plan year: 2016 20171y1fplihzoo3hu5pz2zqk0m1.wpengine.netdna-cdn.com/wp... · 2016-10-03 · plan...
TRANSCRIPT
Plan Year:
2016—2017
Providing Specialized Insurance Services Since 1935
Eligibility for Coverage
All full time employees working 36
or more hours per week are eligible
for the benefits outlined in this
guide.
Legal spouses and dependent
children are eligible for the medical,
dental, and vision benefits outlined
in this guide.
When to Enroll
This is the only time of year
employees are able to make
changes to their benefits without a
qualifying life event.
QCI Nurse Staffing’s Open
Enrollment period runs from May
2 through May 13.
Benefits elected during this time
are effective May 1, June 1. or
How to Make Changes
Unless you have a qualifying change
in your family or employment status
you cannot make changes to your
benefits until the next Open
Enrollment period. All change
requests must be received within
30 days of the qualifying event or
the change may not be made until
the next Open Enrollment period.
For a list of Qualifying Status
Changes refer to the appendix.
2016 Open Enrollment
What You Need to Know QCI Healthcare is pleased to offer its employees an array of benefits
to choose from. The annual Open Enrollment period for 2016 will
begin on Monday, May 2, 2016 and continue through Friday, May
13, 2016. This is the only time of year you can make changes to your
existing coverages, enroll in a coverage you were not previously
enrolled in, add/remove dependents, or remove yourself from the
policy.
One of the medical plan
options in Coverage for
Companies changed from
the Simply Blue PPO
Health Savings Account
(HSA) Silver $2,000 to the
Simply Blue PPO Health
Savings Account (HSA)
Silver $2,700
Dental carrier switch from
IHC/Madison National to
Delta Dental, effective
June 1, 2016
New
for
2016!
If you do NOT complete the Benefit Election Form,
your elections from 2015 will automatically roll over
for 2016 with any applicable plan and/or rate
changes. EXCLUDING THE DENTAL COVERAGE.
ACTION IS REQUIRED FOR THE DENTAL
COVERAGE. See Page 2.
Medical Insurance 1
Dental Insurance 2
Vision Insurance 3
Short Term & Long Term
Disability Insurance 4
Group Life/AD&D Insurance 5
Contact Information 6
Important Employee Disclosures 7-12
Healthcare Education 13 & 14
Glossary of Terms 15-17
Appendix 18
Summary of Benefits & Coverage 19-57
Enrollment/Change Forms
Benefit Election Form
Medical Plan Election Form
TABLE OF CONTENTS
58-73
74
75
2016—2017 BCN HMO
Platinum 20%
BCN HMO Gold
$1,000
Simply Blue PPO
Gold $500
Simply Blue HSA
PPO Silver $2,700
Deductible
Individual/Two or
More
$0 $1,000/$2,000 $500/$1,000 $2,700/$5,400
Coinsurance 20% 20% 20% 20%
Embedded
Coinsurance
Maximum
$1,000/$2,000 $2,500/$5,000 $3,000/$6,000 None
Out-of-Pocket
Maximum $6,600/$13,200 $6,600/$13,200 $6,600/$13,200 $4,500/$9,000
Office Visit/Specialist/
Urgent Care/ER
Copays
$25/$35/$35/
$150
$20/$40/$50/
$150
$20/$40/$60/
$150
Covered at 80% After
Deductible is Met
Prescription Drugs $4/$15/$40/
$80/20%/20%
$4/$15/$40/
$80/20%/20%
$15/
$50/50%/20%/
25%
After Deductible is
Met: $15/
$50/50%/20%/
25%
Coverage for Companies is a private exchange that allows small Michigan employers the ability to offer a wide
selection of quality Blue Cross Blue Shield of Michigan and Blue Care Network group health plans to
their employees. This chart gives a brief overview of the four plan options offered.
Medical Insurance
New!
The benefits shown are for participating Blue Care Network OR Blue Cross Blue Shield of Michigan providers ONLY and are intended
as an easy-to-read summary. Benefits received from non-BCN or BCBSM providers & further plan information can be found in the
Summary of Benefits & Coverages located at the end of this guide.
The rates above INCLUDE the $200 QCI Nurse Staffing contributes to each employee’s total monthly premium
AND Pediatric Dental for enrolled dependents under age 19.
Please visit www.bcbsm.com to find in-network providers.
Delta Dental PPO (Point-of-Service)
*Dental for dependents under age 19 is included in the medical coverage*
Network Delta Dental PPO Delta Dental Premier/Non-
Participating
Annual Maximum
(per person/per calendar year)
$2,000
Includes Diagnostic & Preventive, Basic Services, and Major Services
Diagnostic & Preventive Services 100% 100%
Radiographs—X-Rays 100%
Emergency Palliative Treatment 80%
Periodontal Maintenance 80%
Minor Restorative Services 80%
Relines and Repairs 80%
Simple Extractions 80%
Oral Surgery Services 50%2
Periodontics/Endodontics 50%2
Major Restorative Services 50%2
Prosthodontics 50%2
Implants 50%2
2 Major services will not be covered until after a
person is enrolled in the dental plan for 12
consecutive months. For the initial enrollment ONLY,
the waiting period will be waived for enrollees that
were covered under the IHC/Madison National
dental plan for AT LEAST 12 months.
QCI Healthcare is pleased to announce they are moving their dental coverage from IHC/Madison National to
Delta Dental, effective June 1, 2016.
2016-2017 Rates per MONTH WEEKLY Payroll
Deduction
Employee Only $36.18 $8.35
Employee + Spouse $72.38 $16.70
Employee + Child(ren) $82.82 $19.11
Family $130.86 $30.20
This is intended as an easy-to-read summary. For further plan details, please refer to Summary of Benefits located at the end
of this guide,
New! Dental Insurance
The vision policy offered by QCI Healthcare is 100% EMPLOYEE paid. You will pay for
100% of the cost for yourself and any eligible dependents .
June 1, 2016—May 31, 2017 Voluntary Dental
Pre-Tax Contribution Cost Summary
Whether you were previously
enrolled in the dental policy or not, a
NEW Delta Dental enrollment form
(page 63) MUST be completed!
QCI Healthcare is continuing with their same vision coverage through
The benefits shown are for participating VSP providers only and are intended as an easy-to-read summary. Benefits received from non-VSP providers
& further plan information can be found in the Summary of Benefits located at the end of this guide.
Vision Insurance
VSP with no change in rates or benefits.
The vision policy offered by QCI Healthcare is 100% EMPLOYEE paid. You
will pay for 100% of the cost for yourself and any eligible dependents .
Type of Service from a VSP Doctor Amount You Pay
Exam
WellVision
Contacts
$10
Up to $60
Prescription glasses $25
Contacts No copay applies
Your coverage from a VSP Doctor Frequency
Exam covered in full Every 12 months
Prescription glasses
Lenses covered in full
Frame Every 12 months
Contact Lenses Instead of Glasses Every 12 months
Extra Discounts & Savings on Glasses &
Sunglasses
Average 30% savings on lens options like progressives
and scratch-resistant and anti-reflective coatings.
20% off additional glasses and sunglasses, including
lens options
Contacts
Laser vision correction
2016-2017 Rates per MONTH WEEKLY Payroll
Deduction
Employee Only $14.16 $3.27
Employee + Spouse $21.62 $4.99
Employee + Child(ren) $21.62 $4.99
Family $38.77 $8.95
May 1, 2016—April 30, 2017 Voluntary Vision
Pre-Tax Contribution Cost Summary
Why Short Term
Disability?
Receiving an income while
you’re disabled can make
an enormous financial
difference.
Benefits
Coverage for accidents and sicknesses for up to 26 weeks.
Weekly benefit is 60% of your weekly salary. Maximum benefit
is $750 per week.
Benefits begin on the 1st day for injury, 8th day for sickness, and
8th day for hospital confinement.
How To Enroll:
You must elect and complete the short-term disability coverage
enrollment form at the time of hire or Open Enrollment. Coverage
begins once the eligibility requirements are met and you have
satisfied any waiting period applicable to your policy.
Disability can
happen to anyone.
Accidents happen. Make
sure you and your loved
ones avoid future financial
hardships due to an
accident.
Benefits
Coverage for accidents and sicknesses.
Benefit is 60% of monthly earning up to a maximum of $5,000
per month.
Benefits may begin after the elimination period of 180 days of
absences due to a covered accident or sickness.
Employees must meet the definition of disability as defined in
the policy to be eligible for the benefits described here.
Benefits are not payable for pre-existing conditions as defined in
the policy.
How to enroll
You must elect and complete the short-term disability coverage
enrollment form at the time of hire. Coverage begins once the
eligibility requirements are met and you have satisfied any waiting
period applicable to your policy.
For complete plan details
This highlight flyer is intended to provide an overview of the benefits available from your employer and is not a complete
description of plan provisions. Receipt of this flyer does not certify eligibility for benefits under this plan.
Your employer will provide you with the Dearborn National booklet containing complete plan details, if requested. Please
see the appendix for a brief summary of benefits and coverage.
Disability Insurance
The short term and long term disability policies offered by QCI Healthcare is
100% EMPLOYEE paid. Dependents are not eligible for disability insurance.
QCI Healthcare is continuing with their same short term
and long term disability coverage through Dearborn
National with no change in rates or benefits.
Employees who work more than 36 hours per week are eligible for employer sponsored group
life and accidental death and dismemberment insurance.
Life/AD&D Insurance
For complete plan details
This highlight information is intended to provide an overview of the benefits available from your employer and is not a complete
description of plan provisions. Receipt of this Employee Benefits Guide does not certify eligibility for benefits under this plan.
Your employer will provide you with the Lincoln Financial Group booklet containing complete plan details, if requested. For further plan infor-
mation, please see the Summary of Benefits located at the end of this guide.
35% at age 65
An additional 25% of the original amount at age 70
An additional 15% of the original amount at age 75
Benefits terminate at retirement
Benefits will Reduce:
What is AD&D Insurance?
Accidental Death & Dismemberment (AD&D) insurance provides specified benefits for
a covered accidental bodily injury that directly causes dismemberment (e.g. the loss of
a hand, foot, or eye). In the event that a death occurs from a covered accident, both the
life and the AD&D benefit would be payable.
Eligible employees are guaranteed $25,000 without health questionnaires for life and
accidental death and dismemberment insurance.
Open Enrollment or time of hire are the only times an employee can enroll in the group
life/AD&D insurance without Evidence of Insurability.
A delayed effective date will apply if the employee is not actively at work at time of
enrollment.
If you terminate your employment or become ineligible for this coverage, you have the
option to convert all or part of the amount of coverage in force to an individual life
policy on the date of termination without Evidence of Insurability. Conversion election
must be made within 31 days of your date of termination.
Benefits
Who is Eligible?
The group life and accidental death and
dismemberment (AD&D) policy is paid for by QCI
Healthcare. There is NO employee contribution
required to receive the group life and AD&D insurance.
Company Phone number/website Reasons to contact
General
Information
QCI HealthcareKen Jewett
616.365.9290
Questions regarding
enrollment, eligibility, or
costs.
Medical/
Pharmacy
Blue Cross Blue
Shield of Michigan
Blue Care Network
www.bcbsm.com
800.292.3501
Find participating
physicians
Change your primary
care physician
Inquiries about
eligibility
Confirm benefits
Questions about a bill
or EOB (explanation of
benefits)
Obtain claim forms
File a claim
Problems with
eligibility
Problems with
resolving claims
through your carrier
Problems with
obtaining benefit
information through
your carrier
Dental Delta Dental
www.deltadentalmi.com
800.524.0149
Vision Vision Service Plan
(VSP)
www.vsp.com
800.877.7195
Short and
Long Term
Disability
Dearborn National
www.dearbornnational.com
Short Term: 877.348.0487
Long Term: 800.778.2281
Group Life
and AD&D
Lincoln Financial
Group
www.lfg.com
800.423.2765
Insurance
Agency
Buiten &
Associates, LLC
MaKenzi Bezemek
Makenzi.bezemek@buiteninsurance.
com
616.284.3028
Kevin Cumings
m
616.956.0040
Contact Information
The information in this Employee Benefits Guide is presented for illustrative purposes and is based on information
provided by the employer. The text contained in this Guide was taken from various summary plan descriptions and
benefit information. While every effort was taken to accurately report your benefits, discrepancies or errors are always
possible. In case of discrepancy between the Guide and the actual plan documents the actual plan documents will
prevail. All information is confidential, pursuant to the Health Insurance Portability and Accountability Act of 1996. If you
have any questions about your Guide, contact Human Resources.
Refer to this list for contact information for QCI Nurse Staffing’s benefit vendors/carriers. For general
information, please contact Human Resources. Please contact the carrier directly for issues/
questions pertaining to specific procedures and/or claims .
Employers must provide disclosures to employees regarding certain legal requirements; including the Health Insurance Portability and Accountability Act (HIPAA) and the Patient Protection and Affordable Care Act (PPACA). This document provides you with certain required disclosures related to our employee benefits plan (the “Plan). If you have any questions or need further assistance please contact your Plan Administrator as follows:
QCI Nurse Staffing Kenneth Jewett 2805 Coit Ave NE Grand Rapids, MI 49505
This Document Is For Information Purposes Only This communication is intended for illustrative and information purposes only. The plan documents, summary plan descriptions, insurance certificates, and policies serve as the governing documents to determine plan eligibility, benefits, and payments.
If you have Medicare or will become eligible for Medicare in the next 12 months, federal law gives you more choices about your prescription drug coverage. See page 2 for details.
Limitations And Exclusions Insurance and benefit plans always contain exclusions and limitations. Please see benefit booklets and/or contracts for complete details of coverage and eligibility.
Future Of The Plan QCI Nurse Staffing reserves the right to amend, modify, or terminate its benefit plan at any time, including during treatment.
Notice Regarding Special Enrollment Rights If you do not timely or properly complete the enrollment process, you and your eligible dependents generally will not be covered under the Plan, upon your initial eligibility date. Also, if you fail to specifically enroll your eligible dependents on the enrollment form, your eligible dependents will not be covered under the Plan upon the dependent’s initial eligibility date. If enrollment does not occur on an individual’s initial eligibility date, coverage may not be applied for until the next annual open enrollment period. However, if an employee or dependent experiences a special enrollment rights circumstance, coverage may begin immediately, before the next annual open enrollment. This section explains the special enrollment rights rules.
If an individual experiences a loss of health coverage, if an employee has a new dependent, or an individual loses or gains eligibility with respect to Medicaid or a State
Children’s Health Insurance Program (“CHIP”), an eligible employee and/or a dependent may have special enrollment rights to participate in coverage under the group health plan immediately without being required to wait until the next annual open enrollment period.
• A loss of other coverage may occur when COBRA hasbeen exhausted, an individual becomes ineligible forcoverage (for example, due to a change in status),employer contributions for the coverage have beenterminated, the other coverage is an HMO and theindividual no longer lives or works in the HMO servicearea, coverage is lost because the other plan nolonger offers any benefits to a class of similarly-situated individuals (such as part-time employees), ora benefit package option is terminated unless theindividual is provided a current right to enroll inalternative coverage. A loss of other coverage for thispurpose does not include, however, termination dueto the nonpayment of required contributions, forcause due to the filing of a fraudulent application orclaim, or where the individual voluntarily terminatesother coverage.
• The addition of a new dependent may occur due tomarriage, birth, adoption or placement for adoption.
• If an individual’s Medicaid or CHIP coverage isterminated as a result of a loss of eligibility or if theindividual becomes eligible for a premium assistancesubsidy under Medicaid or a CHIP, the individual hasspecial enrollment rights.
Enrollment must generally be requested in a special enrollment rights situation within 30 days after the loss of other coverage or the addition of the new dependent, whichever is applicable. However, in the case of loss or gain of Medicaid or CHIP eligibility, a health plan must allow immediate enrollment if the individual submits a request within 60 days after the loss or gain of eligibility.
Notice Regarding Women's Health And Cancer Rights Act The Women's Health and Cancer Rights Act requires group health plans and insurers offering mastectomy coverage to also provide coverage for:
• Reconstruction of the breast on which themastectomy was performed;
• Surgery and reconstruction of the other breast toproduce a symmetrical appearance; and
• Prostheses and treatment of physical complicationsat all stages of the mastectomy, including lymphedemas
These services are payable to a patient who is receiving benefits in connection with a mastectomy and elects reconstruction. The physician and patient determine the manner in which these services are performed.
The plan may apply deductibles and copayments consistent with other coverage within the plan. This notice serves as the
Important Employee Disclosures
official annual notice and disclosure of the fact that employer’s health plan has been amended to comply with this law.
Notice Regarding Newborns And Mothers Health Protection Act Group health plans and health insurance issuers offering group health insurance may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child for less than 48 hours following normal vaginal delivery, or less than 96 hours following a cesarean section, or require that a provider obtain authorization from the plan or insurance issuer to prescribe a length of stay not in excess of the above periods.
Notice Regarding GINA The Genetic Information Nondiscrimination Act of 2008 (GINA) states that group health plans and insurance issues may not:
• Adjust group premium or contribution amounts onthe basis of genetic information.
• Request or require individuals to undergo a genetictest
• Request, require or purchase genetic informationprior to or in connection with enrollment, or at anytime for underwriting purposes.
Notice Regarding Patient Protections The following paragraphs outline certain protections under the PPACA and only apply when the Plan requires the designation of a Primary Care Physician.
One of the provisions in the PPACA is for plans and insurers that require or allow for the designation of primary care providers by participants to inform the participants of their rights.
You will have the right to designate any primary care provider who participates in the Plan's network and who is available to accept you and/or your Eligible Dependents. For children, you may designate a pediatrician as the primary care provider. You also do not need prior authorization from the Plan or from any other person (including your primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the Plan's network. 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 or notifying primary care provider or Plan of treatment decisions.
If you do not make a provider designation, the Plan may make one for you. For information on how to select or change a primary care provider, and for a list of the participating primary care providers, pediatricians, or obstetrics or gynecology health care professionals, please contact the insurer.
Other PPACA Protections
Other PPACA requirements include allowing eligible dependent children to continue health coverage until age 26, not retroactively rescinding coverage except as permitted by law and issuing eligible individuals a summary of benefits and coverage (SBC) describing the terms of the group health plan. You will be provided with an SBC as required by law.
Medicare Notice You must notify QCI Nurse Staffing when you or your dependents become Medicare eligible. QCI Nurse Staffing is required to contact the insurer to inform them of your Medicare status. Federal law determines whether Medicare or the group health plan is the primary payer. You must also notify Medicare directly that you have group health insurance coverage. Privacy laws prohibit Medicare from discussing coverage with anyone other than the Medicare beneficiary or their legal guardian. The toll free number to Medicare Coordination of Benefits is 1-800-999-1118.
Important Information About Your Prescription Drug Coverage And Medicare Please note that the following notice only applies to individuals who are eligible for Medicare.
Medicare eligible individuals may include employees, spouses or dependent children who are Medicare eligible for one of the following reasons.
• Due to the attainment of age 65• Due to certain disabilities as determined by the
Social Security Administration• Due to End Stage Renal Disease (ESRD)
If you are covered by Medicare, please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with QCI Nurse Staffing and about your options under Medicare's prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.
There are two important things you need to know about your current coverage and Medicare's prescription drug coverage:
1. Medicare prescription drug coverage became availablein 2006 to everyone eligible for Medicare. You can getthis coverage if you join a Medicare Prescription DrugPlan or join a Medicare Advantage Plan (like an HMO orPPO) that offers prescription drug coverage. AllMedicare drug plans provide at least a standard level ofcoverage set by Medicare. Some plans may also offermore coverage for a higher monthly premium.
2. QCI Nurse Staffing has determined that the prescriptiondrug coverage offered in the Blue Care Network HMO
Important Employee Disclosures
Platinum 20% and HMO Gold $1,000, along with the Simply Blue PPO Gold $500 is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. If your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. If you are enrolled in the Simply Blue PPO HSA $2,700 the prescription drug coverage is NOT creditable and would not be deemed “Creditable Coverage” by Medicare. You will need to pick up a “creditable” Prescription Drug Part D plan.
When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th through December 7th. This may mean that you may have to wait to join a Medicare Prescription Drug Plan and that you may pay a higher premium (a penalty) if you join later. You may pay that higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, if you lose creditable prescription drug coverage, through no fault of your own, you will be eligible for a sixty (60) day Special Enrollment Period because you lost creditable coverage to join a Part D plan. In addition, if you lose or decide to leave employer-sponsored coverage; you will be eligible to join a Part D plan at that time using an Employer Group Special Enrollment Period. You should compare your current prescription drug coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area.
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage and don't join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go 19 months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.
For More Information About This Notice or Your Current Prescription Drug Coverage... Contact your HR Representative. You'll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through your company changes. You also may request a copy of this notice at any time.
For More Information About Your Options Under Medicare Prescription Drug Coverage... More detailed information about Medicare plans that offer prescription drug coverage is in the "Medicare & You" handbook.
You'll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage:
• Visit www.medicare.gov • Call your State Health Insurance Assistance Program
(see the inside back cover of your copy of the "Medicare & You" handbook for their telephone number) for personalized help
• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information, visit Social Security at www.socialsecurity.gov , or call 1-800-772-1213 (TTY 1-800-325-0778).
Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (penalty).
HIPAA Privacy And Security Employer and any health insurance issuer in connection with employer’s group health plan are committed to complying with the privacy and security requirements of HIPAA as modified by the HIPAA/HITECH Omnibus Final Rule. Participants will receive a notice of privacy practices in connection with the Plan. You will also receive a new copy in the event the notice is modified. If you would like to receive another copy of the notice of privacy practices, you may do so at any time, by contacting the plan administrator. Duplicate copies are provided free of charge.
Important Employee Disclosures
ERISA RIGHTS
As a participant in the Plan, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974, as amended (ERISA). ERISA provides that all plan participants shall be entitled to the following:
Receive Information About Your Plan and Benefits
You can examine, without charge, at the Plan Administrator’s office and at other specified locations, such as worksites all documents governing the Plan, including insurance contracts and a copy of the latest annual report (Form 5500 Series) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefit Security Administration.
You can obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the Plan, including insurance contracts and copies of the latest annual report (Form 5500 Series) and an updated summary plan description. The administrator may make a reasonable charge for the copies.
Continue Group Health Plan Coverage
You can continue health care coverage for yourself, spouse, or dependents if there is a loss of coverage under the Plan as a result of a qualifying event. Your or your dependents may have to pay for such coverage. Review your summary plan description and the documents governing the Plan on the rules governing your COBRA continuation coverage rights.
Prudent Actions by Plan Fiduciaries
In addition to creating rights for participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your Plan, called “fiduciaries” of the Plan, have a duty to do so in the interest of you and other Plan participants and beneficiaries. No one, including your Employer, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a benefit or exercising your rights under ERISA.
Enforce Your Rights
If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules.
Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of Plan documents or the latest annual report from the Plan and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the
materials were not sent because of reasons beyond the control of the Plan Administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in state or Federal court. In addition, if you disagree with the Plan’s decision or lack thereof concerning the qualified status of a domestic relations order or a medical child support order, you may file suit in Federal court. If it should happen that Plan fiduciaries misuse the Plan’s money, or if you are discriminated against for asserting your rights, you may seek assistance from the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration.
PLAN ADMINISTRATOR CONTACT INFORMATION
For more information about any of the notices contained herein, or any of your rights under the Plan, please contact the Plan Administrator at:
QCI Nurse Staffing 2805 Coit Ave, NE Grand Rapids, MI 49505 NOTICE OF ELIGIBILITY FOR HEALTH CARE RELATED TO MILITARY LEAVE
If you take a military leave, federal law under the Uniformed Services Employment and Reemployment Rights Act (USERRA) provides the following rights:
• If you leave your job to perform military service, you have the right to elect to continue your existing employer-based health plan coverage for you and your dependents for up to 24 months while in the military. If you don’t elect to continue employer-based health plan coverage during your military services, you have the right to be reinstated in your employer’s health plan when you are reemployed, generally without any waiting period or exclusions (e.g., pre-existing condition exclusions) except for service-connected illnesses or injuries.
The Plan Administrator can provide you with additional information about how to elect continuation coverage under USERRA.
Important Employee Disclosures
Premium Assistance Under Medicaid And The Children’s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).
If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of January 31, 2016. Contact your State for more information on eligibility -
ALABAMA – Medicaid Website: http://www.myalhipp.com Phone: 1-855-692-5447 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 COLORADO – Medicaid Medicaid Website: http://www.colorado.gov/hcpf Medicaid Phone (Out of state): 1-800-221-3943 FLORIDA – Medicaid Website: https://www.flmedicaidtplrecovery.com/ Phone: 1-877-357-3268 GEORGIA – Medicaid Website: http://dch.georgia.gov/Medicaid Click on Health Insurance Premium Payment (HIPP) Phone: 1-404-656-4507 INDIANA – Medicaid Healthy Indiana Plan for low-income adults 19-64 Website: http://www.hip.in.gov Phone: 1-877-438-4479 All other Medicaid Website: http://www.indianamedicaid.com Phone: 800-403-0864 IOWA – Medicaid Website: www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562 KANSAS – Medicaid Website: http://www.kdheks.gov/hcf/ Phone: 1-785-296-3512 KENTUCKY – Medicaid
Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570 LOUISIANA – Medicaid Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 1-888-695-2447 MAINE – Medicaid Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html Phone: 1-800-442-6003 TTY Maine relay 711 MASSACHUSETTS – Medicaid and CHIP Website: http://www.mass.gov/MassHealth Phone: 1-800-462-1120 MINNESOTA – Medicaid Website: http://mn.gov/dhs/ma/ Phone: 1-800-657-3739 MISSOURI – Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005 MONTANA – Medicaid Website: http://dphhs.mt.gov/montanahealthcareprograms/hipp Phone: 1-800-694-3084 NEBRASKA – Medicaid Website: http://dhhs.ne.gov/children_family_services/accessnebraska/pages/accessnebraska_index.aspx Phone: 1-855-632-7633 NEVADA – Medicaid Medicaid Website: http://dwss.nv.gov/ Medicaid Phone: 1-800-992-0900 NEW HAMPSHIRE – Medicaid Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218
Important Employee Disclosures
NEW JERSEY – Medicaid and CHIP Medicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710 NEW YORK – Medicaid Website: http://www.nyhealth.gov/health_care/medicaid/ Phone: 1-800-541-2831 NORTH CAROLINA – Medicaid Website: http://www.ncdhhs.gov/dma Phone: 919-855-4100 NORTH DAKOTA – Medicaid Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825 OKLAHOMA – Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 1-888-365-3742 OREGON – Medicaid Website: http://www.oregonhealthykids.gov Website: http://www.hijossaludablesoregon.gov Phone: 1-800-699-9075 PENNSYLVANIA – Medicaid Website: http://www.dhs.pa.gov/hipp Phone: 1-800-692-7462 RHODE ISLAND – Medicaid Website: www.eohhs.ri.gov Phone: 401-462-5300 SOUTH CAROLINA – Medicaid Website: http://www.scdhhs.gov Phone: 1-888-549-0820 SOUTH DAKOTA - Medicaid Website: http://dss.sd.gov Phone: 1-888-828-0059
TEXAS – Medicaid Website: https://gethipptexas.com/ Phone: 1-800-440-0493 UTAH – Medicaid and CHIP Medicaid: http://health.utah.gov/medicaid CHIP: http://health.utah.gov/chip Phone: 1-877-543-7669 VERMONT– Medicaid Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427 VIRGINIA – Medicaid and CHIP Medicaid Website: http://www.coverva.org/programs_premium_assistance.cfm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.coverva.org/programs_premium_assistance.cfm CHIP Phone: 1-855-242-8282 WASHINGTON – Medicaid Website: http://www.hca.wa.gov/medicaid/premiumpymt/pages/index.aspx Phone: 1-800-562-3022 ext. 15473 WEST VIRGINIA – Medicaid Website: www.dhhr.wv.gov/bms/Medicaid%20Expansion/pages/default.aspx Phone: 1-877-598-5820, HMS Third Party Liability WISCONSIN – Medicaid and CHIP Website: htttp://www.dhs.wisconsin.gov/publications/p1/p10095.pdf Phone: 1-800-362-3002 WYOMING – Medicaid Website: http://wyequalitycare.acs-inc.com/ Phone: 307-777-7531
To see if any other states have added a premium assistance program since January 31, 2016, or for more information on special enrollment rights, 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, Menu Option 4, Ext. 61565
OMB Control Number 1210-0137 (expires 10/31/2016)
Important Employee Disclosures
Think of your health care investment just as you would any other important expense. Use all the resources available to you from both the insurance companies and your employer's human resource department to get the information you need to make an informed decision. Save time and money by using in-network doctors and pharmacies. You'll pay less out of pocket and save time.
Ask for samples Did you ever fill a prescription for a new medicine, only to throw most of it away when your doctor replaces it with a different drug or dosage? Don't be shy about asking for samples. Doctors often have them on hand and this will save you money as he or she is determining the best therapeutic option for you.
Ask for generic drugs Generic drugs have the same active ingredients and as their brand-name counterparts, they are FDA approved, and can save you money. Visit website such as, www.theunadvertisedbrand.com for reliable, useful generic drug information.
Use the Discount Drug Programs at your Local Pharmacy. Many pharmacies (Meijer, Spartan Stores, Wal-Mart Stores, Target, Kroger, etc.) offer hundreds of generic drugs at a deeply discounted price. Generics are often available for reduced rates for a 30 day supply, and for a 90 day supply. Under some programs, certain antibiotics are free. Contact the retail provider for exact cost.
Live a healthy lifestyle Healthy habits like exercising regularly, eating well, and not smoking can increase your stamina, lighten your mood, and lower your risk for certain diseases. Aside from the physical and psychological benefits, healthy living can also offer financial rewards. One recent study noted the impact healthy living has on health care costs:
• A 41 percent difference in health care costsbetween those who ate poorly and those who atewell
• Smokers had a 31 percent higher annual claimscost than non-smokers
• Overweight people were hospitalized 143 percentmore than people of average weight
• People with high blood pressure spent 24 percentmore days in the hospital than people with normalblood pressure.
Stretch your health care dollar
Understand how your health plan works. This is probably the first and most important step in getting the most for your health care dollar. You need to know what is and what is not covered, what procedures you need to follow to ensure your claims are paid, and which providers and facilities to use to get the most cost-effective care. Know the deductibles, copayments, and other out-of-pocket costs you are responsible for paying before you use medical products or services or get a prescription filled.
Use in-network providers. When you go to a non-participating provider you will likely pay a higher coinsurance percentage.
Look into freestanding surgical and diagnostic centers. If you need surgery, you might save money by having it performed at an ambulatory surgical center, a freestanding clinic, which is not a hospital or operated by a hospital. These centers usually charge less than hospitals or their outpatient surgical centers. Freestanding diagnostic centers are also available and tend to charge less for certain tests like MRIs, CAT scans, X-rays, and bone density scans. But before you go, make sure the facility is in your plan‘s network and that your plan‘s benefits cover the service. And as always, talk to your doctor to be sure this course of action is appropriate for you.
Ask your doctor about home testing and monitoring devices. Home tests for blood pressure, diabetes, and other conditions can help ensure you are following your doctor‘s orders and that prescribed treatments are working. These tests will usually cost less than in-office testing. Check with your doctor to be sure in-home testing is appropriate, report your results regularly, and call your doctor if you notice anything unusual. Please note: Terms and definitions may differ from those used in other plan documents describing your coverage
Only go to the hospital emergency room for true emergencies. If you need medical care when your regular doctor is not available, think about going to an urgent care center rather than a hospital emergency room. This can often be a tough call, but for a cold or a minor sprain, avoiding the ER will probably save you money. Getting care at an urgent care center will almost certainly be faster than at the ER. Call your plan‘s health hotline, if available, to get advice on how, when, and where to seek care in a non-emergency situation.
Carefully check all medical bills. Insurance companies and hospitals are not immune from making billing errors. In fact, errors can be common. By reviewing all
Health Care
Education Healthcare Education
documents timely, you could prevent overpayments or overcharges.
Make careful decisions about prescription drugs. Prescription drugs are the fastest rising area of health care costs and one of the biggest reasons behind dramatic increases in health care costs nationwide. The driving factors behind this trend are increased advertising, development of new and expensive drugs, and greater utilization - more people are simply taking more prescription drugs than ever before. Here are some ways you can reduce your prescription drug costs:
• Use generic drugs whenever possible, even for over-the-counter medications. Remember, the most expensive drug is not necessarily the best. There are often generic equivalents that are less expensive than the drugs you see advertised on TV. Before your physician finishes writing your prescription, ask about generic equivalents, lower-cost brand name drugs to treat the same condition, and even over-the-counter options.
• Know how your drug plan works. Your plan has a formulary (a list of preferred drugs they will cover). If your doctor prescribes a medicine not on the Formulary, ask for one that is on the list.
• Use a mail order pharmacy if one is available. Ordering prescriptions by mail can save money and is perfect for patients who take health maintenance medication on an ongoing basis and can place orders in advance.
• Talk to your doctor. Make sure your physician knows if you have to pay for your prescriptions out of your own pocket. Often there are less expensive but equally effective treatment options.
• Compare prices. Shop around for the pharmacy that offers the best value for your needs. You may even need to get different medications from different pharmacies depending on which offers a better price.
Use a health care spending account to pay for medical expenses with pre-tax money. If your employer provides you access to a Flexible Spending Account (FSA) use it. These accounts let you set aside pretax money from your paycheck to pay for eligible items like prescription drugs and over-the-counter medications, deductibles, coinsurance, dental expenses, and vision care.
Health care costs are tied directly to utilization; when you use your health plan more, there are more claims. And the higher the claims, the more you and your employer must contribute to pay for these claims. Don‘t forget that the most cost effective way to reduce the cost of health care is to make better decisions about the way you live, including the way you eat, exercise, and spend your health care dollars.
**This information is for informational purposes only and is not intended to replace the advice of insurance / medical professional.**
Healthcare Education
This glossary has many commonly used terms, but isn’t a full list. These glossary terms and definitions are intended to be educational and may be different from the terms and definitions in your plan. Some of these terms also might not have exactly the same meaning when used in your policy or plan, and in any such case, the policy or plan governs. (See your Summary of Benefits and Coverage for information on how to get a copy of your policy or plan document.)
Allowed Amount - Maximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance" or "negotiated rate." If your provider charges more than the allowed amount, you may have to pay the difference. (See Balance Billing.)
Appeal - A request for your health insurer or plan to review a decision or a grievance again.
Balance Billing - When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services.
Co-insurance - Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.
Complications of Pregnancy - Conditions due to pregnancy, labor and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a non-emergency caesarean section aren’t complications of pregnancy.
Co-payment - A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.
Deductible - The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1000, your plan won’t pay anything until you’ve met your $1000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.
Durable Medical Equipment (DME) - Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.
Emergency Medical Condition - An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm.
Emergency Medical Transportation - Ambulance services for an emergency medical condition.
Emergency Room Care - Emergency services you get in an emergency room.
Emergency Services - Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.
Excluded Services - Health care services that your health insurance or plan doesn’t pay for or cover.
Grievance - A complaint that you communicate to your health insurer or plan.
Habilitation Services - Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.
Health Insurance - A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.
Home Health Care - Health care services a person receives at home.
Hospice Services - Services to provide comfort and support for persons in the last stages of a terminal illness and their families.
Hospitalization - Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.
Hospital Outpatient Care - Care in a hospital that usually doesn’t require an overnight stay.
Health & Medical Terms
In-network Co-insurance - The percent (for example, 20%) you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan. In-network co-insurance usually costs you less than out-of-network co-insurance.
In-network Co-payment - A fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health insurance or plan. In-network co-payments usually are less than out-of-network co-payments.
Medically Necessary - Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
Network - The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.
Non-Preferred Provider - A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers.
Out-of-network Co-insurance - The percent (for example, 40%) you pay of the allowed amount for covered health care services to providers who do not contract with your health insurance or plan. Out-of-network co-insurance usually costs you more than in-network co-insurance.
Out-of-network Co-payment - A fixed amount (for example, $30) you pay for covered health care services from providers who do not contract with your health insurance or plan. Out-of-network co-payments usually are more than in-network co-payments.
Out-of-Pocket Limit - The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges or health care your health insurance or plan doesn’t cover. Some health insurance or plans don’t count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit.
Physician Services - Health care services a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.
Plan - A benefit your employer, union or other group sponsor provides to you to pay for your health care services.
Preauthorization - A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost.
Preferred Provider - A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also “participating” providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more.
Premium - The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.
Prescription Drug Coverage - Health insurance or plan that helps pay for prescription drugs and medications.
Prescription Drugs - Drugs and medications that by law require a prescription.
Primary Care Physician - A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient.
Primary Care Provider - A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services
Provider - A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), health care professional or health care facility licensed, certified or accredited as required by state law.
Reconstructive Surgery - Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions.
Health & Medical Terms
Rehabilitation Services - Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.
Skilled Nursing Care - Services from licensed nurses in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a nursing home.
Specialist - A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.
UCR (Usual, Customary and Reasonable) - The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.
Urgent Care - Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.
Health & Medical Terms
Appendix
All changes in status MUST be received by QCI Nurse
Staffing and Buiten & Associates within 31 days of the
event or you may NOT be able to change your election or
coverage options.
The events listed above do NOT include all qualifying life events. Please contact your Human Resources or Buiten
& Associates to confirm that your specific event qualifies for a change in status and/or elections.
Marriage
Divorce
Legal Separation
Birth or Adoption
Death of Spouse
Change in Child’s Dependent Status
Change in Residence due to an employment transfer for you or your spouse
Commencement or termination of adoption proceedings
Change in spouses’ benefits or employment status
Qualifying Life Events:
Dependent Termination
Age Termination Date
Medical Age 26 End of Calendar Year of
26th Birthday
Pediatric Dental Included in
Medical Age 19 Date of 19th Birthday
Voluntary Dental Age 26 End of the Month of 26th
Birthday
Voluntary Vision Age 23 Day Before 23rd Birthday
at 11:59pm
Benefit Summaries
Medical Page 20-48
Dental Page 49-50
Vision Page 51-53
Short Term Disability Page 54
Long Term Disability Page 55
Group Life/AD&D Page 56-57
BCNHMOSMPlatinum20%
This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and exclusions may apply to covered services. For a complete description of benefits, please see the applicable Blue Care Network certificate and riders. Payment amounts are based on the Blue Care Network approved amount, less any applicable deductible, coinsurance and/or copay amounts required by the plan. If there is a discrepancy between this Benefits-at-a-Glance and any applicable plan documents, the plan document will control. This coverage is provided pursuant to a contract entered into in the State of Michigan and shall be construed under the jurisdiction and according to the laws of the State of Michigan. Services must be provided or arranged by member’s primary care physician or health plan.
Member’sResponsibility:Deductible,Copays,CoinsuranceandDollarMaximumsNote:The Deductible will apply to certain services as defined below.DeductibleNote: Coinsurance and select fixed dollar copays apply once the deductible has been met.
None
Fixeddollarcopays
$25 forofficevisits,$35 forspecialistvisits,$35forurgentcarevisits,$150foremergencyroomvisits,$150forhightechimagingand$5forallergyinjections
Coinsurance 20%and50%forselectservicesasnotedbelowAnnualCoinsuranceMaximum–serviceswithafixeddollarcopayor50%coinsurancedonotapplytotheannualcoinsurancemaximum
$1,000permember/$2,000perfamilypercalendaryear
Deductibleamounts Serviceswithaflatdollarcopay Infertilityservices MaleMastectomy ReductionMammoplasty MaleSterilization ElectiveAbortion
TMJ OrthognathicSurgery WeightReduction
procedures DurableMedicalEquipment PrescriptionDrugs ProstheticsandOrthotics DiabeticSupplies
Annualout‐of‐pocketmaximums– appliestodeductibles,copaysandcoinsuranceamountsforallcoveredservices–includingprescriptiondrugcopays
$6,600permember/$13,200perfamilypercalendaryear
PreventiveServices–as defined by the Affordable Care Act and included in your Certificate of CoverageHealthMaintenanceExam Covered– 100%
AnnualGynecologicalExam Covered– 100%
PapSmearScreening–laboratoryservicesonly Covered– 100%
Well‐BabyandChildCare Covered– 100%
Immunizations–pediatricandadult Covered– 100%
ProstateSpecificAntigen(PSA)Screening–laboratoryservicesonly Covered– 100%
Routinecolonoscopy Covered– 100%
MammographyScreening Covered–100%
VoluntaryFemaleSterilization Covered–100%
BreastPumps(DMEguidelinesapply.Limitedtonomorethanoneper24monthperiod)
Covered–100%
MaternityPre‐NatalCare Covered–100%
PhysicianOfficeServices
PCPOfficeVisits Covered–$25copayConsultingSpecialistCare–whenreferredforotherthanpreventiveservices
Covered–$35copay
Client: CoverageforCompanies
EmergencyMedicalCare
HospitalEmergencyRoom–copaywaivedifadmitted Covered–$150copayUrgentCareCenter Covered–$35copayAmbulanceServices–medicallynecessary Covered–80%
DiagnosticServices LaboratoryandPathologyTests Covered–100%DiagnosticTestsandX‐rays Covered–80%HighTechnologyImaging(MRI,CAT,PET) Covered–$150copayRadiationTherapy Covered–80%
MaternityServicesProvidedbyaPhysician Post‐NatalCare.SeePreventiveServicessectionforPre‐NatalCare Covered–$25copayDeliveryandNurseryCare Covered–100%forprofessionalservices;seeHospitalCarefor
facilitycharges
HospitalCare
GeneralNursingCare,HospitalServicesandSupplies Covered–80%;unlimiteddaysOutpatientSurgery–Seemembercertificateforselectsurgicalcoinsurance
Covered–80%
AlternativestoHospitalCare
SkilledNursingCare Covered–80%upto45dayspercalendaryearHospiceCare Covered–100%whenauthorizedHomeHealthCare Covered–$35copay
SurgicalServices Surgery–includesallrelatedsurgicalservicesandanesthesia. Covered–80%
VoluntaryMaleSterilization–SeePreventiveServicessectionforvoluntaryfemalesterilization
Covered– 50%
ElectiveAbortion(Oneprocedurepertwoyearperiodofmembership) NotCovered
HumanOrganTransplants(subjecttomedicalcriteria) Covered– 80%
Reductionmammoplasty(subjecttomedicalcriteria) Covered– 50%
MaleMastectomy(subjecttomedicalcriteria) Covered– 50%
TemporomandibularJointSyndrome(subjecttomedicalcriteria) Covered– 50%
OrthognathicSurgery(subjecttomedicalcriteria) Covered– 50%
WeightReductionProcedures(subjecttomedicalcriteria)–Limitedtooneprocedureperlifetime
Covered– 50%
MentalHealthCareandSubstanceAbuseTreatmentInpatientMentalHealthCareandSubstanceAbuseCare Covered– 80%OutpatientMentalHealthCare Covered–$25copayOutpatientSubstanceAbuseCare Covered–$25copay
AutismSpectrumDisorders,DiagnosesandTreatment Appliedbehavioralanalyses(ABA)treatment Covered–$25copayOutpatientphysicaltherapy,speechtherapy,occupationaltherapy,nutritionalcounselingforautismspectrumdisorderthroughage18 Physical, speech and occupational therapy for autism spectrum disorder is unlimited.
Covered–$35copay
Othercoveredservices,includingmentalhealthservices,forAutismSpectrumDisorder
Seeyouroutpatientmentalhealthbenefitandmedicalofficevisitbenefit
OtherServices AllergyTestingandserum Covered–50%Allergyofficevisits Covered–50%AllergyInjections Covered–$5copayChiropracticSpinalManipulation–whenreferred Covered–$35copay;upto30visitspercalendaryearRehabilitativeServices–subjecttomeaningfulimprovementwithin90days
OutpatientPhysicalandOccupationalTherapy–limitedtoacombinedbenefitmaximumof30visitspercalendaryear
OutpatientSpeechTherapy–limitedto30visitspercalendaryear
Covered–$35copay
HabilitativeServices OutpatientPhysicalandOccupationalTherapy–limitedtoa
combinedbenefitmaximumof30visitspercalendaryear OutpatientSpeechTherapy–limitedto30visitspercalendar
year
Covered–$35copay
OutpatientCardiacandPulmonaryRehabilitation Covered–$35copay;limitedtoabenefitmaximumof30visitspercalendaryear
InfertilityCounselingandTreatment(excludingIn‐vitrofertilization) Covered–50%onallassociatedcostsDurableMedicalEquipment Covered–50%ProstheticandOrthoticAppliances Covered–50%DiabeticSupplies Covered–80%PediatricVision
EyeExam–Limitedtooncepercalendaryearthroughthelastdayoftheyearinwhichanindividualturnsage19
PrescriptionGlasses–Frames(chosenfromaselectcollection)andlensesarecoveredonceinacalendaryearthroughthelastdayoftheyearinwhichanindividualturnsage19
Covered–100%
PrescriptionDrugs Covered– Tier1A‐$4copay,Tier1B‐$15copay,Tier2‐$40copay,
Tier3‐$80copay,Tier4–20%coinsurance(Max$200),Tier5–20%coinsurance(Max$300);30daysupply.
Excludes drugs for the treatment of sexual dysfunction, weight loss, cough & cold
90daysupplyformailorderandretail:Threetimesapplicablecopayless$10
Contraceptives‐Tier1A–100%,Tier1B–$15copay,Tier2‐$40copay,Tier3‐$80copay
PreventiveDrugscoveredinfull
CLSSSM,CI20%,1KECM,6600PM,CO25,35RP,ER150,UR35,IMG150,DSR20%,PVSN,P415CS,90D3X
BCNHMOSMGold$1000
This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and exclusions may apply to covered services. For a complete description of benefits, please see the applicable Blue Care Network certificate and riders. Payment amounts are based on the Blue Care Network approved amount, less any applicable deductible, coinsurance and/or copay amounts required by the plan. If there is a discrepancy between this Benefits-at-a-Glance and any applicable plan documents, the plan document will control. This coverage is provided pursuant to a contract entered into in the State of Michigan and shall be construed under the jurisdiction and according to the laws of the State of Michigan. Services must be provided or arranged by member’s primary care physician or health plan.
Member’sResponsibility:Deductible,Copays,CoinsuranceandDollarMaximumsNote:The Deductible will apply to certain services as defined below.DeductibleNote: Coinsurance and select fixed dollar copays apply once the deductible has been met.
$1,000perindividual/$2,000perfamilypercalendaryear
Fixeddollarcopays
$20forofficevisits,$40forspecialistvisits,$50forurgentcarevisits,$150foremergencyroomvisits,$150forhightechimagingand$5forallergyinjections
Coinsurance 20%and50%forselectservicesasnotedbelowAnnualCoinsuranceMaximum–ThefollowingservicesDONOTapplytotheAnnualCoinsuranceMaximumiftheyareincludedinyourcoverage:
$2,500permember/$5,000perfamilypercalendaryear
Deductibleamounts Serviceswithaflatdollarcopay Infertilityservices MaleMastectomy ReductionMammoplasty MaleSterilization ElectiveAbortion
TMJ OrthognathicSurgery WeightReduction
procedures DurableMedicalEquipment PrescriptionDrugs ProstheticsandOrthotics DiabeticSupplies
Annualout‐of‐pocketmaximums– appliestodeductibles,copaysandcoinsuranceamountsforallcoveredservices–includingprescriptiondrugcopays
$6,600permember/$13,200perfamilypercalendaryear
PreventiveServices–as defined by the Affordable Care Act and included in your Certificate of CoverageHealthMaintenanceExam Covered– 100%
AnnualGynecologicalExam Covered– 100%
PapSmearScreening–laboratoryservicesonly Covered– 100%
Well‐BabyandChildCare Covered– 100%
Immunizations–pediatricandadult Covered– 100%
ProstateSpecificAntigen(PSA)Screening–laboratoryservicesonly Covered– 100%
RoutineColonoscopy Covered– 100%
MammographyScreening Covered–100%
VoluntaryFemaleSterilization Covered–100%
BreastPumps(DMEguidelinesapply.Limitedtonomorethanoneper24monthperiod)
Covered–100%
MaternityPre‐NatalCare Covered–100%
PhysicianOfficeServices
PCPOfficeVisits Covered–$20copayConsultingSpecialistCare–whenreferredforotherthanpreventiveservices
Covered–$40copay
Client: CoverageforCompanies
EmergencyMedicalCare
HospitalEmergencyRoom–copaywaivedifadmitted Covered–$150copayafterdeductibleUrgentCareCenter Covered–$50copayAmbulanceServices–medicallynecessary Covered–80%afterdeductible
DiagnosticServices LaboratoryandPathologyTests Covered–100%DiagnosticTestsandX‐rays Covered–80%afterdeductibleHighTechnologyImaging(MRI,CAT,PET) Covered–$150copayafterdeductibleRadiationTherapy Covered–80%afterdeductible
MaternityServicesProvidedbyaPhysician Post‐NatalCare.SeePreventiveServicessectionforPre‐NatalCare Covered–$20copayDeliveryandNurseryCare Covered–100%afterdeductibleforprofessionalservices;see
HospitalCareforfacilitycharges
HospitalCare
GeneralNursingCare,HospitalServicesandSupplies Covered–80%afterdeductible;unlimiteddaysOutpatientSurgery–Seemembercertificateforselectsurgicalcoinsurance
Covered–80%afterdeductible
AlternativestoHospitalCare
SkilledNursingCare Covered–80%afterdeductibleupto45dayspercalendaryear
HospiceCare Covered–100%afterdeductiblewhenauthorizedHomeHealthCare Covered–$40copayafterdeductible
SurgicalServices Surgery–includesallrelatedsurgicalservicesandanesthesia. Covered–80%afterdeductible
VoluntaryMaleSterilization–SeePreventiveServicessectionforvoluntaryfemalesterilization
Covered– 50%afterdeductible
ElectiveAbortion(Oneprocedurepertwoyearperiodofmembership)
NotCovered
HumanOrganTransplants(subjecttomedicalcriteria) Covered– 80%afterdeductibleReductionmammoplasty(subjecttomedicalcriteria) Covered– 50%afterdeductibleMaleMastectomy(subjecttomedicalcriteria) Covered– 50%afterdeductibleTemporomandibularJointSyndrome(subjecttomedicalcriteria) Covered– 50%afterdeductibleOrthognathicSurgery(subjecttomedicalcriteria) Covered– 50%afterdeductibleWeightReductionProcedures(subjecttomedicalcriteria)–Limitedtooneprocedureperlifetime
Covered– 50%afterdeductible
MentalHealthCareandSubstanceAbuseTreatmentInpatientMentalHealthCare Covered– 80%afterdeductibleInpatientSubstanceAbuseCare Covered– 80%afterdeductibleOutpatientMentalHealthCare Covered–$20copayOutpatientSubstanceAbuseCare Covered–$20copay
AutismSpectrumDisorders,DiagnosesandTreatment Appliedbehavioralanalyses(ABA)treatment Covered–$20copayOutpatientphysicaltherapy,speechtherapy,occupationaltherapy,nutritionalcounselingforautismspectrumdisorderthroughage18 Physical, speech and occupational therapy for autism spectrum disorder is unlimited.
Covered–$40copayafterdeductible
Othercoveredservices,includingmentalhealthservices,forAutismSpectrumDisorder
Seeyouroutpatientmentalhealthbenefitandmedicalofficevisitbenefit
OtherServices AllergyTestingandserum Covered–50%afterdeductibleAllergyofficevisits Covered–50%afterdeductibleAllergyInjections Covered–$5copayChiropracticSpinalManipulation–whenreferred Covered–$40copay;upto30visitspercalendaryearRehabilitativeServices–subjecttomeaningfulimprovementwithin90days
OutpatientPhysicalandOccupationalTherapy–limitedtoacombinedbenefitmaximumof30visitspercalendaryear
OutpatientSpeechTherapy–limitedto30visitspercalendaryear
Covered–$40copayafterdeductible
HabilitativeService OutpatientPhysicalandOccupationalTherapy–limitedto
acombinedbenefitmaximumof30visitspercalendaryearOutpatientSpeechTherapy–limitedto30visitspercalendaryear
Covered–$40copayafterdeductible
OutpatientCardiacandPulmonaryRehabilitation Covered–$40copayafterdeductible;limitedtoabenefitmaximumof30visitspercalendaryear
InfertilityCounselingandTreatment(excludingIn‐vitrofertilization)
Covered–50%afterdeductibleonallassociatedcosts
DurableMedicalEquipment Covered–50%ProstheticandOrthoticAppliances Covered–50%DiabeticSupplies Covered–80%PediatricVision
EyeExam–Limitedtooncepercalendaryearthroughthelastdayoftheyearinwhichanindividualturnsage19
PrescriptionGlasses–Frames(chosenfromaselectcollection)andlensesarecoveredonceinacalendaryearthroughthelastdayoftheyearinwhichanindividualturnsage19
Covered–100%
PrescriptionDrugs Covered– Tier1A‐$4copay,Tier1B‐$15copay,Tier2‐$40
copay,Tier3‐$80copay,Tier4–20%coinsurance(Max$200),Tier5–20%coinsurance(Max$300);30daysupply.
Excludes drugs for the treatment of sexual dysfunction, weight loss, cough & cold
90daysupplyformailorderandretail;Threetimesapplicablecopayless$10.
Contraceptives‐Tier1A–100%,Tier1B–$15copay,Tier2‐$40copay,Tier3‐$80copay
PreventiveDrugscoveredinfull
CLSSSM,D1000,WDRPOV,CI20%,25ECM,6600PM,CO20,40RP,ER150,UR50,IMG150,DSR20%,PVSN,P415CS,90D3X
* Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a “low access area” by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and the provider’s charge. Simply Blue PPO Gold $500, Rev Date 16 Q1 V1
Simply BlueSM PPO Gold $500 Medical Coverage with Prescription Drugs Benefits-at-a-Glance Effective for groups on their plan year This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and exclusions may apply. Payment amounts are based on BCBSM’s approved amount, less any applicable deductible and/or copay/coinsurance. For a complete description of benefits please see the applicable BCBSM certificates and riders, if your group is underwritten or any other plan documents your group uses, if your group is self-funded. If there is a discrepancy between this Benefits-at-a-Glance and any applicable plan document, the plan document will control. Preauthorization for Select Services – Services listed in this BAAG are covered when provided in accordance with Certificate requirements and, when required, are preauthorized or approved by BCBSM except in an emergency.
Note: A list of services that require approval before they are provided is available online at bcbsm.com/importantinfo. Select Approving covered services.
Pricing information for various procedures by in-network providers can be obtained by calling the customer service number listed on the back of your BCBSM ID card and providing the procedure code. Your provider can also provide this information upon request. Preauthorization for Specialty Pharmaceuticals – BCBSM will pay for FDA-approved specialty pharmaceuticals that meet BCBSM’s medical policy criteria for treatment of the condition. The prescribing physician must contact BCBSM to request preauthorization of the drugs. If preauthorization is not sought, BCBSM will deny the claim and all charges will be the member’s responsibility.
Specialty pharmaceuticals are biotech drugs including high cost infused, injectable, oral and other drugs related to specialty disease categories or other categories. BCBSM determines which specific drugs are payable. This may include medications to treat asthma, rheumatoid arthritis, multiple sclerosis, and many other disease as well as chemotherapy drugs used in the treatment of cancer, but excludes injectable insulin. In-network Out-of-network *
Member’s responsibility (deductibles, copays, coinsurance and dollar maximums) Note: If an in-network provider refers you to an out-of-network provider, all covered services obtained from that out-of-network provider will be subject to applicable out-of-network cost-sharing. Deductibles $500 for one member,
$1,000 for the family (when two or more members are covered under your contract) each calendar year
$1,000 for one member, $2,000 for the family (when two or more members are covered under your contract) each calendar year Note: Out-of-network deductible amounts also count toward the in-network deductible.
Flat-dollar copays • $20 copay for office visits and office consultations with a primary care physician
• $40 copay for office visits and office consultations with a specialist
• $30 copay for chiropractic and osteopathic manipulative therapy
• $60 copay for urgent care visits • $150 copay for emergency room visits
$150 copay for emergency room visits
Coinsurance amounts (percent copays)
Note: Coinsurance amounts apply once the deductible has been met.
• 50% of approved amount for bariatric surgery
• 20% of approved amount for most other covered services
• 50% of approved amount for bariatric surgery
• 40% of approved amount for most other covered services
Client: CoverageforCompanies
* Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a “low access area” by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and the provider’s charge. Simply Blue PPO Gold $500, Rev Date 16 Q1 V1
In-network Out-of-network *
Member’s responsibility (deductibles, copays, coinsurance and dollar maximums), continued Annual coinsurance maximums – applies to coinsurance amounts for all covered services – but does not apply to deductibles, flat-dollar copays, private duty nursing care coinsurance amounts and prescription drug cost-sharing amounts
$3,000 for one member, $6,000 for the family (when two or more members are covered under your contract) each calendar year
$6,000 for one member, $12,000 for the family (when two or more members are covered under your contract) each calendar year Note: Out-of-network coinsurance amounts also count toward the in-network coinsurance maximum.
Annual out-of-pocket maximums – applies to deductibles, flat-dollar copays and coinsurance amounts for all covered services – including prescription drugs cost-sharing amounts
$6,600 for one member, $13,200 for the family (when two or more members are covered under your contract) each calendar year
$13,200 for one member, $26,400 for the family (when two or more members are covered under your contract) each calendar year Note: Out-of-network cost-sharing amounts also count toward the in-network out-of-pocket maximum.
Lifetime dollar maximum None
Preventive care services Health maintenance exam – includes chest x-ray, EKG, cholesterol screening and other select lab procedures
100% (no deductible or copay/coinsurance), one per member per calendar year Note: Additional well-women visits may be allowed based on medical necessity.
Not covered
Gynecological exam 100% (no deductible or copay/coinsurance), one per member per calendar year Note: Additional well-women visits may be allowed based on medical necessity.
Not covered
Pap smear screening – laboratory and pathology services
100% (no deductible or copay/coinsurance), one per member per calendar year
Not covered
Voluntary sterilizations for females 100% (no deductible or copay/coinsurance) 60% after out-of-network deductible Prescription contraceptive devices – includes insertion and removal of an intrauterine device by a licensed physician
100% (no deductible or copay/coinsurance) 100% after out-of-network deductible
Contraceptive injections 100% (no deductible or copay/coinsurance) 60% after out-of-network deductible Well-baby and child care visits 100% (no deductible or copay/coinsurance)
• 8 visits, birth through 12 months • 6 visits, 13 months through 23 months • 6 visits, 24 months through 35 months • 2 visits, 36 months through 47 months • Visits beyond 47 months are limited to
one per member per calendar year under the health maintenance exam benefit
Not covered
Adult and childhood preventive services and immunizations as recommended by the USPSTF, ACIP, HRSA or other sources as recognized by BCBSM that are in compliance with the provisions of the Patient Protection and Affordable Care Act
100% (no deductible or copay/coinsurance) Not covered
Fecal occult blood screening 100% (no deductible or copay/coinsurance), one per member per calendar year
Not covered
Flexible sigmoidoscopy exam 100% (no deductible or copay/coinsurance), one per member per calendar year
Not covered
Prostate specific antigen (PSA) screening 100% (no deductible or copay/coinsurance), one per member per calendar year
Not covered
* Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a “low access area” by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and the provider’s charge. Simply Blue PPO Gold $500, Rev Date 16 Q1 V1
In-network Out-of-network *
Preventive care services, continued Routine mammogram and related reading 100% (no deductible or copay/coinsurance)
Note: Subsequent medically necessary mammograms performed during the same calendar year are subject to your deductible and coinsurance.
60% after out-of-network deductible Note: Out-of-network readings and interpretations are payable only when the screening mammogram itself is performed by an in-network provider.
One per member per calendar year Colonoscopy – routine or medically necessary 100% (no deductible or copay/coinsurance)
for the first billed colonoscopy Note: Subsequent colonoscopies performed during the same calendar year are subject to your deductible and coinsurance.
60% after out-of-network deductible
One per member per calendar year
Physician office services Office visits – must be medically necessary • $20 copay for each office visit with a
primary care physician• $40 copay for each office visit with a
specialist
Note: Simply Blue applies deductible and coinsurance to office services. Services include diagnostic (including complex), therapeutic and surgery. An office visit copay still applies to the exam. Cost-sharing may not apply if preventive or immunization services are performed during the office visit.
60% after out-of-network deductible
Outpatient and home medical care visits – must be medically necessary
80% after in-network deductible 60% after out-of-network deductible
Office consultations – must be medically necessary • $20 copay for each office consultationwith a primary care physician
• $40 copay for each office consultationwith a specialist
Note: Simply Blue applies deductible and coinsurance to office services. Services include diagnostic (including complex), therapeutic and surgery. An office visit copay still applies to the exam. Cost-sharing may not apply if preventive or immunization services are performed during the office visit.
60% after out-of-network deductible
Urgent care visits Urgent care visits – must be medically necessary $60 copay per urgent care visit
Note: Simply Blue applies deductible and coinsurance to office services. Services include diagnostic (including complex), therapeutic and surgery. An office visit copay still applies to the exam. Cost-sharing may not apply if preventive or immunization services are performed during the office visit.
60% after out-of-network deductible
* Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a “low access area” by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and the provider’s charge. Simply Blue PPO Gold $500, Rev Date 16 Q1 V1
In-network Out-of-network *
Emergency medical care Hospital emergency room $150 copay per visit (copay waived if
admitted) $150 copay per visit (copay waived if admitted)
Ambulance services – must be medically necessary
80% after in-network deductible 80% after in-network deductible
Diagnostic services Laboratory and pathology services 80% after in-network deductible 60% after out-of-network deductible Diagnostic tests and x-rays 80% after in-network deductible 60% after out-of-network deductible Therapeutic radiology 80% after in-network deductible 60% after out-of-network deductible
Maternity services provided by a physician or certified nurse midwife Prenatal care visits 100% (no deductible or copay/coinsurance) 60% after out-of-network deductible Postnatal care 80% after in-network deductible 60% after out-of-network deductible Delivery and nursery care 80% after in-network deductible 60% after out-of-network deductible
Hospital care Semiprivate room, inpatient physician care, general nursing care, hospital services and supplies Note: Nonemergency services must be rendered in a participating hospital.
80% after in-network deductible 60% after out-of-network deductible
Unlimited days Inpatient consultations 80% after in-network deductible 60% after out-of-network deductible Chemotherapy 80% after in-network deductible 60% after out-of-network deductible
Alternatives to hospital care Skilled nursing care – must be in a participating skilled nursing facility
80% after in-network deductible 80% after in-network deductible Limited to a maximum of 120 days per member per calendar year
Hospice care 100% (no deductible or copay/coinsurance) 100% (no deductible or copay/coinsurance) Up to 28 pre-hospice counseling visits before electing hospice services; when elected, four 90-day periods – provided through a participating hospice program only; limited to dollar maximum that is reviewed and
adjusted periodically (after reaching dollar maximum, member transitions into individual case management)
Home health care: • must be medically necessary • must be provided by a participating home
health care agency
80% after in-network deductible 80% after in-network deductible
Infusion therapy: • must be medically necessary • must be given by a participating Home
Infusion Therapy (HIT) provider or in a participating freestanding Ambulatory Infusion Center (AIC)
• may use drugs that require preauthorization – consult with your doctor
80% after in-network deductible 80% after in-network deductible
* Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a “low access area” by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and the provider’s charge. Simply Blue PPO Gold $500, Rev Date 16 Q1 V1
In-network Out-of-network *
Surgical services Surgery – includes related surgical services and medically necessary facility services by a participating ambulatory surgery facility
80% after in-network deductible 60% after out-of-network deductible
Presurgical consultations 100% (no deductible or copay/coinsurance) 60% after out-of-network deductible Voluntary sterilization for males Note: For voluntary sterilizations for females, see “Preventive care services.”
80% after in-network deductible 60% after out-of-network deductible
Elective abortions Gender reassignment surgery Not covered Not covered Bariatric surgery 50% after in-network deductible 50% after out-of-network deductible
Limited to a lifetime maximum of one bariatric procedure per member
Human organ transplants Specified human organ transplants – must be in a designated facility and coordinated through the BCBSM Human Organ Transplant Program (1-800-242-3504)
100% (no deductible or copay/coinsurance) 100% (no deductible or copay/coinsurance) – in designated facilities only
Bone marrow transplants – must be coordinated through the BCBSM Human Organ Transplant Program (1-800-242-3504)
80% after in-network deductible 60% after out-of-network deductible
Specified oncology clinical trials Note: BCBSM covers clinical trials in compliance with PPACA.
80% after in-network deductible 60% after out-of-network deductible
Kidney, cornea and skin transplants 80% after in-network deductible 60% after out-of-network deductible
Mental health care and substance abuse treatment Inpatient mental health care and inpatient substance abuse treatment
80% after in-network deductible 60% after out-of-network deductible Unlimited days
Residential psychiatric treatment facility: • covered mental health services must be
performed in a residential psychiatric treatment facility
• treatment must be preauthorized • subject to medical criteria
80% after in-network deductible 60% after out-of-network deductible
Outpatient mental health care: • Facility and clinic 80% after in-network deductible 80% after in-network deductible,
in participating facilities only • Physician’s office 80% after in-network deductible 60% after out-of-network deductible
Outpatient substance abuse treatment – in approved facilities only
80% after in-network deductible 60% after out-of-network deductible (in-network cost-sharing will apply if there is no PPO network)
Not Covered Not Covered
* Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a “low access area” by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and the provider’s charge. Simply Blue PPO Gold $500, Rev Date 16 Q1 V1
In-network Out-of-network *
Autism spectrum disorders, diagnoses and treatment Applied behavioral analysis (ABA) treatment – when rendered by an approved board-certified behavioral analyst – is covered through age 18, subject to preauthorization Note: Diagnosis of an autism spectrum disorder and a treatment recommendation for ABA services must be obtained by a BCBSM approved autism evaluation center (AAEC) prior to seeking ABA treatment.
80% after in-network deductible 80% after in-network deductible
Outpatient physical therapy, speech therapy, occupational therapy, nutritional counseling for autism spectrum disorder
80% after in-network deductible 60% after out-of-network deductible
Physical, speech and occupational therapy with an autism diagnosis is unlimited Other covered services, including mental health services, for autism spectrum disorder
80% after in-network deductible 60% after out-of-network deductible
Other covered services Outpatient Diabetes Management Program (ODMP) Note: Screening services required under the provisions of PPACA are covered at 100% of approved amount with no in-network cost-sharing when rendered by an in-network provider. Note: When you purchase your diabetic supplies via mail order you will lower your out-of-pocket costs.
• 80% after in-network deductible for diabetes medical supplies
• 100% (no deductible or copay/coinsurance) for diabetes self-management training
60% after out-of-network deductible
Allergy testing and therapy 80% after in-network deductible 60% after out-of-network deductible Chiropractic spinal manipulation and osteopathic manipulative therapy
$30 copay per visit Note: Simply Blue applies deductible and coinsurance to office services. Services include diagnostic (including complex), therapeutic and surgery. An office visit copay still applies to the exam.
60% after out-of-network deductible
Limited to a combined 30-visit maximum per member per calendar year (visits are combined with outpatient physical and occupational therapy)
Outpatient physical and occupational therapy – provided for rehabilitation/habilitation
80% after in-network deductible 60% after out-of-network deductible Note: Services at nonparticipating outpatient physical therapy facilities are not covered.
Limited to a 30-visit maximum per member per calendar year Note: This 30-visit outpatient maximum is a combined maximum for all
outpatient visits for physical therapy, occupational therapy, chiropractic services, and osteopathic manipulative therapy.
Outpatient speech therapy 80% after in-network deductible 60% after out-of-network deductible Limited to a 30-visit maximum per member per calendar year
Durable medical equipment Note: DME items required under the provisions of PPACA are covered at 100% of approved amount with no in-network cost-sharing when rendered by an in-network provider. For a list of covered DME items required under PPACA, call BCBSM.
80% after in-network deductible 80% after in-network deductible
Prosthetic and orthotic appliances 80% after in-network deductible 80% after in-network deductible Private duty nursing care Not covered Not covered
Produced: 8/19/2015 4:36 PM
Simply Blue PPO Gold $500, Rev Date 16 Q1 V1
Blue Preferred® Rx Prescription Drug Coverage Custom Select Prescription Drug Plan, 5-Tier Copay/Coinsurance Benefits-at-a-Glance Specialty Pharmaceutical Drugs – The mail order pharmacy for specialty drugs is Walgreens Specialty Pharmacy, LLC, an independent company. Specialty prescription drugs (such as Enbrel® and Humira®
) are used to treat complex conditions such as rheumatoid arthritis, multiple sclerosis and cancer. These drugs require special handling, administration or monitoring. Walgreens Specialty Pharmacy will handle mail order prescriptions only for specialty drugs while many in-network retail pharmacies will continue to dispense specialty drugs (check with your local pharmacy for availability). Other mail order prescription medications can continue to be sent to Express Scripts. (Express Scripts is an independent company providing pharmacy benefit services for Blues members.) A list of specialty drugs is available on our Web site at bcbsm.com/pharmacy. If you have any questions, please call Walgreens Specialty Pharmacy customer service at 1-866-515-1355.
We will not pay for more than a 30-day supply of a covered prescription drug that BCBSM defines as a “specialty pharmaceutical” whether or not the drug is obtained from a 90-Day Retail Network provider or mail-order provider. We may make exceptions if a member requires more than a 30-day supply. BCBSM reserves the right to limit the quantity of select specialty drugs to no more than a 15-day supply for each fill. Your copay/coinsurance will be reduced by one-half for each fill once applicable deductibles have been met. Select Controlled Substance Drugs – BCBSM may limit the initial fill of select controlled substances to a 15-day supply. The member will be responsible for only one-half of their cost-sharing requirement typically imposed on a 30-day fill. Subsequent fills of the same medication will be eligible to be filled as prescribed, subject to the applicable cost-sharing requirement. Select controlled substances affected by this prescription drug requirement are available online at bcbsm.com/pharmacy.
Member’s responsibility (copays and coinsurance amounts)
Note: Your prescription drug copays and coinsurance amounts, including mail order copays and coinsurance amounts, are subject to the same annual out-of-pocket maximum required under your medical coverage. The 25% member liability for covered drugs obtained from an out-of-network pharmacy will not contribute to your annual out-of-pocket maximum.
90-day retail
network pharmacy
* In-network mail order provider
In-network pharmacy
(not part of the 90-day retail network)
Out-of-network pharmacy
Tier 1 – Generic drugs
1 to 30-day period You pay $15 copay You pay $15 copay You pay $15 copay You pay $15 copay plus an additional 25% of BCBSM approved amount for the drug
31 to 60-day period No coverage You pay $30 copay No coverage No coverage 61 to 83-day period No coverage You pay $35 copay No coverage No coverage 84 to 90-day period You pay $35 copay You pay $35 copay No coverage No coverage
Tier 2 – Preferred brand-name drugs
1 to 30-day period You pay $50 copay You pay $50 copay You pay $50 copay You pay $50 copay plus an additional 25% of BCBSM approved amount for the drug
31 to 60-day period No coverage You pay $100 copay No coverage No coverage 61 to 83-day period No coverage You pay $140 copay No coverage No coverage 84 to 90-day period You pay $140 copay You pay $140 copay No coverage No coverage
* BCBSM will not pay for drugs obtained from out-of-network mail order providers, including Internet providers.
Simply Blue PPO Gold $500, Rev Date 16 Q1 V1
Member’s responsibility (copays and coinsurance amounts), continued
90-day retail
network pharmacy
* In-network mail order provider
In-network pharmacy
(not part of the 90-day retail network)
Out-of-network pharmacy
Tier 3 – Nonpreferred brand-name drugs
1 to 30-day period You pay $70 or 50% of the approved amount (whichever is greater), but no more than $100
You pay $70 or 50% of the approved amount (whichever is greater), but no more than $100
You pay $70 or 50% of the approved amount (whichever is greater), but no more than $100
You pay $70 or 50% of the approved amount (whichever is greater), but no more than $100 plus an additional 25% of BCBSM approved amount for the drug
31 to 60-day period No coverage You pay $140 or 50% of the approved amount (whichever is greater), but no more than $200
No coverage No coverage
61 to 83-day period No coverage You pay $200 or 50% of the approved amount (whichever is greater), but no more than $290
No coverage No coverage
84 to 90-day period You pay $200 or 50% of the approved amount (whichever is greater), but no more than $290
You pay $200 or 50% of the approved amount (whichever is greater), but no more than $290
No coverage No coverage
Tier 4 – Generic and preferred brand-name specialty drugs
1 to 30-day period You pay 20% of approved amount, but no more than $200
You pay 20% of approved amount, but no more than $200
You pay 20% of approved amount, but no more than $200
You pay 20% of approved amount, but no more than $200 plus an additional 25% of BCBSM approved amount for the drug
31 to 60-day period No coverage No coverage No coverage No coverage 61 to 83-day period No coverage No coverage No coverage No coverage 84 to 90-day period No coverage No coverage No coverage No coverage
Tier 5 – Nonpreferred brand-name specialty drugs
1 to 30-day period You pay 25% of approved amount, but no more than $300
You pay 25% of approved amount, but no more than $300
You pay 25% of approved amount, but no more than $300
You pay 25% of approved amount, but no more than $300 plus an additional 25% of BCBSM approved amount for the drug
31 to 60-day period No coverage No coverage No coverage No coverage 61 to 83-day period No coverage No coverage No coverage No coverage 84 to 90-day period No coverage No coverage No coverage No coverage
* BCBSM will not pay for drugs obtained from out-of-network mail order providers, including Internet providers.
Simply Blue PPO Gold $500, Rev Date 16 Q1 V1
Covered services
90-day retail
network pharmacy
* In-network mail order provider
In-network pharmacy
(not part of the 90-day retail network)
Out-of-network pharmacy
FDA-approved drugs 100% of approved amount less plan copay/coinsurance
100% of approved amount less plan copay/coinsurance
100% of approved amount less plan copay/coinsurance
75% of approved amount less plan copay/coinsurance
FDA-approved generic and select brand-name prescription preventive drugs, supplements and vitamins as required by PPACA (non-self-administered drugs are not covered)
100% of approved amount
100% of approved amount
100% of approved amount
75% of approved amount
Other FDA-approved brand-name prescription preventive drugs, supplements and vitamins as required by PPACA (non-self-administered drugs are not covered)
100% of approved amount less plan copay/coinsurance
100% of approved amount less plan copay/coinsurance
100% of approved amount less plan copay/coinsurance
75% of approved amount less plan copay/coinsurance
FDA-approved generic and select brand-name prescription contraceptive medication (non-self-administered drugs are not covered)
100% of approved amount
100% of approved amount
100% of approved amount
75% of approved amount
Other FDA-approved brand-name prescription contraceptive medication (non-self-administered drugs are not covered)
100% of approved amount less plan copay/coinsurance
100% of approved amount less plan copay/coinsurance
100% of approved amount less plan copay/coinsurance
75% of approved amount less plan copay/coinsurance
Disposable needles and syringes – when dispensed with insulin, or other covered injectable legend drugs Note: Needles and syringes have no copay/coinsurance.
100% of approved amount less plan copay/coinsurance for the insulin or other covered injectable legend drug
100% of approved amount less plan copay/coinsurance for the insulin or other covered injectable legend drug
100% of approved amount less plan copay/coinsurance for the insulin or other covered injectable legend drug
75% of approved amount less plan copay/coinsurance for the insulin or other covered injectable legend drug
* BCBSM will not pay for drugs obtained from out-of-network mail order providers, including Internet providers.
Simply Blue PPO Gold $500, Rev Date 16 Q1 V1
Features of your prescription drug plan
Custom Select Drug List A continually updated list of FDA-approved medications that represent each therapeutic class. The drugs on the list are chosen by the BCBSM Pharmacy and Therapeutics Committee for their effectiveness, safety, uniqueness and cost efficiency. The goal of the drug list is to provide members with the greatest therapeutic value at the lowest possible cost. Tier 1 (generic) – Tier 1 includes generic drugs made with the same active ingredients, available
in the same strengths and dosage forms, and administered in the same way as equivalent brand-name drugs. They also require the lowest copay/coinsurance, making them the most cost-effective option for the treatment.
Tier 2 (preferred brand) – Tier 2 includes brand-name drugs from the Custom Select Drug List. Preferred brand name drugs are also safe and effective, but require a higher copay/coinsurance.
Tier 3 (nonpreferred brand) – Tier 3 contains brand-name drugs not included in Tier 2. These drugs may not have a proven record for safety or as high of a clinical value as Tier 1 or Tier 2 drugs. Members pay the highest copay/coinsurance for these drugs.
Tier 4 (generic and preferred brand-name specialty) – Tier 4 includes covered specialty drugs listed as generic drugs (Tier 1) or preferred brand-name drugs (Tier 2) from the Custom Select Drug List. These drugs have a proven record for safety and effectiveness, and offer the best value to our members. They have the lowest specialty drug copay/coinsurance.
Tier 5 (nonpreferred brand-name specialty) – Tier 5 includes covered specialty drugs listed as nonpreferred brand name (Tier 3). These drugs may not have a proven record for safety or their clinical value may not be as high as the specialty drugs in Tier 4. They have the highest specialty drug copay/coinsurance.
Prior authorization/step therapy A process that requires a physician to obtain approval from BCBSM before select prescription drugs (drugs identified by BCBSM as requiring prior authorization) will be covered. Step Therapy, an initial step in the Prior Authorization process, applies criteria to select drugs to determine if a less costly prescription drug may be used for the same drug therapy. This also applies to mail order drugs. Claims that do not meet Step Therapy criteria require prior authorization. Details about which drugs require Prior Authorization or Step Therapy are available online at bcbsm.com/pharmacy.
Drug interchange and generic copay/coinsurance waiver
BCBSM’s drug interchange and generic copay/coinsurance waiver programs encourage physicians to prescribe a less-costly generic equivalent. If your physician rewrites your prescription for the recommended generic drug, you will only have to pay a generic copay/coinsurance. In select cases BCBSM may waive the initial copay/coinsurance after your prescription has been rewritten. BCBSM will notify you if you are eligible for a waiver.
Quality limits To stay consistent with FDA approved labeling for drugs, some medications may have quantity limits.
Exclusions The following drugs are not covered: Over-the-counter drugs and drugs with comparable OTC counterparts (e.g., antihistamines,
cough/cold and acne treatment) unless deemed an Essential Health Benefit or not considered a covered service
State-controlled drugs • Brand-name drugs that have a generic equivalent available • Drugs to treat erectile dysfunction and weight loss • Prenatal vitamins (prescribed and over-the-counter) • Brand-name drugs used to treat heartburn • Compounded drugs, with some exceptions • Cosmetic drugs
* Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a “low access area” by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and the provider’s charge. Simply Blue HSA PPO Rx Silver $2700 20%, Rev Date 16 Q1 V1
Simply BlueSM HSA PPO Silver $2700 20%SM Medical Coverage with Prescription Drugs Benefits-at-a-Glance Effective for groups on their plan year This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and exclusions may apply. Payment amounts are based on BCBSM’s approved amount, less any applicable deductible and/or copay/coinsurance. For a complete description of benefits please see the applicable BCBSM certificates and riders, if your group is underwritten or any other plan documents your group uses, if your group is self-funded. If there is a discrepancy between this Benefits-at-a-Glance and any applicable plan document, the plan document will control. Preauthorization for Select Services – Services listed in this BAAG are covered when provided in accordance with Certificate requirements and, when required, are preauthorized or approved by BCBSM except in an emergency.
Note: A list of services that require approval before they are provided is available online at bcbsm.com/importantinfo. Select Approving covered services.
Pricing information for various procedures by in-network providers can be obtained by calling the customer service number listed on the back of your BCBSM ID card and providing the procedure code. Your provider can also provide this information upon request. Preauthorization for Specialty Pharmaceuticals – BCBSM will pay for FDA-approved specialty pharmaceuticals that meet BCBSM’s medical policy criteria for treatment of the condition. The prescribing physician must contact BCBSM to request preauthorization of the drugs. If preauthorization is not sought, BCBSM will deny the claim and all charges will be the member’s responsibility.
Specialty pharmaceuticals are biotech drugs including high cost infused, injectable, oral and other drugs related to specialty disease categories or other categories. BCBSM determines which specific drugs are payable. This may include medications to treat asthma, rheumatoid arthritis, multiple sclerosis, and many other disease as well as chemotherapy drugs used in the treatment of cancer, but excludes injectable insulin. In-network Out-of-network *
Member’s responsibility (deductibles, copays, coinsurance and dollar maximums) Note: If an in-network provider refers you to an out-of-network provider, all covered services obtained from that out-of-network provider will be subject to applicable out-of-network cost-sharing. Deductibles
Note: Your deductible combines deductible amounts paid under your Simply Blue HSA medical coverage and your Simply Blue prescription drug coverage.
$2,700 for one member, $5,400 for the family (when two or more members are covered under your contract) each calendar year
$5,400 for one member, $10,800 for the family (when two or more members are covered under your contract) each calendar year
Flat-dollar copays See “Prescription Drugs” section See “Prescription Drugs” section Coinsurance amounts (percent copays)
Note: Coinsurance amounts apply once the deductible has been met.
• 50% of approved amount for bariatric surgery
• 20% of approved amount for most other covered services
• 50% of approved amount for bariatric surgery
• 40% of approved amount for most other covered services
Annual out-of-pocket maximums – applies to deductibles and coinsurance amounts for all covered services – including prescription drugs cost-sharing amounts
$5,000 for one member, $10,000 for the family (when two or more members are covered under your contract) each calendar year
$10,000 for one member, $20,000 for the family (when two or more members are covered under your contract) each calendar year
Lifetime dollar maximum None
Client: CoverageforCompanies
* Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a “low access area” by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and the provider’s charge. Simply Blue HSA PPO Rx Silver $2700 20%, Rev Date 16 Q1 V1
In-network Out-of-network *
Preventive care services Health maintenance exam – includes chest x-ray, EKG, cholesterol screening and other select lab procedures
100% (no deductible or copay/coinsurance), one per member per calendar year Note: Additional well-women visits may be allowed based on medical necessity.
Not covered
Gynecological exam 100% (no deductible or copay/coinsurance), one per member per calendar year Note: Additional well-women visits may be allowed based on medical necessity.
Not covered
Pap smear screening – laboratory and pathology services
100% (no deductible or copay/coinsurance), one per member per calendar year
Not covered
Voluntary sterilizations for females 100% (no deductible or copay/coinsurance) 60% after out-of-network deductible Prescription contraceptive devices – includes insertion and removal of an intrauterine device by a licensed physician
100% (no deductible or copay/coinsurance) 60% after out-of-network deductible
Contraceptive injections 100% (no deductible or copay/coinsurance) 60% after out-of-network deductible Well-baby and child care visits 100% (no deductible or copay/coinsurance)
• 8 visits, birth through 12 months • 6 visits, 13 months through 23 months • 6 visits, 24 months through 35 months • 2 visits, 36 months through 47 months • Visits beyond 47 months are limited to
one per member per calendar year under the health maintenance exam benefit
Not covered
Adult and childhood preventive services and immunizations as recommended by the USPSTF, ACIP, HRSA or other sources as recognized by BCBSM that are in compliance with the provisions of the Patient Protection and Affordable Care Act
100% (no deductible or copay/coinsurance) Not covered
Fecal occult blood screening 100% (no deductible or copay/coinsurance), one per member per calendar year
Not covered
Flexible sigmoidoscopy exam 100% (no deductible or copay/coinsurance), one per member per calendar year
Not covered
Prostate specific antigen (PSA) screening 100% (no deductible or copay/coinsurance), one per member per calendar year
Not covered
Routine mammogram and related reading 100% (no deductible or copay/coinsurance) Note: Subsequent medically necessary mammograms performed during the same calendar year are subject to your deductible and coinsurance.
60% after out-of-network deductible Note: Out-of-network readings and interpretations are payable only when the screening mammogram itself is performed by an in-network provider.
One per member per calendar year Routine screening colonoscopy 100% (no deductible or copay/coinsurance)
for routine colonoscopy Note: Medically necessary colonoscopies performed during the same calendar year are subject to your deductible and coinsurance.
60% after out-of-network deductible
One routine colonoscopy per member per calendar year
* Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a “low access area” by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and the provider’s charge. Simply Blue HSA PPO Rx Silver $2700 20%, Rev Date 16 Q1 V1
In-network Out-of-network *
Physician office services Office visits – must be medically necessary 80% after in-network deductible 60% after out-of-network deductible Outpatient and home medical care visits – must be medically necessary
80% after in-network deductible 60% after out-of-network deductible
Office consultations – must be medically necessary 80% after in-network deductible 60% after out-of-network deductible Urgent care visits – must be medically necessary 80% after in-network deductible 60% after out-of-network deductible
Emergency medical care Hospital emergency room 80% after in-network deductible 80% after in-network deductible Ambulance services – must be medically necessary 80% after in-network deductible 80% after in-network deductible
Diagnostic services Laboratory and pathology services 80% after in-network deductible 60% after out-of-network deductible Diagnostic tests and x-rays 80% after in-network deductible 60% after out-of-network deductible Therapeutic radiology 80% after in-network deductible 60% after out-of-network deductible
Maternity services provided by a physician or certified nurse midwife Prenatal care visits 100% (no deductible or copay/coinsurance) 60% after out-of-network deductible Postnatal care 80% after in-network deductible 60% after out-of-network deductible Delivery and nursery care 80% after in-network deductible 60% after out-of-network deductible
Hospital care Semiprivate room, inpatient physician care, general nursing care, hospital services and supplies Note: Nonemergency services must be rendered in a participating hospital.
80% after in-network deductible 60% after out-of-network deductible
Unlimited days Inpatient consultations 80% after in-network deductible 60% after out-of-network deductible Chemotherapy 80% after in-network deductible 60% after out-of-network deductible
Alternatives to hospital care Skilled nursing care – must be in a participating skilled nursing facility
80% after in-network deductible 80% after in-network deductible Limited to a maximum of 90 days per member per calendar year
Hospice care 80% after in-network deductible 80% after in-network deductible Up to 28 pre-hospice counseling visits before electing hospice
services; when elected, four 90-day periods – provided through a participating hospice program only; limited to dollar maximum that is
reviewed and adjusted periodically (after reaching dollar maximum, member transitions into individual case management)
Home health care: • must be medically necessary • must be provided by a participating home health
care agency
80% after in-network deductible 80% after in-network deductible
Infusion therapy: • must be medically necessary • must be given by a participating Home Infusion
Therapy (HIT) provider or in a participating freestanding Ambulatory Infusion Center (AIC)
• may use drugs that require preauthorization – consult with your doctor
80% after in-network deductible 80% after in-network deductible
* Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a “low access area” by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and the provider’s charge. Simply Blue HSA PPO Rx Silver $2700 20%, Rev Date 16 Q1 V1
In-network Out-of-network *
Surgical services Surgery – includes related surgical services and medically necessary facility services by a participating ambulatory surgery facility
80% after in-network deductible 60% after out-of-network deductible
Presurgical consultations 80% after in-network deductible 60% after out-of-network deductible Voluntary sterilization for males Note: For voluntary sterilizations for females, see “Preventive care services.”
80% after in-network deductible 60% after out-of-network deductible
Elective abortions Gender reassignment surgery Not covered Not covered Bariatric surgery 50% after in-network deductible 50% after out-of-network deductible
Limited to a lifetime maximum of one bariatric procedure per member
Human organ transplants Specified human organ transplants – must be in a designated facility and coordinated through the BCBSM Human Organ Transplant Program (1-800-242-3504)
80% after in-network deductible 80% after in-network deductible – in designated facilities only
Bone marrow transplants – must be coordinated through the BCBSM Human Organ Transplant Program (1-800-242-3504)
80% after in-network deductible 60% after out-of-network deductible
Specified oncology clinical trials 80% after in-network deductible 60% after out-of-network deductible Kidney, cornea and skin transplants 80% after in-network deductible 60% after out-of-network deductible
Mental health care and substance abuse treatment Inpatient mental health care and inpatient substance abuse treatment
80% after in-network deductible 60% after out-of-network deductible Unlimited days
Residential psychiatric treatment facility: • covered mental health services must be performed
in a residential psychiatric treatment facility • treatment must be preauthorized • subject to medical criteria
80% after in-network deductible 60% after out-of-network deductible
Outpatient mental health care: • Facility and clinic 80% after in-network deductible 80% after in-network deductible,
in participating facilities only • Physician’s office 80% after in-network deductible 60% after out-of-network deductible
Outpatient substance abuse treatment – in approved facilities only
80% after in-network deductible 60% after out-of-network deductible (in-network cost-sharing will apply if there is no PPO network)
Not Covered Not Covered
* Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a “low access area” by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and the provider’s charge. Simply Blue HSA PPO Rx Silver $2700 20%, Rev Date 16 Q1 V1
In-network Out-of-network *
Autism spectrum disorders, diagnoses and treatment Applied behavioral analysis (ABA) treatment – when rendered by an approved board-certified behavioral analyst – is covered through age 18, subject to preauthorization Note: Diagnosis of an autism spectrum disorder and a treatment recommendation for ABA services must be obtained by a BCBSM approved autism evaluation center (AAEC) prior to seeking ABA treatment.
80% after in-network deductible 80% after in-network deductible
Outpatient physical therapy, speech therapy, occupational therapy, nutritional counseling for autism spectrum disorder
80% after in-network deductible 60% after out-of-network deductible
Physical, speech and occupational therapy with an autism diagnosis is unlimited Other covered services, including mental health services, for autism spectrum disorder
80% after in-network deductible 60% after out-of-network deductible
Other covered services Outpatient Diabetes Management Program (ODMP) Note: Screening services required under the provisions of PPACA are covered at 100% of approved amount with no in-network cost-sharing when rendered by an in-network provider. Note: When you purchase your diabetic supplies via mail order you will lower your out-of-pocket costs.
80% after in-network deductible 60% after out-of-network deductible
Allergy testing and therapy 80% after in-network deductible 60% after out-of-network deductible Chiropractic spinal manipulation and osteopathic manipulative therapy
80% after in-network deductible 60% after out-of-network deductible Limited to a combined 30-visit maximum per member per calendar year (visits are combined with outpatient physical and occupational therapy)
Outpatient physical and occupational therapy – provided for rehabilitation/habilitation
80% after in-network deductible 60% after out-of-network deductible Note: Services at nonparticipating outpatient physical therapy facilities are not covered.
Limited to a 30-visit maximum per member per calendar year Note: This 30-visit outpatient maximum is a combined maximum for all
outpatient visits for physical therapy, occupational therapy, chiropractic services, and osteopathic manipulative therapy.
Outpatient speech therapy 80% after in-network deductible 60% after out-of-network deductible Limited to a 30-visit maximum per member per calendar year
Durable medical equipment Note: DME items required under the provisions of PPACA are covered at 100% of approved amount with no in-network cost-sharing when rendered by an in-network provider. For a list of covered DME items required under PPACA, call BCBSM.
80% after in-network deductible 80% after in-network deductible
Prosthetic and orthotic appliances 80% after in-network deductible 80% after in-network deductible Private duty nursing care Not covered Not covered
Produced: 8/19/2015 4:38 PM
5
Simply Blue HSA PPO Rx Silver $2700 20%, Rev Date 16 Q1 V1
Blue Preferred® Rx Prescription Drug Coverage Custom Select Prescription Drug Plan, 5-Tier Copay/Coinsurance Benefits-at-a-Glance Specialty Pharmaceutical Drugs – The mail order pharmacy for specialty drugs is Walgreens Specialty Pharmacy, LLC, an independent company. Specialty prescription drugs (such as Enbrel® and Humira®
) are used to treat complex conditions such as rheumatoid arthritis, multiple sclerosis and cancer. These drugs require special handling, administration or monitoring. Walgreens Specialty Pharmacy will handle mail order prescriptions only for specialty drugs while many in-network retail pharmacies will continue to dispense specialty drugs (check with your local pharmacy for availability). Other mail order prescription medications can continue to be sent to Express Scripts. (Express Scripts is an independent company providing pharmacy benefit services for Blues members.) A list of specialty drugs is available on our Web site at bcbsm.com/pharmacy. If you have any questions, please call Walgreens Specialty Pharmacy customer service at 1-866-515-1355.
We will not pay for more than a 30-day supply of a covered prescription drug that BCBSM defines as a “specialty pharmaceutical” whether or not the drug is obtained from a 90-Day Retail Network provider or mail-order provider. We may make exceptions if a member requires more than a 30-day supply. BCBSM reserves the right to limit the quantity of select specialty drugs to no more than a 15-day supply for each fill. Your copay/coinsurance will be reduced by one-half for each fill once applicable deductibles have been met. Select Controlled Substance Drugs – BCBSM may limit the initial fill of select controlled substances to a 15-day supply. The member will be responsible for only one-half of their cost-sharing requirement typically imposed on a 30-day fill. Subsequent fills of the same medication will be eligible to be filled as prescribed, subject to the applicable cost-sharing requirement. Select controlled substances affected by this prescription drug requirement are available online at bcbsm.com/pharmacy.
Member’s responsibility (copays and coinsurance amounts) Your Simply Blue HSA prescription drug benefits, including mail order drugs, are subject to the same deductible and same annual out-of-pocket maximum required under your Simply Blue HSA medical coverage. Benefits are not payable until after you have met the Simply Blue HSA annual deductible. After you have satisfied the deductible you are required to pay applicable prescription drug copays and coinsurance amounts which are subject to your annual out-of-pocket maximums. Note: The 20% member liability for covered drugs obtained from an out-of-network pharmacy will not contribute to your annual out-of-pocket maximum.
90-day retail
network pharmacy * In-network mail
order provider In-network pharmacy
(not part of the 90-day retail network)
Out-of-network pharmacy
Tier 1 – Generic drugs
1 to 30-day period After deductible is met, you pay $15 copay
After deductible is met, you pay $15 copay
After deductible is met, you pay $15 copay
After deductible is met, you pay $15 copay plus an additional 20% of BCBSM approved amount for the drug
31 to 60-day period No coverage After deductible is met, you pay $30 copay
No coverage No coverage
61 to 83-day period No coverage After deductible is met, you pay $35 copay
No coverage No coverage
84 to 90-day period After deductible is met, you pay $35 copay
After deductible is met, you pay $35 copay
No coverage No coverage
* BCBSM will not pay for drugs obtained from out-of-network mail order providers, including Internet providers.
5
Simply Blue HSA PPO Rx Silver $2700 20%, Rev Date 16 Q1 V1
Member’s responsibility (copays and coinsurance amounts), continued
90-day retail
network pharmacy * In-network mail
order provider In-network pharmacy
(not part of the 90-day retail network)
Out-of-network pharmacy
Tier 2 – Preferred brand-name drugs
1 to 30-day period After deductible is met, you pay $50 copay
After deductible is met, you pay $50 copay
After deductible is met, you pay $50 copay
After deductible is met, you pay $50 copay plus an additional 20% of BCBSM approved amount for the drug
31 to 60-day period No coverage After deductible is met, you pay $100 copay
No coverage No coverage
61 to 83-day period No coverage After deductible is met, you pay $140 copay
No coverage No coverage
84 to 90-day period After deductible is met, you pay $140 copay
After deductible is met, you pay $140 copay
No coverage No coverage
Tier 3 – Nonpreferred brand-name drugs
1 to 30-day period After deductible is met, you pay $70 or 50% of the approved amount (whichever is greater), but no more than $100
After deductible is met, you pay $70 or 50% of the approved amount (whichever is greater), but no more than $100
After deductible is met, you pay $70 or 50% of the approved amount (whichever is greater), but no more than $100
After deductible is met, you pay $70 or 50% of the approved amount (whichever is greater), but no more than $100 plus an additional 20% of BCBSM approved amount for the drug
31 to 60-day period No coverage After deductible is met, you pay $140 or 50% of the approved amount (whichever is greater), but no more than $200
No coverage No coverage
61 to 83-day period No coverage After deductible is met, you pay $200 or 50% of the approved amount (whichever is greater), but no more than $290
No coverage No coverage
84 to 90-day period After deductible is met, you pay $200 or 50% of the approved amount (whichever is greater), but no more than $290
After deductible is met, you pay $200 or 50% of the approved amount (whichever is greater), but no more than $290
No coverage No coverage
Tier 4 – Generic and preferred brand-name specialty drugs
1 to 30-day period After deductible is met, you pay 20% of approved amount, but no more than $200
After deductible is met, you pay 20% of approved amount, but no more than $200
After deductible is met, you pay 20% of approved amount, but no more than $200
After deductible is met, you pay 20% of approved amount, but no more than $200 plus an additional 20% of BCBSM approved amount for the drug
31 to 60-day period No coverage No coverage No coverage No coverage 61 to 83-day period No coverage No coverage No coverage No coverage 84 to 90-day period No coverage No coverage No coverage No coverage
* BCBSM will not pay for drugs obtained from out-of-network mail order providers, including Internet providers.
5
Simply Blue HSA PPO Rx Silver $2700 20%, Rev Date 16 Q1 V1
Member’s responsibility (copays and coinsurance amounts), continued
90-day retail
network pharmacy * In-network mail
order provider In-network pharmacy
(not part of the 90-day retail network)
Out-of-network pharmacy
Tier 5 – Nonpreferred brand-name specialty drugs
1 to 30-day period After deductible is met, you pay 25% of approved amount, but no more than $300
After deductible is met, you pay 25% of approved amount, but no more than $300
After deductible is met, you pay 25% of approved amount, but no more than $300
After deductible is met, you pay 25% of approved amount, but no more than $300 plus an additional 20% of BCBSM approved amount for the drug
31 to 60-day period No coverage No coverage No coverage No coverage 61 to 83-day period No coverage No coverage No coverage No coverage 84 to 90-day period No coverage No coverage No coverage No coverage
Covered services
90-day retail
network pharmacy * In-network mail order provider
In-network pharmacy
(not part of the 90-day retail network)
Out-of-network pharmacy
FDA-approved drugs Subject to Simply Blue HSA medical deductible and prescription drug copay/coinsurance
Subject to Simply Blue HSA medical deductible and prescription drug copay/coinsurance
Subject to Simply Blue HSA medical deductible and prescription drug copay/coinsurance
Subject to Simply Blue HSA medical deductible and prescription drug copay/coinsurance plus an additional 20% prescription drug out-of-network penalty
FDA-approved generic and select brand-name prescription preventive drugs, supplements and vitamins as required by PPACA (non-self-administered drugs are not covered)
100% of approved amount
100% of approved amount
100% of approved amount
80% of approved amount
Other FDA-approved brand-name prescription preventive drugs, supplements and vitamins as required by PPACA (non-self-administered drugs are not covered)
Subject to Simply Blue HSA medical deductible and prescription drug copay/coinsurance
Subject to Simply Blue HSA medical deductible and prescription drug copay/coinsurance
Subject to Simply Blue HSA medical deductible and prescription drug copay/coinsurance
Subject to Simply Blue HSA medical deductible and prescription drug copay/coinsurance plus an additional 20% prescription drug out-of-network penalty
FDA-approved generic and select brand-name prescription contraceptive medication (non-self-administered drugs are not covered)
100% of approved amount
100% of approved amount
100% of approved amount
80% of approved amount
Other FDA-approved brand-name prescription contraceptive medication (non-self-administered drugs are not covered)
Subject to Simply Blue HSA medical deductible and prescription drug copay/coinsurance
Subject to Simply Blue HSA medical deductible and prescription drug copay/coinsurance
Subject to Simply Blue HSA medical deductible and prescription drug copay/coinsurance
Subject to Simply Blue HSA medical deductible and prescription drug copay/coinsurance plus an additional 20% prescription drug out-of-network penalty
* BCBSM will not pay for drugs obtained from out-of-network mail order providers, including Internet providers.
5
Simply Blue HSA PPO Rx Silver $2700 20%, Rev Date 16 Q1 V1
Covered services, continued
90-day retail
network pharmacy * In-network mail order provider
In-network pharmacy
(not part of the 90-day retail network)
Out-of-network pharmacy
Disposable needles and syringes – when dispensed with insulin, or other covered injectable legend drugs Note: Needles and syringes have no copay/coinsurance.
Subject to Simply Blue HSA medical deductible and prescription drug copay/coinsurance for the insulin or other covered injectable legend drug
Subject to Simply Blue HSA medical deductible and prescription drug copay/coinsurance for the insulin or other covered injectable legend drug
Subject to Simply Blue HSA medical deductible and prescription drug copay/coinsurance for the insulin or other covered injectable legend drug
Subject to Simply Blue HSA medical deductible and prescription drug copay/coinsurance for the insulin or other covered injectable legend drug plus an additional 20% prescription drug out-of-network penalty
* BCBSM will not pay for drugs obtained from out-of-network mail order providers, including Internet providers.
Features of your prescription drug plan
Custom Select Drug List A continually updated list of FDA-approved medications that represent each therapeutic class. The drugs on the list are chosen by the BCBSM Pharmacy and Therapeutics Committee for their effectiveness, safety, uniqueness and cost efficiency. The goal of the drug list is to provide members with the greatest therapeutic value at the lowest possible cost. Tier 1 (generic) – Tier 1 includes generic drugs made with the same active ingredients, available in
the same strengths and dosage forms, and administered in the same way as equivalent brand-name drugs. They also require the lowest copay/coinsurance, making them the most cost-effective option for the treatment.
Tier 2 (preferred brand) – Tier 2 includes brand-name drugs from the Custom Select Drug List. Preferred brand name drugs are also safe and effective, but require a higher copay/coinsurance.
Tier 3 (nonpreferred brand) – Tier 3 contains brand-name drugs not included in Tier 2. These drugs may not have a proven record for safety or as high of a clinical value as Tier 1 or Tier 2 drugs. Members pay the highest copay/coinsurance for these drugs.
Tier 4 (generic and preferred brand-name specialty) – Tier 4 includes covered specialty drugs listed as generic drugs (Tier 1) or preferred brand-name drugs (Tier 2) from the Custom Select Drug List. These drugs have a proven record for safety and effectiveness, and offer the best value to our members. They have the lowest specialty drug copay/coinsurance.
Tier 5 (nonpreferred brand-name specialty) – Tier 5 includes covered specialty drugs listed as nonpreferred brand name (Tier 3). These drugs may not have a proven record for safety or their clinical value may not be as high as the specialty drugs in Tier 4. They have the highest specialty drug copay/coinsurance.
Prior authorization/step therapy A process that requires a physician to obtain approval from BCBSM before select prescription drugs (drugs identified by BCBSM as requiring prior authorization) will be covered. Step Therapy, an initial step in the Prior Authorization process, applies criteria to select drugs to determine if a less costly prescription drug may be used for the same drug therapy. This also applies to mail order drugs. Claims that do not meet Step Therapy criteria require prior authorization. Details about which drugs require Prior Authorization or Step Therapy are available online at bcbsm.com/pharmacy.
Drug interchange and generic copay/coinsurance waiver
BCBSM’s drug interchange and generic copay/coinsurance waiver programs encourage physicians to prescribe a less-costly generic equivalent. If your physician rewrites your prescription for the recommended generic drug, you will only have to pay a generic copay/coinsurance. In select cases BCBSM may waive the initial copay/coinsurance after your prescription has been rewritten. BCBSM will notify you if you are eligible for a waiver.
Quality limits To stay consistent with FDA approved labeling for drugs, some medications may have quantity limits.
5
Simply Blue HSA PPO Rx Silver $2700 20%, Rev Date 16 Q1 V1
Exclusions The following drugs are not covered: Over-the-counter drugs and drugs with comparable OTC counterparts (e.g., antihistamines,
cough/cold and acne treatment) unless deemed an Essential Health Benefit or not considered a covered service
State-controlled drugs • Brand-name drugs that have a generic equivalent available • Drugs to treat erectile dysfunction and weight loss • Prenatal vitamins (prescribed and over-the-counter) • Brand-name drugs used to treat heartburn • Compounded drugs, with some exceptions • Cosmetic drugs
BD PPO Plus 80/50/50, $25/$75 deductible Pediatric – Non-voluntary, JUN 2014
Blue DentalSM PPO Plus 80/50/50 Pediatric SG – Non-voluntary $25/$75 deductible Benefits-at-a-Glance
This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and exclusions may apply. Payment amounts are based on BCBSM’s approved amount, less any applicable deductible and/or copay. For a complete description of benefits please see the applicable BCBSM certificates and riders, if your group is underwritten or any other plan documents your group uses, if your group is self-funded. If there is a discrepancy between this Benefits-at-a-Glance and any applicable plan document, the plan document will control.
Note: Pediatric dental benefits are available only to members who are age 18 or younger on the plan’s effective date and are available to them through the end of the calendar year in which they turn 19.
Network access information
With Blue Dental PPO Plus, members can choose any licensed dentist anywhere. However, they’ll save the most money when they choose a dentist who is a member of the Blue Dental PPO network.
Blue Dental PPO network – Blue Dental members have unmatched access to PPO dentists through the Blue Dental PPO network, which offers more than 260,000 dentist locations* nationwide. PPO dentists agree to accept our approved amount as full payment for covered services – members pay only their applicable coinsurance and deductible amounts. Members also receive discounts on noncovered services when they use PPO dentists (in states where permitted by law). To find a PPO dentist near you, please visit mibluedentist.com or call 1-888-826-8152.
* A dentist location is any place a member can see a dentist to receive high-quality dental care. For example, one dentist practicing in two offices would be two dentist locations.
Blue Par SelectSMarrangement – Most non-PPO dentists accept our Blue Par Select arrangement, which means they participate with the Blues
on a “per claim” basis. Members should ask their dentists if they participate with BCBSM before every treatment. Blue Par Select dentists accept our approved amount as full payment for covered services – members pay only applicable coinsurance and deductible amounts, along with any fees for noncovered services. To find a dentist who may participate with BCBSM, please visit mibluedentist.com
Note: Members who go to nonparticipating dentists may be billed for any difference between our approved amount and the dentist’s charge.
Member’s responsibility (deductible, coinsurance and dollar maximums)
Deductible
• Applies to Class II and Class III services only $25 per member limited to a maximum of $75 per family per calendar year
Coinsurance (percentage of BCBSM’s approved amount for covered services)
• Class I services 20%
• Class II services 50%
• Class III services 50%
• Class IV services Not covered
Dollar maximums
• Annual maximum for Class I, II and III services None
• Lifetime maximum for Class IV services Not applicable
Out-of-pocket maximum
• The maximum out-of-pocket expense pediatric members will pay in a calendar year for deductible and coinsurance amounts applied to most covered in-network dental services. The out-of-pocket maximum does not apply to charges that exceed our approved PPO fee, services provided by non-PPO dentists or non-covered services.
$350 for one pediatric member or $700 for two or more pediatric members per calendar year.
Note: This out-of-pocket maximum is separate from the annual out-of-pocket maximum that applies under your hospital and medical coverage (if any).
BD PPO Plus 80/50/50, $25/$75 deductible Pediatric – Non-voluntary, JUN 2014
Plan’s responsibility
The plan’s responsibility is subject to a review of the reported diagnosis, dental necessity verification and the availability of dental benefits at the time the claim is processed, as well as the conditions, exclusions and limitations, and deductible and coinsurance requirements under the applicable BCBSM certificates and riders.
Class I services
Most diagnostic and preventive services:
• Routine oral examinations/evaluations – twice per calendar year 80% of approved amount
• Routine prophylaxes (cleanings) – three times per calendar year 80% of approved amount
• Fluoride treatments – twice per calendar year 80% of approved amount
• Topical fluoride varnish for moderate- to high-risk caries patients – four times per calendar year for members age 3 and younger only and two times per calendar year for members age 4 to 14 only in combination with fluoride treatments
For example, two fluoride treatments or two topical fluoride varnishes or one fluoride treatment and one topical fluoride varnish are payable in a calendar year for high-risk members between the ages of 4 and 14. However, two fluoride treatments and two topical fluoride varnishes are not payable for these members.
80% of approved amount
• Dental sealants – once per tooth per 36 months for first and second permanent molars 80% of approved amount after deductible
Bitewing X-rays:
• A set (up to four films) of bitewing X-rays – once per calendar year 80% of approved amount after deductible
Oral brush biopsy sample collection – twice per calendar year 80% of approved amount after deductible
Class II services
Other diagnostic and preventive services:
• Diagnostic tests and laboratory examinations 50% of approved amount after deductible
• Space maintainers – once per quadrant per lifetime for missing posterior primary teeth (recementation of a space maintainer is payable three times per quadrant per lifetime)
50% of approved amount after deductible
Full-mouth X-rays:
• A full-mouth series of X-rays or panoramic X-rays – once per 60 months 50% of approved amount after deductible
Emergency palliative treatment 50% of approved amount after deductible
Minor restorative services:
• Amalgam and resin-based composite fillings and fillings of similar materials – once per tooth and surface per 48 months for permanent teeth; once per tooth and surface per 24 months for primary teeth
50% of approved amount after deductible
• Recementation or repair of posts, crowns, veneers, inlays and onlays – three times per tooth per calendar year
50% of approved amount after deductible
Extractions and surgical removal of non-impacted teeth 50% of approved amount after deductible
Non-surgical endodontic services:
• Root canal treatments – once per tooth per lifetime (replacement of a root canal 12 or more months after the initial root canal treatment is payable once per tooth per lifetime)
50% of approved amount after deductible
• Therapeutic pulpotomies or pulpal debridement 50% of approved amount after deductible
• Vital pulpotomies on primary teeth 50% of approved amount after deductible
• Apexification 50% of approved amount after deductible
Non-surgical periodontic services:
• Periodontal maintenance – three times per calendar year in place of routine dental prophylaxis
50% of approved amount after deductible
• Periodontal scaling and root planing – once per quadrant per 24 months 50% of approved amount after deductible
Adjustments, repairs, relines, rebases and tissue conditioning for removable prosthetic appliances:
• Relines or rebases of partial dentures or complete dentures – once per 36 month per arch 50% of approved amount after deductible
• Tissue conditioning – once per 36 months per arch 50% of approved amount after deductible
Adjunctive general services:
• General anesthesia or IV sedation 50% of approved amount after deductible
• Office visits after regularly scheduled hours 50% of approved amount after deductible
BD PPO Plus 80/50/50, $25/$75 deductible Pediatric – Non-voluntary, JUN 2014
Class III services
Major restorative services:
• Onlays, crowns and veneers – once per permanent tooth per 84 months for members age 12 and older only
50% of approved amount after deductible
• Substructures, including cores and posts 50% of approved amount after deductible
Oral surgery services:
• 50% of approved amount after deductible
• Incision and drainage of celluliitis or fascial space abscesses of intraoral soft tissue 50% of approved amount after deductible
• Removal of exostoses (excess bony growths of the upper and lower jaw) 50% of approved amount after deductible
• Excision of hyperplastic tissue per arch 50% of approved amount after deductible
• Soft tissue biopsies 50% of approved amount after deductible
• Frenulectomies 50% of approved amount after deductible
Surgical endodontic services:
• Apical surgeries on permanent teeth 50% of approved amount after deductible
• Hemisections – once per tooth per lifetime 50% of approved amount after deductible
Surgical periodontic services:
• Gingivectomies and gingivoplasties 50% of approved amount after deductible
• Clinical crown lengthening – hard tissue 50% of approved amount after deductible
• Gingival flap procedures 50% of approved amount after deductible
• Soft tissue grafts 50% of approved amount after deductible
Prosthodontic services:
• Complete dentures – once per 84 months 50% of approved amount after deductible
• Removable partial dentures and fixed partial dentures (bridges), including abutment crowns and pontics – once per 84 months for members age 16 and older only
50% of approved amount after deductible
• Recementation and repairs of bridges 50% of approved amount after deductible
• Stayplates to replace recently extracted permanent anterior (front) teeth 50% of approved amount after deductible
Simply Blue PPO Gold $500, Rev Date 16 Q1 V1
Blue Vision (Pediatric Only)SM Benefits-at-a-Glance
Blue Vision benefits are provided by Vision Service Plan (VSP), the largest provider of vision care in the nation. VSP is an independent company providing vision benefit services for Blues members. To find a VSP doctor, call 1-800-877-7195 or log on to the VSP Web site at vsp.com.
Note: Vision benefits are only available to members through the last day of the year in which they turn age 19. Members may choose between prescription glasses (lenses and frame) or contact lenses, but not both.
In-network Out-of-network
Member’s responsibility (copays) Eye exam None None Prescription glasses (lenses and/or frames) None None Medically necessary contact lenses None None
Eye exam Complete eye exam by an ophthalmologist or optometrist. The exam includes refraction, glaucoma testing and other tests necessary to determine the overall visual health of the patient.
100% of approved amount Reimbursement up to $34 (member responsible for any difference)
One eye exam per calendar year
Lenses and frames Standard lenses (must not exceed 60 mm in diameter) prescribed and dispensed by an ophthalmologist or optometrist. Lenses may be molded or ground, glass or plastic. Also covers prism, slab-off prism and special base curve lenses when medically necessary. Note: Discounts on additional prescription glasses and savings on lens extras when obtained from a VSP doctor.
100% of approved amount Reimbursement up to approved amount based on lens type (member responsible for any difference)
One pair of lenses, with or without frames, per calendar year Standard frames from a “select” collection 100% of approved amount Reimbursement up to $38.25 (member
responsible for any difference) One frame per calendar year
Contact lenses Medically necessary contact lenses (requires prior authorization approval from VSP and must meet criteria of medically necessary)
100% of approved amount Reimbursement up to $210 (member responsible for any difference)
Covered – annual supply Elective contact lenses that improve vision (prescribed, but do not meet criteria of medically necessary) If prescription contact lenses do not meet criteria for medically necessary, members may elect one of the following quantities of lenses as covered in full:
• Standard (one pair annually)• Monthly (six-month supply)• Bi-weekly (three-month supply)• Dailies (three-month supply)
100% of approved amount $100 allowance that is applied toward contact lens exam (fitting and materials) and the contact lenses (member responsible for any cost exceeding the allowance)
Covered according to quantities in your certificate, per calendar year
Delta Dental of MichiganQCI Nurse Staffing
Join Michigan’s largestdental benefits family!
As a client of Delta Dental ofMichigan, your employees will haveaccess to the nation's largest dentalnetworks: Delta Dental PPO andDelta Dental Premier. With 4 out of5 dentists participating nationwide,these two networks provide superioraccess to care as well as reducedfees through our agreements withparticipating dentists. Lower claimscosts mean lower rates! Plus,your employees cannot be balancebilled - giving them added savings.Enrollees can visit nonparticipatingdentists, but they can be balancebilled and may have to pay more.
Online Access
Our HIPAA compliant e-commercecapabilities let benefit managersand enrollees conduct businesssecurely over the Internet. Benefitmanagers can update eligibility inreal time, even while your employeeis at the dentist. Your members canfind a participating dentist, checkbenefits, select paperless notices,review claims and amounts usedtoward maximums or deductibles,print ID cards, and more at theirconvenience using our ConsumerToolkit.
Quick and Accurate
We process and pay 90% of claimswithin 10 days with 99% accuracy -just another reason why we retainnearly 99% of our subscribers eachyear and 96% of our client groupsrenew their dental benefits withDelta Dental.
91834 - 100/80/50, $0 ded, $2000 annual maxDelta Dental PPO (Point-of-Service) Plan Pays
HIGHLIGHTSCoverage effective June 01, 2016 PPO
DentistPremierDentist
Non-participating
Dentist*
Diagnostic & Preventive
Diagnostic and Preventive Services - exams, cleanings,fluoride, and space maintainers
100% 100% 100%
Sealants - to prevent decay of permanent teeth 100% 100% 100%
Brush Biopsy - to detect oral cancer 100% 100% 100%
Radiographs - X-rays 100% 100% 100%
Basic Services
Emergency Palliative Treatment - to temporarily relievepain
80% 80% 80%
Minor Restorative Services - fillings 80% 80% 80%
Periodontal Maintenance - cleanings following periodontaltherapy
80% 80% 80%
Simple Extractions - non-surgical removal of teeth 80% 80% 80%
Other Basic Services - misc. services 80% 80% 80%
Relines and Repairs - to bridges and dentures 80% 80% 80%
Major Services
Endodontic Services - root canals 50% 50% 50%
Periodontic Services - to treat gum disease 50% 50% 50%
Other Oral Surgery - dental surgery 50% 50% 50%
Major Restorative Services - crowns 50% 50% 50%
Prosthodontic Services - bridges, implants, and dentures 50% 50% 50%
Orthodontics
Orthodontic Services - braces 0% 0% 0%
* When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the
portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. The Nonparticipating
Dentist Fee may be less than what your dentist charges and you are responsible for that difference.
Maximum Payment – $2,000 per person total per calendar year on Diagnostic & Preventive, BasicServices and Major Services.
Deductible – None.
Waiting Period – Major Services will not be covered until after a person is enrolled in the dental planfor 12 consecutive months. For the initial enrollment only, the waiting period(s) can be waived forenrollees covered for at least 12 months under the immediately preceding dental plan.
Quality Dental Program
You know you're getting aquality program because DeltaDental has earned the prestigiousISO 9001 quality certification.This means our procedures andsystems meet a rigorous globalstandard of excellence. Delta Dentalalso offers world-class customerservice from our certified Centerof Excellence call center, asawarded by Benchmark Portal.Delta Dental's customer serviceoperation is recognized for superiorperformance on both cost andquality-related metrics as comparedto our industry peers. The award isone of the most highly sought afterprizes in the customer service andsupport industry.
Passport DentalSM
Your members can receive expertdental care when they areoutside of the United Statesthrough our Passport Dentalprogram. Passport Dental givesDelta Dental's enrollees access toa worldwide network of dentistsand dental clinics. English-speakingoperators are available around theclock to answer questions and helpthem schedule care. Delta Dentalcoverage outside of the UnitedStates is the same as Delta Dentalcoverage within the United States.
THANK YOU!
Thank you for giving Delta Dentalthe opportunity to provide you witha proposal. We encourage you tocall us so that QCI Nurse Specialtiescan join the more than 5,700 clientgroups who enjoy the advantagesof a dental program administeredby Delta Dental of Michigan, Ohio,North Carolina and Indiana. We lookforward to doing business with you!
Rate per subscriber per month guaranteed for One Year
Employee only $36.18
Employee and spouse $72.38
Employee and child(ren) $82.82
Employee, spouse and children $130.86
Subscribers and eligible dependents must enroll for a minimum of 12 months. If coverage isterminated after 12 months, they may not re-enroll prior to the open enrollment that occurs atleast 12 months from the date of termination.
Printed dentist directories are not included. You can find participating dentists on our website atwww.deltadentalmi.com.
The plan specifications are subject to Delta Dental’s standard exclusions and limitations,including:
• No pre-existing condition exclusions or limitations.
• Oral exams are payable twice per calendar year.
• Prophylaxes (cleanings) are payable twice per calendar year.
• Sealants are payable once per tooth per lifetime for the occlusal surface of first permanentmolars up to age nine and second permanent molars up to age 14.
• Crowns, bridges, dentures, and implants are payable once per tooth per five-year period.
• People with specific at-risk health conditions may be eligible for additional prophylaxes(cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment.
Non-standard exclusions and limitations include:
• Fluoride treatments are payable once per calendar year up to age 19.
• Bitewing X-rays are payable once per calendar year and full mouth X-rays are payable once inany three-year period.
Children under age 26 are eligible for benefits, including children who are married, who do notlive with the subscriber, who are not dependents for Federal income tax purposes, and/or whoare not permanently disabled.
Policyholder:
Policy Number:
Employee Benefit Waiting Period:
Late Enrollee Provision:
Employer Anniversary Date:
Premiums:
Benefit Description Copay Frequency
Well Vision Exam Focuses on your eyes and overall wellness$10 Every 12 months
$25 See frame & lenses
$130 allowance for a wide selection of
frames
$150 allowance for the featured name
brands
20% savings on the amount over your
allowance
Single vision, lined bifocal, and lined trifocal
lenses
Polycarbonate lenses for dependent
children
Tints/Photochromic adaptive lenses $0
Standard progressive lenses $50
Premium progressive lenses $80-$90
Custom progressive lenses $120-$160
Average savings of 35-40% on other lens
enhancements
$130 allowance for contacts; copay does
NOT apply
Contact lens exam (fitting and evaluation)
Up to $60
May 1st
Contributory
Lenses
Lens Enhancements
Contacts
(instead of glasses)
Included in
Prescription
Glasses
Every 12 months
Every 12 months
Every 12 months
Schedule of Benefits
Prescription Glasses
Included in
Prescription
Glasses
Every 12 monthsFrame
Your Coverage with a VSP Provider
QCI Nurse Specialists
30-0036-44
Date of HireNone - eligible employees are able to enroll at any time and would become active the
first of the month after receipt of enrollment form
Using your VSP benefit is easy. • Register at vsp.com. Once your plan is
effective, review your benefit information.
• Find an eyecare provider who’s right foryou. To find a VSP provider, visit vsp.com orcall 800.877.7195.
• At your appointment, tell them you haveVSP. There’s no ID card necessary. If you’d likea card as a reference, you can print one onvsp.com.
That’s it! We’ll handle the rest—there are no claim forms to complete when you see a VSP provider.
Choice in Eyewear From classic styles to the latest designer frames, you'll find hundreds of options. Choose from featured frame brands like Anne Klein, bebe®, Calvin Klein, Flexon®, Lacoste, Nike, Nine West, and more1. Visit vsp.com to find a VSP provider who carries these brands.
Enroll in VSP today. You'll be glad you did. Contact us. 800.877.7195 vsp.com
Get the best in eyecare and eyewear with QCI NURSE SPECIALISTS and VSP® Vision Care. Why enroll in VSP? We invest in the things you value most—the best care at the lowest out-of-pocket costs. Because we’re the only national not-for-profit vision care company, you can trust that we’ll always put your wellness first.
• High Quality Vision Care. You’ll get the best care from a VSP provider,including a WellVision Exam®—the most comprehensive exam designedto detect eye and health conditions. Plus, when you see a VSP provider,your satisfaction is guaranteed.
• Choice of Providers. The decision is yours to make—choose a VSPprovider or any out-of-network provider.
• Great Eyewear. It’s easy to find the perfect frame at a price that fitsyour budget.
You’ll like what you see with VSP.
Save with VSP coverage: Without VSPCoverage
With VSPCoverage
Total
*Comparison based on national averages for comprehensive eye exams and most commonly purchased brands
NOTE: Dollar amounts in the savings chart are estimates and don’t reflect additional discounts from current VSP offers and promotions.
Average Annual Savings
$487 with a
VSP Doctor
Eye Exam
Frame
Single Vision Lenses
Photochromic Adaptive Lenses
Anti-reflective Coating
Member-only Annual Contribution
$154
$130
$86
$103
$110
N/A
$10 Copay
$25 Copay
$0
$61
$
$583 $96
Your VSP Vision Benefits Summary QCI NURSE SPECIALISTS and VSP provide you with an affordable eyecare plan.
VSP Provider Network: VSP Signature
Visit vsp.com for more details on your vision benefit and for exclusive savings
and promotions for VSP members.
CopayDescriptionBenefit FrequencyYour Coverage with a VSP Provider
WellVision Exam • Focuses on your eyes and overall wellness $10 Every 12 months
Prescription Glasses $25 See frame and lenses
Frame • $130 allowance for a wide selection of frames• $150 allowance for featured frame brands• 20% savings on the amount over your allowance
Included in Prescription
Glasses Every 12 months
Lenses • Single vision, lined bifocal, and lined trifocal lenses• Polycarbonate lenses for dependent children
Included in Prescription
Glasses Every 12 months
Lens Enhancements
• Tints/Photochromic adaptive lenses• Standard progressive lenses• Premium progressive lenses• Custom progressive lenses• Average savings of 35-40% on other lens enhancements
$0 $50
$80 - $90 $120 - $160
Every 12 months
Contacts (instead of glasses)
• $130 allowance for contacts; copay does not apply• Contact lens exam (fitting and evaluation) Up to $60 Every 12 months
Extra Savings
Glasses and Sunglasses • Extra $20 to spend on featured frame brands. Go to vsp.com/specialoffers for details.• 30% savings on additional glasses and sunglasses, including lens enhancements, from the same VSP provider on
the same day as your WellVision Exam. Or get 20% from any VSP provider within 12 months of your last WellVisionExam.
Retinal Screening • No more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam
Laser Vision Correction • Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities• After surgery, use your frame allowance (if eligible) for sunglasses from any VSP doctor
Visit vsp.com for details, if you plan to see a provider other than a VSP network provider.
Exam ...................................................up to $50 Frame .................................................up to $70
Single Vision Lenses ..................up to $50 Lined Bifocal Lenses ..................up to $75
Lined Trifocal Lenses .................up to $100 Progressive Lenses .....................up to $75
Contacts ...........................................up to $105 Tints .....................................................up to $5
Your Coverage with Out-of-Network Providers
VSP guarantees coverage from VSP network providers only. Coverage information is subject to change. In the event of a conflict between this information and your organization’s contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may vary by location.
1 Brands/Promotion subject to change.
©2014 Vision Service Plan. All rights reserved. VSP, VSP Vision care for life, and WellVision Exam are registered
trademarks of Vision Service Plan. Flexon is a registered trademark of Marchon Eyewear, Inc. All other brands are
trademarks or registered trademarks of their respective owners.
Enroll in VSP today. You'll be glad you did. Contact us. 800.877.7195 vsp.com
Policyholder:
Policy Number:
Employee Benefit Waiting Period:
Late Enrollee Provision:
Employer Anniversary Date:
Premiums:
Maximum Benefit Period:
Sickness:
Hospital Confined:
If your annual salary is at least:You may select a
weekly benefit of:Under 40
Age
40 - 49
Age
50 - 59
Age 60 &
Over
$8,665.00 $100.00 $8.20 $7.20 $9.20 $12.90
$13,000.00 $150.00 $12.30 $10.80 $13.80 $19.35
$17,330.00 $200.00 $16.40 $14.40 $18.40 $25.80
$21,665.00 $250.00 $20.50 $18.00 $23.00 $32.25
$26,000.00 $300.00 $24.60 $21.60 $27.60 $38.70
$30,330.00 $350.00 $28.70 $25.20 $32.20 $45.15
$34,665.00 $400.00 $32.80 $28.80 $36.80 $51.60
$39,000.00 $450.00 $36.90 $32.40 $41.40 $58.05
$43,330.00 $500.00 $41.00 $36.00 $46.00 $64.50
$47,665.00 $550.00 $45.10 $39.60 $50.60 $70.95
$52,000.00 $600.00 $49.20 $43.20 $55.20 $77.40
$56,330.00 $650.00 $53.30 $46.80 $59.80 $83.85
$60,665.00 $700.00 $57.40 $50.40 $64.40 $90.30
$65,000.00 $750.00 $61.50 $54.00 $69.00 $96.75
Schedule of Benefits - Short Term Disability
8th Day
8th Day
Ranging from $100 to $750 per week, in $50 increments not to
exceed 60% of basic weekly income
Monthly Premium Cost
QCI Nurse Specialists
F010816-0001
Date of Hire
(based on 12 payroll deductions per year)
Only able to enroll at open enrollment
July 1st
Contributory
26 Weeks
Injury:
$12.90
Under 40
40-49
50-59
60 & Over
Age Bands - Per $100 of Weekly Benefit
$8.20
$7.20
$9.20
Benefit Schedule:
Policyholder:
Policy Number:
Employee Benefit Waiting Period:
Late Enrollee Provision:
Employer Anniversary Date:
Premiums:
Maximum Monthly Benefit:
Minimum Monthly Benefit:
Elimination Period:
Maximum Benefit Period for Disability
Less than 60 To age 65
Age 60 60 Months
Age 61 48 Months
Age 62 42 Months
Age 63 36 Months
Age 64 30 Months
Age 65 24 Months
Age 66 21 Months
Age 67 18 Months
Age 68 15 Months
Age 69 & Over 12 Months
Under 30 $2.38
30-39 $3.75
40-44 $5.70
45-49 $8.15
50-54 $10.82
55-59 $11.90
60 & Over $12.63
If your annual salary is at least:
You may select a
weekly benefit of:Under 30
Age
30-39
Age
40 - 44
Age
45 - 49
Age
50 - 54
Age
55 - 59
Age 60 &
Over
$8,665.00 $100.00 $2.38 $3.75 $5.70 $8.15 $10.82 $11.90 $12.63
$13,000.00 $150.00 $3.57 $5.63 $8.55 $12.23 $16.23 $17.86 $18.94
$17,330.00 $200.00 $4.76 $7.50 $11.40 $16.31 $21.65 $23.81 $25.25
$21,665.00 $250.00 $5.95 $9.38 $14.25 $20.38 $27.06 $29.76 $31.57
$26,000.00 $300.00 $7.17 $11.26 $17.10 $24.46 $32.47 $35.71 $37.88
$30,330.00 $350.00 $8.33 $13.13 $19.95 $28.54 $37.88 $41.67 $44.19
$34,665.00 $400.00 $9.52 $15.01 $22.80 $32.61 $43.29 $47.62 $50.51
$39,000.00 $450.00 $10.71 $16.88 $25.65 $36.69 $48.70 $53.57 $56.82
$43,330.00 $500.00 $11.90 $18.76 $28.50 $40.76 $54.11 $59.52 $63.13
$47,665.00 $550.00 $13.10 $20.63 $31.35 $44.84 $59.52 $65.48 $69.44
$52,000.00 $600.00 $14.29 $22.51 $34.20 $48.92 $64.94 $71.43 $75.76
$56,330.00 $650.00 $15.48 $24.39 $37.05 $52.99 $70.35 $77.38 $82.07
$60,665.00 $700.00 $16.67 $26.26 $39.90 $57.07 $75.76 $83.33 $88.38
$65,000.00 $750.00 $17.86 $28.14 $42.75 $61.15 $81.17 $89.29 $94.70
$69,330.00 $800.00 $19.05 $30.01 $45.60 $65.22 $86.58 $95.24 $101.01
$73,665.00 $850.00 $20.24 $31.89 $48.45 $69.30 $91.99 $101.19 $107.32
$78,000.00 $900.00 $21.43 $33.77 $51.30 $73.38 $97.40 $107.14 $113.64
$82,330.00 $950.00 $22.62 $65.64 $54.15 $77.45 $102.81 $113.10 $119.95
$86,665.00 $1,000.00 $23.81 $37.52 $57.00 $81.53 $108.23 $119.05 $126.26
$91,000.00 $1,050.00 $25.00 $39.39 $59.85 $85.61 $113.64 $125.00 $132.58
$95,330.00 $1,100.00 $26.19 $41.27 $62.70 $89.68 $119.05 $130.95 $138.89
$99,665.00 $1,150.00 $27.38 $43.15 $65.55 $93.76 $124.46 $136.90 $145.20
Age Bands
Monthly Premium Cost(based on 12 payroll deductions per year)
Age 65 for Accident & Sickness
60% of basic monthly earnings up to $5,000
$100
180 Days
Schedule of Benefits - Long Term Disability
July 1st
Contributory
QCI Nurse Specialists
F010816-0001
Date of Hire
Only able to enroll at open enrollment
Group Life Insurance Life and AD&D
SUMMARY OF BENEFITS
Sponsored by: Small Business Association of Michigan All Full-Time and Regular Part-Time Employees of Employers electing the $25,000 benefit
Life Benefit Employee
Amount $25,000
Guarantee Issue $25,000
AD&D Benefit Employee
Amount $25,000
Guarantee Issue $25,000
Benefit Reduction Employee Benefits will reduce: 35% at age 65
An additional 25% of original amount at age 70; and
An additional 15% of original amount at age 75
Benefits terminate at retirement
Additional Benefits
See Definitions Page: Accelerated Death Benefit
See Definitions Page: Seat Belt, Airbag, and Common Carrier
See Definitions Page: Conversion
Eligibility Employee
All full-time and regular part-time active employees working 20 or more hours per week in an eligible class are eligible for coverage. A delayed effective date will apply if the employee is not actively at work.
(Please see other side)
www.LincolnFinancial.com GLM-07014 Rev. 4/08 Grp_Life-ADD_Dep and Cont
Definitions
Accelerated Death Benefit Accelerated Death Benefit provides an option to withdraw a percentage of your life insurance coverage when diagnosed as terminally ill (as defined in the policy). The death benefit will be reduced by the amount withdrawn. To qualify, you have satisfied the Active Work rule and have been covered under this policy for the required amount of time as defined by the policy. Check with your tax advisor or attorney before exercising this option.
AD&D Accidental Death and Dismemberment (AD&D) insurance provides specified benefits for a covered accidental bodily injury that directly causes dismemberment (e.g., the loss of a hand, foot, or eye). In the event that death occurs from a covered accident, both the life and the AD&D benefit would be payable.
Conversion If you terminate your employment or become ineligible for this coverage, you have the option to convert all or part of the amount of coverage in force to an individual life policy on the date of termination without Evidence of Insurability. Conversion election must be made within 31 days of your date of termination.
Guarantee Issue For timely entrants enrolled within 31 days of becoming eligible, the Guarantee Issue amount is available without any Evidence of Insurability requirement. Evidence of Insurability will be required for any amounts above this, for late enrollees or increase in insurance and it will be provided at your own expense.
Seat Belt, Airbag, Common Carrier
If you die as a result of a covered auto accident while wearing a seat belt or in a vehicle equipped with an airbag, benefits are payable up to $10,000 or 10% of the principal sum, whichever is less. If loss occurs for you due to an accident while riding as a passenger in a common carrier, benefits will be double the amount that would otherwise apply as outlined in the certificate.
Limited Activity A period when a spouse or dependent is confined in a health care facility; or, whether confined or not, is unable to perform the regular and usual activities of a healthy person of the same age and sex.
Term Life Coverage provided to the designated beneficiary upon the death of the insured. Coverage is provided for the time period that you are eligible and premium is paid. There is no cash value associated with this product.
Additional Benefits BeneficiaryConnectSM Support services for beneficiaries who have experienced a loss. TravelConnectSM Travel assistance services for employees and eligible dependents traveling more
than 100 miles from home. For assistance or additional information Contact Lincoln Financial Group at (800) 423-2765 or log on to www.LincolnFinancial.com NOTE: This is not intended as a complete description of the insurance coverage offered. Controlling provisions are provided in the policy, and this summary does not modify those provisions or the insurance in any way. This is not a binding contract. A certificate of coverage will be made available to you that describes the benefits in greater details. Should there be a difference between this summary and the contract, the contract will govern.
©2008 Lincoln National Corporation
Group Insurance products are issued by The Lincoln National Life Insurance Company (Ft. Wayne, IN), which is not licensed and does not solicit business in New York. In New York, group insurance products are issued by Lincoln Life & Annuity Company of New York (Syracuse, NY). Both are Lincoln Financial Group companies. Product availability and/or features may vary by state. Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Each affiliate is solely responsible for its own financial and contractual obligations.
www.LincolnFinancial.com GLM-07014 Rev. 4/08 Grp_Life-ADD_Dep and Cont
Enrollment/Change Forms
Medical-Enrollment &
Change Form Page 58-62
Dental-Enrollment Form Page 63-64
Vision-Enrollment Form Page 65
Page 66-69 Short Term & Long Term
Disability-Enrollment &
Change Form Page 66-69
Group Life/AD&D-
Enrollment Form Page 70-71
Group Life/AD&D-
Beneficiary Change Page 72-73
Benefit Election Form Page 74
Medical Benefit Election
Form Page 75
–Client Name: ____________________________________________ Client#/Subclient#
Enrollment/Corrections to Information (please fill in for spouse/dependents for first-time enrollment or corrections):SPOUSE Name (Last) (First) (M.I.)
Social Security Number Birth Date Status*
DEPENDENT #1 Name (Last) (First) (M.I.)
Social Security Number Birth Date Status*
DEPENDENT #2 Name (Last) (First) (M.I.)
Social Security Number Birth Date Status*
DEPENDENT #3 Name (Last) (First) (M.I.)
Social Security Number Birth Date Status*
DEPENDENT #4 Name (Last) (First) (M.I.)
Social Security Number Birth Date Status*
Eligibility Enrollment/Update
ABCDEF12 43 56
–
Check here if this is a new address
–
Plan Enrollment/Update Information (please indicate type of update and fill in appropriate information):
Type of Update: New Enrollment Reinstatement Change/Correction to Information Termination of Benefits Waive BenefitsGroup Transfer Rate Code Change* Change is for: From: Client/Subclient# To: Client/Subclient# From: To: Effective Date of Change Subscriber Dependent– ––
SexMaleFemale
– – Legal Surviving– –
SexMaleFemale
SexMaleFemale
IRS Dep. Surviving Disabled Sponsored
IRS Dep. Surviving Disabled Sponsored
– – – –
– – – –
SexMaleFemale
IRS Dep. Surviving Disabled Sponsored
– – – –
SexMaleFemale
IRS Dep. Surviving Disabled Sponsored
– – – –
*See reverse side for instructions and explanation of codes. Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Subscriber’s Signature_________________________________________ Date _________________________1314-55 (10-15)
–
–
Active COBRARetiree Surviving
SexMaleFemale
– – – – – –
Subscriber Information (please complete for all enrollments/updates:) Example:Subscriber Name (Last) (First) (M.I.) Status*
Subscriber Social Security Number Birth Date Coverage Effective Date Hire Date
Street Address Email
City State ZIP Code
Check: Indiana Michigan North Carolina Ohio
Please read the following information carefully before completing the other side of this form. You should fill out this form if you are enroll-ing for coverage or changing any information from an earlier enrollment. If you have any questions about filling out this form, your human resources or personnel department can help you.
Subscriber Information – This section must be completed for us to process your enrollment or update your records. All information should apply to you, the primary subscriber. Please print clearly or type.
Effective Date: The date that Delta Dental coverage takes effect for you and/or your dependents.
Status Definitions (Please select only one status):
Active: You are a current/active subscriber.
Retiree: You are retired and your group continues to provide you with dental benefits.
COBRA: You are no longer an active subscriber but you have continued self-paid coverage under COBRA. COBRA requires many employers to offer extended self-paid coverage to certain employees and qualified beneficiaries who lose group medical benefits coverage. Please check with your human resources or personnel department.
Surviving: The surviving spouse or child of a deceased subscriber.
Plan Enrollment/Update Information – This section should only be completed if you are: (1) Enrolling yourself or a family member for the first time, or (2) if your benefits were terminated and are not being reinstated or, (3) if you are making changes to your current enrollment information.
Enrollment: Check for first time enrollment for yourself or your dependents.
Reinstatement: Check for reinstatement coverage for yourself or your dependents.
Change/Corrections: Check if any changes are being submitted on the form.
Termination of Check only if you are terminating Delta Dental coverage forBenefits: yourself or a family member.
Group Transfers: When transferring from one group to another, all dependents will transfer unless otherwise indicated. This section should also be completed when transferring to COBRA.
When reporting a change or correction, the information that is incorrect or has changed should be listed on the line titled “from” and the correct information should be listed on the line titled “to”.
When changing a rate code, please refer to the following explanation to select the code that describes who is being covered by your Delta Dental program.
Rate Codes:Rate 1 Employee OnlyRate 2 Employee and spouseRate 3 Employee, spouse and childrenRate 5 Employee, one child, no spouseRate 6 Employee and more than one child, no spouse
Enrollment/Corrections To Information – This section should be completed when: (1) enrolling dependents or, (2) if you have checked Changes/Corrections and are changing information that was previously submitted to Delta Dental. Please include both first and last names of any individuals for whom you are enrolling or submitting a change or correction.
Dependent Status Definitions:
Legal: Your current spouse
Surviving: The surviving spouse or child of a deceased subscriber.
IRS Dependent: An individual who is your dependent child according to the U.S. Internal Revenue Code. This could include your unmarried dependent child who is attending a university, college, community college, junior college or trade school on a full-time basis and for whom you provide principal support.
Disabled: Your permanently disabled child.
Sponsored: A dependent for whom you are legally responsible. Sponsored dependents could include parents, grandparents and foreign exchange students, but only if specified in your group’s contract with Delta Dental.
Delta DentalAttention: Eligibility ProcessingPO Box 30416Lansing, MI 48909-7916
VISION SERVICE PLAN
MEMBER ENROLLMENT FORM
Name of Group (Employer) ______________________________
I am enrolling in the Vision Service Plan vision program and have selected the
following coverage (please check one):
Employee Only ____
Employee + One Dependent ____
Employee + Children ____
Employee + Family ____
I wish to waive enrollment in the VSP vision program. ____
My date of birth is ____________________ Male ____ Female ____
Signature __________________________________
Social Security Number_______________________
Print Name ________________________________
Effective Date_______________________________
Family status changes may allow you to add or delete coverage during this period. For internal purposes only – DO NOT RETURN TO VSP. Data from this form must be transferred to Excel Enrollment Spreadsheet before submitting to VSP.
___________________________________________________________________
Enrollment and Change Form Administrative Offices: Downers Grove, Illinois I Dallas, Texas
Products and services marketed under the Dearborn National® brand and the star logo are underwritten and/or provided by Dearborn National® Life Insurance Company (Downers Grove, IL) in all states (excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands, Guam and Puerto Rico. 9-552-714
Page 1 of 2 R012815 I Z5222
New Enrollment Change Open Enrollment COBRA Retiree
Employer/Employee Section Enrollment forms must be submitted directly to Dearborn National unless the group is self-administered. If the group is self-administered, submit enrollment forms to Dearborn National only if evidence of insurability is required.
EMPLOYER GROUP NO. / ACCOUNT NUMBER LOCATION
EMPLOYEE NAME - LAST FIRST MIDDLE INITIAL SEX M F
DATE OF BIRTH DATE OF HIRE (FULL TIME)
SOCIAL SECURITY NO. EARNINGS Weekly Monthly Annual
JOB TITLE CLASS
HOME ADDRESS CITY STATE ZIP
HOME PHONE WORK PHONE CELL PHONE
BENEFIT SELECTION - Life & Disability & Critical Illness COVERAGE SELECTION: Your non-medical group insurance program may not include all the benefits listed below. Ask your Employer for the details about the benefits available to you, your cost, if any, and whether you will be required to complete a health questionnaire.
Basic Coverage (Check all that apply) Spouse includes Domestic Partner and Party to a Civil Union as defined in the Certificate.
Term Life / AD&D Short-Term Disability (STD) Long-Term Disability (LTD)
Dependent Term Life / AD&D Critical Illness Spouse Child(ren)
Supplemental Coverage (Check all that apply) Spouse includes Domestic Partner and Party to a Civil Union as defined in the Certificate.
(A)Add, (C)Change (D)Delete
Total Amount of Coverage Desired
If (C)hange, list Prior Coverage
Term Life / AD&D Employee Term Life / AD&D Spouse Term Life / AD&D Child(ren) Critical Illness Employee Critical Illness Spouse Critical Illness Child(ren)
Voluntary Coverage (Check all that apply) Spouse includes Domestic Partner and Party to a Civil Union as defined in the Certificate.
(A)Add, (C)Change (D)Delete
Total Amount of Coverage Desired
If (C)hange, list Prior Coverage
Term Life Employee Term Life Spouse Term Life Child(ren) Voluntary AD&D Employee Family Long-Term Disability (LTD): Incremental Long-Term Disability (LTD): % of Earnings Short-Term Disability (STD): Incremental Short-Term Disability (STD): % of Earnings Critical Illness Employee Critical Illness Spouse Critical Illness Child(ren)
SPOUSE NAME (if Applicant)
- LAST FIRST M.I. SEX M F
SPOUSE DATE OF BIRTH SPOUSE SOCIAL SECURITY #
Has the Employee (if applying) used any tobacco products in the last 2 years? Yes No
Has the Spouse (if applying) used any tobacco products in the last 2 years? Yes No
Enrollment and Change Form Administrative Offices: Downers Grove, Illinois I Dallas, Texas
Products and services marketed under the Dearborn National® brand and the star logo are underwritten and/or provided by Dearborn National® Life Insurance Company (Downers Grove, IL) in all states (excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands, Guam and Puerto Rico. 9-552-714
Page 2 of 2 R012815 I Z5222
BENEFICIARY DESIGNATION: (For Employee Only: Must Be Completed if you have applied for Life or AD&D insurance.) If two or more primary beneficiaries are named, and you do not list benefit percentages, proceeds will be paid in equal shares to the named primary beneficiaries who survive you. If no primary beneficiary survives you, proceeds will be paid to the contingent beneficiary(ies). If you list benefit percentages, the total must equal 100%. (Employee is the beneficiary of proceeds from spouse or child coverage.)
Primary First Name Last Name Social Security No. Date of Birth Relationship Percentage
%
Primary %
Contingent %
Contingent %
BENEFIT SELECTION - DENTAL
ENROLLMENT Spouse includes Domestic Partner and Part to a Civil Union as defined in the Certificate. (Choose One)
Employee
Employee + Spouse
Employee + Child(ren) Family
POLICY CHANGE (Check Reason for Change)
Married
Birth / Adoption
Widowed
Divorced
Address Change
CANCEL COVERAGE
Terminate Coverage Date / /
Leave / Layoff
Other
Date / /
If above selection covers your Spouse, is your Spouse covered under any other dental plan? Yes No If Yes, carrier's name:
COBRA CONTINUATION PRIVILEGE Previously covered with group as: Start Date: / / 1. Employee (termination, reduction in hours, other)
2. Spouse (divorce from Employee, death of Employee) Projected End Date: / / 3. Dependent (reached age limit, married, no longer a Full Time Student, other)
4. Spouse & Dependents (divorce from Employee, death of Employee, other)
For the purposes of this Notice, while prohibited by Federal law, Spouse does not include a same-sex Domestic Partner or Party to a Civil Union. Such benefits may be available under state law of provided by the policyholder.
COVERED SPOUSE AND DEPENDENTS Dependent Child(ren) over the age limit, indicate if Full Time Student
(FTS) or Handicapped (HDCP). First Name Last Name Social Security
Number
Date of Birth
Relationship
SPOUSE
SEX
M F
Adult Child FTS or HDCP
Name of Accredited
School
M F M F M F M F M F
I hereby request to be insured and authorize deductions, if any, from my compensation for my share of the cost of the benefits to which I may be entitled under the group policy (ies) issued to the Employer listed above. I understand that if I am not actively at work on the effective date of my coverage, my insurance will not begin until the day I return to work. I understand that if I do not remain actively at work that my coverage may lapse or terminate. For those coverages I have declined, I understand that if I choose to enroll at a later date, my cost may be higher and a health questionnaire may be required.
EMPLOYEE SIGNATURE
Waiver of Coverage: DATE / /
I DO NOT WISH TO ENROLL at this time and understand that the opportunity to enroll at any future time will be subject to such arrangements as may be made with the company.
EMPLOYEE SIGNATURE
DATE / /
FOR DEARBORN NATIOANL USE ONLY
Fraud Notices Administrative Office:1020 31st Street, Downers Grove, Illinois 60515-5591
Products and services marketed under the Dearborn National® brand and the star logo are underwritten and/or provided by Dearborn National® Life Insurance Company (Downers Grove, IL) in all states (excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands, Guam and Puerto Rico.
Page 1 of 1 R1025_12 I Z6291_LC
The laws of some states require us to furnish you with the following notice:
FOR APPLICATIONS AND CLAIMS:
Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. Colorado: It is unlawful to knowingly provide false, incomplete, or misleading material facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading material facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. District of Columbia: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. Hawaii: For your protection, Hawaii law requires you be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
Louisiana: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Maine & Washington: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
Maryland: Any person who knowingly and willingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
New Mexico: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
Ohio: Any person who, with intent to defraud or knowingly that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Oklahoma: Any person who knowingly, with intent to injure, defraud or deceive any insurer, makes a claim for the proceeds of an insurance policy containing false, incomplete or misleading information is guilty of a felony.
Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
Puerto Rico: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation with the penalty of a fine of not less than five thousand dollars($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.
Rhode Island: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Tennessee: It is a crime to knowingly provide false incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
Virginia: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated the state law.
Fraud Notices Administrative Office:1020 31st Street, Downers Grove, Illinois 60515-5591
Products and services marketed under the Dearborn National® brand and the star logo are underwritten and/or provided by Dearborn National® Life Insurance Company (Downers Grove, IL) in all states (excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands, Guam and Puerto Rico.
Page 2 of 1 R1025_12 I Z6291_LC
The laws of some states require us to furnish you with the following notice:
FOR CLAIMS ONLY:
Alaska: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law. Arizona: For your protection, Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. Arkansas: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. California: For your protection California law requires the following to appear on this form. Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Delaware: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony. Idaho: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement or claim containing false, incomplete, or misleading information is guilty of a felony. Indiana: A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony. Minnesota: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.
New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. Texas: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
FOR APPLICATIONS ONLY: Massachusetts: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
Return completed form to: Grotenhuis Ancillary Department PO Box 140167 Grand Rapids, MI 49514-0167
ENROLLMENT FORM FOR GROUP INSURANCE UNDERWRITTEN BY THE LINCOLN NATIONAL LIFE INSURANCE COMPANY Please Use Ink or Type
GROUP ID: GROUP POLICY #: Billing Division or Location:
A. Employee Information (Complete for ALL Enrollments) Employer Name/Company Name (Please Print) Small Business Association of Michigan
County Employer ZIP State
Employee Last Name First Name Middle Initial Social Security Number Date of Birth
Spouse Last Name First Name Middle Initial Social Security Number Date of Birth
Street Address City State Zip
Gender: Male Female
Marital Status: Married Single Home Phone ( )
Work Phone ( )
Completed By Employer Average Hours Worked Per
Week: Occupation:
Earnings: Hourly Monthly $
Date of Full-Time Employment:
Rehire Date:
B. Product Selection (Complete for ALL Enrollments) Basic Coverage NOTE: Please mark the box or boxes for each coverage you are applying for.
All coverage amounts are subject to the limitations and exclusions as stated in the policy. Class Effective
Date Type of Coverage Amount of Coverage Total
Premium Basic Group Life/AD&D Yes No $ Employer Paid Dependent Life Yes No $ Employer Paid
Short Term Disability Yes No $ Employer Paid Long Term Disability Yes No $ Employer Paid
Voluntary Coverage NOTE: Please mark the box or boxes for each coverage you are applying for. All coverage amounts are subject to the limitations and exclusions as stated in the policy.
TYPE OF COVERAGE AMOUNT OF COVERAGE TOTAL PREMIUMVoluntary Employee Life/AD&D Insurance
Yes No $ $
Voluntary Spouse Life/AD&D Insurance
Yes No $ $
Voluntary Dependent Child Benefit Yes No $10,000 $
C. Beneficiary Information (Complete ONLY for Life or AD&D Enrollments) Primary Beneficiary's Last Name First MI Relationship of
Beneficiary Social Security Number
Street Address City State Zip
Contingent Beneficiary's Last Name First MI Relationship of Beneficiary
Social Security Number
Street Address City State Zip
Note: A Contingent Beneficiary will receive benefits only if the Primary Beneficiary does not survive you. If you wish to designate more than one Primary or Contingent Beneficiary, please attach a separate sheet of paper.
GLAD 4 11/00 Rev. 04/07 MI
GLAD 4 11/00 MI
E. Request for Coverages This coverage has been offered to me and after careful consideration of the benefits, I have decided to:
REQUEST COVERAGE for which I am or may become eligible under the group policies issued by The Lincoln National Life Insurance Company. I hereby apply for group insurance, for which I am eligible or may become eligible. If contributions are required, I authorize my employer to deduct premiums from my salary.
NOT ENROLL myself in the Program. I understand that if I apply for coverage at a later date, and if a physical examination or further medical information is required, it will be at my own expense.
NOT ENROLL my dependents in the Program. I understand that if I apply for coverage for my dependents at a later date, and if a physical examination or further medical information is required, it will be at my own expense.
NOTE: A PERSON COMMITS INSURANCE FRAUD, IF HE OR SHE SUBMITS AN APPLICATION OR CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT WITH INTENT TO DEFRAUD (OR KNOWING THAT HE OR SHE IS HELPING TO DEFRAUD) AN INSURANCE COMPANY.
The insurance requested on this enrollment form will not be effective until approved by the Group Insurance Service Office of The Lincoln National Life Insurance Company, and the initial premium is paid to The Lincoln National Life Insurance Company. A delayed effective date will apply if the employee is not actively at work, or a dependent is in a period of limited activity on the date insurance would otherwise take effect.
Employee Full Name: Employee Signature: Date:
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Page 1 of 2GLA-01299 7/08
The Lincoln National Life Insurance Company, PO Box 2616, Omaha, NE 68103-2616toll free (800) 423-2765www.LincolnFinancial.com
Policy Number (List all affected policy numbers):_________________________________________________________________________
Group ID: ______________ Insured’s Name: _______________________________Social Security Number: _____________________
NAME/ADDRESS CHANGE (First-MI-Last):
From:
To:
BENEFICIARY CHANGE
Primary Beneficiary: Relationship:
Contingent Beneficiary: Relationship:
NOTE: Contingent Beneficiary will receive benefits only if Primary Beneficiary does not survive you. If more than one Primaryor Contingent Beneficiary is wanted, please attach a separate sheet of paper.
DEPENDENTS TO BE ADDED OR REMOVEDRelationship Late
Check One Date of Birth (Spouse or Date of Marriage EntrantAdd Remove Name (First-MI-Last) (Mo. Day Yr.) Child) (Mo. Day Yr.) (Yes or No)
If adding dependent outside eligibility period, please explain reason: For foster or adopted child, show date of placement and any adoption decree. NOTE: If dependents are late entrants for Life coverage, each dependent will need to complete an Evidence of Insurability
form and submit it to The Lincoln National Life Insurance Company for review. If dependents are late entrants forDental coverage, and were previously covered under another plan, please complete the back of this form.
CHANGES IN COVERAGE
Effective Date of Change: ________________________ Current Salary: $_______________________
� 1. Increase Employee coverage to � 2. Add/increase spouse coverage to � 3. Add Dependent Life Coverage
$ _______________________ $ _______________________ $ _______________________
Enrollment form must be attached for items 1-3. Evidence of Insurability may be required.
Effective Date of Change: ________________________
� 1. Reduce Employee coverage to � 2. Reduce spouse coverage to
$ _______________________ $ _______________________
Insured’s Witness’ Date: Signature: Signature:
GROUP INSURANCE CHANGE REQUEST
Please Fax to (877) 573-6177Total pages faxed __________
Employer: ______________________________________________________________________________________________________
Page 2 of 2GLA-01299 7/08
REQUEST FOR REPLACEMENT CERTIFICATION
________ I am requesting a duplicate group insurance certificate.
REQUEST FOR REPLACEMENT IDENTIFICATION CARDS
________ I am requesting duplicate group insurance identification cards.
REQUEST FOR REPLACEMENT GROUP DENTAL INSURANCE Information Regarding Employee:
1. Name of Employee Requesting Coverage:
2. Employer’s Name and Address:
3. Employer’s Policy Number:
Information Regarding Previous Plan:
1. Termination Date of Previous Plan:
2. Reason for Termination of Previous Plan:
PLEASE COMPLETE THE FOLLOWING:
Name of Employee Covered Under Requesting Date of Social Security or Dependent Previous Plan Coverage Birth Number
I request Group Dental Insurance to be effective _____________________________________ which is the day after Dental coverage provided through my previous group plan ends.
I previously refused or did not enroll for Dental coverage through my employer’s group plan only because (I/my) dependents (was/were) covered for benefits through a previous group plan. We have now become ineligible for coverage under this plan. With respect to any part of the requested coverage which is non-contributory (paid entirely by my employer), I waive any rights I may have to coverage earlier than the above stated date.
Date: Employee Signature
BENEFIT ELECTION FORM
Medical: Continue with same plan
Newly Eligible/Enrolling
Waive Coverage
Dental:
Group Life/AD&D:
Short Term & Long Term Disability:
QCI Nurse Specialists offers their full-time employees $15,000
of life and accidental death and dismemberment insurance at
no cost to you, the employee. If you would like to change your
beneficiary, please complete a Lincoln Financial change form.
Vision:
Employee Name: Location:
PLAN YEAR: 2016—2017 Forms must be returned to Ken Jewett by Friday May 13th, 2016
With my signature, I authorize QCI Nurse Staffing to take the necessary deductions from my
earnings for the plans selected on this form. I understand that by signing this form I am
making a binding election for one calendar year (2016—2017). I understand that I will NOT
be able to change my elections during the year unless I have a qualifying change in status.
Signature: Date:
Continue with same plan
Newly Eligible/Enrolling
Waive Coverage
Continue with same plan
Newly Eligible/Enrolling
Waive Coverage
Continue with same plan
Newly Eligible/Enrolling
Waive Coverage
Update/Change Salary Information
Remove self from policy
Remove Dependents
Add Dependents
Remove self from policy
Remove Dependents
Add Dependents
Remove self from policy
Remove Dependents
Add Dependents
Remove self from policy
Any enrollments and/or changes denoted below MUST be accompanied by the carrier’s enrollment OR
change form. Forms can be found in the Employee Benefits Guide or obtained from Ken Jewett.
MEDICAL PLAN ELECTION FORM
Medical:
Please select one of the following medical plans outlined below. If you are electing coverage for the
first time please complete a BCBSM/BCN enrollment form. If you are changing your election, removing
dependents, etc. please complete a Change of Status (ECOS) form.
Employee Name: Location:
PLAN YEAR: 2016—2017
Forms must be returned to Ken Jewett by Friday May 13th, 2016
With my signature, I authorize QCI Nurse Staffing to take the necessary deductions from my earnings
for the plans selected on this form. I understand that by signing this form I am making a binding
election for one calendar year (2016—2017). I understand that I will NOT be able to change my
elections during the year unless I have a qualifying change in status.
Signature: Date:
Plan BCN HMO
Platinum 20% BCN HMO Gold
$1,000 Simply Blue PPO
Gold $500 Simply Blue HSA PPO Silver $2,700
Deductible Individual/Two or
More $0 $1,000/$2,000 $500/$1,000 $2,700/$5,400
Coinsurance 20% 20% 20% 20%
Embedded Coinsur-ance Maximum
$1,000/$2,000 $2,500/$5,000 $3,000/$6,000 None
Out-of-Pocket Maximum
$6,600/$13,200 $6,600/$13,200 $6,600/$13,200 $4,500/$9,000
Office Visit/Specialist/Urgent Care/ER
Copays $25/$35/$35/$150 $20/$40/$50/$150 $20/$40/$60/$150
Covered at 80% After Deductible is Met
Prescription Drugs $4/$15/$40/
$80/20%/20% $4/$15/$40/
$80/20%/20% $15/$50/50%/20%/
25%
After Deductible is Met: $15/$50/50%/20%/
25%
Blue Care Network HMO Platinum 20%
Blue Care Network HMO Gold $1,000
BCBSM Simply Blue PPO Gold $500
BCBSM Simply Blue PPO Health Savings Account HSA) HSA Silver $2,700
*If you are located outside of Michigan, you MUST select one of the Simply Blue PPO options.*
- Must name Primary Care Doctor
- Must name Primary Care Doctor
Providing Specialized Insurance Services Since 1935