803 BCBS Troy NY UAW PPO. se ‘BCBS South Bend UAW PPO WEEKLY EE) cOmPANY | COMPANY OVERAGE TIER CONTRIBUTION | PROPOSAL | PROPOSAL Gurent | “tay.2016 [2097 You Only $ 2208 $ 2058 $ 32.13 You + Spouse $ 48.50 $ 48.50 $ 70.99 You + Chileen) S a1g9 $4189 § 6183 ‘You +Family, $ 6834 $ 68.34 $ 96.25 Waived Coverage / No Covereg $ - S$ a $s ‘You Only $ 2205 $ 2558 $ 40.25 You+ Spouse $ 4850 $ 56.26 § 84.80 ‘You + Child{ren) $ 4 $ 48.59 $ You + Family $ $ @) $ (414.80) Walved Coverage / No Cove $ 8 ei company | company ProPosAL_| PROPOSAL May, 2036 [2017 | ‘You Only $ 248 $ 248 Ss 3.34 *contributions ‘You + Spouse $ 5.46 $ 546 $ 6.20 could increase ‘You + Child(ren) $ 47 $ 47 $ 9.99 for 2017 ‘You + Family $ 7.68 $ 768 $ 11.89 Waived Coverage / No CoverageCORPARY weenyee | company | PROPOSAL luniow [Dental ppo Jcoverace Tier CONTRIBUTION | PROPOSAL | (annual) Current 2017 2057 You only $ 219 $ 219 $ 5.91 “contributions You + Spouse $ 481 § 481 § 1264 could increase You + Chiron) $ 45 $415 § ©1267 for 2017 You + Family s o7 $677 § 7138 Welved Coverage / No Coverag $ = $= $s ‘company Jcoverace, Current _| Proposal 2037 Preventive 100% 100% Deductible $350/$700 _$1,500/$3,000 L~ Oueat Pocket Maximum $1,700/$3,400 steraseome PCP Visits $30 20% Specialty Vets $40 20% Rx Copay Retail $20/835/850 20% Rx Copay Mall Order ‘$40/$70/S300 20% **52,500/85,000 {i annual base pay is $50,000 or less‘The group umber (om the front of your ID ca; ‘The pen? name aad diagnos ‘The mount leay pai to the provider, if aay, ‘Acopy ofthe pid sesp and ‘Acompletedand goed cain fora, 1 claim is aot mbit within 18 months afer the date the Expense ar inte the i fo beats say be denied, However, ify can pove shat there wi good ren for your ao ga ean whi the ine limis the cain may be proceed as if were nt sobmied ate the deine, I benef cae prove 2 ain Ful, BCBS wl sue an Explanation of Bencfes @OB) 1 you cis for tenis is denied, you may appeal our chim acoing vo the proces detcabed under he (Cain Review Produ in Pur 2~ Adkinitetive Provisions, F, Benette-ats-Glance TeNeowere ‘Outof Neowodk ‘Asal Deduciaiee sod Oucck Pocket Maximum Detucaie— “An opin 4,50 deduce pexcoveed | An wpa #300 deduce par laid! ‘penbe il spl. orae! meniba wl apy. ‘Dedheible—Famly | An ptont $3000 dedocie par famay | An pont 600 deduce po ly poi ‘vals Tani Ourof | $2500 per year for glogees wah] 3000 Pocket Maxam | sensed tne py of 5000 ores, 8,0 per yea for ngopes wih tt heparofumedhas $50,900. ‘Fan OntatPoses | 95000 pr yer for Empleo vik | FOO asim seme be py of $5000 or es 500 per ay wth pe india ‘mar of $6880 fr Employ with senaalzd be pay of ore han 55000 “eine Masimas | Nove News Prewensive Care ‘atic physcakbr | Gove a 10s foranaal wil vnand | Noted sche _prcrentie serves. btm 1018 oe cong | 44 otis aareuersemssctTaNewose Oat Network WEAaicae | Coverd 100% forammal wal varand | Norco Gochstngrouie | preventive services ‘xa injections and smunzaions) ‘Amal Prvenin | Covent 00% forsamalwe virend | Notcovred Marmogams, | prventv seven. “Anol Prevention | Covered 04 for saad well taal | Not coved Colosonopiee, | prevent ess adonopes nd | Sigoidocopes ‘Prevenie Lab & | Covered at 1GMéforsanal wall wat and | Nov covered Xen reine seer ‘Pasian Ofce and Physician's Stal Servces amar Cae Ose | Uptrane deco aplon ton pea pays | Upon dace opin en oo Vie OM ae decal pla page 100% | pe S04 of Maxima Ramble ser ost of pocket misinuim a mache. | Charge afer ded; pln pay 00% Waived if pevenive. sf ow pocket marimum sexed. For Cig Saf paricpant: I-nerwork lice vite otf the ign Staff del ac coveed 170% ar dere “pecs Offe= Vise | Uptior deduce ples: che papas | Uptront deduce appleg on plan 0% afer dedacable pian pay 100% | pay Si of Maxon Reimbneee fier oxtof pocket masimam'szevched._ | Charge ier deduce pan pape 10% Ward pevensre ster out poket asim sched Fr Cign Stal partipts Earner fice Waits out ofthe Cig Sa mode are covered 10% fer dele ‘Oe ame vie | Upon dees pie then pn pap | Upnt deduce pling cho ln (Gechutingaegy | 80% kee deduce pa aye 100% | pe 50% of Maxima Rebarble injeion) slercut ofpocket mime ached. | Change fc dedaecle pln pays 100% afer owof pace maxima i eched For Cign St prcipsts Innere na tf the Cigna Staff model ae Coveed a Tis afer deduce zeta name HOW cove | 42TeNewwode OavatNework ‘DisgcndcXoayed_| Upiont deduce apa then plan pas | Upon dace pian hen ln Mbornoryinlaag, | 20% ster dedcabic pan pays 10% | pay SOVof MaimurnReinasable CCATSean nat | afer outorpocker maximum ached | Charge eee deduce plan py 100% ser ou pocket acim eched Trove ony and | Cone 10% forannual wal voted | Noccoreed bor peevenavevermees Tepatient Hoopla Serrete “Anesbslog | Upone edule pple hen pa pp | Upton dedocile ppl hn lan ‘0% afie decuale pan pays 100% | paps 80% of Mesa Reimbanble ster euof pocket masiman’s reached. | Charge fr ded plan paye 109% ser ow of pocket ura ached Tapedent pid, | Upton: ddacobe apa ie pon pa | Upton deduce ppl hen ln ceniptional and | 0% fier dedi pan pays 100% | pae Sof Manus Reinable speech thempy | aie outoFpocker mssimamis reached | Charge afer dedortle: plan pps 10% speech theapy © wat derdopmental | ser ol pocket maxima ethed euy sant comeed _peechhersy ott development iis ayia not covered (Odie Neceny | Upon deduce pli; hn pan pp | Upltnt deal pliog thn an ‘Serves nd Suppl | 0% afer deduce plan pays 100% | pay Ss of Maan Reimburae secowcotpoctermasimamis eachee. | Charge ater det pln pos 100% ser owt pocket mssamum neha ‘Physcn/Surgnon | Upon deduce applies thea plan paps | Upon deceit ln Series 20% afer deduce plan pay 100% | pay 50 of Maman Reibure sfecouofpoctetmimamis ached. | Chg afer dees phn pays 100% z fier ow of pocket msn rahe. ‘Semipivae Room | Upon deduce appl hen pan pa | Upon decusle pling he ln sd Board Par deduesble plan pee 100% | pay Ss of Mas Reimbucee row of pockermasimamis reached | Chage fer deste plan pays 10% she ewofpocker simu a reached. ‘Ouspatent Hamp Ssemes ‘Chemotivapy | Upon dnductle wp on plan pps | Upon eden onan 0% afr deductible plan pes 100% | pay 0s of Maman Rimbuatie ser ouvot pocket masimamiareachee. | Charge fs dedaee an pays 100% fier ow pocket manu i ahed ptt 110016 Ho coreg | 18 ‘sccsaioasT corevesses25677Ta-Nework OuratNerwore Calononoy, ‘Upon dees rp, tna pays | Upton deduce spl hen pae Eodowcopy snd | 8M afer dedi planpye 100%. | pe $0% of Miran Resse Sipecdoncopy | afer ourafpcker maximise | Chg lc deduce pen py 100% Waived i pervert ser et of pocket mass tee, Dis ‘Upon deduce ape hn pn pas | Upsione dedable spl tea plan 0% afer dedi pan pays 10% | page 50% of Maxima Rembvrble | ster ouotpockermasimam is ech} Charge afr dedi pan pays 10% | sar ox of porket maximum eae Taision Tharpy | Upton’ deduce spas then pan pape | Upton deduce pli then ls 0% afer deduce pan pas 100% | pays 50% of Maximum Resnbrsble fer owoepockermasimam reached. | Change afer dedueble plan poy 100% ster ot of pocket masini in eae ‘Oi Neely | Uplsons deve spor den pan pape f Upon decule ppleschen pls Necemary Sevies | 80% air deduce pn pay 100% | pays SOM of Maman Renae se Solin ser cwcopockermasimam reached, | Chge afer acl pln pay 100% ser out pocket mas ie echo Pipa snd | Uptont dod appln tea plan py | Upon ded pple, in plan Spon Changs | 50% ae dedacee pla pay 100% | pay M4 of Nasimn Reimburae shee ouofipocket maximums ached, | Chuge aes dedscle plan paye 10% Predation | Uplsone dado appcy tea pon pyr | Upne educeble pps then ln “Tessng Me afer deduce pan pope 100% | page 50% of Maxum Renner fier owofpockt maxim seached. | Cure ae edule ln poy 00% ace ew-of pocket matin ia eae ‘Sages Gling | Upton deduce pple then pln pays | Uptont dec aplshen plan serves nd opi) | 90% after edb pln pay 100% | pay M6 of Nasir Riri fier outpocket maximo i eaced | Chuge afer duce pla pay 10% sur ow-of pocket marium in eth nergy Gucfora | Upon dcdibe en hen planar | Aloucatanwed Empey dim Mediating | SO afer deduce plan pape 00% | wi be paid tien aod bent condo Gee | afer oetofgockt munmanssached_| el, Coed Series Supine secson or sccxpliason of ates Bovey Cue Noesiexpeney are | Upon date api en plan pay | Uplont deduce app en an 80% ae decile play 100%. | pay SO of Manton Reine sur cut pod sina sachet. | Gunga dete pla pe 102% afer oof poke maxima eth Shae 16 HOP overage | 148TeNewod ‘Ourot Newede “Taino far | Oplont dca apples then plan pa | Allout of anwar Emagen clams eragenie (the | OD afar deduce plan pay 100% | willbe psd athe ivneren bene ene fniy ser ut pockt anima sacked. | ler. roving deguie en) “Abance Upiioa daincae ap tie ln pays | Unt dedible plies then plan tmnsporation Som | 00% er daca plan pgs 100% | pape SO of Masia Rebuerble ‘oe fy save | air out of pocket miu sac | Chase fede pla aps 10% reialynecemey star oof pocket msimamis ened Tiramibdims | Upton Salaciie spp ten pla pape medical oececemy | Pair dedoble ln pee 100% ser onto pocket moi reached, [Not coved fact medal necay. etc 1018 sore omeape | 115 ‘scsi careuesssr256c7TaNewwose ‘Our ctNewrore Ia-Nerwod Que Newrork aera Gare (Ofc vis for | Upiat dedi apo denpan pa | Opin deduce pps hn an Prowl & Portul | 80% scr dec; pan pay 100% | pay SP of Masia Remantle cm fis owospocet maximums reached. | Change ae ded; pe 100% Waived perenre. ster oat pocket marina reached For Cig Saf parcipanis In-twoc ist ou of the Cp Saf model ae covered 1 70% fer decile Bi Comer ‘Uptront decal appli then plan pape | Upon deduce pc tea pas octaingceiind | 80% ar dees plan pas 100% | pays S0%of Maxine Rebar NasesMideif, | aferourof pocket asim a rached. | Chuge af ded: lan pay 100% svher wale fier owtof pocket msi eached, Delvey ‘Uptvar deduce appli i la pr | Uone dedenble applies tes plan (Oakes Svioes ‘ioed ad Bleed | Upfionr deduce pple than aa pays | Uploet Sndocabe wpa ean ‘exataions ‘80% ser dete plan pee 100% | pays 50% of Marian Reimar (oehting fer owo-pocket masimam reached. | Chase ae ded pln poy 100% drat fo fo ier ose of pocker mati eathe, olen) ‘Dunble Medial | Upon dees pin hen pln pap | Upto Soda aplan en plan Bepent 0% afer deeb pln pee 100%” | pe SOY of Masia Reimbursable ter covo-pocker maxima in ached. | Cauge ser dec: lan pay 100% shetwatpedemaiot ast, Tajuy sound | Upon dadacable pes hn pan pap | Upton: dee pli tes plan trl ebay as | 60% afer dedi; pan pays 100% | ye 5% of Maxim Reena xl force after ouvotpocketmszmam weached. | Chap afer deduct lan py 00% sieroue of pocket mania in erched, ‘Ongena | Ihe Beth plans nerwo ensplane | The decle pplny cen te ples Popa uted the deducible apples, | paes0% Afr deduce pln pay hen the plan pays 100% 1a het | 100% ae outf-pcketis eched Phas setwoek elt program not uid he deductible apples then the ln pep 0. Aer deol pan ay 10% fer out-of pockets ech, Plan pay op tos mania of 100 per sight for food od lodging ed exuc Sone v8 ro omens | 18 aS 7 emmscensrTasNeswor ‘Gur of Newrede te fr two people toa ene of cclence, ‘Drtngenede Suga | Upton ddacibeaplen hen plan pap | Upon deduce pen; an as afer decile wo epuic or care | page SMG afer deduce onepar or severe fii efi or disGguemene | cone severe facil deformity ot Statontedoot sone cannot comet | datinzenent ht orhodons sone Papas 100% aero poker | cannot comect Plan pp 107% aero ‘asim etched Se Secon SB. for | of pocket mania s reached See dee. ‘Secon SB for deta, ‘Ores Covenge | Emergency, Unga Ga maar | Ermey, iget Care od ar ‘eons which eqaie mediate | condtons which req immediate ‘reamentarecoreed athe Innework | treatment ae covered tthe oer ‘ene level Osher covered serics pid | bent ere. her covered series pid st Out Neraok beet ee st OncE Newark henfrlen, pores cece reece cr seceded Proseas ‘Upon deduce app; then pnp | Uinnt dedacbl applies ten plan ater dedcabe pan pays 100% | pays 5% oF Nema Reinbusable ster oat.poket maxima isreaced._| Chae afer edo: plan pays 1% sherextok pocket mannan a reihed Vigna ‘Uplca deduce pp then pn oe | Allow of eetwock Emergency iy {Wafer dedcible pan pays 100% | chic wile pid a tein neork ster out poker anna i reached._| benefit ere. ‘Oakes Savices= Limite combined fot Incoodiand Out of aetwor ‘Cicprcic Cae | Deducle apis then pln py 80% | Upon deduce pps then pn sec deductible plan pas 100% ater | pays 50% afer deeb pen pays (ut cbpecet memant a rachedioa | Iie ater oxbebpocter nema sss f90 vii percaendaryear_|reshed o aman of 0 vit pe (coscombaedinncroskand out of | cle yee (on combined nacre | serve bei) sod tet bai) ‘ome eh Ca | BCRS -Upfont deduce applies dn | RGRS- Upton deducele applies en hn pay 80% fer debe plan pays plan pay 50% er decveslpan pays 100% afer out af pecketmasimumns | 100% afer oso pocketmssima seached Tos mucimim of 120 vite per | ceahed Toscan of visi pet (lente ye. oleae ye, ie = Uptont Seale apes ten | Gama Uptroct dabei hen ln pay 8% afer deal plan pays plan pays 0% afer dele pan pays 1094 afer oxo pockeemmm's | 100 afer out of pocket meinem is piston wino18 owe coveage | 147 Beas F.607 ameesea2so77, Oiv-ct Neewodk ‘eathed Foam of 20 das por | tached Towa of 4 da pee abd calendar yeu Twice ‘Upon deduce apis hea pan pay | Uptont decile appcg ca plan (8% afer denen page 100% | pay SO afer dads en pape alter oofipocker mazimamit ached | 1004 afer out of pocket maint is spi de swached wp 0100 dy nboass ‘Uplicr deduce apis; papa | Upton dedxcibleaplics the paw (6 aie deduce pan page 100% | pays SO af dele en pap afi owof pocket masimamis reached | 10% afe out-of pocket ima to minimum of one peal year | reached to sonar of on poe (crept fo indians wah betes | calendar yu (cep ori with nich cate hin ot be imposed). | dab, in which cave hs at wl aot The folowingitens ar led uch | beinposed-The ellowing items ee oppor if, ner wedges oles and_ | exe atch nppor is nsec, ‘hore ave over de cous, ‘wedges, tes, and those arabe over she counter, ‘Outpatient Pysial | Upton’ dedaaie aplon mpl pp | Upliont dedhcle pias han paw ‘Thespy [ar decebeplan page 100% | pape SOV af ded en poy avr owof pocket misimam's ached, | 1004 afc utc pocket maint ‘Tos min of 90 vit pclae | reached Toa maxi 020 wits pet yes eda ee ‘Oupuicat pee: | Dedctble apples then ln pos 0% | Dedacae apa tan pla oye SE sd/ocoenpaion | ater deduce pln pay 100% afer | alter dade plan pay 10% afer ‘ener fot ofpocketmarimmissechedtox | cur of pact maxima ached ta ‘masimam of 30 wit pean da yet _| mai 0f 0 vt pe calendar ee Speech herpy went development | Speech thepy co et deeopetal days not eorse ely is aot eoree Piva Day Nasag_| Upttont dedseati apples thea pla pas | Not Covered ater Seance pln pee 10% thee onto pocket maxim ached lated to open care gen by + eeed mane (RN, LPN oe LYN) foe profeioel ming eres he ‘Seeion ofa doce ited ‘Upton deduce apples ten plan paps | Upton dda mpl thea plan Nuring/Btended | 80% afer deduce plan page 100% | page 504 afer deduct pln pays Car Prey fier owtofpocker maxim reached | 100% sir ou of poche maser toarmaimam of 120d pereaendar | raced to a matran of 120 dy pet _ calendar, Bate 018 HoH coeese | 138 ‘sassrete omewisens780% aie deuce pa pe 10% tf owaf poke masini eached. TaNetwede Ostet Network “Teporomandibahe | Uptoot decile spies thea plan pars | Upton dda pps then in Joint cM) Aster deducable pape 100% | pays Safer deducble plan pays Drsfineion er oot poctet mex tached | 100% er outa pocket mar fervurin eeccved ina Inpettce | rached Sor envi recived in oo ‘Outpent fiy. A evtment mat | Tapas ot Outpatient iy. A papper _seument must be pre approved Biewal Heskh/Substince Aone Their ‘pone ducts api en plan pps | Upon eda appl then lan 0a dedeuble plan pes 100% | pays 50% of Maina Reimbursable ser ooepocke mesma irre | Charge ater decie plan pape 10% ster ol pocket racemes echo Cupaion ‘Upon dda opin en plan pa | Uno dado appli den plan Tracie Doge Uplt dedace apis in plan pape 6 air deuce, pan page 10% ser out of packet maxim is eached ‘Geni Preventive medics stall xe ae provided a cot Nearer Prep Dru ‘Uptontdedsitle spleen pan pa (ae deca pan pqs 100% fer outopoce asian reached, (Genene Prevenre mextons 2 corde nt povided at 0 co ‘Sion ameesen2887 oH coven | 18Te Nemo - ‘OueatNeowoe els Femly Plessing (oth ‘como vasectomy, Line combine for ac and Oxt- Oe Via ‘Upto dedcte apa ten plan py | Upon doce plc ca pas [BM afer ded pan pee 100% | pas SOM alee edocs lan per ser ow poce msm even of | 100% a utof poke mason ‘teins ar not covered Terai | eres of stslnson ae not cored ‘weament se Emied to aoe 015,000 | Iafercywetment ented wa oa ‘maximum pe Covered Peron pet | of $5.00 marin pe Covered Pears eine. Wome’s preventive sees are | pe tine. opin! Oupatiet| Upont delocble ppl; he pn pays | Upton dala ples ic plan sit 80% ser deduces plas pay 100% | pays 50% afer dre; plan pays ser ooo pocket maim evel of | 100% aes ou poke maxim eeintion a not covered Tfeliy | reveals of stetaton ae nt covered ‘wenmcnt ae ited awa of $5000 | Ler reves ae ted to ota smasiman per Covered Peron pet | of $5 mas pet Covered Pscn fie. Women’s preventive serie are | per tine. coved 2 100% Tieng Ca a plo dete appli: hn ln pay | Upton deduce ppc dea plan seslomecic exam | 0% ater deduce pen par 100% | pay SOY ase deduces plan pps ean i evan 10%. For Cign Sutfpaicpa: a ese ints ot ofthe Cigna Sef model ae ___| cored w T%6 afer ecb ‘easing il. inlng | BCBS. Upfront ded ppl; then | BCBS Upon dedaci applca aa ‘mold ln pay 80% afer desl ln pays plan pay 50% fs deduce plen pape 10% Hearing ia ited $1,500 | 100% Heang isa iid o $1300 petheaing si per heaing | ‘Glgna- Upton dedacbie apt ien | Cua -UptnesSdocole pis ar in par 0 aie desl pln pa pln par S04 fn deduct lan ps Bate sn018 HoHP ove | 120 ‘ics oarenvssessen?