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Confidence comes with every card.®

Effective January 1, 2016

Small group plan options

The charts in this brochure are intended as easy-to-read summaries and provide only a general overview of your benefits. This summary of benefits brochure is not a contract. An official description of benefits is contained in applicable Blue Care Network of Michigan certificates and riders. Payment amounts are based on the Blue Care Network approved amount, less any applicable deductible, copayment and coinsurance amounts required by the plan. 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 the member’s primary care physician or health plan, except for Blue Elect PlusSM option plans.

1


Effective 1/1/16

DefinitionsThe benefit year is the one-year (12-month) period designated by the employer and BCN.

The copayment (or copay) is a fixed amount of the BCN-approved amount the member must pay directly to a provider at the time he or she receives covered services and supplies. The copays are listed in the member’s Certificate of Coverage or riders. Copays for “basic health services” may not exceed 50 percent of the approved amount, per Michigan law.

The coinsurance is the member’s share of the costs of a covered service calculated as a percentage of the BCN approved amount. The member may owe this amount after paying any deductible. BCN pays the remainder of the allowed amount. The coinsurance applies to the out-of-pocket maximum.

The annual coinsurance maximum is the most coinsurance a member will pay toward a covered service during a benefit year. Once the maximum is reached, the member will not pay any coinsurance for the remainder of the benefit year, except for those services that are exempt from the coinsurance maximum. These are defined in the member’s Certificate of Coverage and riders.

The deductible is the amount the member must pay before BCN pays for covered services listed in the “Your Benefits” section of the member certificate.

The deductible renews each calendar year or benefit year. With the exception of the high deductible health plan, a deductible paid during the last three months of the calendar year or benefit year is carried over into the new calendar year or benefit year.

The out-of-pocket maximum is the most the member has to pay for covered services during a calendar year. The out-of-pocket maximum includes the medical and pharmacy deductible, copay and coinsurance. This limit never includes the premium, balance billed charges or health care services that BCN does not cover. The out-of-pocket maximum amount may be amended when a rider is attached.

Enrollment guidelines All documents that constitute the terms and agreements between BCN and your organization must be submitted to your Blue Cross Blue Shield of Michigan/BCN sales representative or independent agent at least 25 days before a new group’s effective date or 45 days before an existing group’s effective date.

Eligibility guidelines Enrollment requirements are determined by the number of eligible employees in your group as reported on your payroll record in the preceding and current calendar years. Eligible employees who elect BCBSM coverage will be counted toward your participation requirement. The following participation calculation applies to groups of 50 or fewer full-time equivalent employees and determines if your group meets the BCBSM/BCN participation percentage requirement:

Adjusted eligible employees is the number of eligible employees minus those who opt out of coverage minus those covered by spouse, other employer or a prior retirement plan.

Participation percentage is the number of BCBSM and BCN eligible employees enrolled divided by the adjusted eligible employees.

Participation requirements The following table identifies the participation percentage requirements that apply to groups of 50 or fewer full-time equivalent employees:

Group size Renewal and new business participation percentage

requirement

10 or fewer eligible employees 100 percent

11 to 25 eligible employees 75 percent

26 to 50 eligible employees 50 percent

2

Medical coverage options

BCN Healthy Blue LivingSM HMOBCN Healthy Blue Living offers solid, affordable coverage while putting employees in control of their health. On average, businesses save 8 to 12 percent with Healthy Blue Living (as compared with traditional HMO products). The plan focuses on six areas that directly affect health: blood pressure, blood sugar, cholesterol, depression, tobacco use and weight. We provide members the tools and resources they need to address each area and improve their health.

Deductible plansEmployers can customize their plans by selecting deductibles that are appropriate for their group. We offer options with and without coinsurance.

BCN HSASM HMOOur BCN HMO bronze, silver and gold plans can be coupled with a health savings account to provide quality coverage with convenient, integrated account management. You have a choice of multiple deductible, coinsurance and out-of-pocket maximum designs to meet your business needs and budget.

BCN HRASM HMOOur health reimbursement account gives members a full spectrum of health care at a great value by increasing member responsibility for health care decisions and expenses. Employers can pair gold and platinum plans with an employer-funded health reimbursement account to help employees pay for qualified medical expenses.

Blue Elect Plus Self Referral OptionThis product offers a gold medal plan and combines comprehensive coverage with the flexibility to choose a hospital or provider in or out of our Michigan network.

Members first select a BCN primary care doctor and then have the option to seek care from other doctors and specialists, usually without needing a referral. They pay the most when the doctor doesn’t participate with BCN or any Blue Cross plan.

PCP FocusThe PCP Focus network offers efficient managed care through a tailored primary care physician network in 21 Michigan counties. Groups that pair PCP Focus with select BCN HMO or HSA plans can save between 6 and 9 percent in premiums.

PCP Focus is available to groups with 1 to 50 enrolled members physically located in these counties:

Bay, Calhoun, Clinton, Eaton, Genesee, Ingham, Kalamazoo, Kent, Livingston, Macomb, Monroe, Muskegon, Oakland, Ottawa, Saginaw, Shiawassee, St. Clair, Van Buren, Washtenaw, Wayne

Members living in these counties can choose from a large number of primary care physicians in the local network, while continuing to have the flexibility to see almost any BCN specialist in the state.

BCN routine careBCN is offering reform-compliant plans for value-oriented customers who want “first dollar” coverage for routine care including PCP office visits, lab services and Tier 1 prescription drugs. Fixed dollar copays apply to PCP office visits and Tier 1 drugs, but members don’t have to meet a deductible for these services. An integrated deductible applies to all other medical and pharmacy services.

Drug listsThe BCBSM and BCN Comprehensive Drug List includes more than 2,600 drugs that are approved by the U.S. Food and Drug Administration and reviewed by the BCBSM and BCN Pharmacy and Therapeutics Committee. Medications are selected based on clinical effectiveness, safety and opportunity for cost savings.

The BCBSM and BCN Custom Select Drug List provides lower cost and better value for a customer’s health care dollars. The drug list includes more than 1,400 drugs.

3


Effective 1/1/16

Dental optionsAll small group dental plans include essential dental benefits for pediatric members.1

Blue Dental PPOSM

Deductible(Individual/Family)

Annual max2

(No more than this amount can be used out of network.)

Lifetime max3

(For optional ortho)IN OUT

NONVOLUNTARY

Blue Dental PPO Plus SG 100/80/50 $25/$75 $1,000 or $1,500 $1,000 or $1,500

Blue Dental PPO Plus SG 80/50/50 $25/$75 $1,000 $1,000

Blue Dental PPO SG 100/80/50 (80/50/50) $25/$75 $50/$150 $1,250 ($800) $1,250

Blue Dental PPO SG 100/80/50 (50/50/50) $25/$75 $50/$150 $1,000 or $1,500 $1,000 or $1,500

Blue Dental PPO SG 80/60/50 (50/50/50) $25/$75 $50/$150 $1,000 ($800) or $800 $1,000 ($800) or $800

Blue Dental EPO SG 100/80/50 $25/$75 $1,250 $1,250

VOLUNTARY4

Blue Dental PPO Plus Voluntary SG 100/80/50 $25/$75 $1,000 $1,000

Blue Dental PPO Plus Voluntary SG 80/50/50 $25/$75 $1,000 $1,000

Blue Dental PPO Voluntary SG 100/80/50 (80/50/50) $25/$75 $50/$150 $1,250 ($800) or $1,000 ($800) $1,000

Blue Dental PPO Voluntary SG 80/50/50 (50/50/50) $25/$75 $50/$150 $1,000 ($800) $1,000

Blue Dental EPO Voluntary SG 100/80/50 $25/$75 $1,250 $1,2501Members who are 18 or younger when their coverage begins are considered pediatric members until the end of the plan year in which they turn age 19.2Annual max does not apply to pediatric members.3Lifetime max does apply to pediatric members.4Voluntary dental plans require a minimum participation of 30% of the total eligible employees with at least 10 employees enrolled.

Vision optionsAll small group vision plans are adults only; essential vision benefits for pediatric members1 are packaged with the medical plans.

Blue VisionSM Frequency exam-lenses-frames

Annual allowance for materials Exam copay Materials copay Network

NONVOLUNTARY

Blue Vision SG 12-12-12

Once every12 months - 12 months - 12 months

$130 $5 $10 VSP Choice







VOLUNTARY2

Blue Vision Voluntary SG 12-12-24


$130 $10 $25 VSP Choice



1Members who are 18 or younger when their coverage begins are considered pediatric members until the end of the plan year in which they turn age 19. 2Voluntary vision plans require a minimum participation of 30% of the total eligible employees with at least 10 employees enrolled.

Coverage changesGroups can make a coverage change (groupwide change) once per plan year. The change cannot take place in the last quarter of a group’s plan year.

Upon request, BCN will supply the following information:

A disclosure of BCN’s right to change premium rates and the factors that may affect premium rates.

The provisions of coverage relating to renewability.

The premiums available under all health insurance coverage for which your company is qualified.

4 1These services don’t apply to the annual coinsurance maximum.Notes: Blue Elect Plus doesn’t require a referral. Voluntary first trimester termination of pregnancy not covered for products purchased on the Marketplace.

Benefits at a glance Blue Elect Plus Self Referral Option Gold $1000 BCN HMO packages without deductible

In Network Out of Network BCN HMO Platinum 10% BCN HMO Platinum 20% BCN HMO Gold 30% Deductible and out-of-pocket maximum

Deductible $1,000/$2,000 $2,000/$4,000 None None None

Annual coinsurance maximum $2,500/$5,000 $5,000/$10,000 $1,000/$2,000 $1,000/$2,000 $5,500/$11,000

Out-of-pocket maximum $6,600/$13,200 $13,200/$26,400 $5,000/$10,000 $6,600/$13,200 $6,600/$13,200

Physician office services

Routine office visits $20 copay per visit 40% coinsurance after deductible $20 copay per visit $25 copay per visit $30 copay per visit

Consulting specialist care (when referred) $40 copay per visit 40% coinsurance after deductible $30 copay per visit $35 copay per visit $40 copay per visit

Preventive services (as defined by the Affordable Care Act)

Adult physical exams; newborn and well-child exams Covered in full Not covered Covered in full Covered in full Covered in full

Immunizations Covered in full Not covered Covered in full Covered in full Covered in full

Mammography screening Covered in full 40% coinsurance after deductible Covered in full Covered in full Covered in full

Pap smears (lab services) Covered in full Not covered Covered in full Covered in full Covered in full

Prostate specific antigen screening (lab services) Covered in full Not covered Covered in full Covered in full Covered in full

Routine prenatal care Covered in full 40% coinsurance after deductible Covered in full Covered in full Covered in full

Voluntary female sterilization Covered in full Not covered Covered in full Covered in full Covered in full

Diagnostic and therapeutic procedures

Laboratory tests Covered in full Covered in full Covered in full Covered in full Covered in full

Diagnostic X-rays 20% coinsurance after deductible 40% coinsurance after deductible 10% coinsurance 20% coinsurance 30% coinsurance

High-tech imaging $150 copay per visit 40% coinsurance after deductible $150 copay per visit $150 copay per visit $150 copay per visit

Radiation therapy 20% coinsurance after deductible 40% coinsurance after deductible 10% coinsurance 20% coinsurance 30% coinsurance

Maternity services provided by a physician

Postnatal and nonroutine prenatal care $20 copay per visit 40% coinsurance after deductible $20 copay per visit $25 copay per visit $30 copay per visit

Delivery in hospital and well-baby care in hospital (See “Inpatient hospital care” for facility charges.)

20% coinsurance after deductible 40% coinsurance after deductible Covered in full Covered in full Covered in full

Inpatient hospital care

Inpatient hospital services 20% coinsurance after deductible 40% coinsurance after deductible 10% coinsurance 20% coinsurance 30% coinsurance

Emergency medical care

Hospital emergency room (copay waived if admitted) $150 copay per visit $150 copay per visit $150 copay per visit $150 copay per visit $150 copay per visit

Urgent care center $50 copay per visit $50 copay per visit $35 copay per visit $35 copay per visit $35 copay per visit

Ground and air ambulance services (when medically necessary) $50 copay per visit $50 copay per visit 10% coinsurance 20% coinsurance 30% coinsurance

Mental health care and substance abuse services

Outpatient visits $20 copay per visit 40% coinsurance after deductible $20 copay per visit $25 copay per visit $30 copay per visit


Skilled nursing care

Skilled nursing facility care (limited to 45 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible 10% coinsurance 20% coinsurance 30% coinsurance

In-network and out-of-network days count toward 45-day limit

Other services

Applied behavioral analyses (ABA) treatment $20 copay per visit 40% coinsurance after deductible $20 copay per visit $25 copay per visit $30 copay per visit

Physical, speech and occupational therapy for autism spectrum disorder (through age 18) – unlimited visits

$40 copay per visit 40% coinsurance after deductible $30 copay per visit $35 copay per visit $40 copay per visit

Prosthetics, orthotics and durable medical equipment (when medically necessary)1

Covered in full Not covered 50% coinsurance 50% coinsurance 50% coinsurance

Diabetic supplies1 Covered in full Not covered 10% coinsurance 20% coinsurance 30% coinsurance

Infertility counseling/treatment (excludes in-vitro)1 50% coinsurance after deductlble Not covered 50% coinsurance 50% coinsurance 50% coinsurance

Voluntary male sterilization1 20% coinsurance after deductible2 Not covered 50% coinsurance 50% coinsurance 50% coinsurance

Allergy testing, evaluation and serum; injections1 Covered in full (Includes injections) 50% coinsurance after deductible, including injections 50% coinsurance, $5 injections 50% coinsurance, $5 injections 50% coinsurance, $5 injections

Physical and occupational therapy (combined 30 visits per calendar year)


Combined in- and out-of-network 30-visit limit per calendar year

Speech therapy (30 visits per calendar year) $40 copay per visit 40% coinsurance after deductible $30 copay per visit $35 copay per visit $40 copay per visit


Habilitative physical and occupational therapy (30 visits per calendar year)



Habilitative speech therapy (30 visits per calendar year) $40 copay per visit 40% coinsurance after deductible $20 copay per visit $25 copay per visit $30 copay per visit


Spinal manipulation provided by a participating chiropractor or osteopathic physician (30 visits per calendar year when referred)

$40 copay per visit Not covered $30 copay per visit $35 copay per visit $40 copay per visit

Weight-reduction procedures1 (limited to one procedure per lifetime)

50% coinsurance after deductlble Not covered Covered in full 50% coinsurance 50% coinsurance

Prescription drugs (30-day supply)

Note: The copay/coinsurance is three times the 30-day copay minus $10 for:Retail – 84-90 day supplyMail order – 31-90 day supply

Tier 1A Preferred generics – $4 copay Tier 1A Preferred generics – $4 copay Tier 1A Preferred generics – $4 copay Tier 1A Preferred generics – $6 copay

Tier 1B Generics – $15 copay Tier 1B Generics – $15 copay Tier 1B Generics – $15 copay Tier 1B Generics – $25 copay

Tier 2 Preferred brand – $40 copay Tier 2 Preferred brand – $40 copay Tier 2 Preferred brand – $40 copay Tier 2 Preferred brand – $50 copay

Tier 3 Nonpreferred brand – $80 copay Tier 3 Nonpreferred brand – $80 copay Tier 3 Nonpreferred brand – $80 copay Tier 3 Nonpreferred brand – $80 copay

Tier 4 Preferred specialty – 20% coinsurance (max $200 copay)




Tier 5 Nonpreferred specialty – 20% coinsurance (max $300 copay)




5Effective 1/1/16Note: HMO Platinum 10% and 20% packages available with the Comprehensive Drug List.

Benefits at a glance Blue Elect Plus Self Referral Option Gold $1000 BCN HMO packages without deductible

In Network Out of Network BCN HMO Platinum 10% BCN HMO Platinum 20% BCN HMO Gold 30% Deductible and out-of-pocket maximum

Deductible $1,000/$2,000 $2,000/$4,000 None None None

Annual coinsurance maximum $2,500/$5,000 $5,000/$10,000 $1,000/$2,000 $1,000/$2,000 $5,500/$11,000



Routine office visits $20 copay per visit 40% coinsurance after deductible $20 copay per visit $25 copay per visit $30 copay per visit

Consulting specialist care (when referred) $40 copay per visit 40% coinsurance after deductible $30 copay per visit $35 copay per visit $40 copay per visit


Adult physical exams; newborn and well-child exams Covered in full Not covered Covered in full Covered in full Covered in full

Immunizations Covered in full Not covered Covered in full Covered in full Covered in full

Mammography screening Covered in full 40% coinsurance after deductible Covered in full Covered in full Covered in full

Pap smears (lab services) Covered in full Not covered Covered in full Covered in full Covered in full

Prostate specific antigen screening (lab services) Covered in full Not covered Covered in full Covered in full Covered in full

Routine prenatal care Covered in full 40% coinsurance after deductible Covered in full Covered in full Covered in full

Voluntary female sterilization Covered in full Not covered Covered in full Covered in full Covered in full


Laboratory tests Covered in full Covered in full Covered in full Covered in full Covered in full

Diagnostic X-rays 20% coinsurance after deductible 40% coinsurance after deductible 10% coinsurance 20% coinsurance 30% coinsurance

High-tech imaging $150 copay per visit 40% coinsurance after deductible $150 copay per visit $150 copay per visit $150 copay per visit

Radiation therapy 20% coinsurance after deductible 40% coinsurance after deductible 10% coinsurance 20% coinsurance 30% coinsurance


Postnatal and nonroutine prenatal care $20 copay per visit 40% coinsurance after deductible $20 copay per visit $25 copay per visit $30 copay per visit


20% coinsurance after deductible 40% coinsurance after deductible Covered in full Covered in full Covered in full




Hospital emergency room (copay waived if admitted) $150 copay per visit $150 copay per visit $150 copay per visit $150 copay per visit $150 copay per visit


Ground and air ambulance services (when medically necessary) $50 copay per visit $50 copay per visit 10% coinsurance 20% coinsurance 30% coinsurance


Outpatient visits $20 copay per visit 40% coinsurance after deductible $20 copay per visit $25 copay per visit $30 copay per visit



Skilled nursing facility care (limited to 45 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible 10% coinsurance 20% coinsurance 30% coinsurance

In-network and out-of-network days count toward 45-day limit

Other services

Applied behavioral analyses (ABA) treatment $20 copay per visit 40% coinsurance after deductible $20 copay per visit $25 copay per visit $30 copay per visit



Prosthetics, orthotics and durable medical equipment (when medically necessary)1

Covered in full Not covered 50% coinsurance 50% coinsurance 50% coinsurance

Diabetic supplies1 Covered in full Not covered 10% coinsurance 20% coinsurance 30% coinsurance

Infertility counseling/treatment (excludes in-vitro)1 50% coinsurance after deductlble Not covered 50% coinsurance 50% coinsurance 50% coinsurance

Voluntary male sterilization1 20% coinsurance after deductible2 Not covered 50% coinsurance 50% coinsurance 50% coinsurance

Allergy testing, evaluation and serum; injections1 Covered in full (Includes injections) 50% coinsurance after deductible, including injections 50% coinsurance, $5 injections 50% coinsurance, $5 injections 50% coinsurance, $5 injections

Physical and occupational therapy (combined 30 visits per calendar year)



Speech therapy (30 visits per calendar year) $40 copay per visit 40% coinsurance after deductible $30 copay per visit $35 copay per visit $40 copay per visit





Habilitative speech therapy (30 visits per calendar year) $40 copay per visit 40% coinsurance after deductible $20 copay per visit $25 copay per visit $30 copay per visit



$40 copay per visit Not covered $30 copay per visit $35 copay per visit $40 copay per visit


50% coinsurance after deductlble Not covered Covered in full 50% coinsurance 50% coinsurance


Note: The copay/coinsurance is three times the 30-day copay minus $10 for:Retail – 84-90 day supplyMail order – 31-90 day supply













61PCP Focus available for this plan.2These services don’t apply to the annual coinsurance maximum.

Notes: Voluntary first trimester termination of pregnancy not covered for products purchased on the Marketplace. HMO Platinum $500 available with the Comprehensive Drug List.

Benefits at a glance BCN HMO deductible packages BCN HMO deductible packages1BCN HMO Platinum $500 BCN HMO Gold $500/10% 1BCN HMO Gold $1,000 1BCN HMO Gold $1,500 1BCN HMO Gold $2,000 1BCN HMO Silver $3,000

Deductible and out-of-pocket maximum

Deductible $500/$1,000 $500/$1,000 $1,000/$2,000 $1,500/$3,000 $2,000/$4,000 $3,000/$6,000

Annual coinsurance maximum None $2,500/$5,000 $2,500/$5,000 $1,500/$3,000 $1,000/$2,000 $3,500/$7,000

Out-of-pocket maximum $1,000/$2,000 $6,600/$13,200 $6,600/$13,200 $6,600/$13,200 $6,600/$13,200 $6,600/$13,200


Routine office visits $20 copay per visit $20 copay per visit $20 copay per visit $20 copay per visit $20 copay per visit $30 copay per visit

Consulting specialist care (when referred) $30 copay per visit $40 copay per visit $40 copay per visit $40 copay per visit $40 copay per visit $50 copay per visit


Adult physical exams; newborn and well-child exams Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full

Immunizations Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full

Mammography screening Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full

Pap smears (lab services) Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full

Prostate specific antigen screening (lab services) Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full

Routine prenatal care Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full

Voluntary female sterilization Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full


Laboratory tests Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full

Diagnostic X-rays Covered in full after deductible 10% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible

High-tech imaging $150 copay per visit after deductible $150 copay per visit after deductible $150 copay per visit after deductible $150 copay per visit after deductible $150 copay per visit after deductible $150 copay per visit after deductible

Radiation therapy Covered in full after deductible 10% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible


Postnatal and nonroutine prenatal care $20 copay per visit $20 copay per visit $20 copay per visit $20 copay per visit $20 copay per visit $30 copay per visit


Covered in full after deductible Covered in full after deductible Covered in full after deductible Covered in full after deductible Covered in full after deductible Covered in full after deductible


Inpatient hospital services Covered in full after deductible 10% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible


Hospital emergency room (copay waived if admitted) $150 copay per visit after deductible $150 copay per visit after deductible $150 copay per visit after deductible $150 copay per visit after deductible $150 copay per visit after deductible $250 copay per visit after deductible

Urgent care center $35 copay per visit $50 copay per visit $50 copay per visit $50 copay per visit $50 copay per visit $50 copay per visit

Ground and air ambulance services (when medically necessary) $25 copay after deductible 10% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible


Outpatient visits $20 copay per visit $20 copay per visit $20 copay per visit $20 copay per visit $20 copay per visit $30 copay per visit



Skilled nursing facility care (limited to 45 days per calendar year) Covered in full after deductible 10% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible

Other services

Applied behavioral analyses (ABA) treatment $20 copay per visit $20 copay per visit $20 copay per visit $20 copay per visit $20 copay per visit $30 copay per visit


$30 copay per visit after deductible $40 copay per visit after deductible $40 copay per visit after deductible $40 copay per visit after deductible $40 copay per visit after deductible $50 copay per visit after deductible

Prosthetics, orthotics and durable medical equipment2 (when medically necessary)

50% coinsurance 50% coinsurance 50% coinsurance 50% coinsurance 50% coinsurance 50% coinsurance

Diabetic supplies2 Covered in full 10% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance

Infertility counseling/treatment (excludes in-vitro)2 50% coinsurance after deductlble 50% coinsurance after deductlble 50% coinsurance after deductlble 50% coinsurance after deductlble 50% coinsurance after deductlble 50% coinsurance after deductlble

Voluntary male sterilization2 50% coinsurance after deductlble 50% coinsurance after deductlble 50% coinsurance after deductlble 50% coinsurance after deductlble 50% coinsurance after deductlble 50% coinsurance after deductlble

Allergy testing, evaluation and serum; injections 50% coinsurance after deductible $5 injections

50% coinsurance after deductible $5 injections





Physical and occupational therapy (Combined 30 visits per calendar year)


Speech therapy (30 visits per calendar year) $30 copay per visit after deductible $40 copay per visit after deductible $40 copay per visit after deductible $40 copay per visit after deductible $40 copay per visit after deductible $50 copay per visit after deductible



Habilitative speech therapy (30 visits per calendar year) $20 copay per visit after deductible $40 copay per visit after deductible $40 copay per visit after deductible $40 copay per visit after deductible $40 copay per visit after deductible $50 copay per visit after deductible


$30 copay per visit $40 copay per visit $40 copay per visit $40 copay per visit $40 copay per visit $50 copay per visit


50% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible


Note: The copay/coinsurance is three times the 30-day copay minus $10 for:

Retail – 84-90 day supply

Mail order – 31-90 day supply

Tier 1A Preferred generics – $4 copay Tier 1A Preferred generics – $10 copay Tier 1A Preferred generics – $4 copay Tier 1A Preferred generics – $4 copay Tier 1A Preferred generics – $4 copay Tier 1A Preferred generics – $6 copay

Tier 1B Generics – $15 copay Tier 1B Generics – $30 copay Tier 1B Generics – $15 copay Tier 1B Generics – $15 copay Tier 1B Generics – $15 copay Tier 1B Generics – $25 copay

Tier 2 Preferred brand – $40 copay Tier 2 Preferred brand – $60 copay Tier 2 Preferred brand – $40 copay Tier 2 Preferred brand – $40 copay Tier 2 Preferred brand – $40 copay Tier 2 Preferred brand – $50 copay

Tier 3 Nonpreferred brand – $80 copay Tier 3 Nonpreferred brand – $80 copay Tier 3 Nonpreferred brand – $80 copay Tier 3 Nonpreferred brand – $80 copay Tier 3 Nonpreferred brand – $80 copay Tier 3 Nonpreferred brand – $80 copay













7Effective 1/1/161PCP Focus available with this plan.

Benefits at a glance BCN HMO deductible packages BCN HMO deductible packages1BCN HMO Platinum $500 BCN HMO Gold $500/10% 1BCN HMO Gold $1,000 1BCN HMO Gold $1,500 1BCN HMO Gold $2,000 1BCN HMO Silver $3,000


Deductible $500/$1,000 $500/$1,000 $1,000/$2,000 $1,500/$3,000 $2,000/$4,000 $3,000/$6,000

Annual coinsurance maximum None $2,500/$5,000 $2,500/$5,000 $1,500/$3,000 $1,000/$2,000 $3,500/$7,000















Diagnostic X-rays Covered in full after deductible 10% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible


Radiation therapy Covered in full after deductible 10% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible










Ground and air ambulance services (when medically necessary) $25 copay after deductible 10% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible





Skilled nursing facility care (limited to 45 days per calendar year) Covered in full after deductible 10% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible

Other services






Diabetic supplies2 Covered in full 10% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance







































8

1 PCP Focus availble for this planNotes: Benefit year option available only to HRA packages Voluntary first trimester termination of pregnancy not covered for procucts purchased on the Marketplace

Benefits at a glance BCN HMO deductible packages

BCN HMO Silver $4,000 1BCN HMO Silver $4,000/30%Deductible and out-of-pocket maximum

Deductible $4,000/$8,000 $4,000/$8,000

Annual coinsurance maximum None $2,000/$4,000

Out-of-pocket maximum $1,000/$2,000 $6,600/$13,200


Routine office visits $30 copay per visit $35 copay per visit

Consulting specialist care (when referred) $45 copay per visit $45 copay per visit


Adult physical exams; newborn and well-child exams Covered in full Covered in full

Immunizations Covered in full Covered in full

Mammography screening Covered in full Covered in full

Pap smears (lab services) Covered in full Covered in full

Prostate specific antigen screening (lab services) Covered in full Covered in full

Routine prenatal care Covered in full Covered in full

Voluntary female sterilization Covered in full Covered in full


Laboratory tests Covered in full Covered in full

Diagnostic X-rays Covered in full after deductible 30% coinsurance after deductible

High-tech imaging $150 copay per visit after deductible $150 copay per visit after deductible

Radiation therapy Covered in full after deductible 30% coinsurance after deductible


Postnatal and nonroutine prenatal care $30 copay per visit $35 copay per visit


Covered in full after deductible Covered in full after deductible


Inpatient hospital services Covered in full after deductible 30% coinsurance after deductible


Hospital emergency room (copay waived if admitted) $150 copay per visit after deductible $250 copay per visit after deductible

Urgent care center $50 copay per visit $50 copay per visit

Ground and air ambulance services (when medically necessary) $25 copay after deductible 30% coinsurance after deductible


Outpatient visits $30 copay per visit $35 copay per visit



Skilled nursing facility care (limited to 45 days per calendar year) Covered in full after deductible 30% coinsurance after deductible

Other services

Applied behavioral analyses (ABA) treatment $30 copay per visit $35 copay per visit


$45 copay per visit after deductible $45 copay per visit after deductible


50% coinsurance 50% coinsurance

Diabetic supplies2 Covered in full 30% coinsurance

Infertility counseling/treatment (excludes in-vitro)2 50% coinsurance after deductlble 50% coinsurance after deductlble

Voluntary male sterilization2 50% coinsurance after deductlble 50% coinsurance after deductlble





Speech therapy (30 visits per calendar year) $45 copay per visit after deductible $45 copay per visit after deductible



Habilitative speech therapy (30 visits per calendar year) $45 copay per visit after deductible $50 copay per visit after deductible


$45 copay per visit $45 copay per visit


50% coinsurance after deductible 50% coinsurance after deductible





Tier 1A Preferred generics – $6 copay Tier 1A Preferred generics – $6 copay

Tier 1B Generics – $25 copay Tier 1B Generics – $25 copay

Tier 2 Preferred brand – $50 copay Tier 2 Preferred brand – $50 copay

Tier 3 Nonpreferred brand – $80 copay Tier 3 Nonpreferred brand – $80 copay





9Effective 1/1/16

Benefits at a glance BCN HMO deductible packages

BCN HMO Silver $4,000 1BCN HMO Silver $4,000/30%Deductible and out-of-pocket maximum

Deductible $4,000/$8,000 $4,000/$8,000

Annual coinsurance maximum None $2,000/$4,000



Routine office visits $30 copay per visit $35 copay per visit

Consulting specialist care (when referred) $45 copay per visit $45 copay per visit


Adult physical exams; newborn and well-child exams Covered in full Covered in full








Laboratory tests Covered in full Covered in full

Diagnostic X-rays Covered in full after deductible 30% coinsurance after deductible

High-tech imaging $150 copay per visit after deductible $150 copay per visit after deductible

Radiation therapy Covered in full after deductible 30% coinsurance after deductible


Postnatal and nonroutine prenatal care $30 copay per visit $35 copay per visit


Covered in full after deductible Covered in full after deductible




Hospital emergency room (copay waived if admitted) $150 copay per visit after deductible $250 copay per visit after deductible

Urgent care center $50 copay per visit $50 copay per visit

Ground and air ambulance services (when medically necessary) $25 copay after deductible 30% coinsurance after deductible


Outpatient visits $30 copay per visit $35 copay per visit



Skilled nursing facility care (limited to 45 days per calendar year) Covered in full after deductible 30% coinsurance after deductible

Other services

Applied behavioral analyses (ABA) treatment $30 copay per visit $35 copay per visit




50% coinsurance 50% coinsurance

Diabetic supplies2 Covered in full 30% coinsurance

Infertility counseling/treatment (excludes in-vitro)2 50% coinsurance after deductlble 50% coinsurance after deductlble

Voluntary male sterilization2 50% coinsurance after deductlble 50% coinsurance after deductlble





Speech therapy (30 visits per calendar year) $45 copay per visit after deductible $45 copay per visit after deductible



Habilitative speech therapy (30 visits per calendar year) $45 copay per visit after deductible $50 copay per visit after deductible


$45 copay per visit $45 copay per visit















10

Benefits at a glanceHRA deductible packages

BCN HRA HMO Platinum $1,500 (Employer Contribution $750)

BCN HRA HMO Platinum $2,000 (Employer Contribution $1,000)

1BCN HRA HMO Platinum $5,000 (Employer Contribution $3,500)

BCN HRA HMO Gold $2,000 (Employer Contribution $750)

BCN HRA HMO Gold $4,000 (Employer Contribution $1,500)

Deductible and out-of-pocket maximumDeductible $1,500/$3,000 $2,000/$4,000 $5,000/$10,000 $2,000/$4,000 $4,000/$8,000

Annual coinsurance maximum $500/$1,000 $500/$1,000 None $4,000/$8/000 None


Physician office servicesRoutine office visits $20 copay per visit $20 copay per visit $20 copay per visit $30 copay per visit $30 copay per visit

Consulting specialist care (when referred) $40 copay per visit $40 copay per visit $40 copay per visit $50 copay per visit $50 copay per visit

Preventive services (as defined by the Affordable Care Act)Adult physical exams; newborn and well-child exams Covered in full Covered in full Covered in full Covered in full Covered in full

Immunizations Covered in full Covered in full Covered in full Covered in full Covered in full

Mammography screening Covered in full Covered in full Covered in full Covered in full Covered in full

Pap smears (lab services) Covered in full Covered in full Covered in full Covered in full Covered in full

Prostate specific antigen screening (lab services) Covered in full Covered in full Covered in full Covered in full Covered in full

Routine prenatal care Covered in full Covered in full Covered in full Covered in full Covered in full

Voluntary female sterilization Covered in full Covered in full Covered in full Covered in full Covered in full

Diagnostic and therapeutic proceduresLaboratory tests Covered in full Covered in full Covered in full Covered in full Covered in full

Diagnostic X-rays 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible

High-tech imaging $150 copay per visit after deductible $150 copay per visit after deductible $150 copay per visit after deductible $150 copay per visit after deductible $150 copay per visit after deductible

Radiation therapy 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible

Maternity services provided by a physicianPostnatal and nonroutine prenatal care $20 copay per visit $20 copay per visit $20 copay per visit $30 copay per visit $30 copay per visit


Covered in full after deductible Covered in full after deductible Covered in full after deductible Covered in full after deductible Covered in full after deductible

Inpatient hospital careInpatient hospital services 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible

Emergency medical careHospital emergency room (copay waived if admitted) $150 copay per visit after deductible $150 copay per visit after deductible $150 copay per visit after deductible $150 copay per visit after deductible $150 copay per visit after deductible


Ground and air ambulance services (when medically necessary) 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible

Mental health care and substance abuse servicesOutpatient visits $20 copay per visit $20 copay per visit $20 copay per visit after deductible $30 copay per visit $30 copay per visit

Inpatient hospital services 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible

Skilled nursing careSkilled nursing facility care (limited to 45 days per calendar year) 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible

Other servicesApplied behavioral analyses (ABA) treatment $20 copay per visit $20 copay per visit $20 copay per visit $30 copay per visit $30 copay per visit


$40 copay per visit after deductible $40 copay per visit after deductible $40 copay per visit after deductible $50 copay per visit after deductible $50 copay per visit after deductible


50% coinsurance 50% coinsurance 50% coinsurance 50% coinsurance 50% coinsurance

Diabetic supplies1 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance

Infertility counseling/treatment (excludes in-vitro)1 50% coinsurance after deductlble 50% coinsurance after deductlble 50% coinsurance after deductlble 50% coinsurance after deductlble 50% coinsurance after deductlble

Voluntary male sterilization1 50% coinsurance after deductlble 50% coinsurance after deductlble 50% coinsurance after deductlble 50% coinsurance after deductlble 50% coinsurance after deductlble



50%coinsurance after deductible $5 injections





Speech therapy (30 visits per calendar year) $40 copay per visit after deductible $40 copay per visit after deductible $40 copay per visit after deductible $50 copay per visit after deductible $50 copay per visit after deductible



Habilitative speech therapy (30 visits per calendar year) $40 copay per visit after deductible $40 copay per visit after deductible $40 copay per visit after deductible $50 copay per visit after deductible $50 copay per visit after deductible


$40 copay per visit $40 copay per visit $40 copay per visit $50 copay per visit $50 copay per visit


50% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible

Prescription drugs (30-day supply)Note: The copay/coinsurance is three times the 30-day copay minus $10 for:



Tier 1A Preferred generics – $4 copay Tier 1A Preferred generics – $4 copay Tier 1A Preferred generics – $6 copay Tier 1A Preferred generics – $4 copay Tier 1A Preferred generics – $4 copay

Tier 1B Generics – $15 copay Tier 1B Generics – $15 copay Tier 1B Generics – $25 copay Tier 1B Generics – $15 copay Tier 1B Generics – $15 copay

Tier 2 Preferred brand – $40 copay Tier 2 Preferred brand – $40 copay Tier 2 Preferred brand – $50 copay Tier 2 Preferred brand – $40 copay Tier 2 Preferred brand – $40 copay

Tier 3 Nonpreferred brand – $80 copay Tier 3 Nonpreferred brand – $80 copay Tier 3 Nonpreferred brand – $80 copay Tier 3 Nonpreferred brand – $80 copay Tier 3 Nonpreferred brand – $80 copay











1These services don’t apply to the annual coinsurance maximum. Notes: Benefit year option available only with HRA packages. Voluntary first trimester termination of pregnancy not covered for products purchased on the Marketplace.

11Effective 1/1/16

Benefits at a glanceHRA deductible packages

BCN HRA HMO Platinum $1,500 (Employer Contribution $750)

BCN HRA HMO Platinum $2,000 (Employer Contribution $1,000)

1BCN HRA HMO Platinum $5,000 (Employer Contribution $3,500)

BCN HRA HMO Gold $2,000 (Employer Contribution $750)

BCN HRA HMO Gold $4,000 (Employer Contribution $1,500)

Deductible and out-of-pocket maximumDeductible $1,500/$3,000 $2,000/$4,000 $5,000/$10,000 $2,000/$4,000 $4,000/$8,000

Annual coinsurance maximum $500/$1,000 $500/$1,000 None $4,000/$8/000 None


Physician office servicesRoutine office visits $20 copay per visit $20 copay per visit $20 copay per visit $30 copay per visit $30 copay per visit

Consulting specialist care (when referred) $40 copay per visit $40 copay per visit $40 copay per visit $50 copay per visit $50 copay per visit

Preventive services (as defined by the Affordable Care Act)Adult physical exams; newborn and well-child exams Covered in full Covered in full Covered in full Covered in full Covered in full







Diagnostic and therapeutic proceduresLaboratory tests Covered in full Covered in full Covered in full Covered in full Covered in full

Diagnostic X-rays 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible

High-tech imaging $150 copay per visit after deductible $150 copay per visit after deductible $150 copay per visit after deductible $150 copay per visit after deductible $150 copay per visit after deductible

Radiation therapy 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible

Maternity services provided by a physicianPostnatal and nonroutine prenatal care $20 copay per visit $20 copay per visit $20 copay per visit $30 copay per visit $30 copay per visit


Covered in full after deductible Covered in full after deductible Covered in full after deductible Covered in full after deductible Covered in full after deductible

Inpatient hospital careInpatient hospital services 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible

Emergency medical careHospital emergency room (copay waived if admitted) $150 copay per visit after deductible $150 copay per visit after deductible $150 copay per visit after deductible $150 copay per visit after deductible $150 copay per visit after deductible


Ground and air ambulance services (when medically necessary) 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible

Mental health care and substance abuse servicesOutpatient visits $20 copay per visit $20 copay per visit $20 copay per visit after deductible $30 copay per visit $30 copay per visit

Inpatient hospital services 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible

Skilled nursing careSkilled nursing facility care (limited to 45 days per calendar year) 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible

Other servicesApplied behavioral analyses (ABA) treatment $20 copay per visit $20 copay per visit $20 copay per visit $30 copay per visit $30 copay per visit




50% coinsurance 50% coinsurance 50% coinsurance 50% coinsurance 50% coinsurance

Diabetic supplies1 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance

Infertility counseling/treatment (excludes in-vitro)1 50% coinsurance after deductlble 50% coinsurance after deductlble 50% coinsurance after deductlble 50% coinsurance after deductlble 50% coinsurance after deductlble

Voluntary male sterilization1 50% coinsurance after deductlble 50% coinsurance after deductlble 50% coinsurance after deductlble 50% coinsurance after deductlble 50% coinsurance after deductlble



50%coinsurance after deductible $5 injections





Speech therapy (30 visits per calendar year) $40 copay per visit after deductible $40 copay per visit after deductible $40 copay per visit after deductible $50 copay per visit after deductible $50 copay per visit after deductible



Habilitative speech therapy (30 visits per calendar year) $40 copay per visit after deductible $40 copay per visit after deductible $40 copay per visit after deductible $50 copay per visit after deductible $50 copay per visit after deductible


$40 copay per visit $40 copay per visit $40 copay per visit $50 copay per visit $50 copay per visit


50% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible




Tier 1A Preferred generics – $4 copay Tier 1A Preferred generics – $4 copay Tier 1A Preferred generics – $6 copay Tier 1A Preferred generics – $4 copay Tier 1A Preferred generics – $4 copay

Tier 1B Generics – $15 copay Tier 1B Generics – $15 copay Tier 1B Generics – $25 copay Tier 1B Generics – $15 copay Tier 1B Generics – $15 copay

Tier 2 Preferred brand – $40 copay Tier 2 Preferred brand – $40 copay Tier 2 Preferred brand – $50 copay Tier 2 Preferred brand – $40 copay Tier 2 Preferred brand – $40 copay

Tier 3 Nonpreferred brand – $80 copay Tier 3 Nonpreferred brand – $80 copay Tier 3 Nonpreferred brand – $80 copay Tier 3 Nonpreferred brand – $80 copay Tier 3 Nonpreferred brand – $80 copay











1PCP Focus available with this plan.

12 1These services don’t apply to the annual coinsurance maximum. Notes: Benefit year option available only with HRA packages. Voluntary first trimester termination of pregnancy not covered for products purchased on the Marketplace.

Benefits at a glance Routine care packages

BCN HMO Routine Care Silver $1,500 BCN HMO Routine Care Silver $3,000Deductible and out-of-pocket maximumDeductible $1,500/$3,000 $3,000/$6,000

Annual coinsurance maximum None None


Physician office servicesRoutine office visits $40 copay per visit $30 copay per visit

Consulting specialist care (when referred) 30% coinsurance after deductible 20% coinsurance after deductible

Preventive services (as defined by the Affordable Care Act)Adult physical exams; newborn and well-child exams Covered in full Covered in full







Diagnostic and therapeutic proceduresLaboratory tests Covered in full Covered in full

Diagnostic X-rays 30% coinsurance after deductible 20% coinsurance after deductible

High-tech imaging 30% coinsurance after deductible 20% coinsurance after deductible

Radiation therapy 30% coinsurance after deductible 20% coinsurance after deductible

Maternity services provided by a physicianPostnatal and nonroutine prenatal care 30% coinsurance after deductible 20% coinsurance after deductible



Inpatient hospital careInpatient hospital services 30% coinsurance after deductible 20% coinsurance after deductible

Emergency medical careHospital emergency room (copay waived if admitted) 30% coinsurance after deductible 20% coinsurance after deductible

Urgent care center 30% coinsurance after deductible 20% coinsurance after deductible

Ground and air ambulance services (when medically necessary) 30% coinsurance after deductible 20% coinsurance after deductible

Mental health care and substance abuse servicesOutpatient visits 30% coinsurance after deductible 20% coinsurance after deductible

Inpatient hospital services 30% coinsurance after deductible 20% coinsurance after deductible

Skilled nursing careSkilled nursing facility care (limited to 45 days per calendar year) 30% coinsurance after deductible 20% coinsurance after deductible

Other servicesApplied behavioral analyses (ABA) treatment 30% coinsurance after deductible 20% coinsurance after deductible





Diabetic supplies1 50% coinsurance after deductible 50% coinsurance after deductible

Infertility counseling/treatment (excludes in-vitro)1 50% coinsurance after deductible 50% coinsurance after deductible

Voluntary male sterilization1 50% coinsurance after deductible 50% coinsurance after deductible

Allergy testing, evaluation and serum; injections 50% coinsurance after deductible 50% coinsurance after deductible



Speech therapy (30 visits per calendar year) 30% coinsurance after deductible 20% coinsurance after deductible



Habilitative speech therapy (30 visits per calendar year) 30% coinsurance after deductible 20% coinsurance after deductible












Tier 4 Preferred specialty – 20% coinsurance after deductible (max $200 copay)


Tier 5 Nonpreferred specialty – 20% coinsurance after deductible (max $300 copay)


13Effective 1/1/16

Benefits at a glance Routine care packages

BCN HMO Routine Care Silver $1,500 BCN HMO Routine Care Silver $3,000Deductible and out-of-pocket maximumDeductible $1,500/$3,000 $3,000/$6,000

Annual coinsurance maximum None None


Physician office servicesRoutine office visits $40 copay per visit $30 copay per visit

Consulting specialist care (when referred) 30% coinsurance after deductible 20% coinsurance after deductible








Diagnostic and therapeutic proceduresLaboratory tests Covered in full Covered in full

Diagnostic X-rays 30% coinsurance after deductible 20% coinsurance after deductible

High-tech imaging 30% coinsurance after deductible 20% coinsurance after deductible

Radiation therapy 30% coinsurance after deductible 20% coinsurance after deductible

Maternity services provided by a physicianPostnatal and nonroutine prenatal care 30% coinsurance after deductible 20% coinsurance after deductible



Inpatient hospital careInpatient hospital services 30% coinsurance after deductible 20% coinsurance after deductible

Emergency medical careHospital emergency room (copay waived if admitted) 30% coinsurance after deductible 20% coinsurance after deductible

Urgent care center 30% coinsurance after deductible 20% coinsurance after deductible

Ground and air ambulance services (when medically necessary) 30% coinsurance after deductible 20% coinsurance after deductible

Mental health care and substance abuse servicesOutpatient visits 30% coinsurance after deductible 20% coinsurance after deductible

Inpatient hospital services 30% coinsurance after deductible 20% coinsurance after deductible

Skilled nursing careSkilled nursing facility care (limited to 45 days per calendar year) 30% coinsurance after deductible 20% coinsurance after deductible

Other servicesApplied behavioral analyses (ABA) treatment 30% coinsurance after deductible 20% coinsurance after deductible





Diabetic supplies1 50% coinsurance after deductible 50% coinsurance after deductible

Infertility counseling/treatment (excludes in-vitro)1 50% coinsurance after deductible 50% coinsurance after deductible

Voluntary male sterilization1 50% coinsurance after deductible 50% coinsurance after deductible

Allergy testing, evaluation and serum; injections 50% coinsurance after deductible 50% coinsurance after deductible



Speech therapy (30 visits per calendar year) 30% coinsurance after deductible 20% coinsurance after deductible



Habilitative speech therapy (30 visits per calendar year) 30% coinsurance after deductible 20% coinsurance after deductible
















14

Notes: Benefit year option available only with HRA packages. Voluntary first trimester termination of pregnancy not covered for products purchased on the Marketplace. The deductible does not apply to routine maternity care.

Benefits at a glanceHigh deductible health plan

packages (HSA) High deductible health plan packages (HSA)

BCN HSA HMO Gold $1,300/20% (Employer Contribution $0)

BCN HSA HMO Gold $1,350 (Employer Contribution $0)

BCN HSA HMO Gold $2,700 (Employer Contribution $700 or $1,000)

BCN HSA HMO Silver $2,700 (Employer Contribution $0)

1BCN HSA HMO Silver $3,000 (Employer Contribution $0)


Deductible $1,350/$2,700 $1,350/$2,700 2$2,700/$5,400 2$2,700/$5,400 $3,000/$6,000

Out-of-pocket maximum $2,350/$4,700 $2,350/$4,700 2$5,000/$10,000 2$5,000/$10,000 $6,350/$12,700


Routine office visits 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible

Consulting specialist care (when referred) 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible


Adult physical exams; newborn and well-child exams Covered in full Covered in full Covered in full Covered in full Covered in full








Laboratory tests 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible

Diagnostic X-rays 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible

High-tech imaging 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible

Radiation therapy 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible


Postnatal and nonroutine prenatal care 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible


20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible


Inpatient hospital services 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible


Hospital emergency room (copay waived if admitted) 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible

Urgent care center 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible

Ground and air ambulance services (when medically necessary) 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible


Outpatient visits 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible



Skilled nursing facility care (limited to 45 days per calendar year) 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible

Other services

Applied behavioral analyses (ABA) treatment 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible



Prosthetics, orthotics and durable medical equipment (when medically necessary) 50% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible

Diabetic supplies 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible

Infertility counseling/treatment (excludes in-vitro) 50% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible

Voluntary male sterilization 50% coinsurance after deductlble 50% coinsurance after deductible 50% coinsurance after deductlble 50% coinsurance after deductlble 50% coinsurance after deductible

Allergy testing, evaluation and serum; injections 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible

Physical and occupational therapy (Combined 30 visits per calendar year) 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible

Speech therapy (30 visits per calendar year) 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible

Habilitative physical and occupational therapy (30 visits per calendar year) 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible

Habilitative speech therapy (30 visits per calendar year) 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible



Weight-reduction procedures (limited to one procedure per lifetime) 50% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible




Tier 1A Preferred generics – $4 copay after deductible





Tier 1B Generics – $15 copay after deductible





Tier 2 Preferred brand – $40 copay after deductible





Tier 3 Nonpreferred brand – $80 copay after deductible





Tier 4 Preferred specialty – 20% coinsurance after deductible

(max $200 copay)

Tier 4 Preferred specialty – 20% coinsurance

after deductible (max $200 copay)


(max $200 copay)


(max $200 copay)


(max $200 copay)Tier 5 Nonpreferred specialty –

20% coinsurance after deductible (max $300 copay)

Tier 5 Nonpreferred specialty – 20% coinsurance


Tier 5 Nonpreferred specialty – 20% coinsurance after deductible

(max $300 copay)


(max $300 copay)


(max $300 copay)

15Effective 1/1/16

Benefits at a glanceHigh deductible health plan

packages (HSA) High deductible health plan packages (HSA)

BCN HSA HMO Gold $1,300/20% (Employer Contribution $0)

BCN HSA HMO Gold $1,350 (Employer Contribution $0)

BCN HSA HMO Gold $2,700 (Employer Contribution $700 or $1,000)

BCN HSA HMO Silver $2,700 (Employer Contribution $0)

1BCN HSA HMO Silver $3,000 (Employer Contribution $0)


Deductible $1,350/$2,700 $1,350/$2,700 2$2,700/$5,400 2$2,700/$5,400 $3,000/$6,000

Out-of-pocket maximum $2,350/$4,700 $2,350/$4,700 2$5,000/$10,000 2$5,000/$10,000 $6,350/$12,700


Routine office visits 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible

Consulting specialist care (when referred) 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible


Adult physical exams; newborn and well-child exams Covered in full Covered in full Covered in full Covered in full Covered in full








Laboratory tests 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible

Diagnostic X-rays 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible

High-tech imaging 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible

Radiation therapy 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible


Postnatal and nonroutine prenatal care 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible






Hospital emergency room (copay waived if admitted) 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible

Urgent care center 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible

Ground and air ambulance services (when medically necessary) 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible


Outpatient visits 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible



Skilled nursing facility care (limited to 45 days per calendar year) 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible

Other services

Applied behavioral analyses (ABA) treatment 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible



Prosthetics, orthotics and durable medical equipment (when medically necessary) 50% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible

Diabetic supplies 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible

Infertility counseling/treatment (excludes in-vitro) 50% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible

Voluntary male sterilization 50% coinsurance after deductlble 50% coinsurance after deductible 50% coinsurance after deductlble 50% coinsurance after deductlble 50% coinsurance after deductible

Allergy testing, evaluation and serum; injections 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible

Physical and occupational therapy (Combined 30 visits per calendar year) 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible

Speech therapy (30 visits per calendar year) 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible

Habilitative physical and occupational therapy (30 visits per calendar year) 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible

Habilitative speech therapy (30 visits per calendar year) 20% coinsurance after deductible Covered in full after deductible Covered in full after deductible 20% coinsurance after deductible Covered in full after deductible



Weight-reduction procedures (limited to one procedure per lifetime) 50% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible

























(max $200 copay)

Tier 4 Preferred specialty – 20% coinsurance



(max $200 copay)


(max $200 copay)


(max $200 copay)Tier 5 Nonpreferred specialty –

20% coinsurance after deductible (max $300 copay)

Tier 5 Nonpreferred specialty – 20% coinsurance



(max $300 copay)


(max $300 copay)


(max $300 copay)

1PCP Focus available with these plans.2Deductible is combined for both medical and prescription drug coverage. The full family deductible must be met under a

two-person or family contract before benefits are paid for any person on the contract.This applies to the OOPM as well.

16

Notes: Benefit year option available only with HRA packages. Voluntary first trimester termination of pregnancy not covered for products purchased on the Marketplace. The deductible does not apply to routine maternity care.

Benefits at a glanceHigh deductible health plan packages (HSA)

2BCN HSA HMO Bronze $4,500 (Employer Contribution $0)


Deductible and out-of-pocket maximumDeductible $4,500/$9,000 $6,350/$12,700


Physician office servicesRoutine office visits 20% coinsurance after deductible Covered in full after deductible

Consulting specialist care (when referred) 20% coinsurance after deductible Covered in full after deductible








Diagnostic and therapeutic proceduresLaboratory tests 30% coinsurance after deductible Covered in full after deductible

Diagnostic X-rays 30% coinsurance after deductible Covered in full after deductible

High-tech imaging 30% coinsurance after deductible Covered in full after deductible

Radiation therapy 30% coinsurance after deductible Covered in full after deductible

Maternity services provided by a physicianPostnatal and nonroutine prenatal care 30% coinsurance after deductible Covered in full after deductible


30% coinsurance after deductible Covered in full after deductible

Inpatient hospital careInpatient hospital services 30% coinsurance after deductible Covered in full after deductible

Emergency medical careHospital emergency room (copay waived if admitted) 30% coinsurance after deductible Covered in full after deductible

Urgent care center 30% coinsurance after deductible Covered in full after deductible

Ground and air ambulance services (when medically necessary) 30% coinsurance after deductible Covered in full after deductible

Mental health care and substance abuse servicesOutpatient visits 30% coinsurance after deductible Covered in full after deductible

Inpatient hospital services 30% coinsurance after deductible Covered in full after deductible

Skilled nursing careSkilled nursing facility care (limited to 45 days per calendar year) 30% coinsurance after deductible Covered in full after deductible

Other servicesApplied behavioral analyses (ABA) treatment 30% coinsurance after deductible Covered in full after deductible



Prosthetics, orthotics and durable medical equipment (when medically necessary)


Diabetic supplies 30% coinsurance after deductible Covered in full after deductible

Infertility counseling/treatment (excludes in-vitro) 50% coinsurance after deductible 50% coinsurance after deductible

Voluntary male sterilization 50% coinsurance after deductlble 50% coinsurance after deductible

Allergy testing, evaluation and serum; injections 30% coinsurance after deductible Covered in full after deductible



Speech therapy (30 visits per calendar year) 30% coinsurance after deductible Covered in full after deductible



Habilitative speech therapy (30 visits per calendar year) 30% coinsurance after deductible Covered in full after deductible



Weight-reduction procedures (limited to one procedure per lifetime)





Tier 1A Preferred generics – $10 copay after deductible Tier 1A Preferred generics – Covered in full after deductible

Tier 1B Generics – $30 copay after deductible Tier 1B Generics – Covered in full after deductible

Tier 2 Preferred brand – $60 copay after deductible Tier 2 Preferred brand – Covered in full after deductible

Tier 3 Nonpreferred brand – $80 copay after deductible Tier 3 Nonpreferred brand – Covered in full after deductible


Tier 4 Preferred specialty – Covered in full after deductible


Tier 5 Nonpreferred specialty – Covered in full after deductible

17Effective 1/1/16

Benefits at a glanceHigh deductible health plan packages (HSA)



Deductible and out-of-pocket maximumDeductible $4,500/$9,000 $6,350/$12,700


Physician office servicesRoutine office visits 20% coinsurance after deductible Covered in full after deductible

Consulting specialist care (when referred) 20% coinsurance after deductible Covered in full after deductible








Diagnostic and therapeutic proceduresLaboratory tests 30% coinsurance after deductible Covered in full after deductible

Diagnostic X-rays 30% coinsurance after deductible Covered in full after deductible

High-tech imaging 30% coinsurance after deductible Covered in full after deductible

Radiation therapy 30% coinsurance after deductible Covered in full after deductible

Maternity services provided by a physicianPostnatal and nonroutine prenatal care 30% coinsurance after deductible Covered in full after deductible



Inpatient hospital careInpatient hospital services 30% coinsurance after deductible Covered in full after deductible

Emergency medical careHospital emergency room (copay waived if admitted) 30% coinsurance after deductible Covered in full after deductible

Urgent care center 30% coinsurance after deductible Covered in full after deductible

Ground and air ambulance services (when medically necessary) 30% coinsurance after deductible Covered in full after deductible

Mental health care and substance abuse servicesOutpatient visits 30% coinsurance after deductible Covered in full after deductible

Inpatient hospital services 30% coinsurance after deductible Covered in full after deductible

Skilled nursing careSkilled nursing facility care (limited to 45 days per calendar year) 30% coinsurance after deductible Covered in full after deductible

Other servicesApplied behavioral analyses (ABA) treatment 30% coinsurance after deductible Covered in full after deductible



Prosthetics, orthotics and durable medical equipment (when medically necessary)


Diabetic supplies 30% coinsurance after deductible Covered in full after deductible

Infertility counseling/treatment (excludes in-vitro) 50% coinsurance after deductible 50% coinsurance after deductible

Voluntary male sterilization 50% coinsurance after deductlble 50% coinsurance after deductible

Allergy testing, evaluation and serum; injections 30% coinsurance after deductible Covered in full after deductible



Speech therapy (30 visits per calendar year) 30% coinsurance after deductible Covered in full after deductible



Habilitative speech therapy (30 visits per calendar year) 30% coinsurance after deductible Covered in full after deductible



Weight-reduction procedures (limited to one procedure per lifetime)





Tier 1A Preferred generics – $10 copay after deductible Tier 1A Preferred generics – Covered in full after deductible

Tier 1B Generics – $30 copay after deductible Tier 1B Generics – Covered in full after deductible

Tier 2 Preferred brand – $60 copay after deductible Tier 2 Preferred brand – Covered in full after deductible

Tier 3 Nonpreferred brand – $80 copay after deductible Tier 3 Nonpreferred brand – Covered in full after deductible


Tier 4 Preferred specialty – Covered in full after deductible


Tier 5 Nonpreferred specialty – Covered in full after deductible

1PCP Focus available with these plans.2Deductible is combined for both medical and prescription drug coverage. The full family deductible must be met under a

two-person or family contract before benefits are paid for any person on the contract. This applies to the OOPM as well.

18 1These services don’t apply to the annual coinsurance maximum. Note: Voluntary first trimester termination of pregnancy not covered for products purchased on the Marketplace.

Benefits at a glanceHealthy Blue Living Packages Healthy Blue Living Packages

BCN Healthy Blue Living HMO Platinum $250 BCN Healthy Blue Living HMO Platinum $500 BCN Healthy Blue Living HMO Gold $1,000

Enhanced Standard Enhanced Standard Enhanced StandardDeductible and out-of-pocket maximum

Deductible $250/$500 $1,500/$3,000 $500/$1,000 $3,000/$6,000 $1,000/$2,000 $3,000/$6,000

Annual coinsurance maximum $500/$1,000 $2,500/$5,000 None $3,500/$7,000 $2,000/$4,000 $3,000/$6,000















Diagnostic X-rays 20% coinsurance after deductible 30% coinsurance after deductible Covered in full after deductible 30% coinsurance after deductible 20% coinsurance after deductible 30% coinsurance after deductible


Radiation therapy 20% coinsurance after deductible 30% coinsurance after deductible Covered in full after deductible 30% coinsurance after deductible 20% coinsurance after deductible 30% coinsurance after deductible






Inpatient hospital services 20% coinsurance after deductible 30% coinsurance after deductible Covered in full after deductible 30% coinsurance after deductible 20% coinsurance after deductible 30% coinsurance after deductible




Ground and air ambulance services (when medically necessary) 20% coinsurance after deductible 30% coinsurance after deductible $25 copay after deductible 30% coinsurance after deductible 20% coinsurance after deductible 30% coinsurance after deductible





Skilled nursing facility care (limited to 45 days per calendar year) 20% coinsurance after deductible 30% coinsurance after deductible Covered in full after deductible 30% coinsurance after deductible 20% coinsurance after deductible 30% coinsurance after deductible

Other services






Diabetic supplies1 20% coinsurance 30% coinsurance Covered in full 30% coinsurance 20% coinsurance 30% coinsurance







































19Effective 1/1/16


BCN Healthy Blue Living HMO Platinum $250 BCN Healthy Blue Living HMO Platinum $500 BCN Healthy Blue Living HMO Gold $1,000

Enhanced Standard Enhanced Standard Enhanced StandardDeductible and out-of-pocket maximum

Deductible $250/$500 $1,500/$3,000 $500/$1,000 $3,000/$6,000 $1,000/$2,000 $3,000/$6,000

Annual coinsurance maximum $500/$1,000 $2,500/$5,000 None $3,500/$7,000 $2,000/$4,000 $3,000/$6,000















Diagnostic X-rays 20% coinsurance after deductible 30% coinsurance after deductible Covered in full after deductible 30% coinsurance after deductible 20% coinsurance after deductible 30% coinsurance after deductible


Radiation therapy 20% coinsurance after deductible 30% coinsurance after deductible Covered in full after deductible 30% coinsurance after deductible 20% coinsurance after deductible 30% coinsurance after deductible










Ground and air ambulance services (when medically necessary) 20% coinsurance after deductible 30% coinsurance after deductible $25 copay after deductible 30% coinsurance after deductible 20% coinsurance after deductible 30% coinsurance after deductible





Skilled nursing facility care (limited to 45 days per calendar year) 20% coinsurance after deductible 30% coinsurance after deductible Covered in full after deductible 30% coinsurance after deductible 20% coinsurance after deductible 30% coinsurance after deductible

Other services






Diabetic supplies1 20% coinsurance 30% coinsurance Covered in full 30% coinsurance 20% coinsurance 30% coinsurance







































20


BCN Healthy Blue Living HMO Gold $1,500 BCN Healthy Blue Living HMO Gold $2,000

Enhanced Standard Enhanced StandardDeductible and out-of-pocket maximum

Deductible $1,500/$3,000 $4,000/$8,000 $2,000/$4,000 $4,000/$8,000

Annual coinsurance maximum $1,500/$3,000 $2,500/$5,000 $1,000/$2,000 $2,000/$4,000

Out-of-pocket maximum $6,600/$13,200 $6,600/$13,200 $6,600/$13,200 $6,600/$13,200


Routine office visits $20 copay per visit $35 copay per visit $25 copay per visit $35 copay per visit

Consulting specialist care (when referred) $30 copay per visit $45 copay per visit $35 copay per visit $45 copay per visit


Adult physical exams; newborn and well-child exams Covered in full Covered in full Covered in full Covered in full

Immunizations Covered in full Covered in full Covered in full Covered in full

Mammography screening Covered in full Covered in full Covered in full Covered in full

Pap smears (lab services) Covered in full Covered in full Covered in full Covered in full

Prostate specific antigen screening (lab services) Covered in full Covered in full Covered in full Covered in full

Routine prenatal care Covered in full Covered in full Covered in full Covered in full

Voluntary female sterilization Covered in full Covered in full Covered in full Covered in full


Laboratory tests Covered in full Covered in full Covered in full Covered in full

Diagnostic X-rays 20% coinsurance after deductible 30% coinsurance after deductible 20% coinsurance after deductible 30% coinsurance after deductible

High-tech imaging $150 copay per visit after deductible $150 copay per visit after deductible $150 copay per visit after deductible $150 copay per visit after deductible

Radiation therapy 20% coinsurance after deductible 30% coinsurance after deductible 20% coinsurance after deductible 30% coinsurance after deductible


Postnatal and nonroutine prenatal care $20 copay per visit $35 copay per visit $25 copay per visit $35 copay per visit


Covered in full after deductible Covered in full after deductible Covered in full after deductible Covered in full after deductible


Inpatient hospital services 20% coinsurance after deductible 30% coinsurance after deductible 20% coinsurance after deductible 30% coinsurance after deductible


Hospital emergency room (copay waived if admitted) $150 copay per visit after deductible $250 copay per visit after deductible $150 copay per visit after deductible $250 copay per visit after deductible

Urgent care center $35 copay per visit $50 copay per visit $35 copay per visit $60 copay per visit

Ground and air ambulance services (when medically necessary) 20% coinsurance after deductible 30% coinsurance after deductible 20% coinsurance after deductible 30% coinsurance after deductible


Outpatient visits $20 copay per visit $35 copay per visit $25 copay per visit $35 copay per visit



Skilled nursing facility care (limited to 45 days per calendar year) 20% coinsurance after deductible 30% coinsurance after deductible 20% coinsurance after deductible 30% coinsurance after deductible

Other services

Applied behavioral analyses (ABA) treatment $20 copay per visit $35 copay per visit $25 copay per visit $35 copay per visit


$30 copay per visit after deductible $45 copay per visit after deductible $35 copay per visit after deductible $45 copay per visit after deductible


50% coinsurance 50% coinsurance 50% coinsurance 50% coinsurance

Diabetic supplies1 20% coinsurance 30% coinsurance 20% coinsurance 30% coinsurance

Infertility counseling/treatment (excludes in-vitro)1 50% coinsurance after deductlble 50% coinsurance after deductlble 50% coinsurance after deductlble 50% coinsurance after deductlble

Voluntary male sterilization1 50% coinsurance after deductlble 50% coinsurance after deductlble 50% coinsurance after deductlble 50% coinsurance after deductlble







Speech therapy (30 visits per calendar year) $30 copay per visit after deductible $45 copay per visit after deductible $35 copay per visit after deductible $45 copay per visit after deductible



Habilitative speech therapy (30 visits per calendar year) $30 copay per visit after deductible $45 copay per visit after deductible $35 copay per visit after deductible $45 copay per visit after deductible


$30 copay per visit $45 copay per visit $35 copay per visit $45 copay per visit


50% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible

















1These services don’t apply to the annual coinsurance maximum.2Applies to the annual coinsurance maximum.

21Effective 1/1/16


BCN Healthy Blue Living HMO Gold $1,500 BCN Healthy Blue Living HMO Gold $2,000

Enhanced Standard Enhanced StandardDeductible and out-of-pocket maximum

Deductible $1,500/$3,000 $4,000/$8,000 $2,000/$4,000 $4,000/$8,000

Annual coinsurance maximum $1,500/$3,000 $2,500/$5,000 $1,000/$2,000 $2,000/$4,000

Out-of-pocket maximum $6,600/$13,200 $6,600/$13,200 $6,600/$13,200 $6,600/$13,200


Routine office visits $20 copay per visit $35 copay per visit $25 copay per visit $35 copay per visit

Consulting specialist care (when referred) $30 copay per visit $45 copay per visit $35 copay per visit $45 copay per visit


Adult physical exams; newborn and well-child exams Covered in full Covered in full Covered in full Covered in full

Immunizations Covered in full Covered in full Covered in full Covered in full

Mammography screening Covered in full Covered in full Covered in full Covered in full

Pap smears (lab services) Covered in full Covered in full Covered in full Covered in full

Prostate specific antigen screening (lab services) Covered in full Covered in full Covered in full Covered in full

Routine prenatal care Covered in full Covered in full Covered in full Covered in full

Voluntary female sterilization Covered in full Covered in full Covered in full Covered in full


Laboratory tests Covered in full Covered in full Covered in full Covered in full

Diagnostic X-rays 20% coinsurance after deductible 30% coinsurance after deductible 20% coinsurance after deductible 30% coinsurance after deductible

High-tech imaging $150 copay per visit after deductible $150 copay per visit after deductible $150 copay per visit after deductible $150 copay per visit after deductible

Radiation therapy 20% coinsurance after deductible 30% coinsurance after deductible 20% coinsurance after deductible 30% coinsurance after deductible


Postnatal and nonroutine prenatal care $20 copay per visit $35 copay per visit $25 copay per visit $35 copay per visit


Covered in full after deductible Covered in full after deductible Covered in full after deductible Covered in full after deductible




Hospital emergency room (copay waived if admitted) $150 copay per visit after deductible $250 copay per visit after deductible $150 copay per visit after deductible $250 copay per visit after deductible

Urgent care center $35 copay per visit $50 copay per visit $35 copay per visit $60 copay per visit

Ground and air ambulance services (when medically necessary) 20% coinsurance after deductible 30% coinsurance after deductible 20% coinsurance after deductible 30% coinsurance after deductible


Outpatient visits $20 copay per visit $35 copay per visit $25 copay per visit $35 copay per visit



Skilled nursing facility care (limited to 45 days per calendar year) 20% coinsurance after deductible 30% coinsurance after deductible 20% coinsurance after deductible 30% coinsurance after deductible

Other services

Applied behavioral analyses (ABA) treatment $20 copay per visit $35 copay per visit $25 copay per visit $35 copay per visit




50% coinsurance 50% coinsurance 50% coinsurance 50% coinsurance

Diabetic supplies1 20% coinsurance 30% coinsurance 20% coinsurance 30% coinsurance

Infertility counseling/treatment (excludes in-vitro)1 50% coinsurance after deductlble 50% coinsurance after deductlble 50% coinsurance after deductlble 50% coinsurance after deductlble

Voluntary male sterilization1 50% coinsurance after deductlble 50% coinsurance after deductlble 50% coinsurance after deductlble 50% coinsurance after deductlble







Speech therapy (30 visits per calendar year) $30 copay per visit after deductible $45 copay per visit after deductible $35 copay per visit after deductible $45 copay per visit after deductible



Habilitative speech therapy (30 visits per calendar year) $30 copay per visit after deductible $45 copay per visit after deductible $35 copay per visit after deductible $45 copay per visit after deductible


$30 copay per visit $45 copay per visit $35 copay per visit $45 copay per visit


50% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible

















R042013CB 11976 JUL 15

BCN SERVICE

AREA

Berrien Cass St. Joseph

Van BurenKalamazoo Calhoun

Allegan Barry

OttawaKent

Ionia

Montcalm

Newaygo

Muskegon

Oceana Mecosta

Mason

Manistee

Lake Osceola

Wexford Missaukee Roscommon Ogemaw Iosco

Benzie GrandTraverse Kalkaska Crawford Oscoda Alcona

Leelanau

Antrim Otsego Mont-morency Alpena

Emmet

Cheboygan PresqueIsle

Mackinac

Branch

Charlevoix

Clare GladwinArenac

BayMidlandIsabella

Gratiot Saginaw

ShiawasseeLapeerGenesee

Sanilac

Huron

Tuscola

Hillsdale

Jackson

Ingham LivingstonEaton

Clinton St. Clair

Oakland Macomb

Wayne

Lenawee Monroe

Washtenaw

Gogebic

Ontonagon

Iron

Houghton

Baraga

Marquette

Dickinson

Menominee

Delta

AlgerSchoolcraft

Luce

Chippewa

Keweenaw

BCN is not availablein these counties

BCN is available in these counties

bcbsm.com

bcn small group plan options baag - bcbsm.com€¦ · to a contract entered into in the state of...

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