$250 per individual / $500 per family per calendar year

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1 Benefit Summary - Trinity Grand Rapids 3/1/ /31/2018 This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and exclusions may apply to covered services. For a complete description of benefits, please see the applicable Blue Care Network Certificates and Riders. Payment amounts are based on the BCN approved amount, less any applicable deductible, coinsurance and/or copay amounts required by the plan. If there is a discrepancy between this Benefit Summary and any applicable plan documents, the plan document will control. This coverage is provided pursuant to a contract entered into in the State of Michigan and shall be construed under the jurisdiction and according to the laws of the State of Michigan. Services must be provided or arranged by member s primary care physician or health plan. Healthy Blue Living subscribers must complete program requirements within designated timeframes. To qualify for or maintain enhanced benefits, the subscriber needs to complete a health assessment and qualification form by March 30th and follow their primary care physician s recommendations for a healthy lifestyle. If a tobacco user, must enroll in the BCN sponsored tobacco cessation program by June 29th. If BMI is greater than or equal to 30, must select and begin participating in a weight management program by June 29th. Member s Responsibility: Deductible, Copays, Coinsurance and Dollar Maximums Note: The Deductible will apply to certain services as defined below. Deductible Note: Coinsurance and select fixed dollar copays apply once the deductible has been met. Fixed Dollar Copays Coinsurance Annual out-of-pocket maximums applies to deductibles, copays and coinsurance amounts for all covered services including prescription drug copays Trinity Health Provider Network $250 per individual / $500 per family per calendar year $20 for PCP office visits, $30 for specialist office visits, $35 for urgent care visits, $100 for emergency room visits, $50 outpatient surgery 10% after deductible 50% of approved amount after deductible for select services $2,500 per member / $5,000 per family per calendar year BCN Provider Network $750 per individual / $1,500 per family per calendar year $30 for PCP office visits, $40 for specialist office visits, $35 for urgent care visits, $100 for emergency room visits, $500 inpatient admission, $100 outpatient surgery 20% after deductible 50% of approved amount after deductible for select services $4,750 per member / $9,500 per family per calendar year 1

2 Preventive Services Trinity Health Provider Network BCN Provider Network Health Maintenance Exam 100% 100% Annual Gynecological Exam 100% 100% Pap Smear Screening laboratory services only 100% 100% Well-Baby and Child Care 100% 100% Immunizations pediatric and adult 100% 100% Prostate Specific Antigen (PSA) Screening laboratory 100% 100% services only Routine Colonoscopy 100% 100% Mammography Screening - including 3D 100% 100% Breast Pumps DME guidelines apply 100% 100% Maternity Pre-Natal Care 100% 100% Physician Office Services PCP Office Visits $20 copay $30 copay Consulting Specialist Care when referred for other than preventive services $30 copay $40 copay Emergency Medical Care Hospital Emergency Room copay waived if admitted $100 copay $100 copay Urgent Care Center $35 copay $35 copay Ambulance Services medically necessary 10% coinsurance after deductible 10% coinsurance after Trinity network deductible Diagnostic Services Laboratory and Pathology Tests 100%; Office visit copay may apply 100%; Office visit copay may apply Diagnostic Tests and X-rays 10% coinsurance after deductible 20% coinsurance after deductible High Technology Imaging (MRI, CAT, PET) 10% coinsurance after deductible 20% coinsurance after deductible Radiation Therapy 10% coinsurance after deductible 20% coinsurance after deductible 2

3 Maternity Services Provided by a Physician Trinity Health Provider Network BCN Provider Network Prenatal and Postnatal Care 100% 100% Delivery and Nursery Care 100% after deductible for professional services (See Hospital Care for facility charges) 100% after deductible for professional services (See Hospital Care for facility charges) Hospital Services General Nursing Care, Hospital Services and Supplies 10% coinsurance after deductible; unlimited days $500 copay after deductible then 20% coinsurance; unlimited days Outpatient Surgery See member certificate for select surgical coinsurance $50 copay after deductible then 10% coinsurance $100 copay after deductible then 20% coinsurance Alternatives to Hospital Care Skilled Nursing Care 10% coinsurance after deductible 10% coinsurance after Trinity network deductible Limited to 45 days per calendar year Hospice Care 100% after deductible when authorized 100% after deductible when authorized Home Health Care $30 copay $30 copay Private Duty Nursing 10% coinsurance after deductible $500 copay after deductible then 20% coinsurance Limited to 120 days per member per calendar year 3

4 Surgical Services Trinity Health Provider Network BCN Provider Network Surgery includes all related surgical services and anesthesia. See Hospital Care for inpatient and outpatient See Hospital Care for inpatient and outpatient copays copays Voluntary Sterilization Not covered Not covered Elective Abortion Not covered Not covered Human Organ Transplants (subject to medical criteria) 10% coinsurance after deductible 20% coinsurance after deductible Weight Reduction Procedures (subject to medical criteria) 10% coinsurance after deductible 20% coinsurance after deductible Reduction Mammoplasty (subject to medical criteria) 50% coinsurance after deductible 50% coinsurance after deductible Male Mastectomy (subject to medical criteria) 50% coinsurance after deductible 50% coinsurance after deductible Temporomandibular Joint Syndrome (subject to medical 50% coinsurance after deductible 50% coinsurance after deductible criteria) Orthognathic Surgery (subject to medical criteria) 50% coinsurance after deductible 50% coinsurance after deductible Mental Health Care and Substance Abuse Treatment Inpatient Mental Health Care 10% coinsurance after deductible $500 copay after deductible then 20% coinsurance Inpatient Substance Abuse Care 10% coinsurance after deductible $500 copay after deductible then 20% coinsurance Outpatient Mental Health Care $20 copay $30 copay Outpatient Substance Abuse Care $20 copay $30 copay Autism Spectrum Disorders, Diagnoses and Treatment Applied behavioral analyses (ABA) treatment $20 copay $30 copay Outpatient physical therapy, speech therapy, occupational therapy, nutritional counseling for autism spectrum disorder through age 18 $30 copay $40 copay Physical, speech and occupational therapy for autism spectrum disorder is unlimited. Other covered services, including mental health services, for See your outpatient mental health benefit and See your outpatient mental health benefit and medical 4

5 Autism Spectrum Disorder medical office visit benefit office visit benefit Other Services Trinity Health Provider Network BCN Provider Network Allergy Testing and Therapy 50% coinsurance after deductible 50% coinsurance after deductible Allergy Injections $5 copay $5 copay Chiropractic Spinal Manipulation when referred $30 copay $40 copay Outpatient Physical, Speech and Occupational Therapy subject to meaningful improvement within 60 days $30 copay $40 copay Limited to 60 visits for each PT/OT/ST per medical episode per calendar year Habilitative Services $30 copay $40 copay Limited to 60 visits combined for each therapy per calendar year Infertility Counseling and Treatment (excluding In-vitro fertilization) 10% coinsurance after deductible for medical services. 50% coinsurance after deductible for drugs dispensed through the pharmacy. 50% coinsurance after deductible; 50% coinsurance after deductible for drugs dispensed through the pharmacy. Durable Medical Equipment (DME) must be preauthorized an 10% coinsurance after deductible 10% coinsurance after Trinity Network deductible obtained from a BCN supplier Prosthetic and Orthotic Appliances (P&O) 10% coinsurance after deductible 10% coinsurance after Trinity Network deductible Diabetic Supplies 10% coinsurance after deductible 10% coinsurance after Trinity Network deductible Weight Management Program Program defined by Saint Mary s Hospital Prescription Drugs Saint Mary s Pharmacy Retail 30 day supply: Tier 1 - $8 copay; Tier 2 20% coinsurance ($24 minimum copay/$64 maximum copay); Tier 3 40% coinsurance ($48 minimum copay/$80 maximum copay) Sexual dysfunction drugs and contraceptives - Not Retail day supply: Tier 1 - $16 copay; Tier 2 20% coinsurance ($48 minimum copay/$128 maximum copay); Tier 3 40% coinsurance ($96 minimum copay/$160 maximum copay) Sexual dysfunction drugs and 5 Saint Mary s Pharmacy Retail 30 day supply: Tier 1 - $8 copay; Tier 2 20% coinsurance ($24 minimum copay/$64 maximum copay); Tier 3 40% coinsurance ($48 minimum copay/$80 maximum copay) Sexual dysfunction drugs and contraceptives - Not Retail day supply: Tier 1 - $16 copay; Tier 2 20% coinsurance ($48 minimum copay/$128 maximum copay); Tier 3 40% coinsurance ($96 minimum/$160 maximum copay). Sexual dysfunction drugs and contraceptives Not

6 contraceptives - Not BCN Pharmacy Retail and Mail Order 30 day supply: Tier 1 - $10 copay; Tier 2 20% coinsurance ($30 minimum copay/$80 maximum copay); Tier 3 40% coinsurance ($60 minimum copay/$100 maximum copay). Sexual dysfunction drugs and contraceptives Not Retail day supply: Tier 1 - $20 copay; Tier 2 20% coinsurance ($60 minimum copay/$160 maximum copay); Tier 3 40% coinsurance ($120 minimum copay/$200 maximum copay) Sexual dysfunction drugs and contraceptives Not Mail Order day supply: Tier 1 - $25 copay; Tier 2 20% coinsurance ($75 minimum copay/$200 maximum copay); Tier 3 40% coinsurance ($150 minimum copay/$250 maximum copay) Sexual dysfunction drugs and contraceptives Not BCN Pharmacy Retail and Mail Order 30 day supply: Tier 1 - $10 copay; Tier 2 20% coinsurance ($30 minimum copay/$80 maximum copay); Tier 3 40% coinsurance ($60 minimum copay/$100 maximum copay). Sexual dysfunction drugs and contraceptives Not Retail day supply: Tier 1 - $20 copay; Tier 2 20% coinsurance ($60 minimum copay/$160 maximum copay); Tier 3 40% coinsurance ($120 minimum copay/$200 maximum copay) Sexual dysfunction drugs and contraceptives Not Mail Order day supply: Tier 1 - $25 copay; Tier 2 20% coinsurance ($75 minimum copay/$200 maximum copay); Tier 3 40% coinsurance ($150 minimum copay/$250 maximum copay). Sexual dysfunction drugs and contraceptives Not Non-Surgical Weight Loss Therapy The Plan will cover nutritional and/or behavioral based counseling services for the purpose of non-surgical weight loss. These benefits are not subject to Deductible and Out-of-Pocket Maximums. Upon successful completion of the non-surgical weight loss program, benefits are payable at 100% up to a $500 annual maximum, to include: - Outpatient counseling or therapy; - Office visits rendered by a licensed Physician; - Lab services performed during a course of treatment; - Behavioral and/or nutritional counseling services for weight loss rendered by a Trinity Health Regional Health Ministry; and 6

7 - Nationally recognized programs that include behavioral modification and/or nutrition counseling as part of their programs (such as the behavioral and/or nutritional counseling program offered by Jenny Craig, Weight Watchers and LA Weight Loss), for the purpose of non-surgical weight loss. Weight loss expenses that are not covered are: - Services administered exclusively through an Internet-based forum - Medication or injection expenses for weight loss, unless otherwise covered for an unrelated medical condition - Charges for food or nutritional supplements, unless included in the initial program fee - Charges for over-the counter diet aids - Health clubs or exercise equipment - Services or programs that are not approved in the United States - Charges in connection with acupuncture, hypnotism or biofeedback training Not are: - Charges for food and/or nutritional supplements - Health clubs, gyms, personal trainers, exercise classes or exercise equipment - Services administered exclusively in a Web-based forum - Pharmacotherapy and/or injection expenses associated with weight loss - Charges for over-the-counter diet aids - Charges in connection with acupuncture, hypnotism, and/or biofeedback training - Services and/or programs not approved and/or provided in the United States Case Management / Disease Management If you agree to participate, a BCN nurse case manager will administer an assessment and an individualized plan that includes condition and goals based on your assessment results. Note: Cancer Treatment Centers of America (CTCA) - There is no In-Network or Out-of-Network coverage for both health care services provided by the facility; and health care services provided by physicians and other health care professionals at any of their facilities. 7