Medical Plan Footnotes

1 All covered services are subject to deductible, except preventive care services.

2 Calendar year deductible runs from 1.1 to 12.31.

3 Out-of-network deductible amounts also apply toward the in-network deductible.

4 Your deductible combines the deductible amounts paid under your medical coverage and your prescription drug coverage.

5 The full family deductible must be met under a two-person or family contract before benefits are paid for any person.

6 Coinsurance kicks in once the calendar-year deductible has been met.

7 For private duty nursing, your coinsurance % is 50%, in-network and out-of-network.

8 Annual coinsurance dollar maximum applies to coinsurance amounts for all covered services – including mental health and substance abuse services. For the GOLD and SILVER medical plans, it does not apply to fixed dollar copays and private duty nursing coinsurance amounts. For the BRONZE and COPPER medical plans, your coinsurance dollar maximum combines coinsurance and copay amounts paid under your Simply Blue HSA medical coverage and your Simply Blue prescription drug coverage.

9 Hearing care coverage includes: audiometric exam (once every 36 months), hearing aid evaluation (once every 36 months), ordering and fitting the hearing aid (once every 36 months), and hearing aid conformity test (once every 36 months). Refer to the BCBSM Summary of Benefits for additional details.

10 For mental health and substance abuse treatment, refer to the BCBSM Summary of Benefits for additional details including limits on the number of visits.

11 Specified human organ transplants and bone marrow transplants are allowed in designated facilities only, when coordinated through the BCBSM Human Organ Transplant Program – (800) 242-3504.

12 Specified human organ transplants are limited to $1 million lifetime maximum per member per transplant type for transplant procedure(s) and related professional, hospital and pharmacy service.

13 The 20% prescription drug out-of-network copay will not be applied toward your calendar year deductible, out-of-pocket maximum or lifetime maximum.

14 BCBSM custom formulary. 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 formulary 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, making them the most cost-effective option for the treatment. Tier 2 (formulary brand) – Tier 2 includes brand-name drugs from the Custom Formulary. Formulary options are also safe and effective, but require a higher copay. Tier 3 (nonformulary brand) – Tier 3 contains brand-name drugs not included in the Custom Formulary. Members pay the highest copay for these drugs.

15 Mandatory preauthorization. A process that requires a physician to obtain approval from BCBSM before select prescription drugs (drugs identified by BCBSM as requiring preauthorization) 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. Some over-the-counter medications may be covered under step therapy guidelines. This also applies to mail order drugs. Only claims that do not meet Step Therapy criteria require preauthorization. Details about which drugs require preauthorization or step therapy are available online site at bcbsm.com. Log in under “I am a Member” and click on “Prescription Drugs.”

16 Mandatory maximum allowable Cost (MAC) drugs. If your prescription is filled by any type of network pharmacy, and the pharmacist fills it with a generic equivalent drug, you pay only the copay. If you obtain a formulary brand name drug when a generic equivalent drug is available, you MUST pay the difference in cost between the formulary brand name drug dispensed and the maximum allowable cost for the generic drug plus your copay regardless of whether you or your doctor requests the formulary brand name drug. If you obtain a nonformulary brand-name drug when a generic equivalent is available, the nonformulary brand-name drug is not a covered benefit. Exception: If your physician requests and receives authorization for a nonformulary brand-name drug with a generic equivalent from BCBSM and writes “Dispense as Written” or “DAW” on the prescription order, you pay only your applicable copay

17 Physician-administered injectable drugs. Injectable drugs administered by a health care professional (not self-administered) are not covered under the pharmacy benefit, but may be covered under your medical benefit.

18 Drug interchange and generic copay waiver. Certain drugs may not be covered for a second prescription if a suitable alternate drug is identified by BCBSM, unless the prescribing physician demonstrates that the drug is medically necessary. A list of drugs that may require authorization is available at bcbsm.com. If your physician rewrites your prescription for the recommended generic or OTC alternate drug, you will only have to pay a generic copay. If your physician rewrites your prescription for the recommended brand-name alternate drug, you will have to pay a brand-name copay. In select cases BCBSM may waive the initial copay after your prescription has been rewritten. BCBSM will notify you if you are eligible for a waiver

19 Quantity limits. Select drugs may have limitations related to quantity and doses allowed per prescription unless the prescribing physician obtains preauthorization from BCBSM. A list of these drugs is available at bcbsm.com.

20 No more than $100.

21 Coverage for expenses incurred by a covered person for physical exams, preventive screening tests and services, and any other tests or preventive measures determined to be appropriate by the attending physician.

22 If any of the cancer screening tests are not covered by Medicare, the plan will pay the usual and customary charges incurred.

23 Semi-private room and board, general nursing, and miscellaneous services and supplies

24 A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

25 In or out of the hospital and out-patient hospital treatment, such as physician’s services, in-patient and out-patient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment.

26 Blood deductible applies to hospital confinement and out-patient medical expenses, when furnished by a hospital or skilled nursing facility during a covered stay.

27 Semi-private room and board, skilled nursing and rehabilitative services and other services and supplies.

28 You must meet Medicare requirements, including having been in a hospital for at least three consecutive days and having entered a Medicare-approved facility within 30 days of discharge from the hospital.

29 Supportive services needed for care and pain relief for terminally ill patients provided by a Medicare-participating hospice program when the patient elects this type of care.

30 BCBSM custom formulary. 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 formulary 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, making them the most cost-effective option for the treatment. Tier 2 (formulary brand) – Tier 2 includes brand-name drugs from the Custom Formulary. Formulary options are also safe and effective, but require a higher copay. Tier 3 (nonformulary brand) – Tier 3 contains brand-name drugs not included in the Custom Formulary. Members pay the highest copay for these drugs.

31 Mandatory preauthorization. A process that requires a physician to obtain approval from BCBSM before select prescription drugs (drugs identified by BCBSM as requiring preauthorization) 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. Some over-the-counter medications may be covered under step therapy guidelines. This also applies to mail order drugs. Only claims that do not meet Step Therapy criteria require preauthorization. Details about which drugs require preauthorization or step therapy are available online site at bcbsm.com. Log in under “I am a Member” and click on “Prescription Drugs.”

32 Mandatory maximum allowable Cost (MAC) drugs. If your prescription is filled by any type of network pharmacy, and the pharmacist fills it with a generic equivalent drug, you pay only the copay. If you obtain a formulary brand name drug when a generic equivalent drug is available, you MUST pay the difference in cost between the formulary brand name drug dispensed and the maximum allowable cost for the generic drug plus your copay regardless of whether you or your doctor requests the formulary brand name drug. If you obtain a nonformulary brand-name drug when a generic equivalent is available, the nonformulary brand-name drug is not a covered benefit. Exception: If your physician requests and receives authorization for a nonformulary brand-name drug with a generic equivalent from BCBSM and writes “Dispense as Written” or “DAW” on the prescription order, you pay only your applicable copay

33 Physician-administered injectable drugs. Injectable drugs administered by a health care professional (not self-administered) are not covered under the pharmacy benefit, but may be covered under your medical benefit.

34 Drug interchange and generic copay waiver. Certain drugs may not be covered for a second prescription if a suitable alternate drug is identified by BCBSM, unless the prescribing physician demonstrates that the drug is medically necessary. A list of drugs that may require authorization is available at bcbsm.com. If your physician rewrites your prescription for the recommended generic or OTC alternate drug, you will only have to pay a generic copay. If your physician rewrites your prescription for the recommended brand-name alternate drug, you will have to pay a brand-name copay. In select cases BCBSM may waive the initial copay after your prescription has been rewritten. BCBSM will notify you if you are eligible for a waiver

35 Quantity limits. Select drugs may have limitations related to quantity and doses allowed per prescription unless the prescribing physician obtains preauthorization from BCBSM. A list of these drugs is available at bcbsm.com.