ce
rtain
EH
B ca
tego
ries,
such
as p
resc
riptio
n dr
ugs,
or if
you
r plan
pro
vide
s cov
erag
e of
spec
ific
EBH
cat
egor
ies, f
or e
xam
ple
pres
crip
tion
drug
s, th
roug
h an
othe
r ca
rrier
. In
thes
e sit
uatio
ns y
ou w
ill n
eed
to c
onta
ct y
our p
lan a
dmin
istra
tor f
or in
form
atio
n on
whe
ther
you
r plan
mee
ts th
e m
inim
um v
alue
stan
dard
for t
he
bene
fits i
t pro
vide
s.)
Tra
nsl
atio
n a
vaila
ble
To
get
help
read
ing
in y
our l
angu
age
call
the
cust
omer
serv
ice n
umbe
r on
the
back
of y
our I
D c
ard.
––––
––––
––––
––––
––––
––To
see e
xamp
les of
how
this
plan
migh
t cov
er cos
ts for
a sa
mple
medic
al sit
uatio
n, see
the n
ext p
age.–
––––
––––
––––
––––
––––
–
Co
vera
ge
Exa
mp
les
7
of 8
A
bo
ut
thes
e C
ove
rag
e E
xam
ple
s:
Thes
e ex
ampl
es sh
ow h
ow th
is pl
an m
ight
co
ver m
edica
l car
e in
giv
en si
tuat
ions
. Use
thes
e ex
ampl
es to
see,
in g
ener
al, h
ow m
uch
finan
cial
prot
ectio
n a
sam
ple
patie
nt m
ight
get
if th
ey a
re
cove
red
unde
r diff
eren
t plan
s.
Th
is is
n
ot
a co
st
esti
mat
or.
D
on’t
use
thes
e ex
ampl
es to
es
timat
e yo
ur a
ctua
l cos
ts
unde
r thi
s plan
. The
act
ual
care
you
rece
ive
will
be
diffe
rent
from
thes
e ex
ampl
es, a
nd th
e co
st o
f th
at c
are
will
also
be
diff
eren
t.
See
the
next
pag
e fo
r im
porta
nt in
form
atio
n ab
out
thes
e ex
ampl
es.
Hav
ing
a b
aby
(nor
mal
del
iver
y)
Am
ou
nt
ow
ed t
o p
rovi
der
s: $
7,54
0
Pla
n p
ays
$5,8
90
P
atie
nt
pay
s $1
,650
S
amp
le c
are
cost
s:
Hos
pita
l cha
rges
(mot
her)
$2,7
00
Rout
ine
obst
etric
car
e $2
,100
H
ospi
tal c
harg
es (b
aby)
$9
00
Ane
sthe
sia
$900
La
bora
tory
test
s $5
00
Pres
crip
tions
$2
00
Radi
olog
y $2
00
Vac
cines
, oth
er p
reve
ntiv
e $4
0 T
otal
$7
,540
P
atie
nt
pay
s:
Ded
uctib
les
$250
Co
-pay
s $0
Co
-insu
ranc
e $1
,250
Li
mits
or e
xclu
sions
$1
50
Tot
al
$1,6
50
M
anag
ing
typ
e 2
dia
bet
es
(rou
tin
e m
ain
ten
ance
of
a
wel
l-co
ntr
olle
d c
ond
itio
n)
A
mo
un
t o
wed
to
pro
vid
ers:
$5,
400
P
lan
pay
s $4
,47
0
P
atie
nt
pay
s $9
30
S
amp
le c
are
cost
s:
Pres
crip
tions
$2
,900
M
edica
l Equ
ipm
ent a
nd S
uppl
ies
$1,3
00
Offi
ce V
isits
and
Pro
cedu
res
$700
E
duca
tion
$300
La
bora
tory
test
s $1
00
Vac
cines
, oth
er p
reve
ntiv
e $1
00
Tot
al
$5,4
00
Pat
ien
t p
ays:
D
educ
tibles
$2
50
Co-p
ays
$340
Co
-insu
ranc
e $2
60
Lim
its o
r exc
lusio
ns
$80
T
otal
$9
30
If y
ou a
re a
lso c
over
ed b
y an
acc
ount
-type
plan
such
as a
n in
tegr
ated
hea
lth re
imbu
rsem
ent a
rran
gem
ent (
HRA
), an
d/or
an
healt
h sa
ving
s acc
ount
(HSA
), th
en
you
may
hav
e ac
cess
to a
dditi
onal
fund
s to
help
cov
er c
erta
in o
ut-o
f-poc
ket e
xpen
ses-
like
dedu
ctib
le, c
o-pa
ymen
ts, o
r co-
insu
ranc
e or
ben
efits
not
oth
erw
ise
cove
red.
Co
vera
ge
Exa
mp
les
Qu
esti
ons:
Call
(800
) 662
-666
7 or
visi
t us a
t ww
w.B
CBSM
.com
. If y
ou a
ren’
t clea
r abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
view
the
Glo
ssar
y at
http
://w
ww
.dol
.gov
/ebs
a/pd
f/SB
CUni
form
Glo
ssar
y.pdf
or c
all (8
00) 6
62-6
667
to re
ques
t a c
opy.
8
of 8
Q
ues
tio
ns
and
an
swer
s ab
ou
t th
e C
ove
rag
e E
xam
ple
s:
Wh
at a
re s
om
e o
f th
e as
sum
pti
on
s b
ehin
d t
he
Co
vera
ge
Exa
mp
les?
Cost
s don
’t in
clude
pre
miu
ms.
Sa
mpl
e ca
re c
osts
are
bas
ed o
n na
tiona
l av
erag
es su
pplie
d by
the
U.S
. Dep
artm
ent
of H
ealth
and
Hum
an S
ervi
ces,
and
aren
’t sp
ecifi
c to
a p
artic
ular
geo
grap
hic
area
or
healt
h pl
an.
Th
e pa
tient
’s co
nditi
on w
as n
ot a
n ex
clude
dor
pre
exist
ing
cond
ition
.
All
serv
ices a
nd tr
eatm
ents
star
ted
and
ende
d in
the
sam
e co
vera
ge p
erio
d.
Th
ere
are
no o
ther
med
ical e
xpen
ses f
or
any
mem
ber c
over
ed u
nder
this
plan
.
Out
-of-p
ocke
t exp
ense
s are
bas
ed o
nly
on
treat
ing
the
cond
ition
in th
e ex
ampl
e.
The
patie
nt re
ceiv
ed a
ll ca
re fr
om in
-ne
twor
k p
rovi
der
s. If
the
patie
nt h
ad
rece
ived
car
e fr
om o
ut-o
f-net
wor
k p
rovi
der
s, co
sts w
ould
hav
e be
en h
ighe
r.
Cove
rage
exa
mpl
es a
re c
alcul
ated
bas
ed
on in
divi
dual
cove
rage
.
W
hat
do
es a
Co
vera
ge
Exa
mp
le
sho
w?
Fo
r eac
h tre
atm
ent s
ituat
ion,
the
Cove
rage
E
xam
ple
help
s you
see
how
ded
uct
ible
s,
co-p
aym
ents
, and
co-
insu
ran
ce c
an a
dd u
p. It
als
o he
lps y
ou se
e w
hat e
xpen
ses m
ight
be
left
up to
you
to p
ay b
ecau
se th
e se
rvice
or
treat
men
t isn
’t co
vere
d or
pay
men
t is l
imite
d.
C
an I
use
Co
vera
ge
Exa
mp
les
to
com
par
e p
lan
s?
Y
es. W
hen
you
look
at t
he S
umm
ary
of B
enef
its
and
Cove
rage
for o
ther
plan
s, yo
u’ll
find
the
sam
e Co
vera
ge E
xam
ples
. Whe
n yo
u co
mpa
re p
lans,
chec
k th
e “P
atien
t Pay
s” b
ox in
eac
h ex
ampl
e. Th
e sm
aller
that
num
ber,
the
mor
e co
vera
ge th
e pl
an p
rovi
des.
Do
es t
he
Co
vera
ge
Exa
mp
le
pre
dic
t m
y o
wn
car
e n
eed
s?
N
o. T
reat
men
ts sh
own
are
just
exa
mpl
es.
The
care
you
wou
ld re
ceiv
e fo
r thi
s con
ditio
n co
uld
be d
iffer
ent,
base
d on
you
r doc
tor’s
ad
vice
, you
r age
, how
serio
us y
our c
ondi
tion
is, a
nd m
any
othe
r fac
tors
.
Are
th
ere
oth
er c
ost
s I s
ho
uld
co
nsi
der
wh
en c
om
par
ing
pla
ns?
Yes
. An
impo
rtant
cos
t is t
he p
rem
ium
you
pay
. G
ener
ally,
the
low
er y
our p
rem
ium
, the
mor
e yo
u’ll
pay
in o
ut-o
f-poc
ket c
osts
, suc
h as
co
-pay
men
ts, d
edu
ctib
les,
and
co-i
nsu
ran
ce.
You
shou
ld a
lso c
onsid
er c
ontri
butio
ns to
ac
coun
ts su
ch a
s hea
lth sa
ving
s acc
ount
s (H
SAs)
, fle
xibl
e sp
endi
ng a
rran
gem
ents
(FSA
s) o
r hea
lth
reim
burs
emen
t acc
ount
s (H
RAs)
that
help
you
pay
ou
t-of-p
ocke
t exp
ense
s.
Do
es t
he
Co
vera
ge
Exa
mp
le
pre
dic
t m
y fu
ture
exp
ense
s?
N
o. C
over
age
Exa
mpl
es a
re n
ot c
ost
estim
ator
s. Y
ou c
an’t
use
the
exam
ples
to
estim
ate
cost
s for
an
actu
al co
nditi
on. T
hey
are
for c
ompa
rativ
e pu
rpos
es o
nly.
You
r ow
n co
sts w
ill b
e di
ffere
nt d
epen
ding
on
the
care
yo
u re
ceiv
e, th
e pr
ices y
our p
rovi
der
s ch
arge
, an
d th
e re
imbu
rsem
ent y
our h
ealth
plan
all
ows.
Sta
nd
ard
Hea
lth
y B
lue
Liv
ing
HM
O $
250
S
um
mar
y o
f B
enef
its
and
Co
vera
ge:
Wha
t th
is P
lan
Cov
ers
& W
hat
it C
osts
Co
vera
ge
for:
All
Con
trac
t Typ
esP
lan
Typ
e: H
MO
Qu
esti
ons:
Call
(800
) 662
-666
7 or
visi
t us a
t ww
w.B
CBSM
.com
. If y
ou a
ren’
t clea
r abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
view
the
Glo
ssar
y at
http
://w
ww
.dol
.gov
/ebs
a/pd
f/SB
CUni
form
Glo
ssar
y.pdf
or c
all (8
00) 6
62-6
667
to re
ques
t a c
opy.
SBC8
335
1 of
8
Th
is is
on
ly a
su
mm
ary.
If y
ou w
ant m
ore
deta
il ab
out y
our c
over
age
and
cost
s, yo
u ca
n ge
t the
com
plet
e te
rms i
n th
e po
licy
or p
lan d
ocum
ent
at w
ww
.BC
BSM
.com
or b
y ca
lling
(800
) 66
2-66
67.
Imp
ort
ant
Qu
esti
on
s A
nsw
ers:
Mem
ber
/ F
amil
y W
hy
this
Mat
ters
:
Wh
at is
th
e ov
eral
l d
edu
ctib
le?
$150
0/$3
000
Doe
sn't
appl
y to
lab,
pre
vent
ive
care
, D
ME
/P&
O, P
CP o
ffice
visi
ts, u
rgen
t car
e, all
ergy
injec
tions
You
mus
t pay
all
the
cost
s up
to th
e d
edu
ctib
le a
mou
nt b
efor
e th
is pl
an b
egin
s to
pay
for c
over
ed se
rvice
s you
use
. Che
ck y
our p
olicy
or p
lan d
ocum
ent t
o se
e w
hen
the
ded
uct
ible
star
ts o
ver (
usua
lly, b
ut n
ot a
lway
s, Ja
nuar
y 1s
t). S
ee th
e ch
art s
tarti
ng
on p
age
2 fo
r how
muc
h yo
u pa
y fo
r cov
ered
serv
ices a
fter y
ou m
eet t
he d
edu
ctib
le.
Are
th
ere
oth
er
ded
uct
ible
s fo
r sp
ecif
ic
serv
ices
? N
o Y
ou d
on’t
have
to m
eet d
edu
ctib
les
for s
pecif
ic se
rvice
s, bu
t see
the
char
t sta
rting
on
pag
e 2
for o
ther
cos
ts fo
r ser
vice
s thi
s plan
cov
ers.
Is t
her
e an
ou
t–of
–p
ocke
t lim
it o
n m
y ex
pen
ses?
Y
es. $
3000
/$60
00
The
out-
of-p
ocke
t lim
it is
the
mos
t you
cou
ld p
ay d
urin
g a
cove
rage
per
iod
(usu
ally
one
year
) for
you
r sha
re o
f the
cos
t of c
over
ed se
rvice
s. Th
is lim
it he
lps y
ou p
lan fo
r he
alth
care
exp
ense
s.
Wh
at is
not
incl
ud
ed in
th
e ou
t–of
–poc
ket
limit
? Pr
emiu
ms,
balan
ced
bille
d ch
arge
s and
hea
lth
care
this
plan
doe
s not
cov
er
Eve
n th
ough
you
pay
thes
e ex
pens
es, t
hey
don’
t cou
nt to
war
d th
e ou
t-of
-poc
ket
limit
.
Is t
her
e an
ove
rall
ann
ual
lim
it o
n w
hat
th
e p
lan
pay
s?
No.
Th
e ch
art s
tarti
ng o
n pa
ge 2
des
crib
es a
ny li
mits
on
wha
t the
plan
will
pay
for s
pecif
ic co
vere
d se
rvice
s, su
ch a
s offi
ce v
isits
.
Doe
s th
is p
lan
use
a
net
wor
k of
pro
vid
ers?
Y
es. F
or a
list
of B
CN p
rovi
ders
, see
w
ww
.BCB
SM.co
m o
r call
(800
) 662
-666
7
If y
ou u
se a
n in
-net
wor
k do
ctor
or o
ther
hea
lth c
are
pro
vid
er, t
his p
lan w
ill p
ay
som
e or
all
of th
e co
sts o
f cov
ered
serv
ices.
Be a
war
e, yo
ur in
-net
wor
k do
ctor
or
hosp
ital m
ay u
se a
n ou
t-of-n
etw
ork
pro
vid
er fo
r som
e se
rvice
s. P
lans u
se th
e te
rm
in-n
etw
ork,
pre
ferr
ed, o
r par
ticip
atin
g fo
r pro
vid
ers
in th
eir n
etw
ork.
See
the
char
t st
artin
g on
pag
e 2
for h
ow th
is pl
an p
ays d
iffer
ent k
inds
of p
rovi
der
s.
Do
I n
eed
a r
efer
ral t
o se
e a
spec
ialis
t?
Yes
, in-
netw
ork
only.
Pap
er o
r elec
troni
c.
This
plan
will
pay
som
e or
all
of th
e co
sts t
o se
e a
spec
ialis
t for
cov
ered
serv
ices b
ut
only
if yo
u ha
ve th
e pl
an’s
perm
issio
n be
fore
you
see
the
spec
ialis
t.
Are
th
ere
serv
ices
th
is
pla
n d
oesn
’t c
over
? Y
es
Som
e of
the
serv
ices t
his p
lan d
oesn
’t co
ver a
re li
sted
on
page
5. S
ee y
our p
olicy
or
plan
doc
umen
t for
add
ition
al in
form
atio
n ab
out e
xclu
ded
ser
vice
s.
Cor
ners
tone
Edu
catio
n G
roup
2
of 8
C
o-p
aym
ents
are
fixe
d do
llar a
mou
nts (
for e
xam
ple,
$15)
you
pay
for c
over
ed h
ealth
car
e, us
ually
whe
n yo
u re
ceiv
e th
e se
rvice
.
Co-
insu
ran
ce is
your
shar
e of
the
cost
s of a
cov
ered
serv
ice, c
alcul
ated
as a
per
cent
of t
he a
llow
ed a
mou
nt f
or th
e se
rvice
. For
exa
mpl
e, if
the
plan
’s al
low
ed a
mou
nt
for a
n ov
erni
ght h
ospi
tal s
tay
is $1
,000
, you
r co-
insu
ran
ce p
aym
ent o
f 20%
wou
ld b
e $2
00.
This
may
cha
nge
if yo
u ha
ven’
t met
yo
ur d
edu
ctib
le.
Th
e am
ount
the
plan
pay
s for
cov
ered
serv
ices i
s bas
ed o
n th
e al
low
ed a
mou
nt.
If a
n ou
t-of-n
etw
ork
pro
vid
er c
harg
es m
ore
than
the
allo
wed
am
oun
t, yo
u m
ay h
ave
to p
ay th
e di
ffer
ence
. For
exa
mpl
e, if
an o
ut-o
f-net
wor
k ho
spita
l cha
rges
$1,
500
for a
n ov
erni
ght s
tay
and
the
allo
wed
am
oun
t is
$1,0
00, y
ou m
ay h
ave
to p
ay th
e $5
00 d
iffer
ence
. (Th
is is
calle
d b
alan
ce b
illin
g.)
Th
is pl
an m
ay e
ncou
rage
you
to u
se In
Net
wor
k p
rovi
der
s by
cha
rgin
g yo
u lo
wer
ded
uct
ible
s, co
-pay
men
ts a
nd c
o-in
sura
nce
am
ount
s. Co
mm
on
M
edic
al E
ven
t S
ervi
ces
Yo
u M
ay N
eed
Yo
ur
cost
if
you
use
Pro
vid
ers:
Lim
itat
ion
s &
Exc
epti
on
s In
Net
wo
rk
Ou
t o
f N
etw
ork
If y
ou v
isit
a h
ealt
h
care
pro
vid
er’s
off
ice
or c
linic
Prim
ary
care
visi
t to
treat
an
inju
ry o
r illn
ess
$30
co-p
ay/v
isit
Not
cov
ered
––
––––
––––
–non
e–––
––––
––––
Spec
ialist
visi
t $4
0 co
-pay
/visi
t N
ot c
over
ed
Requ
ires r
efer
ral.
50%
co-
insu
ranc
e fo
r alle
rgy
offic
e vi
sit/$
5 co
-pay
for a
llerg
y in
jectio
ns
Oth
er p
ract
ition
er o
ffice
visi
t $4
0 co
-pay
/visi
t N
ot c
over
ed
Requ
ires r
efer
ral /
30
com
bine
d vi
sits f
or
spin
al m
anip
ulat
ions
per
form
ed b
y a
chiro
prac
tor o
r ost
eopa
thic
phys
ician
Prev
entiv
e ca
re/s
cree
ning
/im
mun
izat
ion
No
char
ge
Not
cov
ered
––
––––
––––
–non
e–––
––––
––––
If y
ou h
ave
a te
st
Diag
nost
ic te
st (x
-ray,
bloo
d w
ork)
30
% c
o-in
sura
nce
N
ot c
over
ed
May
requ
ire p
rior a
utho
rizat
ion/
Ded
uctib
le ap
plies
exc
ept f
or la
b se
rvice
s
Imag
ing
(CT/
PET
scan
s, M
RIs)
$1
50 c
o-pa
y
Not
cov
ered
Re
quire
s prio
r aut
horiz
atio
n/D
educ
tible
appl
ies
If y
ou n
eed
dru
gs t
o tr
eat
you
r ill
nes
s or
co
nd
itio
n
Mor
e in
form
atio
n ab
out
pre
scri
pti
on d
rug
cove
rage
is a
vaila
ble
ww
w.B
CBSM
.com
Tier
1A
- V
alue
Gen
erics
$6
/30
days
N
ot C
over
ed
•Prio
r-aut
horiz
atio
n an
d st
ep-th
erap
y ap
ply
to
selec
t dru
gs
•50%
co-
insu
ranc
e fo
r Sex
ual D
ysfu
nctio
n dr
ugs
•Ove
rall
out-o
f-poc
ket m
ax a
pplie
s •9
0 da
y m
ail o
rder
and
reta
il co
-pay
s are
3x
the
stan
dard
reta
il co
-pay
s min
us $
10
•Pre
vent
ive
Dru
gs c
over
ed in
full
Tier
1B
- Gen
erics
$2
5/30
day
s N
ot C
over
ed
Tier
2 -
Pref
erre
d Br
and
$50/
30 d
ays
Not
Cov
ered
Tier
3 -
Non
-Pre
ferr
ed B
rand
$8
0/30
day
s N
ot C
over
ed
Tier
4 -
Pref
erre
d Sp
ecial
ty
20%
co-
insu
ranc
e $2
00 m
ax/3
0 da
ys
Not
Cov
ered
•L
imite
d to
a 3
0 da
y su
pply
Tier
5 -
Non
-Pre
ferr
ed S
pecia
lty
20%
co-
insu
ranc
e $3
00 m
ax/3
0 da
ys
Not
Cov
ered
3
of 8
Co
mm
on
M
edic
al E
ven
t S
ervi
ces
Yo
u M
ay N
eed
Yo
ur
cost
if
you
use
Pro
vid
ers:
Lim
itat
ion
s &
Exc
epti
on
s In
Net
wo
rk
Ou
t o
f N
etw
ork
If y
ou h
ave
outp
atie
nt
surg
ery
Facil
ity fe
e (e
.g.,
ambu
lator
y su
rger
y ce
nter
) 30
% c
o-in
sura
nce
N
ot c
over
ed
May
requ
ire p
rior a
utho
rizat
ion/
50%
co-
insu
ranc
e fo
r weig
ht re
duct
ion
proc
edur
es,
TMJ,
orth
ogna
thic
surg
ery,
redu
ctio
n m
amm
oplas
ty, m
ale m
aste
ctom
y/D
educ
tible
appl
ies
Phys
ician
/sur
geon
fees
30
% c
o-in
sura
nce
N
ot c
over
ed
See
"Out
patie
nt su
rger
y fa
cility
fee"
If y
ou n
eed
imm
edia
te
med
ical
att
enti
on
Em
erge
ncy
room
serv
ices
$150
co-
pay/
visit
$1
50 c
o-pa
y/vi
sit
Copa
y w
aived
if a
dmitt
ed/D
educ
tible
appl
ies
Em
erge
ncy
med
ical t
rans
porta
tion
30%
co-
insu
ranc
e
30%
co-
insu
ranc
e
Non
-em
erge
nt tr
ansp
ort i
s not
co
vere
d/D
educ
tible
appl
ies
Urg
ent c
are
$35
co-p
ay/v
isit
$35
co-p
ay/v
isit
––––
––––
–––n
one–
––––
––––
––
If y
ou h
ave
a h
osp
ital
st
ay
Facil
ity fe
e (e
.g.,
hosp
ital r
oom
) 30
% c
o-in
sura
nce
N
ot c
over
ed
Requ
ires p
rior a
utho
rizat
ion/
50%
co-
insu
ranc
e fo
r weig
ht re
duct
ion
proc
edur
es,
TMJ,
orth
ogna
thic
surg
ery,
redu
ctio
n m
amm
oplas
ty, m
ale m
aste
ctom
y/D
educ
tible
appl
ies
Phys
ician
/sur
geon
fee
No
char
ge
Not
cov
ered
Se
e "H
ospi
tal s
tay
facil
ity fe
e"
If y
ou h
ave
men
tal
hea
lth
, beh
avio
ral
hea
lth
, or
sub
stan
ce
abu
se n
eed
s
Men
tal/
Beha
vior
al he
alth
outp
atien
t ser
vice
s$3
0 co
-pay
/visi
t N
ot c
over
ed
Requ
ires p
rior a
utho
rizat
ion
Men
tal/
Beha
vior
al he
alth
inpa
tient
serv
ices
30%
co-
insu
ranc
e
Not
cov
ered
Re
quire
s prio
r aut
horiz
atio
n/D
educ
tible
appl
ies
Subs
tanc
e us
e di
sord
er o
utpa
tient
serv
ices
$30
co-p
ay/v
isit
Not
cov
ered
Re
quire
s prio
r aut
horiz
atio
n
Subs
tanc
e us
e di
sord
er in
patie
nt se
rvic
es
30%
co-
insu
ranc
e
Not
cov
ered
Re
quire
s prio
r aut
horiz
atio
n/D
educ
tible
appl
ies
If y
ou a
re p
regn
ant
Pren
atal
and
post
nata
l car
e N
o ch
arge
N
ot c
over
ed
Post
nata
l and
non
-rout
ine
pren
atal
offic
e vi
sits-
$30
copa
y D
elive
ry a
nd a
ll in
patie
nt se
rvice
s 30
% c
o-in
sura
nce
N
ot c
over
ed
Ded
uctib
le ap
plies
If y
ou n
eed
hel
p
reco
veri
ng
or h
ave
oth
er s
pec
ial h
ealt
h
nee
ds
Hom
e he
alth
care
$4
0 co
-pay
/visi
t N
ot c
over
ed
Ded
uctib
le ap
plies
Reha
bilit
atio
n se
rvice
s $4
0 co
-pay
/visi
t N
ot c
over
ed
Requ
ires p
rior a
utho
rizat
ion/
One
per
iod
of
treat
men
t for
any
com
bina
tion
of th
erap
ies
with
in 6
0 co
nsec
utiv
e da
ys p
er C
alend
ar Y
ear.
Ded
uctib
le ap
plies
4
of 8
Co
mm
on
M
edic
al E
ven
t S
ervi
ces
Yo
u M
ay N
eed
Yo
ur
cost
if
you
use
Pro
vid
ers:
Lim
itat
ion
s &
Exc
epti
on
s In
Net
wo
rk
Ou
t o
f N
etw
ork
Hab
ilita
tion
serv
ices
$40
co-p
ay/v
isit
/ABA
- $3
0 co
-pa
y/vi
sit
Not
cov
ered
Lim
ited
to A
BA o
nly-
25
hour
s of l
ine
ther
apy
per w
eek
thro
ugh
age
18. P
T/O
T/ST
for
autis
m sp
ectru
m d
isord
er h
as u
nlim
ited
visit
s. Re
quire
s prio
r aut
horiz
atio
n
Skill
ed n
ursin
g ca
re
30%
co-
insu
ranc
e
Not
cov
ered
Re
quire
s prio
r aut
horiz
atio
n/Li
mite
d to
45
days
per
cale
ndar
yea
r/D
educ
tible
appl
ies
Dur
able
med
ical
equi
pmen
t 50
% c
o-in
sura
nce
N
ot c
over
ed
Mus
t be
auth
oriz
ed a
nd o
btain
ed b
y a
BCN
su
pplie
r/30
% c
oins
uran
ce fo
r diab
etic
supp
lies
Hos
pice
serv
ice
No
char
ge
Not
cov
ered
In
patie
nt c
are
requ
ires
auth
oriz
atio
n/D
educ
tible
app
lies
If y
our
child
nee
ds
den
tal o
r ey
e ca
re
Eye
exa
m
Not
cov
ered
N
ot c
over
ed
See
plan
adm
inist
rato
r for
cov
erag
e in
form
atio
n
Glas
ses
Not
cov
ered
N
ot c
over
ed
See
plan
adm
inist
rato
r for
cov
erag
e in
form
atio
n
Den
tal c
heck
-up
Not
cov
ered
N
ot c
over
ed
See
plan
adm
inist
rato
r for
cov
erag
e in
form
atio
n
5
of 8
E
xclu
ded
Ser
vice
s &
Oth
er C
ove
red
Ser
vice
s:
Ser
vice
s Y
ou
r P
lan
Do
es N
OT
Co
ver
(Th
is is
n’t
a c
omp
lete
list
. Ch
eck
you
r p
olic
y or
pla
n d
ocu
men
t fo
r ot
her
exc
lud
ed s
ervi
ces.
)
A
cupu
nctu
re
Co
smet
ic su
rger
y
D
enta
l Car
e (A
dult)
E
lectiv
e A
borti
on
H
earin
g aid
s
Lo
ng-te
rm c
are
N
on-e
mer
genc
y ca
re w
hen
trave
ling
outs
ide
the
U.S
.
Pr
ivat
e-du
ty n
ursin
g
Ro
utin
e ey
e ca
re (A
dult)
Ro
utin
e fo
ot c
are
W
eight
loss
pro
gram
s
Oth
er C
ove
red
Ser
vice
s (T
his
isn
’t a
com
ple
te li
st. C
hec
k yo
ur
pol
icy
or p
lan
doc
um
ent
for
oth
er c
over
ed s
ervi
ces
and
you
r co
sts
for
thes
e se
rvic
es.)
Ba
riatri
c su
rger
y
Chiro
prac
tic c
are
In
ferti
lity
treat
men
t
6
of 8
Y
ou
r R
igh
ts t
o C
on
tin
ue
Co
vera
ge:
If
you
lose
cov
erag
e un
der t
he p
lan, t
hen,
dep
endi
ng u
pon
the
circu
mst
ance
s, Fe
dera
l and
Sta
te la
ws m
ay p
rovi
de p
rote
ctio
ns th
at a
llow
you
to k
eep
healt
h co
vera
ge. A
ny su
ch ri
ghts
may
be
limite
d in
dur
atio
n an
d w
ill re
quire
you
to p
ay a
pre
miu
m, w
hich
may
be
signi
fican
tly h
ighe
r tha
n th
e pr
emiu
m y
ou p
ay w
hile
cove
red
unde
r the
plan
. Oth
er li
mita
tions
on
your
righ
ts to
con
tinue
cov
erag
e m
ay a
lso a
pply.
Fo
r mor
e in
form
atio
n on
you
r rig
hts t
o co
ntin
ue c
over
age,
cont
act t
he p
lan a
t (80
0) 6
62-6
667.
You
may
also
con
tact
you
r sta
te in
sura
nce
depa
rtmen
t, th
e U
.S.
Dep
artm
ent o
f Lab
or, E
mpl
oyee
Ben
efits
Sec
urity
Adm
inist
ratio
n at
1-8
66-4
44-3
272
or w
ww
.dol
.gov
/ebs
a, or
the
U.S
. Dep
artm
ent o
f Hea
lth a
nd H
uman
Se
rvic
es a
t 1-8
77-2
67-2
323
x615
65 o
r ww
w.cc
iio.cm
s.gov
.
Yo
ur
Gri
evan
ce a
nd
Ap
pea
ls R
igh
ts:
If y
ou h
ave
a co
mpl
aint o
r are
diss
atisf
ied w
ith a
den
ial o
f cov
erag
e fo
r clai
ms u
nder
you
r plan
, you
may
be
able
to a
pp
eal o
r file
a g
riev
ance
. Fo
r que
stio
ns
abou
t you
r rig
hts,
this
notic
e, or
ass
istan
ce, y
ou c
an c
onta
ct: B
lue
Care
Net
wor
k, A
ppea
ls an
d G
rieva
nce
Uni
t, M
C C2
48, P
.O. B
ox 2
84, S
outh
field
, MI 4
8086
or
fax
1-88
8-45
8-07
16.
For s
tate
of M
ichig
an a
ssist
ance
con
tact
the
Dep
artm
ent o
f Ins
uran
ce a
nd F
inan
cial S
ervi
ces,
Hea
lthca
re A
ppea
ls Se
ctio
n, O
ffice
of G
ener
al Co
unse
l, 61
1 O
ttaw
a,
3rd F
loor
, P. O
. Box
302
20, L
ansin
g, M
I 489
09-7
720,
mic
higa
n.go
v/di
fs; c
all 1
-877
-999
-644
2 or
fax:
517
-241
-416
8.
For D
epar
tmen
t of L
abor
ass
istan
ce c
onta
ct th
e E
mpl
oyee
Ben
efits
Sec
urity
Adm
inist
ratio
n at
1-8
66-4
44-E
BSA
(327
2) o
r ww
w.d
ol.g
ov/e
bsa/
healt
href
orm
. A
dditi
onall
y, a
cons
umer
ass
istan
ce p
rogr
am c
an h
elp y
ou fi
le yo
ur a
ppea
l. Co
ntac
t the
Mich
igan
Hea
lth In
sura
nce
Cons
umer
Ass
istan
ce P
rogr
am (H
ICA
P),
Dep
artm
ent o
f Ins
uran
ce a
nd F
inan
cial S
ervi
ces,
P. O
. Box
302
20, L
ansin
g, M
I 489
09-7
720,
mic
higa
n.go
v/di
fs; O
fir-h
icap
@m
ichi
gan.
gov.
Do
es t
his
Co
vera
ge
Pro
vid
e M
inim
um
Ess
enti
al C
ove
rag
e?
The
Affo
rdab
le Ca
re A
ct re
quire
s mos
t peo
ple
to h
ave
healt
h ca
re c
over
age
that
qua
lifies
as “
min
imum
ess
entia
l cov
erag
e.” T
his p
lan o
r pol
icy d
oes p
rovi
de
min
imum
ess
entia
l cov
erag
e.
Do
es t
his
Co
vera
ge
Mee
t th
e M
inim
um
Val
ue
Sta
nd
ard
?
In o
rder
for c
erta
in ty
pes o
f hea
lth c
over
age
(for e
xam
ple,
indi
vidu
ally
purc
hase
d in
sura
nce
or jo
b-ba
sed
cove
rage
) to
quali
fy a
s min
imum
ess
entia
l cov
erag
e, th
e pl
an m
ust p
ay, o
n av
erag
e, at
leas
t 60
perc
ent o
f allo
wed
cha
rges
for c
over
ed se
rvic
es. T
his i
s call
ed th
e “m
inim
um v
alue
stan
dard
.” T
his h
ealth
cov
erag
e do
es
mee
t the
min
imum
valu
e st
anda
rd fo
r the
ben
efits
it p
rovi
des.
(IMPO
RTA
NT:
Blu
e Ca
re N
etw
ork
of M
ichig
an is
ass
umin
g th
at y
our c
over
age
prov
ides
for a
ll E
ssen
tial H
ealth
Ben
efit
(EH
B) c
ateg
ories
as d
efin
ed b
y th
e St
ate
of M
ichig
an.
The
min
imum
valu
e of
you
r plan
may
be
affe
cted
if y
our p
lan d
oes n
ot c
over
ce
rtain
EH
B ca
tego
ries,
such
as p
resc
riptio
n dr
ugs,
or if
you
r plan
pro
vide
s cov
erag
e of
spec
ific
EBH
cat
egor
ies, f
or e
xam
ple
pres
crip
tion
drug
s, th
roug
h an
othe
r ca
rrier
. In
thes
e sit
uatio
ns y
ou w
ill n
eed
to c
onta
ct y
our p
lan a
dmin
istra
tor f
or in
form
atio
n on
whe
ther
you
r plan
mee
ts th
e m
inim
um v
alue
stan
dard
for t
he
bene
fits i
t pro
vide
s.)
Tra
nsl
atio
n a
vaila
ble
To
get
help
read
ing
in y
our l
angu
age
call
the
cust
omer
serv
ice n
umbe
r on
the
back
of y
our I
D c
ard.
––––
––––
––––
––––
––––
––To
see e
xamp
les of
how
this
plan
migh
t cov
er cos
ts for
a sa
mple
medic
al sit
uatio
n, see
the n
ext p
age.–
––––
––––
––––
––––
––––
–
Co
vera
ge
Exa
mp
les
7
of 8
A
bo
ut
thes
e C
ove
rag
e E
xam
ple
s:
Thes
e ex
ampl
es sh
ow h
ow th
is pl
an m
ight
co
ver m
edica
l car
e in
giv
en si
tuat
ions
. Use
thes
e ex
ampl
es to
see,
in g
ener
al, h
ow m
uch
finan
cial
prot
ectio
n a
sam
ple
patie
nt m
ight
get
if th
ey a
re
cove
red
unde
r diff
eren
t plan
s.
Th
is is
n
ot
a co
st
esti
mat
or.
D
on’t
use
thes
e ex
ampl
es to
es
timat
e yo
ur a
ctua
l cos
ts
unde
r thi
s plan
. The
act
ual
care
you
rece
ive
will
be
diffe
rent
from
thes
e ex
ampl
es, a
nd th
e co
st o
f th
at c
are
will
also
be
diff
eren
t.
See
the
next
pag
e fo
r im
porta
nt in
form
atio
n ab
out
thes
e ex
ampl
es.
Hav
ing
a b
aby
(nor
mal
del
iver
y)
Am
ou
nt
ow
ed t
o p
rovi
der
s: $
7,54
0
Pla
n p
ays
$4,1
50
P
atie
nt
pay
s $3
,390
S
amp
le c
are
cost
s:
Hos
pita
l cha
rges
(mot
her)
$2,7
00
Rout
ine
obst
etric
car
e $2
,100
H
ospi
tal c
harg
es (b
aby)
$9
00
Ane
sthe
sia
$900
La
bora
tory
test
s $5
00
Pres
crip
tions
$2
00
Radi
olog
y $2
00
Vac
cines
, oth
er p
reve
ntiv
e $4
0 T
otal
$7
,540
P
atie
nt
pay
s:
Ded
uctib
les
$1,5
00
Co-p
ays
$10
Co-in
sura
nce
$1,7
30
Lim
its o
r exc
lusio
ns
$150
T
otal
$3
,390
M
anag
ing
typ
e 2
dia
bet
es
(rou
tin
e m
ain
ten
ance
of
a
wel
l-co
ntr
olle
d c
ond
itio
n)
A
mo
un
t o
wed
to
pro
vid
ers:
$5,
400
P
lan
pay
s $3
,55
0
P
atie
nt
pay
s $1
,850
Sam
ple
car
e co
sts:
Pr
escr
iptio
ns
$2,9
00
Med
ical E
quip
men
t and
Sup
plies
$1
,300
O
ffice
Visi
ts a
nd P
roce
dure
s $7
00
Edu
catio
n $3
00
Labo
rato
ry te
sts
$100
V
accin
es, o
ther
pre
vent
ive
$100
T
otal
$5
,400
P
atie
nt
pay
s:
Ded
uctib
les
$1,1
50
Co-p
ays
$240
Co
-insu
ranc
e $3
80
Lim
its o
r exc
lusio
ns
$80
T
otal
$1
,850
If y
ou a
re a
lso c
over
ed b
y an
acc
ount
-type
plan
such
as a
n in
tegr
ated
hea
lth re
imbu
rsem
ent a
rran
gem
ent (
HRA
), an
d/or
an
healt
h sa
ving
s acc
ount
(HSA
), th
en
you
may
hav
e ac
cess
to a
dditi
onal
fund
s to
help
cov
er c
erta
in o
ut-o
f-poc
ket e
xpen
ses-
like
dedu
ctib
le, c
o-pa
ymen
ts, o
r co-
insu
ranc
e or
ben
efits
not
oth
erw
ise
cove
red.
Co
vera
ge
Exa
mp
les
Qu
esti
ons:
Call
(800
) 662
-666
7 or
visi
t us a
t ww
w.B
CBSM
.com
. If y
ou a
ren’
t clea
r abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
view
the
Glo
ssar
y at
http
://w
ww
.dol
.gov
/ebs
a/pd
f/SB
CUni
form
Glo
ssar
y.pdf
or c
all (8
00) 6
62-6
667
to re
ques
t a c
opy.
8
of 8
Q
ues
tio
ns
and
an
swer
s ab
ou
t th
e C
ove
rag
e E
xam
ple
s:
Wh
at a
re s
om
e o
f th
e as
sum
pti
on
s b
ehin
d t
he
Co
vera
ge
Exa
mp
les?
Cost
s don
’t in
clude
pre
miu
ms.
Sa
mpl
e ca
re c
osts
are
bas
ed o
n na
tiona
l av
erag
es su
pplie
d by
the
U.S
. Dep
artm
ent
of H
ealth
and
Hum
an S
ervi
ces,
and
aren
’t sp
ecifi
c to
a p
artic
ular
geo
grap
hic
area
or
healt
h pl
an.
Th
e pa
tient
’s co
nditi
on w
as n
ot a
n ex
clude
dor
pre
exist
ing
cond
ition
.
All
serv
ices a
nd tr
eatm
ents
star
ted
and
ende
d in
the
sam
e co
vera
ge p
erio
d.
Th
ere
are
no o
ther
med
ical e
xpen
ses f
or
any
mem
ber c
over
ed u
nder
this
plan
.
Out
-of-p
ocke
t exp
ense
s are
bas
ed o
nly
on
treat
ing
the
cond
ition
in th
e ex
ampl
e.
The
patie
nt re
ceiv
ed a
ll ca
re fr
om in
-ne
twor
k p
rovi
der
s. If
the
patie
nt h
ad
rece
ived
car
e fr
om o
ut-o
f-net
wor
k p
rovi
der
s, co
sts w
ould
hav
e be
en h
ighe
r.
Cove
rage
exa
mpl
es a
re c
alcul
ated
bas
ed
on in
divi
dual
cove
rage
.
W
hat
do
es a
Co
vera
ge
Exa
mp
le
sho
w?
Fo
r eac
h tre
atm
ent s
ituat
ion,
the
Cove
rage
E
xam
ple
help
s you
see
how
ded
uct
ible
s,
co-p
aym
ents
, and
co-
insu
ran
ce c
an a
dd u
p. It
als
o he
lps y
ou se
e w
hat e
xpen
ses m
ight
be
left
up to
you
to p
ay b
ecau
se th
e se
rvice
or
treat
men
t isn
’t co
vere
d or
pay
men
t is l
imite
d.
C
an I
use
Co
vera
ge
Exa
mp
les
to
com
par
e p
lan
s?
Y
es. W
hen
you
look
at t
he S
umm
ary
of B
enef
its
and
Cove
rage
for o
ther
plan
s, yo
u’ll
find
the
sam
e Co
vera
ge E
xam
ples
. Whe
n yo
u co
mpa
re p
lans,
chec
k th
e “P
atien
t Pay
s” b
ox in
eac
h ex
ampl
e. Th
e sm
aller
that
num
ber,
the
mor
e co
vera
ge th
e pl
an p
rovi
des.
Do
es t
he
Co
vera
ge
Exa
mp
le
pre
dic
t m
y o
wn
car
e n
eed
s?
N
o. T
reat
men
ts sh
own
are
just
exa
mpl
es.
The
care
you
wou
ld re
ceiv
e fo
r thi
s con
ditio
n co
uld
be d
iffer
ent,
base
d on
you
r doc
tor’s
ad
vice
, you
r age
, how
serio
us y
our c
ondi
tion
is, a
nd m
any
othe
r fac
tors
.
Are
th
ere
oth
er c
ost
s I s
ho
uld
co
nsi
der
wh
en c
om
par
ing
pla
ns?
Yes
. An
impo
rtant
cos
t is t
he p
rem
ium
you
pay
. G
ener
ally,
the
low
er y
our p
rem
ium
, the
mor
e yo
u’ll
pay
in o
ut-o
f-poc
ket c
osts
, suc
h as
co
-pay
men
ts, d
edu
ctib
les,
and
co-i
nsu
ran
ce.
You
shou
ld a
lso c
onsid
er c
ontri
butio
ns to
ac
coun
ts su
ch a
s hea
lth sa
ving
s acc
ount
s (H
SAs)
, fle
xibl
e sp
endi
ng a
rran
gem
ents
(FSA
s) o
r hea
lth
reim
burs
emen
t acc
ount
s (H
RAs)
that
help
you
pay
ou
t-of-p
ocke
t exp
ense
s.
Do
es t
he
Co
vera
ge
Exa
mp
le
pre
dic
t m
y fu
ture
exp
ense
s?
N
o. C
over
age
Exa
mpl
es a
re n
ot c
ost
estim
ator
s. Y
ou c
an’t
use
the
exam
ples
to
estim
ate
cost
s for
an
actu
al co
nditi
on. T
hey
are
for c
ompa
rativ
e pu
rpos
es o
nly.
You
r ow
n co
sts w
ill b
e di
ffere
nt d
epen
ding
on
the
care
yo
u re
ceiv
e, th
e pr
ices y
our p
rovi
der
s ch
arge
, an
d th
e re
imbu
rsem
ent y
our h
ealth
plan
all
ows.
Corn
erst
one
Educ
atio
n G
roup
Sum
mar
y of
Ben
efits
and
Cov
erag
e:W
hat t
his
Pla
n C
over
s &
Wha
t it C
osts
Cov
erag
e fo
r:In
divi
dual
/Fam
ilyPl
an T
ype:
PP
O
Gro
up
Nu
mb
er
007023341-
0000
Qu
est
ion
s: C
allth
e n
um
ber
on
th
e b
ack o
f yo
ur
BC
BSM
ID
car
do
r vis
it u
s at
ww
w.b
cbsm
.co
m.If
yo
u a
ren
’t c
lear
ab
out
any
of
the
un
der
lined
ter
ms
use
d in
th
isfo
rm, se
e th
e G
loss
ary.
Yo
u c
an v
iew
th
eG
loss
ary
ath
ttp
://w
ww
.do
l.go
v/eb
sa/p
df/
SB
CU
nif
orm
Glo
ssar
y.p
df
or
call
the
num
ber
on
th
e b
ack o
f yo
ur
BC
BSM
ID
car
d t
o r
eques
t a
cop
y.SB
C000000431415
1of
8
This
is o
nly
a su
mm
ary.
If y
ou w
ant
mo
re d
etai
l ab
out
your
cover
age
and c
ost
s, y
ou c
an g
et t
he
com
ple
te t
erm
s in
th
e p
olic
y o
r p
lan
do
cum
ent
atw
ww
.bcb
sm.c
om
or
by
calli
ng
the
num
ber
on
th
e b
ack o
f yo
ur
BC
BSM
ID
car
d.
Impo
rtan
t Que
stio
nsA
nsw
ers
Why
this
Mat
ters
:In
-Net
wor
kO
ut-o
f-Net
wor
k
Wh
at
is t
he o
vera
lld
ed
ucti
ble
?$5
00 I
ndiv
idual
/$1
,000 F
amily
$1,0
00 I
ndiv
idual
/$2
,000 F
amily
Yo
u m
ust
pay
all
the
cost
s up
to
th
ed
ed
ucti
ble
amo
un
t b
efo
re t
his
pla
n b
egin
s to
pay
for
cover
ed s
ervic
es y
ou u
se. C
hec
k y
our
po
licy
or
pla
n d
ocu
men
t to
see
wh
en t
he
ded
ucti
ble
star
ts o
ver
(usu
ally
, b
ut
no
t al
way
s, J
anuar
y 1st
).See
th
e ch
art
star
tin
g o
n
pag
e2 f
or
ho
w m
uch
yo
u p
ay f
or
cover
ed s
ervic
es a
fter
yo
u m
eet
the
ded
ucti
ble
.
Are
th
ere
oth
er
ded
ucti
ble
s fo
rsp
ecif
ic s
erv
ices?
No
.Y
ou d
on
’t h
ave
to m
eet
ded
ucti
ble
s fo
r sp
ecif
ic s
ervic
es, b
ut
see
the
char
t st
arti
ng
on
pag
e2 f
or
oth
er c
ost
s fo
r se
rvic
es t
his
pla
n c
over
s.
Is t
here
an
ou
t-o
f-p
ock
et
lim
ito
n m
y e
xp
en
ses?
(May
in
clude
a co
-in
sura
nce
max
imum
)
$2,0
00 I
ndiv
idual
/$4
,000 F
amily
$4,0
00 I
ndiv
idual
/$8
,000 F
amily
Th
eo
ut-
of-
po
ck
et
lim
itis
th
e m
ost
yo
u c
ould
pay
duri
ng
a co
ver
age
per
iod (
usu
ally
on
e ye
ar)
for
your
shar
e o
f th
e co
st o
f co
ver
ed s
ervic
es. T
his
lim
it h
elp
s yo
u p
lan
fo
rh
ealt
h c
are
exp
ense
s.
Wh
at
is n
ot
inclu
ded
in
the
ou
t-o
f-p
ock
et
lim
it?
Pre
miu
ms,
bal
ance
-bill
ed c
har
ges,
an
yp
har
mac
y p
enal
ty a
nd h
ealt
h c
are
this
pla
n d
oes
n’t
co
ver
.E
ven
th
ough
yo
u p
ay t
hes
e ex
pen
ses,
th
ey d
on
’t c
oun
t to
war
d t
he
ou
t-o
f-p
ock
et
lim
it.
Is t
here
an
ove
rall
an
nu
al
lim
ito
n w
hat
the p
lan
pays?
No
.T
he
char
t st
arti
ng
on
pag
e2 d
escr
ibes
an
y lim
its
on
wh
at t
he
pla
n w
ill p
ay f
or
spec
ific
cover
ed s
ervic
es, su
ch a
s o
ffic
e vis
its.
Do
es
this
pla
n u
se a
netw
ork
of
pro
vid
ers
?
Yes
.F
or
a lis
t o
f in
-net
wo
rk p
rovid
ers,
see
ww
w.b
cbsm
.co
m o
r ca
llth
en
um
ber
on
th
e b
ack o
f yo
ur
BC
BSM
ID c
ard
.
If y
ou u
se a
nin
-net
wo
rkdo
cto
r o
r o
ther
hea
lth
car
ep
rovi
der,
th
isp
lan
will
pay
so
me
or
all o
f th
e co
sts
of
cover
ed s
ervic
es. B
e aw
are,
yo
ur
in-n
etw
ork
do
cto
r o
r h
osp
ital
may
use
an
out-
of-
net
wo
rkp
rovi
der
for
som
e se
rvic
es.
Pla
ns
use
th
e te
rmin
-net
wo
rk,
pre
ferr
ed
, o
rp
arti
cip
atin
gfo
rp
rovi
ders
in
th
eir
netw
ork
. S
ee t
he
char
t st
arti
ng
on
pag
e2 f
or
ho
w t
his
pla
n p
ays
dif
fere
nt
kin
ds
of
pro
vid
ers
.
Do
I n
eed
a r
efe
rral
to s
ee a
specia
list
?N
o.
Yo
u c
an s
ee t
he
specia
list
you c
ho
ose
wit
ho
ut
per
mis
sio
n f
rom
th
isp
lan
.
Are
th
ere
serv
ices
this
pla
nd
oesn
’t c
ove
r?Y
es.
So
me
of
the
serv
ices
th
isp
lan
do
esn
’t c
over
are
lis
ted o
n p
age
5. See
yo
ur
po
licy
or
pla
ndo
cum
ent
for
addit
ion
al in
form
atio
n a
bo
ut
exclu
ded
serv
ices.
2of
8
·C
o-p
aym
en
tsar
e fi
xed d
ollar
am
oun
ts (
for
exam
ple
, $1
5)
you p
ay f
or
cover
ed h
ealt
h c
are,
usu
ally
wh
en y
ou r
ecei
ve
the
serv
ice.
·C
o-i
nsu
ran
ce
isyo
ursh
are
of
the
cost
s o
f a
cover
ed s
ervic
e, c
alcu
late
d a
s a
per
cen
t o
f th
eall
ow
ed
am
ou
nt
for
the
serv
ice.
Fo
r ex
amp
le, if
th
ep
lan
’sall
ow
ed
am
ou
nt
for
an o
ver
nig
ht
ho
spit
al s
tay
is $
1,0
00, yo
ur
co
-in
sura
nce
pay
men
t o
f 20%
wo
uld
be
$200. T
his
may
ch
ange
if
you h
aven
’t m
etyo
ur
ded
ucti
ble
.
·T
he
amo
un
t th
ep
lan
pay
s fo
r co
ver
ed s
ervic
es is
bas
ed o
n t
he
all
ow
ed
am
ou
nt .
If
ano
ut-
of-
net
wo
rkp
rovi
der
char
ges
mo
re t
han
th
eall
ow
ed
am
ou
nt,
yo
u m
ay h
ave
to p
ay t
he
dif
fere
nce
. F
or
exam
ple
, if
an
out-
of-
net
wo
rk h
osp
ital
ch
arge
s $1
,500 f
or
an o
ver
nig
ht
stay
an
d t
he
all
ow
ed
am
ou
nt
is $
1,0
00, yo
u m
ay h
ave
to p
ay t
he
$500 d
iffe
ren
ce. (T
his
is
calle
db
ala
nce b
illi
ng
.)
·T
his
pla
n m
ay e
nco
ura
ge y
ou t
o u
sein
-net
wo
rkp
rovi
ders
by
char
gin
g yo
u lo
wer
ded
ucti
ble
s,co
-paym
en
tsan
dco
-in
sura
nce
amo
un
ts.
Com
mon
Med
ical
Eve
ntSe
rvic
es Y
ou M
ayN
eed
Your
cos
t if y
ou u
se a
Lim
itatio
ns &
Exc
eptio
nsIn
-Net
wor
k Pr
ovid
erO
ut-o
f-Net
wor
k Pr
ovid
er
If y
ou
vis
it a
healt
hcare
pro
vid
er’
s o
ffic
eo
r cli
nic
Pri
mar
y ca
re v
isit
to
trea
t an
in
jury
or
illn
ess
No
t C
over
ed40%
co
-in
sura
nce
aft
erded
uct
ible
---n
on
e---
Sp
ecia
list
vis
itN
ot
Co
ver
ed40%
co
-in
sura
nce
aft
erded
uct
ible
---n
on
e---
Oth
er p
ract
itio
ner
off
ice
vis
it
$20 c
o-p
ay f
or
Ch
iro
pra
ctic
and o
steo
pat
hic
man
ipula
tive
ther
apy
40%
co
-in
sura
nce
aft
erded
uct
ible
fo
r C
hir
op
ract
ican
d o
steo
pat
hic
man
ipula
tive
ther
apy
Lim
ited
to
a c
om
bin
ed m
axim
um
of
24 v
isit
s p
erm
emb
er p
er c
alen
dar
yea
r fo
r ch
iro
pra
ctic
an
do
steo
pat
hic
man
ipula
tive
ther
apy.
Pre
ven
tive
care
/sc
reen
ing/
imm
un
izat
ion
No
Ch
arge
No
t C
over
ed--
-no
ne-
--
If y
ou
have
a t
est
Dia
gno
stic
tes
t (x
-ray
,b
loo
d w
ork
)20%
co
-in
sura
nce
aft
erded
uct
ible
40%
co
-in
sura
nce
aft
erded
uct
ible
---n
on
e---
Imag
ing
(CT
/P
ET
scan
s, M
RIs
)20%
co
-in
sura
nce
aft
erded
uct
ible
40%
co
-in
sura
nce
aft
erded
uct
ible
---n
on
e---
If y
ou
need
dru
gs
totr
eat
yo
ur
illn
ess
or
co
nd
itio
nSo
me
pla
ns
may
hav
e a
sep
arat
e o
ut
of
po
cket
max
imum
fo
rp
resc
rip
tio
n d
rug
cover
age,
fo
r m
ore
info
rmat
ion
ple
ase
con
tact
yo
ur
pla
nad
min
istr
ato
r
Gen
eric
or
pre
scri
bed
over
-th
e-co
un
ter
dru
gs
$15 c
o-p
ay f
or
reta
il 30-d
aysu
pp
ly; $3
0 c
o-p
ay f
or
reta
ilo
r m
ail o
rder
90-d
ay s
up
ply
In-N
etw
ork
co
-pay
plu
s an
addit
ion
al 2
5%
of
the
BC
BSM
ap
pro
ved
am
oun
t fo
rth
e dru
g
Fo
r in
form
atio
n o
n w
om
en's
co
ntr
acep
tive
cover
age,
co
nta
ct y
our
pla
n a
dm
inis
trat
or.
90-d
aysu
pp
ly n
ot
cover
ed o
ut-
of-
net
wo
rk. S
pec
ialt
ydru
gs lim
ited
to
a 3
0-d
ay s
up
ply
per
fill
.
Fo
rmula
ry (
pre
ferr
ed)
bra
nd-n
ame
dru
gs
$30
co-p
ay f
or r
etai
l 30-
day
supp
ly; $
60 c
o-pa
y fo
r re
tail
or m
ail o
rder
90-
day
supp
ly
In-N
etw
ork
co
-pay
plu
s an
addit
ion
al 2
5%
of
the
BC
BSM
ap
pro
ved
am
oun
t fo
rth
e dru
g
90-d
ay s
up
ply
no
t co
ver
ed o
ut-
of-
net
wo
rk.
Sp
ecia
lty
dru
gs lim
ited
to
a 3
0-d
ay s
up
ply
per
fill
No
nfo
rmula
ry(n
on
pre
ferr
ed)
bra
nd-
nam
e dru
gs
$30
co-p
ay f
or r
etai
l 30-
day
supp
ly; $
60 c
o-pa
y fo
r re
tail
or m
ail o
rder
90-
day
supp
ly
In-N
etw
ork
co
-pay
plu
s an
addit
ion
al 2
5%
of
the
BC
BSM
ap
pro
ved
am
oun
t fo
rth
e dru
g
90-d
ay s
up
ply
no
t co
ver
ed o
ut-
of-
net
wo
rk.
Sp
ecia
lty
dru
gs lim
ited
to
a 3
0-d
ay s
up
ply
per
fill
3of
8
Com
mon
Med
ical
Eve
ntSe
rvic
es Y
ou M
ayN
eed
Your
cos
t if y
ou u
se a
Lim
itatio
ns &
Exc
eptio
nsIn
-Net
wor
k Pr
ovid
erO
ut-o
f-Net
wor
k Pr
ovid
er
If y
ou
have
ou
tpati
en
tsu
rgery
Fac
ility
fee
(e.
g.,
amb
ula
tory
surg
ery
cen
ter)
20%
co
-in
sura
nce
aft
erd
educt
ible
40%
co
-in
sura
nce
aft
erded
uct
ible
---n
on
e---
Ph
ysic
ian
/su
rgeo
n f
ees
20%
co
-in
sura
nce
aft
erd
educt
ible
40%
co
-in
sura
nce
aft
erded
uct
ible
---n
on
e---
If y
ou
need
im
med
iate
med
ical
att
en
tio
n
Em
erge
ncy
ro
om
serv
ices
$150 c
o-p
ay$1
50 c
o-p
ayC
o-p
ay w
aived
if
adm
itte
d o
r fo
r an
acc
iden
tal
inju
ry.
Em
erge
ncy
med
ical
tran
spo
rtat
ion
20%
co
-in
sura
nce
aft
erd
educt
ible
20%
co
-in
sura
nce
aft
erded
uct
ible
---n
on
e---
Urg
ent
care
No
t C
over
ed40%
co
-in
sura
nce
aft
erded
uct
ible
---n
on
e---
If y
ou
have
a h
osp
ital
stay
Fac
ility
fee
(e.
g., h
osp
ital
roo
m)
20%
co
-in
sura
nce
aft
erd
educt
ible
40%
co
-in
sura
nce
aft
erded
uct
ible
---n
on
e---
Ph
ysic
ian
/su
rgeo
n f
ee20%
co
-in
sura
nce
aft
erd
educt
ible
40%
co
-in
sura
nce
aft
erded
uct
ible
---n
on
e---
If y
ou
have
men
tal
healt
h,
beh
avi
ora
lh
ealt
h,
or
sub
stan
ce
ab
use
need
s
Men
tal/
Beh
avio
ral
hea
lth
outp
atie
nt
serv
ices
20%
co
-in
sura
nce
aft
erd
educt
ible
40%
co
-in
sura
nce
aft
erded
uct
ible
---n
on
e---
Men
tal/
Beh
avio
ral
hea
lth
in
pat
ien
t se
rvic
es20%
co
-in
sura
nce
aft
erd
educt
ible
40%
co
-in
sura
nce
aft
erded
uct
ible
---n
on
e---
Sub
stan
ce u
se d
iso
rder
outp
atie
nt
serv
ices
20%
co
-in
sura
nce
aft
erd
educt
ible
40%
co
-in
sura
nce
aft
erded
uct
ible
---n
on
e---
Sub
stan
ce u
se d
iso
rder
inp
atie
nt
serv
ices
20%
co
-in
sura
nce
aft
erd
educt
ible
40%
co
-in
sura
nce
aft
erded
uct
ible
---n
on
e---
If y
ou
are
pre
gn
an
t
Pre
nat
al a
nd p
ost
nat
alca
reN
o C
har
ge40%
co
-in
sura
nce
aft
erded
uct
ible
---n
on
e---
Del
iver
y an
d a
llin
pat
ien
t se
rvic
es20%
co
-in
sura
nce
aft
erd
educt
ible
40%
co
-in
sura
nce
aft
erded
uct
ible
---n
on
e---
4of
8
Com
mon
Med
ical
Eve
ntSe
rvic
es Y
ou M
ayN
eed
Your
cos
t if y
ou u
se a
Lim
itatio
ns &
Exc
eptio
nsIn
-Net
wor
k Pr
ovid
erO
ut-o
f-Net
wor
k Pr
ovid
er
If y
ou
need
help
reco
veri
ng
or
have
oth
er
specia
l h
ealt
hn
eed
s
Ho
me
hea
lth
car
e20%
co
-in
sura
nce
aft
erd
educt
ible
20%
co
-in
sura
nce
aft
erded
uct
ible
---n
on
e---
Reh
abili
tati
on
ser
vic
es20%
co
-in
sura
nce
aft
erd
educt
ible
40%
co
-in
sura
nce
aft
erded
uct
ible
Ph
ysic
al, Sp
eech
an
d O
ccup
atio
nal
Th
erap
y is
limit
ed t
o a
co
mb
ined
max
imum
of
60 v
isit
s p
erm
emb
er, p
er c
alen
dar
yea
r.
Hab
ilit
atio
n s
ervic
es
20%
co
-in
sura
nce
aft
erd
educt
ible
fo
r A
pp
lied
Beh
avio
ral A
nal
ysis
; 20%
co
-in
sura
nce
aft
er d
educt
ible
fo
rP
hys
ical
, Sp
eech
an
dO
ccup
atio
nal
Th
erap
y
20%
co
-in
sura
nce
af
ter
ded
uct
ible
fo
r A
pp
lied
Beh
avio
ral A
nal
ysis
; 40%
co
-in
sura
nce
aft
er d
educt
ible
fo
rP
hys
ical
, Sp
eech
an
dO
ccup
atio
nal
Th
erap
y
Tre
atm
ent
of
Ap
plie
d B
ehav
iora
l A
nal
ysis
(A
BA
)fo
r A
uti
sm lim
ited
to
25 h
ours
of
dir
ect
line
ther
apy
per
wee
k p
er m
emb
er t
hro
ugh
age
18.
Ph
ysic
al, O
ccup
atio
nal
, an
d S
pee
ch T
her
apy
limit
sar
e co
mb
ined
wit
h R
ehab
ilita
tio
n s
ervic
es lim
its.
AB
A s
ervic
es n
ot
avai
lab
le o
uts
ide
of
Mic
hig
an.
Skille
d n
urs
ing
care
20%
co
-in
sura
nce
aft
erd
educt
ible
20%
co
-in
sura
nce
aft
erded
uct
ible
Lim
ited
to
a m
axim
um
of
120 d
ays
per
mem
ber
per
cal
endar
yea
r.
Dura
ble
med
ical
equip
men
t20%
co
-in
sura
nce
aft
erd
educt
ible
20%
co
-in
sura
nce
aft
erded
uct
ible
---n
on
e---
Ho
spic
e se
rvic
eN
o C
har
geN
o C
har
ge--
-no
ne-
--
If y
ou
r ch
ild
need
sd
en
tal
or
eye c
are
Fo
r m
ore
in
form
atio
n o
np
edia
tric
vis
ion
or
den
tal,
con
tact
yo
ur
pla
nad
min
istr
ato
r
Eye
exam
No
t C
over
edN
ot
Co
ver
ed--
-no
ne-
--
Gla
sses
No
t C
over
edN
ot
Co
ver
ed--
-no
ne-
--
Den
tal ch
eck-u
pN
ot
Co
ver
edN
ot
Co
ver
ed--
-no
ne-
--
5of
8
Excl
uded
Ser
vice
s &
Oth
er C
over
ed S
ervi
ces:
Serv
ices
You
r Pla
n D
oes
NO
T C
over
(Th
is i
sn’t
a c
om
ple
te l
ist.
Ch
eck
yo
ur
po
licy o
r p
lan
do
cu
men
tfo
r o
ther
exclu
ded
serv
ices.
)
·A
cup
un
cture
·C
osm
etic
surg
ery
·D
enta
l ca
re (
Adult
)
·H
eari
ng
aids
·In
fert
ility
tre
atm
ent
·L
on
g-te
rm c
are
·R
outi
ne
eye
care
(A
dult
)
·R
outi
ne
foo
t ca
re
·W
eigh
t lo
ss p
rogr
ams
Oth
er C
over
ed S
ervi
ces
(Th
is i
sn’t
a c
om
ple
te l
ist.
Ch
eck
yo
ur
po
licy o
r p
lan
do
cu
men
t fo
r o
ther
co
vere
d s
erv
ices
an
d y
ou
r co
sts
for
these
serv
ices.
)
·B
aria
tric
surg
ery
·C
hir
op
ract
ic C
are
·C
over
age
pro
vid
ed o
uts
ide
the
Un
ited
Sta
tes.
See
htt
p:/
/p
rovid
er.b
cbs.
com
·If
yo
u a
re a
lso
co
ver
ed b
y an
acc
oun
t-ty
pe
pla
n s
uch
as
an in
tegr
ated
hea
lth
fle
xib
lesp
endin
g ar
ran
gem
ent
(FSA
), h
ealt
hre
imb
urs
emen
t ar
ran
gem
ent
(HR
A),
an
d/o
r a
hea
lth
sav
ings
acc
oun
t (H
SA
), t
hen
yo
u m
ayh
ave
acce
ss t
o a
ddit
ion
al f
un
ds
to h
elp
co
ver
cert
ain
out-
of-
po
cket
exp
ense
s – lik
e th
eded
uct
ible
, co
-pay
men
ts, o
r co
-in
sura
nce
, o
rb
enef
its
no
t o
ther
wis
e co
ver
ed
·N
on
-Em
erge
ncy
car
e w
hen
tra
vel
ing
outs
ide
the
U.S
·P
rivat
e D
uty
Nurs
ing
6of
8
Your
Rig
hts
to C
ontin
ue C
over
age:
If y
ou lo
se c
over
age
un
der
th
e p
lan
, th
en, dep
endin
g up
on
th
e ci
rcum
stan
ces,
Fed
eral
an
d S
tate
law
s m
ay p
rovid
e p
rote
ctio
ns
that
allo
w y
ou t
o k
eep
hea
lth
cover
age.
An
y su
ch r
igh
ts m
ay b
e lim
ited
in
dura
tio
n a
nd w
ill r
equir
e yo
u t
o p
ay a
pre
miu
m, w
hic
h m
ay b
e si
gnif
ican
tly
hig
her
th
an t
he
pre
miu
m y
ou p
ay w
hile
cover
ed u
nder
th
e p
lan
. O
ther
lim
itat
ion
s o
n y
our
righ
ts t
o c
on
tin
ue
cover
age
may
als
o a
pp
ly.
Fo
r m
ore
in
form
atio
n o
n y
our
righ
ts t
o c
on
tin
ue
cover
age,
co
nta
ct t
he
pla
n a
tth
e n
um
ber
on
th
e b
ack o
f yo
ur
BC
BSM
ID
car
d.
Yo
u m
ay a
lso
co
nta
ct y
our
stat
ein
sura
nce
dep
artm
ent,
th
e U
.S. D
epar
tmen
t o
f L
abo
r, E
mp
loye
e B
enef
its
Sec
uri
ty A
dm
inis
trat
ion
at
1-8
66-4
44-3
272
or
ww
w.d
ol.g
ov/eb
sa, o
r th
e U
.S.
Dep
artm
ent
of
Hea
lth
an
d H
um
an S
ervic
es a
t 1-8
77-2
67-2
323 x
61565
or
ww
w.c
ciio
.cm
s.go
v.
Your
Grie
vanc
e an
d A
ppea
ls R
ight
s:If
yo
u h
ave
a co
mp
lain
t o
r ar
e dis
sati
sfie
d w
ith
a d
enia
l o
f co
ver
age
for
clai
ms
un
der
yo
ur
pla
n, yo
u m
ay b
e ab
le t
oap
peal
or
file
ag
rieva
nce. F
or
ques
tio
ns
abo
ut
your
righ
ts, th
is n
oti
ce, o
r as
sist
ance
, yo
u c
an c
on
tact
Blu
e C
ross
®an
d B
lue
Sh
ield
®o
f M
ich
igan
by
calli
ng
the
num
ber
on
th
e b
ack o
f yo
ur
BC
BSM
ID
car
d.
Or,
yo
u c
an c
on
tact
Mic
hig
an O
ffic
e o
f F
inan
cial
an
d I
nsu
ran
ce R
egula
tio
n a
tw
ww
.mic
hig
an
.go
v/o
fir
or
1-8
77-9
99-6
442. F
or
gro
up
hea
lth
co
ver
age
sub
ject
to E
RIS
A, yo
u m
ay a
lso
co
nta
ct E
mp
loye
e B
enef
its
Sec
uri
ty A
dm
inis
trat
ion
at
1-8
66-4
44-E
BSA
(3272).
Doe
s th
is C
over
age
Prov
ide
Min
imum
Ess
entia
l Cov
erag
e?T
he
Aff
ord
able
Car
e A
ct r
equir
es m
ost
peo
ple
to
hav
e h
ealt
h c
are
cover
age
that
qual
ifie
s as
“m
inim
um
ess
enti
al c
over
age.
” T
his
pla
n o
r p
olic
y do
es p
rovid
em
inim
um
ess
enti
al c
over
age.
Doe
s th
is C
over
age
Mee
t the
Min
imum
Val
ue S
tand
ard?
In o
rder
fo
r ce
rtai
n t
ypes
of
hea
lth
co
ver
age
(fo
r ex
amp
le, in
div
idual
ly p
urc
has
ed in
sura
nce
or
job
-bas
ed c
over
age)
to
qual
ify
as m
inim
um
ess
enti
al c
over
age,
th
ep
lan
must
pay
, o
n a
ver
age,
at
leas
t 60 p
erce
nt
of
allo
wed
ch
arge
s fo
r co
ver
ed s
ervic
es. T
his
is
calle
d t
he
“min
imum
val
ue
stan
dar
d.”
T
his
hea
lth
co
ver
age
do
esm
eet
the
min
imum
val
ue
stan
dar
d f
or
the
ben
efit
s it
pro
vid
es. (I
MP
OR
TA
NT
: B
lue
Cro
ss B
lue
Sh
ield
of
Mic
hig
an is
assu
min
g th
at y
our
cover
age
pro
vid
es f
or
all
Ess
enti
al H
ealt
h B
enef
it (
EH
B)
cate
gori
es a
s def
ined
by
the
Sta
te o
f M
ich
igan
. T
he
min
imum
val
ue
of
your
pla
n m
ay b
e af
fect
ed if
your
pla
n d
oes
no
t co
ver
cert
ain
EH
B c
ateg
ori
es, su
ch a
s p
resc
rip
tio
n d
rugs
, o
r if
yo
ur
pla
n p
rovid
es c
over
age
of
spec
ific
EH
B c
ateg
ori
es, fo
r ex
amp
le p
resc
rip
tio
n d
rugs
, th
rough
an
oth
erca
rrie
r. In
th
ese
situ
atio
ns
you w
ill n
eed t
o c
on
tact
yo
ur
pla
n a
dm
inis
trat
or
for
info
rmat
ion
on
wh
eth
er y
our
pla
n m
eets
th
e m
inim
um
val
ue
stan
dar
d f
or
the
ben
efit
s it
pro
vid
es.)
Lang
uage
Acc
ess
Serv
ices
Fo
r as
sist
ance
in
a lan
guag
e b
elo
w p
leas
e ca
llth
e n
um
ber
on
th
e b
ack o
f yo
ur
BC
BSM
ID
car
d.
SP
AN
ISH
(E
spañ
ol)
:P
ara
ayuda
en e
spañ
ol,
llam
e al
núm
ero
de
serv
icio
al cl
ien
te q
ue
se e
ncu
entr
a en
est
e av
iso
ó e
n e
l re
ver
so d
e su
tarj
eta
de
iden
tifi
caci
ón
.T
AG
AL
OG
(T
agal
og)
:P
ara
sa t
ulo
ng
sa w
ikan
g T
agal
og,
man
gyar
ing
tum
awag
sa
num
ero
ng
serb
isyo
sa
mam
imili
na
nak
alag
ay s
a lik
od n
g iy
on
g p
agkak
akila
nla
nkar
d o
sa
pau
naw
ang
ito
.
CH
INE
SE
(中文
):要获取中文帮助，请致电您的身份识别卡背面或本通知提供的客户服务
号码。
NA
VA
JO (
Din
e):
Taa
’din
eji’k
eego
sh
ii’k
aa’a
hdo
ol’w
oo
l n
iniz
in’g
oo
, b
eesh
beh
ane’
e n
aal’t
soo
s b
ikii
sin
’dah
iigii
bin
ii’dee
hgo
eeh
’do
odag
o d
i’naa
ltso
o b
ikai
igii
bic
hi’h
oo
dilln
ii.
––––––––––––––––––––––T
o se
e ex
ampl
es o
f ho
w thi
s pl
an m
ight
cov
er c
osts
for
a s
ampl
e m
edical
situa
tion
, se
eth
ene
xt
page
.–––––––––––
–––––––––––
7of
8
Abo
ut th
ese
Cov
erag
eEx
ampl
es:
Th
ese
exam
ple
s sh
ow
ho
w t
his
pla
n m
igh
tco
ver
med
ical
car
e in
giv
en s
ituat
ion
s. U
se t
hes
eex
amp
les
to s
ee, in
gen
eral
, h
ow
much
fin
anci
alp
rote
ctio
n a
sam
ple
pat
ien
t m
igh
t ge
t if
th
ey a
reco
ver
ed u
nder
dif
fere
nt
pla
ns.
This
isno
t a c
ost
estim
ator
.
Do
n’t
use
th
ese
exam
ple
s to
esti
mat
e yo
ur
actu
al c
ost
sun
der
th
isp
lan
. T
he
actu
alca
re y
ou r
ecei
ve
will
be
dif
fere
nt
fro
m t
hes
eex
amp
les,
an
d t
he
cost
of
that
car
e w
ill al
so b
edif
fere
nt.
See
th
e n
ext
pag
e fo
rim
po
rtan
t in
form
atio
n a
bo
ut
thes
e ex
amp
les.
Ple
ase
no
te: C
over
age
exam
ple
s ar
e ca
lcula
ted
bas
ed o
n in
div
idual
co
ver
age.
Hav
ing
a ba
by(n
orm
al
deli
very
)
nA
mou
nt o
wed
to p
rovi
ders
:$7,
540
nPl
an p
ays
$5,5
20n
Patie
nt p
ays
$2,0
20
Sam
ple
care
cos
ts:
Ho
spit
al c
har
ges
(mo
ther
)$2
,700
Ro
uti
ne
ob
stet
ric
care
$2,1
00
Ho
spit
al c
har
ges
(bab
y)$9
00
An
esth
esia
$900
Lab
ora
tory
tes
ts$5
00
Pre
scri
pti
on
s$2
00
Rad
iolo
gy$2
00
Vac
cin
es, o
ther
pre
ven
tive
$40
To
tal
$7,5
40
Patie
nt p
ays:
Ded
uct
ible
s$5
00
Co
-pay
s$2
0
Co
-in
sura
nce
$1,3
50
Lim
its
or
excl
usi
on
s$1
50
To
tal
$2,0
20
Man
agin
g ty
pe 2
dia
bete
s(r
ou
tin
e m
ain
ten
an
ce o
f
a w
ell
-co
ntr
oll
ed
co
nd
itio
n)
nA
mou
nt o
wed
to p
rovi
ders
:$5,
400
nPl
an p
ays
$3,0
30n
Patie
nt p
ays
$2,3
70
Sam
ple
care
cos
ts:
Pre
scri
pti
on
s$2
,900
Med
ical
Equip
men
t an
d S
up
plie
s$1
,300
Off
ice
Vis
its
and P
roce
dure
s$7
00
Educa
tio
n$3
00
Lab
ora
tory
tes
ts$1
00
Vac
cin
es, o
ther
pre
ven
tive
$100
To
tal
$5,4
00
Patie
nt p
ays:
Ded
uct
ible
s$5
00
Co
-pay
s$6
00
Co
-in
sura
nce
$180
Lim
its
or
excl
usi
on
s$1
,090
To
tal
$2,3
70
Qu
est
ion
s: C
allth
e n
um
ber
on
th
e b
ack o
f yo
ur
BC
BSM
ID
car
d o
r vis
it u
s at
ww
w.b
cbsm
.co
m. If
yo
u a
ren
’t c
lear
ab
out
any
of
the
un
der
lined
ter
ms
use
d in
th
isfo
rm, se
e th
e G
loss
ary.
Yo
u c
an v
iew
th
e G
loss
ary
ath
ttp
://w
ww
.do
l.go
v/eb
sa/p
df/
SB
CU
nif
orm
Glo
ssar
y.p
df
or
call
the
num
ber
on
th
e b
ack o
f yo
ur
BC
BSM
ID
car
d t
o r
eques
t a
cop
y.8
of8
Que
stio
ns a
nd a
nsw
ers
abou
tthe
Cov
erag
e Ex
ampl
es:
Wha
t are
som
e of
the
assu
mpt
ions
beh
ind
the
Cov
erag
e Ex
ampl
es?
·C
ost
s do
n’t
in
clude
pre
miu
ms.
·Sam
ple
car
e co
sts
are
bas
ed o
n n
atio
nal
aver
ages
sup
plied
by
the
U.S
. D
epar
tmen
to
f H
ealt
h a
nd H
um
an S
ervic
es, an
d a
ren
’tsp
ecif
ic t
o a
par
ticu
lar
geo
grap
hic
are
a o
rh
ealt
hp
lan
.
·T
he
pat
ien
t’s
con
dit
ion
was
no
t an
exc
luded
or
pre
exis
tin
g co
ndit
ion
.
·A
ll se
rvic
es a
nd t
reat
men
ts s
tart
ed a
nd
ended
in
th
e sa
me
cover
age
per
iod.
·T
her
e ar
e n
o o
ther
med
ical
exp
ense
s fo
ran
y m
emb
er c
over
ed u
nder
th
isp
lan
.
·O
ut-
of-
po
cket
exp
ense
s ar
e b
ased
on
ly o
ntr
eati
ng
the
con
dit
ion
in
th
e ex
amp
le.
·T
he
pat
ien
t re
ceiv
ed a
ll ca
re f
rom
in
-n
etw
ork
pro
vid
ers
. I
f th
e p
atie
nt
had
rece
ived
car
e fr
om
out-
of-
net
wo
rkp
rovid
ers
, co
sts
wo
uld
hav
e b
een
hig
her
.
Wha
t doe
s a
Cov
erag
e Ex
ampl
esh
ow?
Fo
r ea
ch t
reat
men
t si
tuat
ion
, th
e C
over
age
Exa
mp
le h
elp
s yo
u s
ee h
ow
ded
ucti
ble
s,co
-paym
en
ts, an
dco
-in
sura
nce c
an a
dd u
p. It
also
hel
ps
you s
ee w
hat
exp
ense
s m
igh
t b
e le
ftup
to
yo
uto
pay
bec
ause
th
e se
rvic
e o
rtr
eatm
ent
isn
’t c
over
ed o
r p
aym
ent
is lim
ited
.
Can
I us
eC
over
age
Exam
ples
toco
mpa
re p
lans
?ü
Yes.
Wh
en y
ou lo
ok a
t th
e Sum
mar
yo
f B
enef
its
and C
over
age
for
oth
er p
lan
s, y
ou’ll
fin
d t
he
sam
eC
over
age
Exa
mp
les.
Wh
en y
ou c
om
par
e p
lan
s,ch
eck t
he
“Pat
ien
t P
ays”
bo
xin
eac
h e
xam
ple
. T
he
smal
ler
that
num
ber
, th
e m
ore
co
ver
age
the
pla
np
rovid
es.
Doe
s th
e C
over
age
Exam
ple
pred
ict m
y ow
n ca
re n
eeds
?û
No
.T
reat
men
ts s
ho
wn
are
just
exam
ple
s.
Th
e ca
re y
ou w
ould
rece
ive
for
this
co
ndit
ion
could
be
dif
fere
nt,
bas
ed o
n y
our
do
cto
r’s
advic
e, y
our
age,
ho
w s
erio
us
your
con
dit
ion
is, an
d m
any
oth
er f
acto
rs.
Are
ther
e ot
her c
osts
I sh
ould
con
side
rw
hen
com
parin
g pl
ans?
üY
es.
An
im
po
rtan
t co
st is
the
pre
miu
m y
ou p
ay.
Gen
eral
ly, th
e lo
wer
yo
ur
pre
miu
m, th
e m
ore
yo
u’ll
pay
in
out-
of-
po
cket
co
sts,
such
as
co
-paym
en
ts,d
ed
ucti
ble
s, a
nd
co
-in
sura
nce.
Yo
u s
ho
uld
als
o c
on
sider
co
ntr
ibuti
on
s to
acc
oun
tssu
ch a
s h
ealt
h s
avin
gs a
cco
un
ts (
HSA
s), fl
exib
lesp
endin
g ar
ran
gem
ents
(F
SA
s) o
r h
ealt
hre
imb
urs
emen
t ac
coun
ts (
HR
As)
th
at h
elp
yo
u p
ayo
ut-
of-
po
cket
exp
ense
s.
Doe
s th
e C
over
age
Exam
ple
pred
ict m
y fu
ture
exp
ense
s?û
No
.C
over
age
Exa
mp
les
are
no
t co
st
esti
mat
ors
. Y
ou
can
’t u
se t
he
exam
ple
s to
esti
mat
e co
sts
for
an a
ctual
co
ndit
ion
. T
hey
are
for
com
par
ativ
e p
urp
ose
s o
nly
. Y
our
ow
nco
sts
will
be
dif
fere
nt
dep
endin
g o
n t
he
care
you
rece
ive,
th
e p
rice
s yo
ur
pro
vid
ers
char
ge,
and t
he
reim
burs
emen
t yo
ur
hea
lth
pla
nal
low
s.
Confidence comes with every card.®
You now can get quality health care, anytime, anywhere.*Life is online 24/7/365 You’re used to the convenience of banking, shopping and taking care of personal business online when you’re pressed for time, or when it’s convenient for you. Medical care doesn’t have to be any different. Why not see a board certified doctor online too?
No appointment needed You can get fast, convenient, affordable online health care 24 hours a day, seven days a week, wherever you are in the U.S.* Just choose an available doctor, click and go. It’s as simple as using your mobile device or computer to meet with a doctor face-to-face, online, when:
• Your primary care doctor isn’t available.
• You can’t leave your home or workplace.
• You’re on vacation or traveling for work.
• You’re caring for children or a family member and can’t leave home.
• You’re looking for affordable after-hours care.
It’s for the whole family Family members on your plan can also use 24/7 online health care. Just add your spouse and children to your account so it’s ready when they need to use it.
When should I use an online doctor? You can use Amwell™, American Well’s award-winning and easy-to-use online health care technology, for minor, nonemergency illnesses, such as:
• Sinus and respiratory infections
• Colds, flu and seasonal allergies
• Urinary tract infections
• Vomiting
• Diarrhea
• Headache
• Strains and sprains
• Pinkeye
• Rashes
24/7 online health care
POWERED BY AMERICAN WELL®
How do I get started with 24/7 online health care? Enroll now:
Mobile – Download the Amwell™ app
Web – Go to bcbsm.amwell.com
Phone – Call 1-844-733-3627
• Use service key BCBSM.
• Add your Blue Cross or BCN health plan information.
How does it work? Fast and easy:
• Create an account.
• Log in by Web, or launch the Amwell app from your mobile device.
• Choose an available doctor who’s right for you.
• Talk to your doctor and get a prescription, if needed.*
• At the end of your visit, you’ll get a full report to share with your family doctor or other health care providers.
• You can also view your explanation of benefits statement and claims for online health care at bcbsm.com.
What kind of doctor will I see? A quality, Amwell doctor who:
• Is in network
• Is U.S. board certified
• Has an average of 15 years of experience
• Is specially trained in online care
• Has seen thousands of patients online
Choose the doctor who’s right for you Every doctor has an online photo with a profile listing:
• Languages spoken
• Experience
• Affiliations
• Practice philosophy
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.Blue Cross and BCN do not control the content of the Amwell website.Blue Cross Blue Shield of Michigan has contracted with American Well®, an independent company, to provide online health care for Blue Cross and Blue Care Network members.
CF 15249 OCT 15
IT ONLY TAKES ABOUT
three minutes
TO START YOUR
ONLINE CONSULTATION.
FACE TO FACE
24/7 online health care
IS PRIVATE AND SECURE.
WATCH YOUR DOCTOR’S
“webside manner” video
AND READ QUALITY REVIEWS BY PATIENTS JUST LIKE YOU.
*U.S. only. Some states have visit and prescribing restrictions. Online health care doesn’t replace primary doctor relationships.
R045054
Benefit information illustrated within this material reflects the plan covered by Guardian as of 08/17/2016
Group Number: 00450928
About Your Benefits:
A visit to your dentist can help you keep a great smile and prevent many health issues. But dental care can be costly and you can befaced with unforeseen expenses. Did you know, a crown can cost as much as $1,4001? Guardian dental insurance will help you payfor it. With access to one of the largest network of dental providers in the country, who agreed to charge negotiated fees for theirservices of up to 30% less than average charges in the same community, you will benefit from lower out-of-pocket costs, quality carefrom screened and reviewed dentist, no claim forms to file, and excellent customer service. Enroll today and smile next time you seeyour dentist!1http://health.costhelper.com/dental-crown.html.
With your PPO plan, you can visit any dentist; but you pay less out-of-pocket when you choose a PPO dentist.
THREE PILLARS: AN EDUCATIONAL SERVICES PROVIDER CEO, DIRECTORS, PRINCIPALS, DEANS Benefit SummaryThe Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY 10004
Dental Benefit Summary
Cornerstone Education Group
Your Dental Plan PPO
Your Network is DentalGuard PreferredCalendar year deductible In-Network Out-of-NetworkIndividual $0 $25Family limit 3 per familyWaived for Not applicable NoneCharges covered for you (co-insurance) In-Network Out-of-NetworkPreventive Care 100% 100%Basic Care 90% 80%Major Care 60% 50%Orthodontia 50% 50%Annual Maximum Benefit $1000 $1000Lifetime Orthodontia Maximum $1000Dependent Age Limits(Non-Student/Student) 20/26
3
A Sample of Services Covered by Your Plan:
THREE PILLARS: AN EDUCATIONAL SERVICES PROVIDER CEO, DIRECTORS, PRINCIPALS, DEANS Benefit SummaryThe Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY 10004
PPOPlan pays (on average)In-network Out-of-network
Preventive Care Cleaning (prophylaxis) 100% 100%Frequency: Once Every 6 Months
Fluoride Treatments 100% 100%Limits: Under Age 19
Oral Exams 100% 100%Sealants (per tooth) 100% 100%X-rays 100% 100%
Basic Care Anesthesia* 90% 80%
Fillings‡ 90% 80%
Perio Surgery 90% 80%Periodontal Maintenance 90% 80%Frequency: Once Every 3 Months
(Enhanced)
Repair & Maintenance ofCrowns, Bridges & Dentures 90% 80%
Root Canal 90% 80%Scaling & Root Planing (per quadrant) 90% 80%Simple Extractions 90% 80%
Major Care Bridges and Dentures 60% 50%Inlays, Onlays, Veneers** 60% 50%Single Crowns 60% 50%Surgical Extractions 60% 50%
Orthodontia Orthodontia 50% 50%Limits: Child(ren)
This is only a partial list of dental services. Your certificate of benefits will show exactly what is covered and excluded. **For PPO andor Indemnity members, Crowns, Inlays, Onlays and Labial Veneers are covered only when needed because of decay or injury or otherpathology when the tooth cannot be restored with amalgam or composite filing material. When Orthodontia coverage is for"Child(ren)" only, the orthodontic appliance must be placed prior to the age limit set by your plan; If full-time status is required byyour plan in order to remain insured after a certain age; then orthodontic maintenance may continue as long as full-time student statusis maintained. If Orthodontia coverage is for "Adults and Child(ren)" this limitation does not apply. The total number of cleanings andperiodontal maintenance procedures are combined in a 12 month period. *General Anesthesia – restrictions apply. ‡For PPO and orIndemnity members, Fillings – restrictions may apply to composite fillings.This handout is for illustrative purposes only and is an approximation. If any discrepancies between this handout and your paycheck stub exist,your paycheck stub prevails.
Manage Your Benefits:
Go to www.GuardianAnytime.com to access secure informationabout your Guardian benefits including access to an image of yourID Card. Your on-line account will be set up within 30 days afteryour plan effective date..
Find A Dentist:
Visit www.GuardianAnytime.comClick on “Find A Provider”; You will need to know your plan,which can be found on the first page of your dental benefitsummary.
EXCLUSIONS AND LIMITATIONSn Important Information about Guardian’s DentalGuard Indemnity andDentalGuard Preferred Network PPO plans: This policy provides dentalinsurance only. Coverage is limited to those charges that are necessary toprevent, diagnose or treat dental disease, defect, or injury. Deductibles apply.The plan does not pay for: oral hygiene services (except as covered underpreventive services), orthodontia (unless expressly provided for), cosmetic orexperimental treatments (unless they are expressly provided for), anytreatments to the extent benefits are payable by any other payor or for whichno charge is made, prosthetic devices unless certain conditions are met, andservices ancillary to surgical treatment. The plan limits benefits for diagnostic
consultations and for preventive, restorative, endodontic, periodontic, andprosthodontic services. The services, exclusions and limitations listed above donot constitute a contract and are a summary only. The Guardian plandocuments are the final arbiter of coverage. Contract # GP-1-DG2000 et al.
n PPO and or Indemnity Special Limitation: Teeth lost or missing before acovered person becomes insured by this plan. A covered person may have one ormore congenitally missing teeth or have lost one or more teeth before he becameinsured by this plan. We won’t pay for a prosthetic device which replaces such teethunless the device also replaces one or more natural teeth lost or extracted after thecovered person became insured by this plan. R3-DG2000
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Life Benefit Summary
THREE PILLARS: AN EDUCATIONAL SERVICES PROVIDER CEO, DIRECTORS, PRINCIPALS, DEANS BenefitSummary
Group Number: 00450928
Cornerstone Education Group
Benefit information illustrated within this material reflects the plan covered by Guardian as of 08/17/2016
About Your Benefits:
Your family depends on you in many ways and you’ve worked hard to ensure their financial security. But if something happened toyou, will your family be protected? Will your loved ones be able to stay in their home, pay bills, and prepare for the future. Lifeinsurance provides a financial benefit that your family can depend on. And getting it at work is easier, more convenient and moreaffordable than doing it on your own. If you have financial dependents- a spouse, children or aging parents, having life insurance is aresponsible and a smart decision. Enroll today to secure their future!
What Your Benefits Cover:
BASIC LIFE VOLUNTARY TERM LIFE
Employee Benefit Your employer provides Basic LifeCoverage for all full timeemployees in the amount of 100%of your annual salary, to amaximum of $100,000.
You may elect one of thefollowing benefit options: $20,000,$40,000, $60,000, $80,000,$100,000. See Cost Illustrationpage for details.
Accidental Death and Dismemberment Your Basic Life coverage includesAccidental Death andDismemberment coverage equalto one times the employee's lifebenefits.
Enhanced employee, spouse, andchild(ren) coverage. Maximum 1times life amount.
Spouse/Domestic Partner‡ Benefit N/A You may elect one of thefollowing benefit options: $10,000,$20,000. See Cost Illustrationpage for details.
Child Benefit N/A Your dependent children age 14days to 23 years (25 if full timestudent).You may elect one of thefollowing benefit options: $5,000,$10,000. Subject to state limits.See Cost Illustration page fordetails.
Guarantee Issue: The ‘guarantee’ means you are not required toanswer health questions to qualify for coverage up to and includingthe specified amount, when you sign up for coverage during the initialenrollment period.
Guarantee Issue coverage up to$100,000 per employee
We Guarantee Issue coverage upto:Employee Less than age 65$100,000, 65-69 $50,000, 70+$10,000.Spouse Less than age 65 $20,000,65-69 $10,000, 70+ $0.Dependent children $10,000.
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THREE PILLARS: AN EDUCATIONAL SERVICES PROVIDER CEO, DIRECTORS, PRINCIPALS, DEANS BenefitSummary
BASIC LIFE VOLUNTARY TERM LIFE
Premiums Covered by your company if youmeet eligibility requirements
Increase on plan anniversary afteryou enter next five-year agegroup
Portability: Allows you to take your coverage with you if youterminate employment.
Yes, with age and otherrestrictions, including evidence ofinsurability
Yes, with age and otherrestrictions
Conversion: Allows you to continue your coverage after your groupplan has terminated.
Yes, with restrictions; seecertificate of benefits
Yes, with restrictions; seecertificate of benefits
Accelerated Life Benefit: A lump sum benefit is paid to you if youare diagnosed with a terminal condition, as defined by the plan.
Yes Yes
Waiver of Premiums: Premium will not need to be paid if you aretotally disabled.
For employees disabled prior toage 60, with premiums waiveduntil age 65, if conditions are met
For employees disabled prior toage 60, with premiums waiveduntil age 65, if conditions met
LifeAssistSM: Provides supplemental income that is calculated basedoff a percentage of your Life benefit to a specified dollar amount ifyou are ADL disabled. Benefits are paid to the lesser of 100 monthsor to when waiver of premium ends.
Yes No
Benefit Reductions: Benefits are reduced by a certain percentage asan employee ages.
35% at age 65, 50% at age 70, 75%at age 75
35% at age 65, 60% at age 70, 75%at age 75, 85% at age 80
Subject to coverage limits� Spouse coverage terminates at age 70.
Manage Your Benefits:
Go to www.GuardianAnytime.com to access secure information aboutyour Guardian benefits. Your on-line account will be set up within 30days after your plan effective date.
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Voluntary Life Cost Illustration:
To determine the most appropriate level of coverage, as a rule of thumb, you should consider about 6 - 10 times your annual income,factoring in projected costs to help maintain your family’s current life style. To help you assess your needs, you can also go toGuardian Anytime and use our Life Insurance Explorer Tool.
THREE PILLARS: AN EDUCATIONAL SERVICES PROVIDER CEO, DIRECTORS, PRINCIPALS, DEANS BenefitSummary
Bi-weekly premiums displayed. Cost of AD&D is included.Policy Election Amount Policy Election Cost Per Age Bracket
Employee < 30 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69†
$20,000 $.83 $.93 $1.27 $1.63 $2.31 $3.85 $5.89 $8.51 $21.86
$40,000 $1.66 $1.87 $2.55 $3.27 $4.62 $7.70 $11.78 $17.02 $43.72
$60,000 $2.49 $2.80 $3.82 $4.90 $6.92 $11.55 $17.67 $25.53 $65.58
$80,000 $3.32 $3.73 $5.10 $6.54 $9.23 $15.40 $23.56 $34.04 $87.43
$100,000 $4.15 $4.66 $6.37 $8.17 $11.54 $19.25 $29.45 $42.55 $109.29
Policy Election Amount
Spouse/DP
$10,000 $.42 $.47 $.64 $.82 $1.15 $1.93 $2.95 $4.26 $10.93
$20,000 $.83 $.93 $1.27 $1.63 $2.31 $3.85 $5.89 $8.51 $21.86
Policy Election Amount
Child(ren)
$5,000 $0.47 $0.47 $0.47 $0.47 $0.47 $0.47 $0.47 $0.47 $0.47
$10,000 $0.93 $0.93 $0.93 $0.93 $0.93 $0.93 $0.93 $0.93 $0.93
Refer to Guarantee Issue row on page above for Voluntary Life GI amounts.Premiums for Voluntary Life Increase in five-year increments‡Spouse/DP coverage premium is based on Employee age. Coverage for the spouse terminates at spouse’s age 70.†Benefit reductions apply.
Manage Your Benefits:
Go to www.GuardianAnytime.com to access secure information aboutyour Guardian benefits. Your on-line account will be set up within 30days after your plan effective date.
7
THREE PILLARS: AN EDUCATIONAL SERVICES PROVIDER CEO, DIRECTORS, PRINCIPALS, DEANS BenefitSummary
LIMITATIONS AND EXCLUSIONS:
A SUMMARYOF PLANLIMITATIONSANDEXCLUSIONS FORLIFEANDAD&DCOVERAGE:You must be working full-time on the effective date of your coverage; otherwise, yourcoverage becomes effective after you have completed a specific waiting period. Employeesmust be legally working in the United States in order to be eligible for coverage.Underwriting must approve coverage for employees on temporary assignment: (a)exceeding one year; or (b) in an area under travel warning by the US Department of State.Subject to state specific variations. Evidence of Insurability is required on all late enrollees.This coverage will not be effective until approved by a Guardian underwriter. This proposalis hedged subject to satisfactory financial evaluation. Please refer to certificate of coverage forfull plan description.Dependent life insurance will not take effect if a dependent, other than a newborn, isconfined to the hospital or other health care facility or is unable to perform the normalactivities of someone of like age and sex.A person is ADL-disabled if he or she is (a) physically unable to perform two or more ADLswithout continuous physical assistance; or (b) cognitively impaired, and requires verbalcueing to protect himself/herself or others. ADLs are bathing, dressing, toileting,transferring, continence, and eating.
Accelerated Life Benefit is not paid to an employee under the following circumstances: onewho is required by law to use the benefit to pay creditors; is required by court order to paythe benefit to another person; is required by a government agency to use the payment toreceive a government benefit; or loses his or her group coverage before an acceleratedbenefit is paid.
Voluntary LifeOnly:We pay no benefits if the insured’s death is due to suicide within two years from theinsured’s original effective date. This two year limitation also applies to any increase inbenefit. This exclusion may vary according to state law. Late entrants and benefit increasesrequire underwriting approval.GP-1-R-LB-90, GP-1-R-EOPT-96Guarantee Issue/Conditional Issue amounts may vary based on age and case size. See yourPlan Administrator for details. Late entrants and benefit increases require underwritingapproval.
For AD&D: We pay no benefits for any loss caused: by willful self-injury; sickness, diseaseor medical treatment; by participating in a civil disorder or committing a felony; Travelingon any type of aircraft while having duties er on that aircraft; by declared or undeclared actof war or armed aggression; while a member of any armed force (May vary by state); whiledriving a motor vehicle without a current, valid driver’s license; by legal intoxication; or byvoluntarily using a non-prescription controlled substance. Contract #GP-1-R-ADCL1-00 etal. We won't pay more than 100% of the Insurance amount for all losses due to the sameaccident, except as stated. The loss must occur within a specified period of time of theaccident. Please see contract for specific definition; definition of loss may vary depending onthe benefit payable.
This handout is for illustrative purposes only and is an approximation. If any discrepancies between this handout and your paycheck stub exist, your paycheckstub prevails.
8
About Your Benefits:
You probably have insurance for your car or home, but what about the source of income that pays for it? You rely on yourpaycheck for so many things, but what if you were suddenly unable to work due to an accident or illness? How will you put foodon the table, pay your mortgage or heat your home? Disability insurance can help replace lost income and make a difficult time alittle easier. Protect your most valuable asset, your paycheck-enroll today!
What Your Benefits Cover:
Cornerstone Education Group
THREE PILLARS: AN EDUCATIONAL SERVICES PROVIDER CEO, DIRECTORS, PRINCIPALS, DEANS Benefit SummaryThe Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY 10004
Disability Benefit SummaryGroup Number: 00450928
Benefit information illustrated within this material reflects the plan covered by Guardian as of 08/17/2016
Short-Term Disability Long-Term Disability.
Coverage amount60% of salary to maximum$900/week
60% of salary to maximum$5000/month
Maximum payment period: Maximum length of time you canreceive disability benefits.
13 weeksSocial Security Normal RetirementAge
Accident benefits begin: The length of time you must bedisabled before benefits begin.
Day 1 Day 91
Illness benefits begin: The length of time you must be disabledbefore benefits begin.
Day 8 Day 91
Evidence of Insurability: A health statement requiring you toanswer a few medical history questions. Health Statement may be required Health Statement may be required
Guarantee Issue: The ‘guarantee’ means you are not required toanswer health questions to qualify for coverage up to and includingthe specified amount, when applicant signs up for coverage duringthe initial enrollment period.
We Guarantee Issue $900 incoverage
We Guarantee Issue $5000 incoverage
Minimum work hours/week: Minimum number of hours youmust regularly work each week to be eligible for coverage. Planholder Determines Planholder Determines
Pre-existing conditions: A pre-existing condition includes anycondition/symptom for which you, in the specified time period priorto coverage in this plan, consulted with a physician, receivedtreatment, or took prescribed drugs.
Not Applicable6 months look back; 24 monthsafter exclusion
UNDERSTANDING YOUR BENEFITS—DISABILITY (Some information may vary by state)l Disability (long-term): For first five years of disability, you will receive benefit payments while you are unable to work inyour own occupation. After five years, you will continue to receive benefits if you cannot work in any occupation based ontraining, experience and education.
l Earnings definition: Your covered salary excludes bonuses and commissions.
l Special limitations: Provides a 24-month benefit limit for mental health and substance abuse.
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THREE PILLARS: AN EDUCATIONAL SERVICES PROVIDER CEO, DIRECTORS, PRINCIPALS, DEANS Benefit SummaryThe Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY 10004
l Work incentive: Plan benefit will not be reduced for a specified amount of months so that you have part-time earnings whileyou remain disabled, unless the combined benefit and earnings exceed 100% of your previous earnings.
Manage Your Benefits:
Go to www.GuardianAnytime.com to access secure informationabout your Guardian benefits. Your on-line account will be set upwithin 30 days after your plan effective date.
A SUMMARY OF DISABILITY PLAN LIMITATIONSAND EXCLUSIONS
n Evidence of Insurability is required on all late enrollees. This coverage willnot be effective until approved by a Guardian underwriter. This proposal ishedged subject to satisfactory financial evaluation. Please refer to certificateof coverage for full plan description.
n You must be working full-time on the effective date of your coverage;otherwise, your coverage becomes effective after you have completed aspecific waiting period.
n Employees must be legally working in the United States in order to beeligible for coverage. Underwriting must approve coverage for employeeson temporary assignment: (a) exceeding one year; or (b) in an area undertravel warning by the US Department of State. Subject to state specificvariations.
n For Long-Term Disability coverage, we pay no benefits for a disabilitycaused or contributed to by a pre-existing condition unless the disabilitystarts after you have been insured under this plan for a specified period oftime. We limit the duration of payments for long term disabilities caused bymental or emotional conditions, or alcohol or drug abuse.
n We do not pay benefits for charges relating to a covered person: takingpart in any war or act of war (including service in the armed forces)committing a felony or taking part in any riot or other civil disorder orintentionally injuring themselves or attempting suicide while sane or insane.We do not pay benefits for charges relating to legal intoxication, including
but not limited to the operation of a motor vehicle, and for the voluntaryuse of any poison, chemical, prescription or non-prescription drug orcontrolled substance unless it has been prescribed by a doctor and is usedas prescribed. We limit the duration of payments for long term disabilitiescaused by mental or emotional conditions, or alcohol or drug abuse. Wedo not pay benefits during any period in which a covered person is confinedto a correctional facility, an employee is not under the care of a doctor, anemployee is receiving treatment outside of the US or Canada, and theemployee’s loss of earnings is not solely due to disability.
n This policy provides disability income insurance only. It does not provide"basic hospital", "basic medical", or "medical" insurance as defined by theNew York State Insurance Department.
n If this plan is transferred from another insurance carrier, the time aninsured is covered under that plan will count toward satisfying Guardian'spre-existing condition limitation period. State variations may apply.
n When applicable, this coverage will integrate with NJ TDB, NY DBL, CASDI, RI TDI, Hawaii TDI and Puerto Rico DBA.
Contract #.s GP-1-LTD94-A,B,C-1.0 et al.; GP-1-LTD2K-1.0 et al;GP-1-LTD07-1.0 et al. Contract #.s GP-1-STD94-1.0 et al;GP-1-STD2K-1.0 et al; , GP-1-STD07-1.0 et al.
This handout is for illustrative purposes only and is an approximation. If any discrepancies between this handout and your paycheck stub exist, yourpaycheck stub prevails.
12
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Financial Services Employees can receive telephonic consultations with seasoned financial professionals and certified public accountants (CPA). Each consultation is limited to 30 minutes per issue. Local refer-rals are available for more complex financial planning issues, such as: credit counseling, debt and budget assistance, basic tax planning, and retirement and college planning questions.
Assistance with Document Preparation A simple and inexpensive online process enable members to com-plete their own legal document preparation from home. This elimi-nates the cost of an attorney or dealing with lengthy completion and delivery periods!
Dedicated Legal/Financial Website Each member is provided with unlimited access to a dedicated legal/financial website, which includes legal and financial tools. Examples include legal and financial forms, financial calculators, helpful articles and answers to frequently asked questions.
Legal Services Employees can receive an initial 30 minute office or telephone consultation with an attorney. Plus, if the attorney is retained to provide legal services, the member can apply a 25% discount off the attorney’s normal hourly rate on legal fees. Virtually all types of legal matters are eligible for these services.
WorkLifeMattersSM
• Budgeting • Civil/Consumer Issues • Criminal Matters • Debt/Credit Counseling • Estate Planning Law
• Financial Services • Immigration • IRS Matters • Motor Vehicle • Personal/Family Legal
Services • Real Estate • Tax Consultation/
Preparation • And more!
WorkLifeMatters, an Employee Assistance Program, provides a range of legal and financial services to eligible members to help with issues related to:
Legal and Financial
Call 1-800-386-7055 www.ibhworklife.com The Guardian Life Insurance Company of America, New York, NY 10004.
WorkLifeMattersSM Program services are provided by Integrated Behavioral Health, Inc., and its contractors. The Guardian Life Insurance Company of America (Guardian) does not provide any part of WorkLifeMattersSM Program services. Guardian is not responsible or liable for care or advice given by any provider or resource under the program. This information is for illustra-tive purposes only. It is not a contract. Only the Administration Agreement can provide the actual terms, services, limitations and exclusions. Guardian and IBH reserve the right to discontinue the WorkLifeMattersSM Program at any time without notice.
2007-5879
Hello,Neighbor
More,for less. . .
Cornerstone Education Group
• You’re on the ADVANTAGENetwork
• For a complete list ofproviders near you, useour Provider Locator onwww.eyemed.com andchoose the ADVANTAGEnetwork or call1-888-203-7437.
• For Lasik providers, call1-877-5LASER6 orvisit eyemedlasik.com.
40%Complete pairof prescriptioneyeglasses
20%Non-prescriptionsunglasses
30%Remaining balancebeyond plan coverage
These discounts are forin-network providers only
Vision Care In-Network Out-of-NetworkServices Member Cost Reimbursement
OFF
OFF
OFF
ExamWith Dilation as Necessary $10 Copay Up to $35
Contact Lens Fit and Follow-Up (Contact lens fit and two follow up visits are available once a comprehensive eye exam has been completed)
Standard Contact Lens Fit & Follow-Up Up to $40 N/APremium Contact Lens Fit & Follow-Up 10% off retail price N/A
Frames $120 allowance; 80% of balance over $120 Up to $48
Standard Plastic LensesSingle Vision $25 Copay Up to $25Bifocal $25 Copay Up to $40Trifocal $25 Copay Up to $60Standard Progressive Lens $85 Up to $40Premium Progressive Lens $85, 70% of charge less $110 Allowance Up to $40
Lens Options (paid by the member and added to the base price of the lens)UV Treatment $12 N/ATint (Solid and Gradient) $12 N/AStandard Plastic Scratch Coating $12 N/AStandard Polycarbonate $35 N/AStandard Anti-Reflective Coating $40 N/AOther Add-Ons and Services 30% off retail price N/A
Contact LensesConventional $135 allowance; 15% off retail price over $135 Up to $95Disposable $135 Allowance; plus balance over $135 Up to $95Medically Necessary $0 Copay; Paid in Full Up to $200
Laser Vision CorrectionLasik or PRK from U.S. Laser Network 15% off the retail price or 5% off the promotional price N/A
FrequencyExamination Once every 12 monthsLenses or Contact Lenses Once every 12 monthsFrame Once every 12 months
_____________________________ _________________________________________ _________________
What’s in it for me? Options. It’s simple really. We love our members—that’s why we are dedicated to helping you see clearly and we’ve built a network that gives you lots of choices and flexibility. You can choose from independent doctors and retail providers to find the one that best fits your needs and schedule. No matter which one you choose, our plan is designed to be easy to use and to save you money. Welcome to EyeMed.
eyemed.com
Benefits Snapshot With UsOut-of-NetworkReimbursement
Exam with dilation as necessary (Once every 12 months)
Frames (Once every 12 months)
Single Vision Lenses (Once every 12 months)
Or
Contacts (Once every 12 months)
Benefits are not provided from services or materials arising from: 1) Orthoptic or vision training, subnormal vision aids and any associated supplemental testing; Aniseikonic lenses; 2)Medical and/or surgical treatment of the eye, eyes or supporting structures; 3) Any eye or Vision Examination, or any corrective eyewear required by a Policyholder as a condition ofemployment; Safety eyewear; 4) Services provided as a result of any Workers’ Compensation law, or similar legislation, or required by any governmental agency or program whetherfederal, state or subdivisions thereof; 5) Plano (non-prescription) lenses and/or contact lenses; 6) Non-prescription sunglasses; 7) Two pair of glasses in lieu of bifocals; 8) Services ormaterials provided by any other group benefit plan providing vision care 9) Services rendered after the date an Insured Person ceases to be covered under the Policy, except when VisionMaterials ordered before coverage ended are delivered, and the services rendered to the Insured Person are within 31 days from the date of such order. 10) Lost or broken lenses, frames,glasses, or contact lenses will not be replaced except in the next Benefit Frequency when Vision Materials would next become available. Benefits may not be combined with any discount,promotional offering, or other group benefit plans. Standard/Premium Progressive lens not covered-fund as a Bifocal lens. Standard Progressive lens covered-fund Premium Progressiveas a Standard. Underwritten by Fidelity Security Life Insurance Company of Kansas City, Missouri, except in New York. This is a snapshot of your benefits. The Certificate of Insurance is onfile with your employer. Benefit allowance provides no remaining balance for future use within the same benefit year.
$10 Copay Up to $35
$120 allowance; 80% of balance over $120 Up to $48
$25 Copay Up to $25
$135 Allowance; plus balance over $135 Up to $95
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IMPORTANT SALARY TEAM MEMBER CONTACT INFORMATION
The information contained in this summary should in no way be construed as a promise or guarantee of employment or benefits. The company reserves the right to modify, amend, suspend, or terminate any plan at any time for any reason. If there is a conflict between the information in this notice and the actual plan policies, the policies will always govern. Complete details about the benefits can be obtained by reviewing current plan descriptions, contracts, certificates, and policies available from the HR Department.
1‐800‐662‐6667 www.bcbsm.com
1‐877‐790‐2583 www.bcbsm.com
1‐800‐627‐4200 www.guardianany me.com
1‐866‐9‐EYEMED www.eyemedvisioncare.com
1‐877‐858‐0828 Customer Service Team
Dan Ward
Area Vice President
248‐502‐1100
Sue Fiehn
Benefit Analyst
248‐502‐1119
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