Selecting a Primary Care Physician (PCP) for your BCN HMO

For care to be covered, all services have to be handled through your PCP.

Each member of your family can select a PCP, or you can choose one for your whole family.

You must let BCN know who you have selected for your PCP(s), either on the enrollment form or online via your member portal at bcbsm.com. See Your Primary Care Physician: Your Blue Care Network Connection to Care document for more details.

Health Plan Choice – Healthy Blue Living HMO

PPO • The PPO plan has a network

of providers, but also allows use of medical providers outside of the plan’s network (typically with greater employee cost-sharing).

• Referrals may not be required.

• There are BCBS PPO networks nationwide. PPO’s provide out-of-network benefits, but they are at a lower coverage rate.

• The Sindecuse Medical Center and Pharmacy are both in-network.

WMU is adding a Healthy Blue Living HMO medical plan option through Blue Care Network (BCN). You will have the opportunity to elect this plan during the annual open enrollment period in October/November. The plan effective date is January 1, 2017. Dental and vision plans remain the same for 2017. If you are currently covered under the BCBSM Community Blue PPO plan and wish to continue coverage, no action is needed – your 2016 benefit elections will roll over into 2017. FSA elections must be renewed each year during open enrollment. FSA elections will not roll over into 2017. There are some notable differences between the current PPO plan and the new HMO health plan choice. We have prepared this document to highlight some of these differences. More details can be found in the documents referenced throughout this piece by visiting wmich.edu/hr/healthplanchoice.

The documents referenced can be found at wmich.edu/hr/healthplanchoice.

HMO • The HMO plan covers services performed solely

by in-network BCN providers.

• In order to seek care from a specialty provider, you must have a referral from your PCP.*

• If you go out of state: And require an ER visit – emergency services are covered as in-network, no matter where you are. And become ill – go to the nearest BlueCard provider/facility and the in-network cost share would apply. Specifically for care - you must call your PCP before you travel to arrange for coordinated care and required authorizations.

• You may use the Sindecuse Pharmacy; however, Sindecuse Medical Center is not covered under the HMO plan.

*BCN’s Woman’s Choice Program is a self-referral program. This means for routine women’s health services, you may visit certain BCN-contracted specialists without a referral from your PCP.

Health Plan Summary Comparison

BCBSM Community Blue PPO BCN Healthy Blue Living HMO Current Plan Standard benefit level Enhanced benefit level Individual Family Individual Family Individual Family

Deductible $ 400 $ 800 $1,000 $2,000 $ 400 $ 800

Annual Out-of-Pocket Maximum $1,400 $2,800 $2,800 $5,600 $1,400 $2,800

Preventive Care Covered 100% Covered 100% Covered 100%

Primary Care Office Visit $35 copay $30 copay $20 copay

Specialist Office Visit $35 copay $40 copay after deductible $30 copay

Urgent Care $35 copay $50 copay $35 copay

Emergency Room (copay waived if admitted) $150 copay $150 copay after deductible $150 copay after deductible

Hospital Services Covered 100% after deductible 30% coinsurance after deductible Covered 100% after deductible

Coinsurance Covered 100% after deductible for

most services; selected services covered at 50%

Covered 70% after deductible for most services; selected services

covered at 50%

Covered 100% after deductible for most services; selected services

covered at 50%

Prescription Drugs

Days In-Network Pharmacy

Sindecuse Preferred Pricing

In-Network Pharmacy

In-Network Pharmacy

Tier 1 Generic

30 90

$15.00 copay $37.50 copay

$10.00 copay $12.50 copay

$20.00 copay 2x applicable copay

$15.00 copay 2x applicable copay

Tier 2 Preferred Brand

30 90

$35.00 copay $87.50 copay

$30.00 copay $37.50 copay

$60.00 copay 2x applicable copay

$35.00 copay 2x applicable copay

Tier 3 Nonpreferred Brand

30 90

$ 60.00 copay $150.00 copay

$40.00 copay $50.00 copay

$80.00 copay 2x applicable copay

$60.00 copay 2x applicable copay

Tier 4 Preferred Specialty

30 90

See Tier 3 N/A 20% coinsurance (max $450) 2x applicable copay

$85.00 copay 2x applicable copay

Tier 5 Nonpreferred Specialty

30 90

See Tier 3 N/A 20% coinsurance (max $600) 2x applicable copay

$85.00 copay 2x applicable copay

Additional prescription coverage is available; see official plan documents for details. See BCN Healthy Blue Living HMO Benefits-at-a-Glance document for more details.

� Schedule an appointment with your PCP and have him or her complete and electronically submit your BCN Qualification Form on time.

� Take an interactive health assessment that’s easy to complete by logging in as a member at bcbsm.com.

� If your qualification form shows you use tobacco, enroll in BCN tobacco-cessation program. Program participation is required until you stop using tobacco.

� With a body mass index (BMI) of 30 or more – confirmed through your qualification form - join a BCN-sponsored weight-management program. Program participation is required until your BMI falls below 30.

90 DAYS Within the first

of plan year

120 DAYS Within the first

of plan year

Healthy Blue Living HMO – Wellness requirements to maintain the Enhanced benefit level The employee is the only member responsible for completing these requirements. All covered members will receive the same benefit level as the employee.

Members will automatically begin with the enhanced benefit level. If the employee does not complete the wellness requirements within the timeframes, covered members will move to the standard benefit level on the 91st day of the plan year and remain there for the rest of the year.

See Healthy Blue Living HMO document for more details.

Western Wellness – Wellness requirements for reduced per-pay premiums Requirements for the Western Wellness program will be separate from the Healthy Blue Living wellness requirements. Participation in the Western Wellness program will result in lower per-pay premiums on both the BCBSM Community Blue PPO plan and the BCN Healthy Blue Living HMO plan.