Working to give you quality, affordable health care

Michigan’s largest HMO network of doctors, hospitals

Emergency care worldwide

Prescriptions at your local pharmacy at the lower mail-order rate

Blue Care Network of Michigan

2013

Enroll now by calling

Retiree Health Care Connect

1-866-637-7555

MiBCN.com/URMBT2

Top-of-the-line health care

Blue Care Network delivers more than your average health care plan by helping you get quality care, live a healthier life and save money.

The brand you know and trust

BCN is Blue Cross Blue Shield of Michigan’s affiliated health maintenance organization. We offer the quality medical benefits you expect from Michigan’s most trusted name in health care. Some 690,000 people in Michigan trust us with their care, making us the state’s largest HMO.

If you were with Blue Cross before you retired, we hope you’ll stay with the brand you know and trust.

Unmatched provider network

Most doctors and hospitals across the state are part of BCN’s extensive provider network. In fact, we have the largest HMO provider network in Michigan.

Care that travels

Our service area starts in Michigan, but you can count on care when you travel beyond Michigan’s borders. You’ll have access to hospitals and doctors who participate with Blue plans across the country. And emergency care is covered anywhere in the world.

To choose Blue Care Network call Retiree Health

Care Connect1-866-637-7555

Health care value

We’re always working with doctors and hospitals to make sure you get the best value for your hard-earned health care dollar. We also partner with Michigan and national companies to give you discounts on goods and services you use to stay healthy.

3

As a Michigan-based plan, we’re proud of our long, steady partnership with UAW

members. We’ve worked with the UAW Retiree Medical Benefits Trust since its creation to provide

high quality, member-friendly coverage.

With more than 2,300 UAW-represented members at the Michigan Blues, we proudly serve more than 1.1 million autoworkers, retirees and their family members. We’re proud to be the Trust’s largest

health carrier. Our size and strength help us protect you and deliver quality, affordable health care.

UAWStrong

• The most recognized health care brand: the Blue Cross and Blue Shield

• Unlimited office visits with your primary care doctor for a $25 copay

• No out-of-pocket charges for services from doctors in our network

• Prescriptions at your local pharmacy at the lower mail-order rate

• Exceptional health and wellness support

• Valuable online tools to help you take charge of your health

• Discounts on health and fitness services

See much more in Benefits at a glance on Pages 7 to 9.

One amazing card, giving you:

MiBCN.com/URMBT4

Sharpening your vision

• A routine eye exam every 12 months, the best you’ll find

• 20 percent discount on glasses

For details, call VSP® Vision Care at 1-800-877-7195. Or, go online to vsp.com.

Traveling with you, easing your mind

Whether you’re vacationing up north or down south, BCN coverage travels with you. And with your dependents, too.

Moving for the winter?

We have you covered. Before you go, coordinate care away from home with your primary care physician.

Stamping out hassles at the counter

Thousands of pharmacies nationwide, including most major chains, accept our ID cards. To get the meds you take all the time, you have a choice of mail order or retail pharmacies.

Just go to MiBCN.com/find. Or call BCN customer service at 1-800-222-5992

or 1-800-257-9980 (TTY)

BCBSM maintains bcbsm.com, MiBCN.com and theunadvertisedbrand.com. The Blues do not control any other websites referenced in this publication or endorse their general content.

5

Promoting good health

Preventive care is the foundation of our coverage because it’s easier to stay healthy than to get healthy. Good health starts with regular checkups, health screenings and immunizations. A primary care physician, or PCP, coordinates preventive care as routine Blue Care Network care.

Selecting a PCP is an important first step to a healthful lifestyle. Your doctor will become your partner in maintaining your good health. PCPs also treat illness, injury and chronic conditions, such as a heart condition or asthma. PCPs also arrange for lab tests, hospitalizations and the care you need from specialists.

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

Helping you through long-term illness

If you have asthma, diabetes, congestive heart failure or other chronic conditions, turn to us for ongoing help. Nurse case managers will work with you when you’re sick to help you manage your condition.

Health care educators are just a phone call away to answer your questions about high blood pressure, cholesterol, weight and stress, plus much more.

Making access easy

With the state’s largest HMO provider network, it’s easy to find a Blue Care Network doctor or hospital among:

• 5,000 primary care physicians

• 15,500 specialists

• Most of the state’s leading hospitals

MiBCN.com/URMBT6

Get a wealth of information at your fingertips at bcbsm.com

New. Improved. Easy. bcbsm.com.

We’ve redesigned our website to make it easier for you to get the information you need to make smarter

health care decisions.

• Confirm coverage

• Select or change your primary care physician, using factors important to you

• View benefits and claims information

• Request ID cards

• Get personalized alerts on health assessments, tailored health plans, newsletters and coaching tools

• Find pharmacies, prescription history, benefit details, medication prices, drug information and mail order refills — all based on your BCN prescription drug plan

Reach us on the go

Members who register in Member Secured Services at bcbsm.com can use Blue Mobile to instantly access health plan details on smart phones or other smart mobile devices.

Save money on healthy products and services

Go to healthybluextras.com to unlock big savings and member discounts just for Michigan Blues members. Enjoy exclusive savings on products and services you use to stay healthy from groceries to fitness gear and travel from companies across the great state of Michigan. Healthy Blue XtrasSM makes it easy to get the balanced lifestyle members deserve.

7

Deductible, copays and dollar maximumsDeductible Note: Deductible does not apply to protected class. Protected class members are responsible for copays only.

$215 per member $430 per family

CopaysFixed dollar copay

Percent copay

$25 primary care physician office visits; $35 specialist office visits; $100 emergency room visits; $50 urgent care visitsNone

Copay dollar maximumsFixed dollar copay Percent dollar copay

None None

Dollar maximums NonePhysician office servicesRoutine office visits $25 copay per visit

Consulting specialist care (when referred) $35 copay per visit/protected class – $25 copay per visit

Periodic physical exam $25 copay per visitRoutine pediatric care $25 copay per visitAnnual gynecological exam $25 copay per visitPreventive servicesVision exam – VSP 1-800-877-7195 $25 copay covered once every 12 monthsImmunization – pediatric and adult Covered in full; office visit copay may applyMammography screening Covered in fullPap smears Covered in full; office visit copay may applyProstate-specific antigen (PSA) screening – laboratory services only

Covered in full; office visit copay may apply

Diagnostic and therapeutic proceduresLaboratory tests Covered in full; office visit copay may applyDiagnostic X-rays Covered in full after deductibleRadiation therapy Covered in full after deductible

2013 BCN benefits at a glance for UAW Retiree Medical Benefits Trust members

8

2013 BCN benefits at a glance for UAW Retiree Medical Benefits Trust members (continued)

Maternity services provided by a physicianPrenatal and postnatal care $25 copay per visitDelivery and nursery care Covered in full for professional services

after deductibleHospital care (inpatient/outpatient)Number of days of care UnlimitedIn-hospital physician care, general nursing care, surgery (including all related surgical services, anesthesia, lab, X-rays and drugs)

Covered in full after deductible

Outpatient facility services Covered in full after deductible

Emergency medical care*Hospital emergency room (co-payment waived if admitted as an inpatient)

$100 copay per visit

Urgent care facility $50 copay per visitAmbulance services Covered in full after deductible – ground and air

service*Ford Protected: $0 copay for emergency room and urgent care

Mental health careOutpatient visits Contact plan for specific copaymentsInpatient psychiatric hospital services Covered in full up to 45 days, per calendar year

renewable after 60 days of non-confinement.Alcoholism and substance abuse servicesOutpatient visits for crisis intervention and short-term therapy

Up to 35 visits per year, covered in full

Intermediate care (intermediate days combined with inpatient mental health)

Covered in full up to 45 days per calendar year, renewable after 60 days of non-confinement

Detoxification Covered in fullSkilled nursing careSkilled nursing facility care Covered in full after deductible;100 days

renewable after 60 days of non-confinementNursing services in the home (when medically necessary)

Covered in full after deductible

Home health care (when medically necessary)

Covered in full after deductible

Hospice care Covered in full after deductible

9

MiBCN.com/URMBT

Other servicesProsthetics, orthotics and corrective appliance (when medically necessary)

Covered in full

Vasectomies, tubal ligations Covered in full after deductible; office visit copay may apply

Infertility treatment Not covered – exclusions include in-vitro fertilization, artificial insemination and infertility drugs

Durable medical equipment (when medically necessary)

Covered in full

Allergy testing, evaluation and serum Covered in full after deductibleAllergy injections Covered in full; office visit copay may apply per

member per visitPhysical therapy: 60 treatments per condition per year

Covered in full after deductible – Limited to 60 visits per medical episode, per plan year

Hearing aid – Hearing examination and aid covered once each 36 months

Covered in full; office visit copay may apply per member per visitBinaural hearing aids every 36 months if younger than 19

PharmacyRetail prescription drug copay including contraceptives; 30-day supply

Tier 1 Formulary Preferred – mostly generic $11 copay Tier 2 Formulary Options – brand $33 copay Tier 3 Nonformulary $88 copay

Retail prescription drug copay including contraceptives; 84-90 day supply

Tier 1 Formulary Preferred – mostly generic $22 copay Tier 2 Formulary Options – brand $66 copay Tier 3 Nonformulary $176 copay

Mail-order prescription drug copay including contraceptives; 31-90 day supply

Tier 1 Formulary Preferred – mostly generic $22 copay Tier 2 Formulary Options – brand $66 copay Tier 3 Nonformulary $176 copay

ExclusionsCoverage for erectile dysfunction (ED) medications (e.g. Viagra, Cialis, Levitra). Except in prior authorized cases of pulmonary arterial hypertension.Coverage for proton pump inhibitor drug class (e.g. omeprazole, Prilosec, Zegerid, Nexium, Aciphex, Prevacid, Protonix). Except in prior authorized cases of Barrett’s Esophagitis, Zoellinger-Ellison Syndrome and documented medical necessity.

9

MiBCN.com/URMBT10

To choose Blue Care Network call Retiree Health

Care Connect

1-866-637-7555

Blue Care Network customer service

1-800-222-5992 or

1-800-257-9980 (TTY)

Just a call gets the wheels turning

Enroll or ask questions about coverage by calling Retiree

Health Care Connect. Join at any time with a short wait. To make BCN your plan starting

Jan. 1, enroll by Nov. 30.

11

Berrien Cass St. Joseph

Van BurenKalamazoo Calhoun

Allegan Barry

OttawaKent

Ionia

Montcalm

Newaygo

Muskegon

Oceana Mecosta

Mason

Manistee

Lake Osceola

Wexford Missaukee Roscommon Ogemaw Iosco

Benzie GrandTraverse Kalkaska Crawford Oscoda Alcona

Leelanau

Antrim Otsego Mont-morency Alpena

Emmet

Cheboygan PresqueIsle

Branch

Charlevoix

Clare GladwinArenac

BayMidlandIsabella

Gratiot Saginaw

ShiawasseeLapeerGenesee

Sanilac

Huron

Tuscola

Hillsdale

Jackson

Ingham LivingstonEaton

Clinton St. Clair

Oakland Macomb

Wayne

Lenawee Monroe

Washtenaw

BCN is not availablein these counties

BCN is available in these counties

BCN is only available in portions of these counties

Mackinac

Gogebic

Ontonagon

Iron

Houghton

Baraga

Marquette

Dickinson

Menominee

Delta

AlgerSchoolcraft

Luce

Chippewa

Keweenaw

BCN is proud to be the largest

HMO network of physicians

and hospitals in the state.

CB 12196 NOV 12 R008275

As your partner in health care, we’re here to support you every step of the way.

MiBCN.com/urmbt

About the artwork: Shown in part, “Detroit Industry” is one of four huge paintings at the Detroit Institute of Arts. Mexican muralist Diego Rivera (1886–1957)

completed the series in 1933 as a tribute to the city’s manufacturing base and labor force. Source: dia.org/art/rivera-court.aspx

Connect with us online

news.bcbsm.comahealthiermichigan.orgfacebook.com/MiBCN