ABC Sample Communication

ABC Company
Annual Enrollment
Effective September 1, 2011
Employee Benefits For the 2011-2012 Plan Year
September 1, 2011 through August 31, 2012 All Employees of ABC Company
Member Services Contact Information

BCBSM PPO Member Services
(for BCBSM members to call with PPO benefits questions, claim issues)
(for BCN HMO members to call with benefits questions, claim issues)
BCN Member Services
BCBSM DenteMax Dental Member Services

(for members to call with dental benefits questions, claim issues)
800.637.2227
www.bcbsm.com
EyeMed Vision Member Services (for members to call with vision benefits questions, claim issues) 888.362.7463 (Enrolled Participants) 866.299.1358 (Pre-enrollment Questions) www.eyemedvisioncare.com
800.662.6667
www.mibcn.com
800.752.1547
www.dentemax.com
Accredo Limited Distribution Specialty Pharmacy

(for members to call regarding Limited Distribution Specialty mail order medications)
Walgreens Specialty Pharmacy Member Services

(for members to call regarding Specialty mail order medications)
800.803.2523
866.515.1355
www.walgreensspecialtyrx.com
Medco Pharmacy Services

(for pharmacies to call regarding prior authorization/step therapy, and eligibility)
800.437.3803
(for members to call regarding mail order maintenance prescriptions)
Medco Mail Order Member Services 800.903.8346
Medco Retail Pharmacy Services

(for members / pharmacies to call regarding eligibility, claims inquiries, vacation overrides)
800.922.1557
Table of Contents
Open Enrollment The Blue Care Network HMO Plans The BCBSM Community Blue PPO Plans Emergencies Urgent Care vs. Emergency Room Medco Pharmacy Services Prescription Drugs Medical Benefit Comparison BCN / BCBSM Member Perks Dental Benefits Vision Benefits Coordination of Benefits Premium Conversion & Contributions Eligibility Guidelines Life / A&D & Disability Benefits Waiving Coverage and Special Enrollment Rights Womens Health and Cancer Right Act Newborns & Mothers Protection Act HIPAA Privacy Notice Medicaid & CHIP Notes Election / Waiver Form 3 4 11 12 12 12 13 15 19 20 22 22 23 24 24 24 25 25 25 26 28 31
ABC Company
2011 - 2012 Open Enrollment
n recent years, the cost of quality health care has risen considerably. Some factors impacting these increases include new treatments, improved technology, unhealthy lifestyles and an aging population. As health plan premiums continue to rise, we maintain a commitment to you and your family by offering an excellent benefit package. Recognizing your benefit needs may vary significantly from those of your co-workers, we are pleased to give you the opportunity to participate in one of the following quality medical plans administered by BCN & BCBSM:

The plan you select is the plan you will remain in until the next open enrollment for a September 1, 2012 effective date.
Some things to remember... 1. During this open enrollment period you have the opportunity to enroll in one of the medical plans if you have previously waived coverage or enroll eligible dependents not currently enrolled. 2. If you wish to add or delete dependents, you must also complete an Enrollment/Change of Status form for each plan (available from Human Resources), in addition to the Election/Waiver Form. 3. If enrolling for the first time, you must complete an Enrollment Form for each plan and the Election/Waiver Form. 4. If you are changing medical, dental or vision plans you must complete the applicable forms to accommodate your changes in addition to the Election/Waiver Form. 5. If you wish to waive coverage, you must complete the Election/Waiver Form. 6. If you are making no changes to your current enrollment, complete the Election/Waiver Form indicating NO CHANGES to your current elections and turn it into Human Resources.
BCN Healthy Blue Living (HBL) HMO Plan 5 BCN Healthy Blue Living (HBL) HMO Plan 2 BCBSM Community Blue PPO Plan 12 BCBSM Community Blue PPO Plan 4
During open enrollment, you may also elect:

Your choice of dental plans Your choice of vision plans
Please keep in mind that...
You and your eligible dependents must each enroll in the same plan options.
All carrier enrollment forms are available through Human Resources. All Employees Must Complete the Attached Enrollment Form and return to Human Resources No Later Than Friday, July 29, 2011 (EVEN IF YOU ARE NOT CHANGING YOUR ELECTIONS). This package contains a summary of your benefits for the 2011-2012 plan year (September 1, 2011 through August 31, 2012).
The information in this packet is offered for informational purposes only. It is not intended as a substitute for, or alteration of, any federal or state law or regulation, policy or provision of any written plan document or agreement between ABC Company and any contracted provider. In the event of any inconsistency between this information and any federal or state law or regulation, legal plan documents, contracts and insurance policies will govern, and no person or entity shall be entitled to claim detrimental reliance on any information provided or expressed herein. Effort has been made to ensure the accuracy of the information in this Open Enrollment packet; however, Human Resources reserves the right to interpret any ambiguity arising from any information provided.
Medical Benefits
The Blue Care Network HMO Plans

Please note: The ABC Company HMO group health plan requires the designation of a PCP. You have the right to designate any PCP who participates in the network who is available to accept you and your family members. Until you make this designation, the BCN Healthy Blue Living HMO Plan designates one for you. For information on how to select a PCP, or for a list of participating providers, contact BCN Member Services at 800.662.6667 or go to www.mibcn.com. For children, you may designate a pediatrician as the PCP. You do not need prior authorization from BCN or from any other person (including your PCP) in order to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact BCN at 800.662.6667.
hen you enroll in the BCN Healthy Blue Living (HBL) HMO plan, you and your family members each select a Primary Care Physician (PCP) in the network who will perform, arrange or authorize all medical treatment. This includes tests and referrals to specialists when necessary. Any services not authorized by your PCP will not be covered. If you elect to change your PCP, simply contact Member Services at 800.662.6667 for direction. You may also go online at www.mibcn.com. Blue Care Network has contracted with a network of local physicians, hospitals and other health care providers to provide health care services to those covered under the plan. The network of physicians includes PCPs, such as family practitioners, internists, obstetricians/gynecologists, pediatricians, and specialty care physicians. While BCN requires you to utilize specialty physicians within the BCN HMO network of doctors and hospitals with referrals from your PCP, your PCP may only refer you to specialists within their own practice or hospital group. Check with your PCP for more information on their referral policies for specialty care.
Healthy Blue Living Plan
he BCN Health Blue Living (HBL) Plan is an HMO product consisting of two benefit levels: Enhanced and Standard. These two levels offer the same great coverage through BCNs HMO network, but the amount of money required for copayments, deductibles and coinsurance is lower when an employee (and spouse) is willing to work towards and maintain a healthy lifestyle. Employees (and their covered spouses) who do not follow the guidelines established by BCN are moved to the Standard plan. This move may happen after the first 90 days of the plan (following the plans renewal or after initial enrollment in the plan) or midway through the plan year if a subscriber and/or spouse fails to follow through on a plan guideline.
ABC Employee Benefits Plan Effective 09/01/2011
Blue Care Network measures six health targets. Depending upon your compliance with the requirements of the HBL plan and your willingness to work towards these health targets, BCN will either leave or move your contract to Enhanced or Standard after the first 90 days following the plans renewal date. See the following pages for more information on the plans guidelines to remain in the Enhanced benefit level. Page 4
Medical Benefits
Healthy Blue Living HMO Timeframes
s of September 1, 2011 the requirements change for members to qualify for the Enhanced benefit level. Please read this section carefully. If you are already enrolled in the HBL HMO plan, your Enhanced or Standard benefit level stays at that level for the first 90 days after the plan renewal date. If you are enrolling in the HBL HMO for the first time, you will be placed into the Enhanced benefit level for the first 90 days following your effective date in the HBL HMO plan. If you complete the necessary requirements as stated below, on the 91st day you will either (1) remain in the Enhanced benefit level if you are already in that level, or (2) be moved up to the Enhanced benefit level from the Standard benefit level.
If you do not complete the necessary requirements, on the 91st day you will either be (1) moved from the Enhanced to the Standard benefit level or (2) remain in the Standard benefit level. In addition, if you are a tobacco user or have a Body Mass Index (BMI) of 30 or more, you must complete additional requirements within 120 days of the plan renewal date or initial enrollment in the medical plan. Refer to the following pages for more details.
HBL HMO Enhanced Benefit Level Requirements
ithin the first 90 days, both you and your covered spouse must meet the requirements for Enhanced benefits or your entire contract will be placed in the Standard benefit level. 1. Visit your Primary Care Physician (PCP) for an evaluation and completion of the health 90 Qualification Form on the following health Days measurement targets: Tobacco Blood Sugar Weight Depression Blood Pressure Cholesterol If your doctor noted last year on your Qualification Form that your follow-up visit will be in 13-24 months, you do not have to send BCN another Qualification Form until next year (be sure to keep your follow-up appointment). You must still complete Step #2. You are ultimately responsible for making sure your Qualification Form is sent to BCN, not your PCP. Be sure to keep a copy! 2. Complete an online Health Assessment (HA) at www.mibcn.com. You may also call 90 800.662.6667 for a package to be mailed to Days your home) within 90 days of your enrollment date. Be sure to leave enough time for returning the HA to the Blues via mail.
3. Depending on the results of your Qualification Form, you may also need to meet these requirements within 120 days of your initial enrollment or from the plan renewal date in order to receive Enhanced benefits. Tobacco Use-if you use tobacco you 120 need to enroll and actively participate in Days BCNs Quit the Nic program. Weight Management-if you have a body mass index of 30 or more then you will 120 need to actively participate in a BCN- Days sponsored weight management program until your BMI falls below 30. Your options are Weight Watchers or the WalkingSpree Pedometer-based Walking Program. 4. Continue to follow your doctors prescribed treatment plan throughout the year.
Even if you use tobacco or have a health condition such as diabetes, you can qualify for Enhanced benefits by following your doctors treatment plans, participating in required BCN-sponsored programs and meeting the follow-up requirements. Both you and your covered spouse must meet the requirements for Enhanced benefits or your entire contract is moved to the Standard benefit level. Children and adult dependents do not need to meet the requirements. Page 5
ABC Employee Benefits Plan Effective 09/01/2011
Medical Benefits
BCNs HBL Qualification Form
CN has introduced a new Qualification Form
for the HBL plans. This form will provide you and your PCP with a snap shot of your health related to six high-impact health measures. These target areas are manageable by individuals and allows you to work with your doctor to develop a treatment plan to set obtainable goals to improve your health. The Qualification Form tracks your status using an A-B-C grading system. You will be moved to the appropriate benefit level on the 91st day of the plan year based on completion of the necessary requirements. If you or your covered spouse score a C on any measure, you will both receive Standard benefits. You can download a copy of the Qualification Form at
www.mibcn.com. The A-B-C status on the Qualification Form means: A = You are meeting the wellness target. B = You have a health condition that may not be controlled but you are actively participating in treatment to improve the condition. C = You are not meeting the wellness target and you have not committed to treatment to improve your condition. Be sure to take a new Qualification Form with you on your initial PCP visit and to any follow-up visits you may have with your PCP throughout the year. Failure to do so could result in your contract being moved to the Standard benefit level mid-year.
How Points are Scored on the Qualification Form Health Measure If I do not meet the wellness target, how can I work to qualify for Enhanced benefits?
w Ne
Wellness Targets
Member Grading System on the Qualification Form
Tobacco
Non-tobacco user (must be confirmed by PCP through blood or urine cotinine testing) Body Mass Index (BMI) below 30
A. Enroll in BCNs Quit the Nic tobacco cessation program B. and actively participate until you complete the program and quit C. using tobacco
New
Does not use tobacco. Tobacco user: commits to enroll/is enrolled in BCN designated smoking cessation program. Tobacco user: Does not commit to and is not enrolled in BCN designated smoking cessation program. BMI<30. BMI is >30. Commits to enroll in a BCN-sponsored weight-management program. BMI is >30. Does not commit to enroll in a BCNsponsored weight-management program. Does not have high blood pressure or it is controlled. Has high blood pressure that is not controlled, but is following treatment. Has high blood pressure; does not commit to or is not following treatment. Does not have high cholesterol or it is well controlled. Has high cholesterol that is not controlled but is following treatment or does not tolerate treatment. Has high cholesterol; does not commit to or is not following treatment. Does not have diabetes or A1C is well controlled. A1C is not controlled but is following treatment. A1C is not controlled; does not commit to or is not following treatment. Does not have either history or current symptoms of depression. Has depression and is following treatment. Has depression and does not commit to or is not following treatment.
Weight
Participate in Weight Watchers or WalkingSpree C. program until BMI falls below 30 A. B. C. A. B. C. A. B. C. A.
A. B.
Blood Pressure
Below 140/90
Commit to and follow doctors treatment plan
Cholesterol
LDL below target (based on risk Commit to and follow doctors factors: <100, <130 treatment plan and <160) At or below target Commit to and follow doctors (fasting blood sugar treatment plan or A1C)
Blood sugar
New
Depression
Any depression is in full remission
Commit to and follow doctors treatment plan
B. C.
ABC Company Employee Benefits Plan Effective 09/01/2011
Page 6
Medical Benefits
Working Towards BCNs Enhanced Benefits
Weight Management If you have a BMI of 30 or more, you are required to participate in a BCNsponsored weight management program. BCN offers two programs: Weight W a t c h e r s a n d WalkingSpree, a pedometerbased walking program with online reporting. (You will need a personal computer available for downloading your steps if you elect to participate in the WalkingSpree program.) You must remain in the program you choose until your BMI falls below 30, which is the threshold to earn Enhanced benefits as indicated in the table on page 6. BCN will cover the cost of either program (not both), although some restrictions apply. Members may only pick one program and must register within 120 days of the start of the plan year. Members also must start participating in the selected program within one week of registration. You can only switch from one program to the other at the start of the plan year. You are evaluated on a quarterly basis and to receive Enhanced benefits you must attend 11 out of 13 weekly meetings per session if you choose the Weight Watchers option. For the WalkingSpree program, you must average 5,000 daily steps per three-month period. If your BMI drops below 30 during the year, BCN will continue to pay for either program until the end of the plan year to encourage you to continue. If you choose not to participate in either weight management option, you and everyone else in your contract (spouse, children) are moved to the Standard benefit level. Once your BMI is below 30, return to your doctor and complete and submit to BCN a Qualification Form to show you have met the requirement. When BCN receives the updated form, you will no longer need to participate in either the Weight Watchers or WalkingSpree program. To select a weight management program option, go online to www.mibcn.com and login to Member Secured Services.
Tobacco Use
obacco use is now determined by continine testing which confirms the presence of nicotine via a blood or urine test conducted by your PCP. Continine testing is required for all new and renewing members for the first year of enrollment in HBL and those who test positive for nicotine will be tested annually. In addition, if your PCP suspects tobacco use on current members, they may order the test. If you or your covered spouse use tobacco, you are required to enroll and actively participate in BCNs free Quit the Nic tobacco cessation program until you quit using tobacco to earn Enhanced benefits. If you use tobacco and choose not to participate in Quit the Nic, you and everyone on your contract (spouse/children) will be moved to the Standard benefit level. To confirm you have quit using tobacco, you must complete and submit a new Qualification Form signed by your PCP. You may submit the form at any time during the plan year. After BCN receives the updated form, you will no longer need to participate in Quit the Nic. Depression
epression replaces alcohol as one of the health care measures on the Qualification Form this year. Depression is the #1 cause of disability worldwide. People with depression are more likely to develop cardiovascular disease and diabetes. Screening for depression is easily completed during your visit to your physicians office by simply answering a few questions. BCN gives you access to behavioral health services 24 hours a day, seven days a week, by going online to www.mibcn.com or calling the Member Services number on the back of your BCN ID card, 800.662.6667. BCN certified Health Coaches provide telephone support and can develop a personal plan with members. You can request services of a health coach by calling 888.772.7147 or send an e-mail to: hblhealthcoach@bcbsm.com Page 7
Medical Benefits
Working Towards BCNs Enhanced Benefits
You enroll in the HBL Plan
If a New Enrollment: You and your family are automatically enrolled in the Enhanced Benefit Level for the first 90 days of the plan. If at Renewal: You remain in your current plan for the first 90 days following the plan effective date.
If enr ollin th the fi e BCN H g in MO fo receiv rst time r comp e your B , wait unti CN ID ly leting your and H card ou Quali befo ealt sure to co h Assess fication F re ment, mple orm the fi rst 90 te both ite but be ms w days ithin of the plan.
Health Assessment
Yesyou and your spouse completed the HA within 90 days

n ar o t our If y last ye rm tha in Fo ed not ation will be ot tor n ic t doc Qualif p visi u do her -u r yo ot you follow nths, N an til ur 4 mo d BC m un yo -2 n r 13 to se ion Fo r. e t a hav alifica xt ye ne Qu
Noyou and your spouse did not complete the HA within 90 days
Qualification Form
Yesyou and your spouse complete the Qualification Form within 90 days
Noyou and/or your spouse do not complete the Qualification Form within 90 days
You and/or your spouse scored all As on the Qualification Form
You and/or your spouse scored Bs on the Qualification Form
You and/or your spouse scored Cs on the Qualification Form
You and/or your spouse agree to enroll in applicable programs (weight management, smoking cessation) and to work with your PCP & BCN Health Coaches, if necessary, to work towards a healthier lifestyle
You and/or your spouse Do Not agree to applicable programs (weight management, smoking cessation) or to work with your PCP & BCN Health Coaches to work towards a healthier lifestyle
You and your family are enrolled in the Enhanced Benefit Level after 90 days
You and your family are enrolled in the Standard Benefit Level after 90 days Page 8
Medical Benefits
Completing the BCN Online Health Assessment (HA)
he purpose of the HA is to provide an opportunity for employees to see areas where they are doing well and areas that may need attention in terms of living a healthy, balanced life. The more you know about your health, the better you can control the potential risks. Based on the information you enter, you will receive a detailed profile that provides you with a snapshot of your health and health risks, as well as tips and advice on how you can minimize those risks. Questions cover areas such as diet, exercise and stress, and only takes about 20 minutes to complete. Go to www.mibcn.com. From Member Secured Services you can view your benefits, check the status of a claim, order ID cards and more. 1. Log in to Member Secured Services.
2. Click the BlueHealthConnection link.
3. Click the Complete Health Assessment link. 4. Complete the Health Assessment and click
Submit. You will receive your lifestyle score and a personalized plan indicating what you are doing well and what you can do better. Both you and your enrolled spouse need to complete the Health Assessment within the first 90 days of the plan or within the first 90 days following the plans renewal. If you cannot access the online HA, call 800.662.6667 to have a paper copy of the HA mailed to you. You and your enrolled spouse must call Member Services separately for a paper copy. Do not photocopy someone elses HA. They are individually coded to each member to track compliance with the requirements.
If you have not already done so, you are required to register with Member Secured Services. Your health plan ID card has the information you need to enroll. If you have any questions about your log in or registration, please call 877.258.3932.
IMPORTANT: Each member taking the HA must log in with their own ID and password for BCN to record the completed assessment.
How to Stay in the Enhanced Level
ou worked hard to get into the Enhanced Level, so dont get moved to the Standard Level in the middle of the plan year. Heres how you can stay in the Enhanced Level for the entire plan year. Make an appointment now with your PCP to complete your Qualification Form before the 90 day deadline expires. Mail to BCN (PO Box 68710, Grand Rapids, MI 49516-8710) or fax (866.637.4972) your Qualification Form before the 90-day deadline. Its your responsibility to ensure the form gets to BCN; not your PCPs. Use the results from your Qualification Form to complete your online Health Assessment at www.mibcn.com. Print the confirmation page at the end of the Assessment to show youre done within 90 days. If necessary, join Quit the Nic and/or one of the weight management programs for weight management within 120 days of renewal or enrollment. Follow up with your PCP as required throughout the plan year. Be sure to complete a new Qualification Form with each visit and keep copies of all your Qualification Forms. Page 9
1 2 3 4 5
Medical Benefits
Blue Care Network Away From Home
s a Blue Care Network member, you can receive benefits when you are away from home. Your dependents are also covered when they are at school away from home. Always carry your ID card for easy reference and access to service. You should not have to complete claim forms or pay up front for health care expenses, except for your usual out-of-pocket expenses such as copayments, deductibles and coinsurance. You will be responsible for noncovered services. Before you travel, please call BCN Member Services at 800.662.6667 for more details about your health care benefits away from home. If You're Traveling... And you need...
As a BCN member you have access to Blue Plan physicians and hospitals nationwide. Your BCN coverage includes BlueCard, a program of the Blue Cross and Blue Shield Association. The chart below tells you how to access and arrange for care when you are away from home.
Heres what you do...
EMERGENCY CARE (The symptoms are severe enough that someone with Call 911 or go to the nearest emergency average health knowledge believes room. immediate medical attention is needed) In Michigan where BCN is offered Call your Primary Care Physician. BCN URGENT CARE (The condition requires a Member Services can help you locate a medical evaluation within 48 hours) participating urgent care center. Call 800.662.6667. F OLLOW-UP C ARE (for a medical Call 888.656.8276 to find a physician at condition that started before you left your destination. home) In Michigan where BCN is not offered (you are covered for emergency care only) Call 911 or go to the nearest hospital emergency room. Call 911 or go to the nearest hospital emergency room. Call BlueCard at 800.810.BLUE (2583). Call BlueCard at 800.810.BLUE (2583) to find a physician at your destination.
EMERGENCY CARE
EMERGENCY CARE URGENT CARE In the United States but outside Michigan FOLLOW-UP CARE
ROUTINE CARE for members living away Call BlueCard at 800.810.BLUE (2583). from home Outside the United States EMERGENCY CARE Go to the nearest hospital emergency room (you may be required to pay for services and then seek reimbursement). Page 10
Medical Benefits
The BCBSM Community Blue PPO Plans
he BCBS Community Blue PPO plans provides you with freedom of choice. Blue Preferred PPO plan members are not required to select a Primary Care Physician and they do not need a referral to see another PPO network provider. Blue Preferred PPO members do not have to notify BCBSM when changing physicians. When you choose to receive services from a provider who is not a member of the PPO network, the copayment, deductible and coinsurance amount for which you are responsible increases. In addition to increased copayment amounts, some services are not payable when rendered by nonPPO providers. However, if a member goes to a non-PPO provider with a referral from a PPO provider, out-of-network copayments are waived. Network Providers You are the one to determine the best provider from whom to receive care, regardless of whether that provider is in the Blue Preferred PPO provider network or not; however, your out-of-pocket costs for related services will be less (i.e. lower deductible and coinsurance) if you utilize Blue Preferred PPO network providers. In other words, the plan will pay a higher percentage of these services if you receive them from Blue Preferred PPO providers. To find PPO providers in your area, simply go to www.bcbsm.com and select Find a Doctor or hospital. Non-Network Providers Be aware you may still be responsible for charges which exceed the BCBS approved amount if you do not use participating providers. When you receive care from a provider who is not part of the Community Blue PPO network, without a referral from a PPO provider, your care is considered out-ofnetwork. Before choosing a nonnetwork provider, verify if the service is
covered. Some services, such as your preventive care services, are not covered out-of-network. If you choose to receive services from a non-network provider, you can still limit out-of-pocket costs if the provider participates in the Traditional plans. If you use Blue participating providers outside the PPO network: The provider will bill BCBSM directly for your services. You will not be billed for any differences between BCBSM approved amount and their charges. Nonparticipating Providers Nonparticipating providers have not signed agreements with Blue Cross Blue Shield of Michigan. If you receive services from a nonparticipating provider, you are usually required to pay providers directly and may be required to submit a claim to BCBSM for payment. When you use a provider who does not participate with BCBSM: You will receive payment directly from BCBSM. The amount you receive from BCBSM may be significantly less than the amount a nonparticipating provider charges you. You are responsible for paying the provider. You are responsible for any difference between BCBSs payment and the providers charges. BCBSM coverage at nonparticipating hospitals is limited to services needed to treat an accidental injury or medical emergency. There is no coverage for non-emergency hospital services performed by a nonparticipating hospital or for services received at mental health or substance abuse treatment facilities, ambulatory surgery facilities, end stage renal dialysis facilities, home infusion therapy providers, hospices, outpatient physical therapy facilities, skilled nursing facilities or home health care Page 11
Emergencies
ne of the most frequently asked questions is, When are emergencies covered under the plan? To avoid unnecessary expenses, you need to know what qualifies as an emergency, and the benefits available for emergency services. Covered services for emergencies include two categories:
Accidental Injury Medical Emergency
A medical emergency is an i n t e r n a l c o n d it i o n t h a t threatens life or bodily functions, or one that could result in serious bodily harm unless treated promptly. Examples of a medical emergency include, but are not limited to: severe chest pain; severe bleeding (not a result of an injury); convulsions; and loss of consciousness. Your health plan will pay for the treatment of serious symptoms only when the condition (or its symptoms) occurs suddenly and unexpectedly and the physician agrees when the patient arrived in the emergency room, a threat to life and bodily functions appeared to exist. Treatment must be given within 72 hours of the onset of the condition to be deemed an emergency.
An accidental injury is any injury caused by an external action, object or chemical agent. Examples of accidental injuries include, but are not limited to: sprains or cuts requiring prompt treatment by a physician; inhalation of smoke and burns; swallowing of poison; overdoses of medication; frostbite; allergic reactions caused by bee stings or insect bites; and attempted suicide.
Urgent Care vs Emergency Room
rgent that condition average believes evaluation or injury.
Care is a type of care is required for any that a person with health knowledge requires a medical with 48 hours of onset
Studies show that Urgent Care wait times are typically much shorter than E.R. wait times. Also, the copayment required for an Urgent Care visit is much lower than your Emergency Room co-pay. Urgent Care should be used when your PCP is not available and the condition does not require Emergency Room treatment. Urgent Care facilities are never an option for follow-up care. To locate an Urgent Care facility near you, contact BCN Member Services at 800.662.6667 or BCBSM Member Services at 800.637.2227.
Urgent Care DIFFERS from Emergency Room Care because the patients condition is usually NOT LIFE-THREATENING. Examples of conditions requiring Urgent Care include sinus/ear infections, moderate fever, minor burns and cuts, sprains and flu-like symptoms.
Medco Pharmacy Services
edco is contracted with BCBSM and BCN to administer your retail prescription program. In order to fill a prescription, a retail pharmacy must first confirm your BCN prescription benefits through Medco. If you ever experience difficulty getting a prescription filled at a retail pharmacy, call Medco Pharmacy Services at 800.922.1557 and follow the prompts to speak with a Member Services representative. The Medco representative can advise you on why your prescription may not be
authorized or what needs to be done to fix any issues. Medco can also suggest lower cost equivalent alternative prescriptions covered by your plan. If Medco informs you your doctor failed to get Prior Authorization, you can contact your physicians office right from the pharmacy and remind them to call Pharmacy Clinical help desk at 800.437.3803. This will reduce waiting time in the pharmacy on your part and prevent you from paying out-ofpocket cost for medications that should be covered as a part of your prescription program. Page 12
Prescription Benefits
Your Prescription Drug Copayments
CN HMO prescription drugs are covered by two-tiered drug copayments. That means you pay one of two copayments depending on the type of medication your doctor prescribes for you. Community Blue PPO prescription drugs are covered by three-tiered drug copayments; that means you pay one of three copayments depending on the type of medication your doctor prescribes for you. The tables below are your member copayments for 30-day and 90-day supplies of medication for all plans, available at retail pharmacies or through the mail order prescription program**.
30-Day Prescription (Retail Pharmacy) BCN HBL HMO 5 Type of Drug Generic Rx Preferred Brand Rx NonPreferred Brand Rx BCN HBL HMO 2 BCBSM CBP PPO
Mail Order Drugs: When you utilize mail order prescriptions for maintenance medications, a 90-day supply of maintenance medication is mailed directly to your home. Maintenance medication is taken on a regular or longterm basis. Your Medco order will be sent to your home via UPS or First Class Mail. Reorder information will be included in your prescription shipment. Go to www.medcohealth.com for more information on BCBSM and BCNs mail order prescription program with Medco. To participate in the mail order plan through Medco, have your doctor write you a 90-day prescription and download an enrollment form from www.mibcn.com. Complete the form and mail it, with your copayment and original prescription in the envelope provided. Your prescription will be mailed directly to your home and you will save money on required copayments. Specialty Drugs: Specialty drugs are used to treat complex, chronic conditions such as cancer, chronic kidney failure, multiple sclerosis, organ transplants and rheumatoid arthritis. These drugs require special handling or monitoring and are not available through regular mail order. Not all retail pharmacies will dispense specialty drugs so BCBSM and BCN offer mail order service through Walgreens Specialty Pharmacies. Have your doctor fax your specialty medication prescription to Walgreens Specialty Pharmacy at 866.515.1356, or complete the form available online at www.mibcn.com. Walgreens Customer Service is available at 866.515.1355 if you have questions about your specialty drug order. Go to www.mibcn.com for a complete list of Specialty Drugs. Some manufacturers limit the distribution of specialty drugs; these are called Limited Distribution Specialty Drugs. BCBSM and BCN have been able to secure access to these drugs through Accredo, Medcos specialty pharmacy. Accredo can be reached at 800.803.2523. Page 13
Enhanced Standard Enhanced Standard CBP 12 CBP 4 $10 $40 $15 $50 $10 $40 $15 $50 $10 $40 $15 $30
NC
NC
NC
NC
$80
$60
90-Day Prescription (Retail Pharmacy) BCN HBL HMO 5 BCN HBL HMO 2 BCBSM CBP PPO Type of Enhanced Standard Enhanced Standard CBP 12 Drug Generic Rx Preferred Brand Rx NonPreferred Brand Rx $20 $80 $30 $100 $10 $40 $15 $50 $20 $80 CBP 4 $15 $30
NC
NC
NC
NC
$160
$60
**A 90-day supply of medication is available from retail pharmacies or mail order for twotimes your regular 30-day copayment.
You can view the BCBSM and BCN drug formularies at www.bcbsm.com and www.mibcn.com.
Prescription Benefits
BCN Pharmacy Initiatives
CBSM and BCN monitor the use of certain medications to ensure members receive the most appropriate and cost-effective drug therapy. Your prescription drug coverage will include the following BCBSM and BCN pharmacy initiatives. Prior Authorization: Physicians are required to get Prior Authorization on some medications. This is a process requiring a physician to obtain approval from BCBSM and BCN before select prescription drugs are covered. Step Therapy is an initial phase in the Prior Authorization process that applies criteria to select drugs to determine if a less costly prescription drug may be used for the same drug therapy. Some over-the-counter (OTC) medications may be covered under step-therapy guidelines. This also applies to Mail Order Drugs. Claims that do not meet Step Therapy criteria require Prior Authorization. Details on which drugs require Prior Authorization or Step Therapy are available at www.mibcn.com under Member Secured Services. Your physician can contact the BCBSM and BCN Medco Pharmacy Clinical help desk to request Prior Authorization for these drugs by calling 800.437.3803. You may be required to pay for the full cost of the drug if your physician does not obtain Prior Authorization. Physician-Administered Injectable Drugs: Injectable drugs administered by a health care professional (not self-administered) are not covered under the pharmacy benefits, but may be covered under your medical benefit.
Quantity Limits: Select drugs may have limitations related to quantity and doses allowed per pr escr ipt ion unless t he prescribing physician obtains Prior Authorization from BCBSM and BCN. Lists of these drugs with quantity limits i s a v a i l a b l e a t www.bcbsm.com and www.mibcn.com. Drug Interchange and Generic Copayment Waiver: Certain drugs may not be covered for future prescriptions if an alternative drug is identified by BCBSM and BCN unless the prescribing physician demonstrates the drug is medically necessary (see Prior Authorization to the left). A list of drugs that may require Prior Authorization is available at www.bcbsm.com and www.mibcn.com. If your physician rewrites your prescription for the recommended generic or OTC alternative drug, you will only pay a generic copayment. If your physician rewrites your prescription for the recommended brand name alternative drug, you pay a brand name copayment. In select cases BCBSM or BCN may waive the initial copayment after your prescription has been written. BCBSM or BCN will notify you if you are eligible for a waiver. Mandatory Maximum Allowable Cost: If you fill a prescription at a network pharmacy and it is filled with a generic equivalent drug, you pay only your prescription copayment. If you obtain a formulary brand name drug when a generic equivalent is available, you must pay the difference in cost between the formulary brand name drug dispensed and the maximum allowable cost of the generic drug plus your prescription copayment, regardless of whether you or your doctor requests the formulary drug. If you obtain a non-formulary brand name drug when a generic equivalent is available, the non-formulary brand name drug is not a covered benefit. Exceptions to this are when your physician requests and receives authorization for a non-formulary brand name drug with a generic equivalent from BCBSM and BCN and writes Dispense as Written or DAW on the prescription. Page 14
Medical Benefits Comparison
he following pages contain are examples of your estimated out-of-pocket costs under the BCN Healthy Blue Living HMO plans. In the event of any inconsistency between this information and any federal or state law or regulation, policy, written plan document or agreement, the provisions of the relevant law, policy, plan document or agreement will govern. Healthy Blue Living 5 HMO
Enhanced Benefits Standard Benefits $1,500 $3,000 30% to $1,500 30% to $3,000 Up to $1,0001 Up to $2,0001 $2,000 $4,000 Required of PCP
30% after deductible1 30% after deductible1 30% after 30% after deductible1 deductible1 30% after deductible1 $150 copayment after deductible
ITEM
Healthy Blue Living 2 HMO

Enhanced Benefits $0 $0 25% to $1,000 25% to $2,000 Up to $1,0001 Up to $2,0001 Minimal Minimal Required of PCP
25%1 25%1 25%1 25%1 25%1 $150 copayment
Standard Benefits $1,000 $2,000 30% to $1,500 30% to $3,000 Up to $1,0001 Up to $2,0001 $1,500 $3,000 Required of PCP
30% after deductible1 30% after deductible1 30% after deductible1 30% after deductible1 30% after deductible1 $150 copayment after deductible
Calendar Year Deductible For an Individual You Pay $250 For a Family You Pay $500 Calendar Year Coinsurance For an Individual You Pay 20% to $1,000 For a Family You Pay 20% to $2,000 Coinsurance Reimbursement For Individual Coverage Up to $1,0001 For Family Coverage Up to $2,0001 Your Total Maximum Cost2 For an Individual You Pay $250 For a Family You Pay $500 When You Go to the Hospital, You Pay Hospital Pre-Certification Required of PCP 20% after deductible1 Hospital Room & Board 20% after deductible1 In-Patient Surgery 20% after deductible1 Delivery and Nursery Care 20% after deductible1 In-Patient Psychiatric 20% after deductible1 In-Patient Substance Abuse Emergency Room
Waived if admitted
$150 copayment after deductible
Urgent Care Diagnostic X-Ray & Lab

Office visit copayment may apply
$35
20% after deductible
$50
$35
0%
$35
When You Go to the Doctor's Office You Pay PCP Doctor Office Visits $30 copayment Specialist Office Visits $30 after deductible Outpatient and Home Visits $30 after deductible Pre & Post Natal Care $30 copayment Allergy Testing & Therapy 50% after deductible Allergy Injections $5 copayment Chiropractic Care (PCP Referral Only) $30 after deductible Out-Patient Surgery 20% after deductible1 Out-Patient Psychiatric $30 after deductible Out-Patient Substance Abuse $30 after deductible When You Receive Preventive Services You Pay -0Routine Physical Exams -0GYN Exams -0Well Child Care -0Immunizations -0Routine Pap Smear -0Routine Screening Mammogram ABC Company Employee Benefits Plan Effective 09/01/2011
$30 copayment $30 after deductible $30 after deductible $30 copayment 50% after deductible $5 copayment $30 after deductible 30% after deductible1 $30 after deductible $30 after deductible
-0-0-0-0-0-0-
$20 copayment $20 copayment $20 copayment $20 copayment 50% after deductible $5 copayment $20 copayment 25%1 $20 copayment $20 copayment
-0-0-0-0-0-0-
$20 copayment $20 after deductible $20 after deductible $20 copayment 50% after deductible $5 copayment $20 after deductible 30% after deductible1 $20 after deductible $20 after deductible
-0-0-0-0-0-0-
Page 15

ITEM
Ambulance Services Durable Medical Equipment Prosthetics & Orthotics Home Health Care Prescriptions 30 day supply Generic Formulary Brand Name Non-formulary Brand Name Contraceptives Mail Order & Retail Prescriptions 90 day supply Generic Formulary Brand Name Non-formulary Brand Name Contraceptives
1

Enhanced Benefits Standard Benefits
20% after deductible 50% 50% $30 after deductible 30% after deductible 50% 50% $30 after deductible

Enhanced Benefits
$25 copayment 50% 50% $20 copayment
Standard Benefits
30% after deductible 50% 50% $20 after deductible
WHEN YOU RECEIVE PHARMACY SERVICES YOU PAY $10 copayment $40 copayment Not Covered Included $20 copayment $80 copayment Not Covered Included $15 copayment $50 copayment Not Covered Included $30 copayment $100 copayment Not Covered Included $10 copayment $40 copayment Not Covered Included $10 copayment $40 copayment Not Covered Included $15 copayment $50 copayment Not Covered Included $15 copayment $50 copayment Not Covered Included
ABC Company reimburses $1,000 per individual / $2,000 per family for coinsurance under the BCN HBL HMO Plan. This reimbursement applies to noted services only (specifically hospitalization and surgical services only). In order to provide reimbursement of the coinsurance requirements of the plan, you submit a copy of your Explanation of Benefits (EOB) from Blue Care Network along with a completed Medical Reimbursement Claim Form to Human Resources.
2
Total Maximum Cost does not include any copayment requirements under the plan (i.e. - office visits, prescription drugs, etc.). It includes the deductible and coinsurance requirements of the plans.
Page 16
he following pages contain are examples of your estimated out-of-pocket costs under the BCBSM Community Blue PPO plans. In the event of any inconsistency between this information and any federal or state law or regulation, policy, written plan document or agreement, the provisions of the relevant law, policy, plan document or agreement will govern.
ITEM
Calendar Year Deductible For an Individual You Pay For a Family You Pay Calendar Year Coinsurance For an Individual You Pay For a Family You Pay Coinsurance Reimbursement For Individual Coverage For Family Coverage Your Total Maximum Cost2 For an Individual You Pay For a Family You Pay When You Go to the Hospital, You Pay Hospital Room & Board In-Patient Surgery Delivery and Nursery Care In-Patient Psychiatric In-Patient Substance Abuse Emergency Room Waived if admitted or accidental injury Urgent Care Diagnostic X-Ray & Lab Doctor Office Visits (medically necessary) Outpatient and Home Visits Second Surgical Option Pre & Post Natal Care Allergy Testing & Therapy Chiropractic Care Out-Patient Surgery Out-Patient Psychiatric Out-Patient Substance Abuse When You Go to the Doctor's Office You Pay $30 copayment 20% after deductible $30 copayment -0-0$30 copayment 24 visits per year 20% after deductible1 20% after deductible 20% after deductible 40% after deductible 40% after deductible 40% after deductible 40% after deductible 40% after deductible 40% after deductible 40% after deductible 40% after deductible 40% after deductible $20 copayment 20% after deductible $20 copayment -0-0$20 copayment 24 visits per year 20% after deductible1 20% after deductible 20% after deductible 40% after deductible 40% after deductible 40% after deductible 40% after deductible 40% after deductible 40% after deductible 40% after deductible 40% after deductible 40% after deductible 20% after deductible1 20% after deductible1 20% after deductible1 20% after 20% after deductible1 deductible1 40% after deductible 40% after deductible 40% after deductible 40% after deductible 40% after deductible 20% after deductible1 20% after deductible1 20% after deductible1 20% after 20% after deductible1 deductible1 40% after deductible 40% after deductible 40% after deductible 40% after deductible 40% after deductible 20% to $2,500 20% to $5,000 Up to $1,0001 Up to $2,0001 $2,500 $5,000 40% up to $3,000 40% up to $6,000 -0-0$5,000 $10,000 20% up to $1,500 20% up to $3,000 Up to $1,0001 Up to $2,0001 $1,000 $2,000 40% up to $3,000 40% up to $6,000 -0-0$4,000 $8,000 $1,000 $2,000 $2,000 $4,000 $500 $1,000 $1,000 $2,000
COMMUNITY BLUE 12 PPO

Network Non-Network

Network Non-Network
$150 copayment Subject to balance billing if non-network provider used $30 20% after deductible 40% after deductible 40% after deductible
$150 copayment Subject to balance billing if non-network provider used $20 20% after deductible 40% after deductible 40% after deductible
Mental Health/Substance Abuse procedures that are equivalent of an office visit (consultative services rendered in the physicians office) will be treated and processed like an office visit, subject to the fixed dollar office visit copayment.
Page 17

ITEM

Network Non-Network

Network Non-Network
When You Receive Preventive Services You Pay See your plan document and carrier benefit outline for frequency & limitation guidelines. Routine Physical Exams GYN Exams Well Child Care Immunizations Routine Pap Smear $0 $0 $0 $0 $0 Not covered Not covered Not covered Not covered Not covered $0 $0 $0 $0 $0 Not covered Not covered Not covered Not covered Not covered
Routine Screening Mammogram
40% after deductible 40% after deductible Non-network readings and Non-network readings and $0 $0 interpretations are payable interpretations are payable (subsequent medically (subsequent medically only when the screening only when the screening necessary tests subject to necessary tests subject to mammogram itself is mammogram itself is deductible/coinsurance) deductible/coinsurance) performed by a network performed by a network provider. provider.
When You Receive These Services You Pay Retail Prescription Drugs Generic Preferred Brand Name Non-Preferred Brand Name Contraceptives Mail Order Prescriptions Generic Preferred Brand Name Non-Preferred Brand Name Ambulance Services (must be medically necessary) Durable Medical Equipment Prosthetics and Orthotics Home Health Care (must be medically necessary) $10 copayment $40 copayment $80 copayment Included 25% plus copayment $20 copayment $80 copayment $160 copayment Included 20% after deductible 20% after deductible 20% after deductible 20% after deductible $15 copayment $30 copayment $60 copayment Included 20% after deductible 20% after deductible 20% after deductible 20% after deductible $15 copayment $30 copayment $60 copayment Included 25% plus copayment
ABC Company reimburses $1,000 per individual / $2,000 per family for IN-NETWORK coinsurance, after the deductible is satisfied under the BCBS PPO Plan. This reimbursement applies to noted services only (specifically hospitalization and surgical services only). In order to provide reimbursement of coinsurance requirements of the plan, you must submit a copy of your Explanation of Benefits (EOB) from Blue Cross Blue Shield of Michigan along with a completed Medical Reimbursement Claim Form to Human Resources.
2
Your Total Maximum Cost does not include any co-payment requirements under the plan (i.e. - office visits, prescription drugs, etc.). It includes deductible and coinsurance requirements of the plans.
Page 18
BCN / BCBSM Member Perks

When you become a Blues customer, there are several wellness programs available to members and their dependents. Designed to improve health and complement traditional health care, some of the programs also save employees money. Go to www.bcbsm.com/blue365/ for information on money saving discount programs and services.
Receive two free weeks of YogaMedics Spine Care, plus an exclusive 30-day offer for only $69 at participating YogaMedics locations.
BlueSafeThis is a discount program at various BlueSafe Michigan retailers. Members save money on a variety of safety and health equipment like bike helmets, life vests, and more. For example:
Receive two free weeks of unlimited yoga when you show your card. Locations in Birmingham, Grosse Pointe, Royal Oak and West Bloomfield.
Show your card and save 15% at Michigan Wright & Filippis stores on all home medical equipment not covered by your health coverage.
Members receive a discount on Weight Watchers memberships and fees by showing their identification card.
Save up to 20% at Michigan Dunhams Sports on helmets, in-line skates and scooters, athletic braces and supports and life jackets.
Show your card and save 5% everyday on your total purchases at Plum Markets. On Tuesdays, you can save 10% off produce at Westborn Market locations.
Naturall y Bl ue Mem bers can obt ain complementary health services at a discount. This program includes services such as acupuncture, exercise/movement, diet and supplement advisors, wellness/fitness centers, reference library, and more. For example:
Show your card and save 50% off the current special enrollment rate at Powerhouse Gym. Restrictions may apply.
Quit the Nic!A free smoking cessation program, Quit the Nic!, has a proven track record of helping members give up tobacco for good. Participants receive telephone support, educational materials, and opportunities to speak with a health coach about how to kick the habit. Call 800.775.BLUE (2583) to join.
As a blues member, you can receive 15% off equipment at American Home Fitness merchandise. Offer valid at participating locations.
Bl ueHeal t hConnect i on T he BlueHea lt h Connection Health Coach Hot Line provides you with access to registered nurses and other health education materials. Supported by board-certified physicians, their nurses assist individuals who may be uncertain about whether to seek medical care.
Page 19
Page 19
Dental Benefits
BC Company offers two dental plans through BCBSM DenteMax network. The dental plans run on a calendar year basis. If you have waived dental coverage previously and would like to enroll in the plan now, or if you would like to change dental plans, you may also do so at this time. Under the dental plans, you have the option to receive services from any dentist for choose, however you will have the lowest out-of-pocket costs when services are received from dentists who are part of the DenteMax dental network. To find DenteMax dentists near you, go online at www.dentemax.com or call DenteMax at 800.752.1547.
When you visit a participating dentist, claims are paid based on a negotiated fee schedule. The participating dentist will accept payment from BCBSM as payment in full minus your required coinsurance. The required coinsurance must be paid plus the difference between the amount your insurance pays and what the dentist charged for the procedure. If you stay in-network your out-ofpocket expenses will be minimal. Remember, should you utilize a non-participating dentist, your out-of-pocket costs will be greater.
There is a 12-month waiting period for Class III & Class IV benefits under the Blue Choice Dental 3 Plan option. The waiting period will be satisfied on the last day of the 12-month period with benefits becoming effective on the first date following. For example, if the your coverage becomes effective on September 1, 2011 the last date of the waiting period will be August 31, 2012, with benefits becoming active on September 1, 2012.
Important Notes Regarding Your Dental Benefits

1. The BCBS dental plan is a PPO plan using the DenteMax provider network. 2. When you receive services from a network participating dentist, you will only be responsible for your deductible and coinsurance under the plan. 3. If you elect to receive services from a nonparticipating dentist, the provider may bill you the difference between the actual charge and the approved amount, in addition to the deductible and coinsurance requirements that may apply. 4. When you receive services from a DenteMax network dentist, you'll have the lowest out-of-pocket cost. 5. You will also receive discounts on non covered services when you use DenteMax network dentists. 6. Because all DenteMax dentists participate, they file claims for you and receive payment directly from BCBS. You are only responsible for paying your deductible, copayments, and any fees for non covered services. To locate a network dentist, visit the DenteMax web site at www.dentemax.com. 7. You have the option to receive services from ANY provider you choose at ANY time. There are no requirements you receive services from a DenteMax or BCBSM Blue Par Select provider. 8. Blue Par Select SM Most dentists that are not in the DenteMax network participate with BCBS on a per claim basis (94% of claims are submitted to BCBS as participating. This means these dentists file claims for you and receive payment directly from BCBS. They accept payment in full from BCBSM for all covered services you pay the dentist only for your copayment, deductible and/or any fees for non covered services. 9. Go to http://www.blueparselect.com for a Directory of Registered Dentists 10. When going to a provider outside the DenteMax network, it is important that you ask before every service whether the dentist participates with BCBSM!
Page 20
Dental Benefits
ITEM Deductible Individual Family Coinsurance Class I Preventive Class II Basic Class III Major Class IV Orthodontics Annual Maximum (I-III) Lifetime Maximum (IV) Pre-Determination Amount BLUE CHOICE DENTAL 3 Waived for Type I $50 $100 -025% 50% 50% $1,000 $1,000 TRADITIONAL PLUS DENTAL 7 -0-0-025% 50% 50% $1,500 $1,500
None, but for non-urgent, complex or expensive dental treatment such as crowns, bridges or dentures, members should encourage their dentist to submit the claim to BCBSM before treatment begins. Examples of Covered Dental Benefits Oral Exams (2 x per calendar year) Bitewing X-Rays (2 x per calendar year) Prophylaxis (2 x per calendar year) Fluoride Treatment (2 x per calendar year Space Maintainer (1 per quadrant per lifetime to age 19) Full-mouth & Panoramic X-Rays (1x 60 months) Sealants (1 x 36 months to age 19) Emergency Palliative Care Fillings Oral Surgery / Extractions Recementing Crowns, Veneers, Inlays, Onlays & Bridges (3 x per tooth per calendar year after six years) Root Canal Treatment (1 x 12 months per tooth) Scaling & Root Planning (1 x 24 months per quadrant) Occlusal adjustments (5 x 60-month period) Occlusal Biteguards (1 x 12 months) Relining/Rebasing partials or complete dentures (1 x 36 months) Repairs / Adjustments of Dentures General Anesthesia Oral Exams (2 x per calendar year) Bitewing X-Rays (2 x per calendar year) Prophylaxis (2 x per calendar year) Fluoride Treatment (2 x per calendar year Space Maintainer (1 per quadrant per lifetime to age 19) Full-mouth & Panoramic X-Rays (1x 60 months) Sealants (1 x 36 months to age 19) Emergency Palliative Care Fillings Oral Surgery / Extractions Onlays / Crowns / Veneer Fillings (1 x 60 months per tooth) Recementing Crowns, Veneers, Inlays, Onlays & Bridges (3 x per tooth per calendar year after six years) Root Canal Treatment (1 x 12 months per tooth) Scaling & Root Planning (1 x 24 months per quadrant) Occlusal adjustments (5 x 60-month period) Occlusal Biteguards (1 x 12 months) Relining/Rebasing partials or complete dentures (1 x 36 months) Repairs / Adjustments of Dentures General Anesthesia
Class I Preventive
Class II Basic
12 Month Waiting Period for Class III Services Onlays / Crowns / Veneer Fillings (1x60 months per Removable Dentures & Bridges (1 x 60 months) Class III Major tooth) Endosteal Implants Removable Dentures & Bridges (1 x 60 months) Endosteal Implants 12 Month Waiting Period for Class IV Services Class IV Treatment & procedures to control harmful habits & Treatment & procedures to control harmful habits & Orthodontics Tooth guidance appliances Tooth guidance appliances This is a very brief overview. Make sure to check your benefit certificate for additional information regarding coverage and limitations on frequency of services.
Page 21
Vision Benefits
ision benefits are provided through EyeMed Vision Care.
Under the EyeMed plan, you may receive services anywhere you choose, but will have the lowest outof-pocket costs receiving services from providers who are part of the EyeMed network. You may
ITEM Frequency Exam with Dialation (as Necessary) Standard Contact Exam Premium Contact Exam Frames: Lenses (per pair) Single Bifocal Trifocal Standard Progressive Premium Progressive Contact Lenses (fitting & materials) Conventional Disposables Medically Necessary Lens Options UV Treatment Tint (Solid and Gradient) Standard Plastic Scratch Coating Standard Polycarbonate Standard Anti-Reflective Coating Other Add-Ons and Services Second Pair of Glasses Second Pair of Contacts LASIK and PSK Vision Correction
choose from two plans (the only difference between the plans is the frequency of purchase of new frames either each 12 months, or each 24 months). Find a provider near you online at www.eyemedvisioncare.com (select the Advantage network) or call EyeMed Vision Care at 866.299.1358.
EYEMED VISION PLAN OPTION #2 ADVANTAGE NETWORK OUT OF-NETWORK Exam, Lenses & Frames Every 12 Months $10 co-payment Up to $40 10% discount $120 Allowance + 20% discount on balance $10 copay $10 copay $10 copay $70 copay $70 copay plus 70% of charge less $110 allowance $135 Allowance; 15% discount on balance $135 Allowance 100% $12 $12 $12 $35 $40 30% off retail price 40% discount 15% discount 15% off retail price Reimbursed up to $35 Not covered Not covered Reimbursed up to $48 Reimbursed up to $25 Reimbursed up to $40 Reimbursed up to $60 Reimbursed up to $40 Reimbursed up to $40
EYEMED VISION PLAN OPTION #1 ADVANTAGE NETWORK OUT OF-NETWORK Exam & Lenses Every 12 Months Frames Every 24 Months $10 co-payment Reimbursed up to $35 Up to $40 Not covered 10% discount Not covered $120 Allowance + 20% Reimbursed up to $48 discount on balance $10 copay $10 copay $10 copay $70 copay $70 copay plus 70% of charge less $110 allowance $135 Allowance; 15% discount on balance $135 Allowance 100% $12 $12 $12 $35 $40 30% off retail price 40% discount 15% discount 15% off retail price Reimbursed up to $25 Reimbursed up to $40 Reimbursed up to $60 Reimbursed up to $40 Reimbursed up to $40
Up to $95 Up to $95 Up to $200
Up to $95 Up to $95 Up to $200
No Additional Discount
No Additional Discount
No Additional Discount Not Covered
No Additional Discount Not Covered
Coordination of Benefits
lease be aware that two person and family participants of the Blue Cross Blue Shield (BCBS) plan will receive a Coordination of Benefits Subscriber Questionnaire. The purpose of this questionnaire is to determine if any member on your medical contract is covered under another group health plan. If this questionnaire is not returned to BCBS, and a claim is received, the claim will not be paid. The claim will be pended (held by BCBS).
BCBS will then send another questionnaire to you with a request to return it within 15 days, or claims will be rejected. If the second questionnaire is not returned to BCBS within 45 days from the day the claim is received, the claim will be rejected. You and/or your provider will be advised the rejection is due to your failure to return the completed questionnaire. If the questionnaire is then returned completed, you must resubmit any claims that have been rejected for manual processing. You will receive this questionnaire annually from BCBS. Please complete the questionnaire and return it promptly to BCBS to avoid any claim problems. Page 22
Premium Conversion & Contributions
ayroll contributions are required for employees to participate in the medical, dental and vision plans. You must complete an Election/Waiver Form to acknowledge your understanding of the payroll deductions taken on a weekly basis for the premium. If you wish to waive coverage, please complete the waiver portion of the Election/Waiver Form indicating your understanding you may not enroll in the plans until the next open enrollment period unless you experience a qualifying family status event. By participating in the Premium Conversion plan, you can pay for the cost of your insurance coverage with pre -tax dollars (before taxes are withheld). When you have the cost deducted from your pay on a pre-tax basis, your net take home pay is higher than if the contribution is deducted on a post-tax basis. Under the Premium Conversion plan you must make your election prior to the beginning of each plan year. You cannot change your election during the plan
year, except in the event of a family status change as defined by the Internal Revenue Service (IRS). These family status changes include the following: marriage or divorce birth or adoption of a child death of an eligible dependent change in employment status of you or your spouse
If you experience one of these events you may be allowed to make a change in your election that is consistent with the reason for change. Otherwise, your election cannot be changed until the next open enrollment period for the 2012 plan year. Family status changes must be reported to Human Resources within 30 days of the date of the event. If you wait more than 30 days you are required to wait until the next open enrollment period to make the change.
BCN HBL HMO PLAN HBL5 INDIVIDUAL 2 PERSON FAMILY SPONS DEP1 Per Pay Contribution $24.30 $55.89 $63.18 $233.30 Effect to Take Home Pay $17.01 $39.13 $44.23 $163.31 BCN HBL HMO PLAN HBL2 INDIVIDUAL 2 PERSON FAMILY SPONS DEP1 Per Pay Contribution $43.73 $100.60 $113.71 $256.62 Effect to Take Home Pay $30.61 $70.42 $79.60 $179.63 BCBS CBP PPO PLAN 12 INDIVIDUAL 2 PERSON FAMILY SPONS DEP1 Per Pay Contribution $78.35 $205.06 $303.10 $347.85 Effect to Take Home Pay $54.84 $143.54 $212.17 $243.49 BCBS CBP PPO PLAN 4 INDIVIDUAL 2 PERSON FAMILY SPONS DEP1 Per Pay Contribution $105.41 $270.01 $384.28 $385.73 Effect to Take Home Pay $73.78 $189.01 $269.00 $270.01 BCBS BLUE CHOICE 3 DENTAL INDIVIDUAL 2 PERSON FAMILY SPONS DEP1 PLAN Per Pay Contribution $10.23 $25.20 $31.98 Not Available Effect to Take Home Pay $7.16 $17.64 $22.39 Not Available BCBS TRADITIONAL 7 DENTAL PLAN INDIVIDUAL 2 PERSON FAMILY SPONS DEP1 Per Pay Contribution $20.38 $49.56 $62.43 Not Available Effect to Take Home Pay $14.27 $34.69 $43.70 Not Available EYEMED VISION CARE PLAN INDIVIDUAL 2 PERSON FAMILY SPONS DEP1 Option #1 12/12/24 Plan Per Pay Contribution $3.38 $6.42 $9.42 Not Available Effect to Take Home Pay $2.37 $4.49 $6.59 Not Available EYEMED VISION CARE PLAN INDIVIDUAL 2 PERSON FAMILY SPONS DEP1 Option #2 12/12/12 Plan Per Pay Contribution $4.08 $7.74 $11.36 Not Available Effect to Take Home Pay $2.86 $5.42 $7.95 Not Available 1 Spons. Dep. Sponsored Dependent is an additional rate charged for dependents related by blood or marriage, financially dependent on your for more than half of his or her support as defined by the Internal Revenue Code and reported as a dependent on your most recent tax return.
Page 23
Eligibility Guidelines
MEDICAL & DENTAL COVERAGE: Eligible dependents include your spouse and children until the end of the calendar year in which they reach age 26. Children over 26 who are physically or mentally handicapped may be eligible for coverage. Contact Human Resources Department if you have a special situation. VISION COVERAGE: Eligible dependents include your spouse and children until the date they reach age 26. Eligible dependents, which include your spouse and children (regardless of marital or student status) until the end of the calendar year in which they reach age 26, are eligible on the plan. Eligible dependents include your dependent children, are defined as son, daughter, stepson, stepdaughter, legally adopted child or eligible foster child of the employee. Your dependent children: Do not have to be living with a parent; Do not have to be dependents on their parents income tax return; Do not have to be full-time students; and May be married (eligibility not available to the dependents spouse or children).
Life/AD&D & Disability Benefits

Basic Life / AD&D Benefits Each eligible employee receives a company-provided benefit of basic life and accidental death & dismemberment (AD&D) insurance of two times (2x) annual income up to a maximum of $600,000. Life insurance amounts in excess of $500,000 require evidence of insurability and approval from the carrier. This benefit is provided at no cost to you. Long-Term Disability More than of all Americans live pay check to pay check. A serious illness or injury can harm more than your healthit can have an impact on your ability to work and meet your familys living expenses. Disability income insurance helps you meet your expenses while you are unable to work. It provides you with income in order for you to make mortgage or rent payments, as well as cover other necessities such as groceries, utility bills, and car payments. Realizing the importance of continued income in the event of disability, all eligible employees receive a company paid long term disability benefit. The LTD benefit provides 60% of basic monthly earnings up to a maximum of $10,000 per month following 90 days (13 weeks) of disability. If you qualify for FMLA leave, ABC Company will provide 60% of basic monthly earnings during 61st 89th day of disability. Under the program a Qualified Disability means you are unable to perform the substantial and material duties of your own occupation. After 24 months, this is extended to include any occupation you are qualified for through education, training or experience. Benefits continue until normal social security retirement age or the date you return to work.
Waiving Coverage and Special Enrollment Rights

We understand you may be covered under another health plan and may not need coverage under the ABC Company plans. Employees who do not elect the coverage will be asked to sign a waiver of the benefits. Please keep in mind, if you choose to waive coverage, you may not be able to get back into this plan until the next open enrollment (for a September 1, 2012) effective date) unless specific circumstances apply. Important note regarding Special Enrollment Rights: If you decline enrollment for yourself or your dependents (including your spouse) due to other health insurance or health coverage, and lose your other coverage, or if the employer stops contributing towards you or your dependents other coverage, you may enroll in this plan within 30 days from the date your other coverage ends (or after the employer stops contributing toward the other coverage). Your coverage will become effective the date your other coverage is lost, provided you have satisfied the waiting period of this plan. (This may vary with certain situations. You should consult your spouses employer for continuation rights between the date of loss and coverage effective date.) In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to
enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. It is your responsibility to report family status changes under the health care plan to Human Resources. These changes include divorce, legal separation, or when child ceases to be a dependent (e.g., child turns 26, child marries). At the time one of these qualifying events occurs, Human Resources must receive notification within 30 days from the date of the qualifying event or the date on which coverage is lost. Provided notification is timely, a COBRA Election Notice and Election Form is provided to qualified beneficiaries within 14 days of the date of the qualifying event or loss of coverage; Human Resources is made aware of the loss of coverage; or Human Resources is made aware of a qualifying event. We are not required to offer COBRA continuation coverage if notice is not provided timely. To request special enrollment or obtain more information, contact Human Resources.
Page 24
Regulations
Womens Health and Cancer Right Act
he Womens Health and Cancer Right Act (WHCRA) of 1998 was a part of the omnibus appropriations bill passed by Congress and signed into law on October 21, 1998. This law applies to group health plans, health insurance companies and HMOs, if the plans or coverage provide medical and surgical benefits for a mastectomy. Under WHCRA, mastectomy benefits must include coverage for: Reconstruction of the breast upon which the mastectomy has been performed, Surgery and reconstruction of the other breast to produce a symmetrical or balanced appearance, Prostheses (or breast implant), and Physical complications at all stages mastectomy, including lymph edema. of
Benefits must be provided on the same basis as for any other illness or injury under the medical plan. Mastectomy benefits may have ye a r l y d e d u c t i b l e s a n d coinsurance like those established for other benefits under the plan or coverage. The WHCRA will not allow: Plans and insurance issuers to deny patients eligibility or continued eligibility to enroll or renew coverage under the plan to avoid the requirements of WHCRA. Plans and insurance issuers to provide incentives to or penalize doctors to cause them to provide care in a manner not supportive with WHCRA.
Coverage for reconstructive breast surgery may not be denied or reduced on the grounds it is cosmetic in nature or it otherwise does not meet the coverage definition of medically necessary.
WHCRA is administered by the U.S. Departments of Labor and Health and Human Services. More information is available from the Department of Labors website, at www.dol.gov/ebsa.
Newborns & Mothers Health Protection Act
roup health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother's or newborn's
attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
HIPAA Privacy Notice
he American Recovery and Reinvestment Act expanded HIPAA by requiring new notices in the event of an unauthorized use, access, or disclosure of protected health information. If a covered entity (such as our medical claims administrator) discovers a breach in privacy and security protocols, they will provide, within 60 days
of discovery, notice by first class mail to each individual whose protected health information has been (or is reasonably believed to have been) breached. Please refer to your Employee Benefits Handbook for a complete notice of your privacy rights. Page 25
Regulations
Medicaid and the Childrens Health Insurance Program (CHIP) Offer Free Or Low-Cost Health Coverage To Children And Families
f you are eligible for health coverage from your employer, but are unable to afford the premiums, some States have premium assistance programs that can help pay for coverage. These States use funds from their Medicaid or CHIP programs to help people who are eligible for employersponsored health coverage, but need assistance in paying their health premiums. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, you can 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, you can 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, you can ask the State if it has a program which may help you pay the premiums for an employer-sponsored plan. Once it is determined you or your dependents are eligible for premium assistance under Medicaid or CHIP, your employers health plan is required to permit you and your dependents to enroll in the plan as long as you and your dependents are eligible, but not already enrolled in the employers plan. This is called a special enrollment opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance.
If you live in one of the following States, you may be eligible for assistance with paying your employer health plan premiums. The following list of States is current as of September 1, 2010. You should contact your State for further information on eligibility. To see if any more States have added a premium assistance program since September 1, 2010, or for more information on special enrollment rights, you can contact either: U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Ext. 61565
ALABAMA Medicaid Website: http://www.medicaid.alabama.gov Phone: 1-800-362-1504 ALASKA Medicaid Website: http://health.hss.state.ak.us/dpa/programs/medicaid/ Phone (Outside of Anchorage): 1-888-318-8890 Phone (Anchorage): 907-269-6529 ARIZONA CHIP Website: http://www.azahcccs.gov/applicants/default.aspx Phone: 602-417-5422 ARKANSAS CHIP Website: http://www.arkidsfirst.com/ Phone: 1-888-474-8275 CALIFORNIA Medicaid Website: http://www.dhcs.ca.gov/services/Pages/ TPLRD_CAU_cont.aspx Phone: 1-866-298-8443 COLORADO Medicaid and CHIP Medicaid Website: http://www.colorado.gov/ Medicaid Phone: 1-800-866-3513 CHIP Website: http:// www.CHPplus.org CHIP Phone: 303-866-3243 FLORIDA Medicaid Website: http://www.fdhc.state.fl.us/Medicaid/index.shtml Phone: 1-866-762-2237
GEORGIA Medicaid Website: http://dch.georgia.gov/ Click on Programs, then Medicaid Phone: 1-800-869-1150 IDAHO Medicaid and CHIP Medicaid Website: www.accesstohealthinsurance.idaho.gov Medicaid Phone: 208-334-5747 CHIP Website: www.medicaid.idaho.gov CHIP Phone: 1-800-926-2588 INDIANA Medicaid Website: http://www.in.gov/fssa/2408.htm Phone: 1-877-438-4479 IOWA Medicaid Website: www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562 KANSAS Medicaid Website: https://www.khpa.ks.gov Phone: 800-766-9012 KENTUCKY Medicaid Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570
Page 26
Regulations
The CHIP Program Continued
LOUISIANA Medicaid Website: www.dhh.louisiana.gov/offices/?ID=92 Phone: 1-888-342-6207 MAINE Medicaid Website: http://www.maine.gov/dhhs/oms/ Phone: 1-800-321-5557 MASSACHUSETTS Medicaid and CHIP Medicaid & CHIP Website: http://www.mass.gov/MassHealth Medicaid & CHIP Phone: 1-800-462-1120 MINNESOTA Medicaid Website: http://www.dhs.state.mn.us/ Click on Health Care, then Medical Assistance Phone: 800-657-3739; 651-431-2670 (outside Twin City area) MISSOURI Medicaid Website: http://www.dss.mo.gov/mhd/index.htm Phone: 573-751-6944 MONTANA Medicaid Website: http://medicaidprovider.hhs.mt.gov/clientpages/ Telephone: 1-800-694-3084 NEBRASKA Medicaid Website: http://www.dhhs.ne.gov/med/medindex.htm Phone: 1-877-255-3092 NEVADA Medicaid and CHIP Medicaid Website: http://dwss.nv.gov/ Medicaid Phone: 1-800-992-0900 CHIP Website: http://www.nevadacheckup.nv.org/ CHIP Phone: 1-877-543-7669 NEW HAMPSHIRE Medicaid Website: http://www.dhhs.state.nh.us/DHHS/ MEDICAIDPROGRAM/default.htm Phone: 1-800-852-3345 x 5254 NEW JERSEY Medicaid and CHIP Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Medicaid Phone: 1-800-356-1561 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710 NEW MEXICO Medicaid and CHIP Medicaid Website: http://www.hsd.state.nm.us/mad/index.html Medicaid Phone: 1-888-997-2583 CHIP Website: http://www.hsd.state.nm.us/mad/index.html Click on Insure New Mexico CHIP Phone: 1-888-997-2583 NEW YORK Medicaid Website: http://www.nyhealth.gov/health_care/medicaid/ Phone: 1-800-541-2831 NORTH CAROLINA Medicaid Website: http://www.nc.gov Phone: 919-855-4100 NORTH DAKOTA Medicaid Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-800-755-2604 OKLAHOMA Medicaid Website: http://www.insureoklahoma.org Phone: 1-888-365-3742 OREGON Medicaid and CHIP Medicaid Website: http://www.oregon.gov/DHS/healthplan/index.shtml Medicaid Phone: 1-800-359-9517 CHIP Website: http://www.oregon.gov/DHS/healthplan/app_benefits/ ohp4u.shtml CHIP Phone: 1-800-359-9517 PENNSYLVANIA Medicaid Website: http://www.dpw.state.pa.us/partnersproviders/ medicalassistance/doingbusiness/003670053.htm Phone: 1-800-644-7730 RHODE ISLAND Medicaid Website: www.dhs.ri.gov Phone: 401-462-5300 SOUTH CAROLINA Medicaid Website: http://www.scdhhs.gov Phone: 1-888-549-0820 TEXAS Medicaid Website: https://www.gethipptexas.com/ Phone: 1-800-440-0493 UTAH Medicaid Website: http://health.utah.gov/medicaid/ Phone: 1-866-435-7414 VERMONT Medicaid Website: http://ovha.vermont.gov/ Telephone: 1-800-250-8427 VIRGINIA Medicaid and CHIP Medicaid Website: http://www.dmas.virginia.gov/rcp-HIPP.htm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.famis.org/ CHIP Phone: 1-866-873-2647 WASHINGTON Medicaid Website: http://hrsa.dshs.wa.gov/premiumpymt/Apply.shtm Phone: 1-877-543-7669 WEST VIRGINIA Medicaid Website: http://www.wvrecovery.com/hipp.htm Phone: 304-342-1604 WISCONSIN Medicaid Website: http://dhs.wisconsin.gov/medicaid/publications/p-10095.htm Phone: 1-800-362-3002 WYOMING Medicaid Website: http://www.health.wyo.gov/healthcarefin/index.html Telephone: 307-777-7531
OBM Control Number 1210-0137 (expires 09/30/2013)

Page 27
Notes...
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Page 28
ABC COMPANY Election / Waiver Form
NAME: Address: City: Email Address: State:
Plan Year 09/01/201108/31/2012
Zip:
This is a two-page form. Be sure to complete both pages (front and back). Pick one of the following:
I elect to participate in the ABC Company health plan. I elect to have my required contributions for coverage deducted from my pay on a pre-tax basis. (Complete Section A below) I am waiving participation in the ABC Company health plan. (Complete Section B on the following page) I elect to continue my current plan elections with no changes for the 2011 Plan Year. I elect to have my required contributions for coverage deducted from my pay on a pre-tax basis. Check the box below to indicate your elections for coverage. I UNDERSTAND THAT:
Section A: My Plan Pre-Tax Selections for the Year are:

Plan Options BCN HBL HMO Plan 5 BCN HBL HMO Plan 2 BCBS CBP PPO Plan 12 BCBS CBP PPO Plan 4 BCBSM Blue Dental Choice 3 Plan BCBSM Traditional Dental Plus 7 Plan EyeMed Vision Care Plan Option 1 - 12/12/24 EyeMed Vision Care Plan Option 2 - 12/12/12 I may not change my election during the plan year unless I experience a Qualifying Event as defined by the IRS (an eligible change in Family Status, including marriage, divorce, death of a spouse, birth, death or adoption of child, termination of employment of spouse or other such event as allowed by the plan) and I need to supply Human Resources with the necessary documentation within 30 days of said event. I agree to abide by the regulations and terms of the plan I have enrolled in according to the summary plan description for the plan. I request membership in the plan I have elected on this form for which I am an eligible ABC Company employee. I authorize the plan administrator (ABC Company) to deduct from my paycheck all appropriate premiums for my election on a pre-tax basis as applicable. Required contribution means that amount I must pay for employee or dependent coverage under the employer-sponsored health plans. This election will automatically terminate if the plan is terminated or discontinued, or if I cease to receive compensation from the company which, before reduction, is less than equal to the amount of my elected reduction. This election is in addition to any reduction under other agreements or benefit plans. By reducing my compensation on a pre-tax basis, my social security benefits may be reduced. I will be notified of any subsequent change in the required contribution. I understand all provisions of my insurance are dictated by the insurance contracts. It is my responsibility to familiarize myself with the details of my benefit program. The Plan may use my personal health information for the purposes of treatment, payment, and health care operations and other uses as outlined in the plans privacy notice, and consistent with federal HIPAA regulations. A copy of our Notice of Privacy Practices is provided upon request to Human Resources. Individual 2 Person Family
Election/Waiver Form continued on next page.
ABC COMPANY ELECTION / WAIVER FORM Page 2
Plan Year 09/01/201108/31/2012 Continued
Section B:
Waiving Medical Coverage
Complete this section if waiving health coverage.
Please check box to indicate understanding of waiver of coverage: Waive medical coverage Waive dental coverage Waive vision coverage
I have been given the opportunity to apply for coverage under my employer's benefit plans but, after due consideration have decided to waive participation in the plan options selected above (check all that apply): I acknowledge I have been notified by my employer I am eligible to enroll in the medical coverage offered to me under the employee benefits plan, provided I have reported a qualifying event within 30 days of the event. However, I hereby waive coverage for the medical benefits under my employers plan with respect to myself and my present and/or future dependents. I understand if coverage is declined at this time for myself or my dependents because of other health coverage, I may not be able to get back into this plan until the next open enrollment period, unless I lose that coverage involuntarily (e.g., spouses loss of employment, divorce, etc.). I understand it is my responsibility to notify my employer within 30 days from the date of the loss. You should consult your other plan administrator for continuation rights between the date of loss and coverage effective date. In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents, provided you request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. I hereby waive coverage for the following reasons: I have coverage through an individual policy. I am covered under another group health plan not offered by my employer (spouse, parent, etc.).
I do not want the group health coverage offered through my employer at this time because:
________________________________
Section D:
Consent to Receive Electronic Notices
As a plan participant, you are entitled to a comprehensive description of your rights and obligations under the group health plan. A copy of the summary plan description (SPD) and certificates of insurance coverage are available via email upon. In order to ensure that you fully understand the benefits available to you and your obligations as a plan participant, it is imperative that you familiarize yourself with the information contained within the SPD. If you would like to receive a paper copy of the SPD, you may email hr@abccompany.com or call 555.555.5555 and one will be provided to you free of charge. I understand that: 1. The following documents and/or notices may be provided to me electronically: Summary Plan DescriptionsSummaries of Material ModificationsSummary Annual Reports 2. I may provide notice of a revised email address or revoke my consent at any time without charge by sending an email to hr@abccompany.com or calling 555.555.5555. I am entitled to request and obtain a paper copy of any electronically furnished document free of charge by contacting hr@abccompany.com or calling 555.555.5555. 3. In order to access information provided electronically, I must have: A computer with Internet access, An email account that allows me to send and receive emails, Microsoft Word 95 (or higher) or Adobe Acrobat Reader 5.0 (or higher). My signature here confirms I hereby AGREE to receive the documents and notices referenced above electronically. SIGNATURE:________________________________ My signature here confirms I hereby DO NOT AGREE to receive the documents and notices referenced above electronically. SIGNATURE:____________________________________
AcknowledgementThis Agreement, as detailed on these pages, is subject to the terms of the ABC Company Plan (as may be amended from time to time). My signature below indicates I have read and
Employee Name Printed Employee Signature Date
25900 W. 11 Mile Road, Suite 210 Southfield, MI 48034 Phone: 248.355.9600 Fax: 248.355.3145 www.jsclarkagency.com

ABC Sample Communication

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ABC Sample Communication

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ABC Company

Member Services Contact Information

BCN Member Services

BCBSM DenteMax Dental Member Services

Accredo Limited Distribution Specialty Pharmacy

Walgreens Specialty Pharmacy Member Services

Medco Pharmacy Services

(for members to call regarding mail order maintenance prescriptions)

Medco Mail Order Member Services 800.903.8346

Medco Retail Pharmacy Services

2011 - 2012 Open Enrollment

During open enrollment, you may also elect:

Your choice of dental plans Your choice of vision plans

Please keep in mind that...

The Blue Care Network HMO Plans

Healthy Blue Living Plan

HBL HMO Enhanced Benefit Level Requirements

ABC Employee Benefits Plan Effective 09/01/2011

CN has introduced a new Qualification Form

Member Grading System on the Qualification Form

Participate in Weight Watchers or WalkingSpree C. program until BMI falls below 30 A. B. C. A. B. C. A. B. C. A.

Commit to and follow doctors treatment plan

Any depression is in full remission

Commit to and follow doctors treatment plan

ABC Company Employee Benefits Plan Effective 09/01/2011

Yesyou and your spouse completed the HA within 90 days

You and/or your spouse scored all As on the Qualification Form

You and/or your spouse scored Bs on the Qualification Form

You and/or your spouse scored Cs on the Qualification Form

2. Click the BlueHealthConnection link.

How to Stay in the Enhanced Level

ABC Company Employee Benefits Plan Effective 09/01/2011

Heres what you do...

ABC Company Employee Benefits Plan Effective 09/01/2011

Urgent Care vs Emergency Room

rgent that condition average believes evaluation or injury.

Medco Pharmacy Services

ABC Company Employee Benefits Plan Effective 09/01/2011

ABC Company Employee Benefits Plan Effective 09/01/2011

Medical Benefits Comparison

Healthy Blue Living 2 HMO

$150 copayment after deductible

Urgent Care Diagnostic X-Ray & Lab

Medical Benefits Comparison

Healthy Blue Living 5 HMO

Healthy Blue Living 2 HMO

Medical Benefits Comparison

COMMUNITY BLUE 12 PPO

COMMUNITY BLUE 4 PPO

Medical Benefits Comparison

COMMUNITY BLUE 12 PPO

COMMUNITY BLUE 4 PPO

Routine Screening Mammogram

BCN / BCBSM Member Perks

ABC Company Employee Benefits Plan Effective 09/01/2011

Important Notes Regarding Your Dental Benefits

ABC Company Employee Benefits Plan Effective 09/01/2011

ision benefits are provided through EyeMed Vision Care.

Up to $95 Up to $95 Up to $200

Up to $95 Up to $95 Up to $200

No Additional Discount Not Covered

No Additional Discount Not Covered

Premium Conversion & Contributions