Health Alliance Plan · Skilled nursing care 50% coinsurance after deductible Not Covered Covered for authorized services- Up to 100 days per benefit period Durable medical equipment

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plandocument at www.hap.org or by calling 1-800-422-4641.

Important Questions Answers Why this Matters:

What is the overalldeductible?

$500 person / $1,000family: doesn't apply topreventive care, officevisits, urgent care,emergency care, orpharmacy.

You must pay all the costs up to the deductible amount before this plan begins to pay for coveredservices you use. Check your policy or plan document to see when the deductible starts over (usually,but not always, January 1st). See the chart starting on page 2 for how much you pay for coveredservices after you meet the deductible.

Are there otherdeductibles for specificservices?

No. You don't have to meet deductibles for specific services, but see the chart starting on page 2 for othercosts for services your plan covers.

Is there anout–of–pocket limit onmy expenses?

Yes. $6,600 person /$13,200 family

The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for yourshare of the costs of covered services. This limit helps you plan for health care expenses.

What is not included inthe out–of–pocket limit?

Premiums, Balance BilledCharges, and HealthCare this plan does notcover.

Even though you pay these expenses, they don't count toward the out-of-pocket limit.

Is there an overall annuallimit on what the planpays?

No. The chart starting on page 2 describes any limits on what the plan will pay for specific coveredservices, such as office visits.

Does this plan use anetwork of providers?

Yes. See www.hap.org orcall 1-800-422-4641 for alist of preferred providers.

If you use an in-network doctor or other health care provider, this plan will pay some or all of thecosts of covered services. Be aware, your in-network doctor or hospital may use an out-of-networkprovider for some services. Plans use the term in-network, preferred, or participating for providers intheir network. See the chart starting on page 2 for how this plan pays different kinds of providers.

Do I need a referral to seea specialist? Yes.

Written referrals are not required for specialist visits within the member's assigned network forselected services. Referrals or oral approvals are required in other instances. Further information onthe referral process can be found at www.hap.org.

Are there services thisplan doesn’t cover? Yes. Some of the services this plan doesn't cover are listed on page 5. See your policy or plan document for

additional information about excluded services.

Health Alliance PlanSummary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual+Family | Plan Type: HMO

Questions: Call 1-800-422-4641 or visit us at www.hap.org.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat http://www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-800-422-4641 to request a copy. Utica2 Any

1 of 8

Coverage Period: 07/01/2015 - 06/30/2016

• Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.• Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if

the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change ifyou haven’t met your deductible.

• The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than theallowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay andthe allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)

• This plan may encourage you to use participating providers by charging you lower deductibles, copayments and coinsurance amounts.

Common MedicalEvent Services You May Need Your cost if you use an

In-Network ProviderYour cost if you use an

Out-of-Network Provider Limitations & Exceptions

If you visit a healthcare provider’s officeor clinic

Primary care visit to treat aninjury or illness $15 copay per visit Not Covered --------------None---------------

Specialist visit $15 copay per visit Not Covered --------------None---------------

Other practitioner office visit$15 PCP Other Practitionercopay per visit/ $15 SpecialistOther Practitioner copay pervisit

Not CoveredChiropractic manipulation ofthe spine for subluxation only -35 visits per benefit yearAcupuncture Not Covered

Preventivecare/screening/immunization No Charge Not Covered Coverage information available

at www.hap.org.

If you have a test

Diagnostic test (x-ray, bloodwork) No Charge after deductible Not Covered Some services require prior

authorization.

Imaging (CT/PET scans,MRIs) No Charge after deductible Not Covered Services require prior

authorization.

If you need drugs totreat your illness orconditionMore informationabout prescriptiondrug coverage isavailable atwww.hap.org.

Generic Drugs $10 copay/prescription (retail) Not Covered

Applies to all categories below.Retail: 30 day supply for non-maintenance drugs at 1 copay;90 day supply for eligiblemaintenance drugs at 2 copays;Mail Order: 90 day supply forboth eligible maintenance andnon-maintenance drugs at 2copays

Preferred brand drugs $40 copay/prescription (retail) Not Covered

Non-preferred brand drugs $40 copay/prescription (retail) Not Covered

Specialty drugs $40 copay/prescription (retail) Not Covered


2 of 8




If you haveoutpatient surgery

Facility fee (e.g., ambulatorysurgery center) No Charge after deductible Not Covered Some services require prior

authorization.

Physician/surgeon fees No Charge after deductible Not Covered --------------None---------------

If you needimmediate medicalattention

Emergency room services $100 copay per visit $100 copay per visit Copay will be waived ifadmitted

Emergency medicaltransportation No Charge after deductible No Charge after deductible Emergency Transport Only

Urgent care $35 copay per visit $35 copay per visit --------------None---------------

If you have a hospitalstay

Facility fee (e.g., hospital room) No Charge after deductible Not Covered Some services require priorauthorization.

Physician/surgeon fee No Charge after deductible Not Covered --------------None---------------

If you have mentalhealth, behavioralhealth, or substanceabuse needs

Mental/Behavioral healthoutpatient services $15 copay per visit Not Covered

Some services require priorauthorization. Services can beaccessed by calling 1-800-444-5755

Mental/Behavioral healthinpatient services No Charge after deductible Not Covered

Services require priorauthorization. Services can beaccessed by calling 1-800-444-5755

Substance use disorderoutpatient services $15 copay per visit Not Covered


Substance use disorderinpatient services No Charge after deductible Not Covered


If you are pregnantPrenatal and postnatal care $15 copay per visit Not Covered No Charge for Prenatal care

Delivery and all inpatientservices No Charge after deductible Not Covered Some services require prior

authorization.


3 of 8




If you need helprecovering or haveother special healthneeds

Home health care 50% coinsurance afterdeductible Not Covered Up to 60 visits per benefit

period .

Rehabilitation services $15 copay after deductible Not CoveredUp to 60 combined visits perbenefit period- May berendered at home

Habilitation services $15 copay after deductible Not Covered

Limited to Applied BehaviorAnalysis (ABA) and Physical,Speech and OccupationalTherapy services associatedwith the treatment of AutismSpectrum Disorders throughage 18. Services require priorauthorization. *See outpatientMental Health for ABA costshare amount.

Skilled nursing care 50% coinsurance afterdeductible Not Covered

Covered for authorizedservices- Up to 100 days perbenefit period

Durable medical equipment 50% coinsurance afterdeductible Not Covered

Coverage provided forapproved equipment based onHAP's guidelines. Someservices require priorauthorization.

Hospice service No Charge after deductible Not Covered Up to 210 days per lifetime

If your child needsdental or eye care

Eye exam $15 copay per visit Not Covered No Charge for preventive eyeexam

Glasses Not Covered Not Covered --------------None---------------

Dental check up Not Covered Not Covered --------------None---------------


4 of 8

Excluded Services & Other Covered Services:Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)

• Acupuncture • Hearing Aids • Private-Duty Nursing

• Cosmetic Surgery • Long-Term Care • Routine Foot Care (Only when meets Planguidelines)

• Dental Care (Adult) • Non-Emergency Care When TravelingOutside the U.S.

• Vision Hardware (Unless additional riderpurchased)

Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for theseservices.)

• Bariatric Surgery • Infertility Treatment (Only when meets Planguidelines)

• Weight Loss Programs

• Chiropractic Care • Routine Eye Care (Adult)


5 of 8

Your Rights to Continue Coverage:

If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep healthcoverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you paywhile covered under the plan. Other limitations on your rights to continue coverage may also apply.

For more information on your rights to continue coverage, contact the plan at 1-800-422-4641. You may also contact your state insurance department, theU.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health andHuman Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.

Your Grievance and Appeals Rights:

If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questionsabout your rights, this notice, or assistance, you can contact HAP at 1-800-422-4641or visit us at www.hap.org

For more information regarding grievance and appeals, contact the plan at 1-800-422-4641. You may also contact your state insurance department, the U.S.Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and HumanServices at 1-877-267-2323 x61565 or www.cciio.cms.gov. Additionally, a consumer assistance program can help you file your appeal. Contact MichiganHealth Insurance Consumer Assistance Program (HICAP), Michigan Office of Financial and Insurance Regulation, P.O.Box 30220, Lansing, MI 48909,phone 1-877-999-6442, website: http://michigan.gov/ofir, e-mail [email protected].

Does this Coverage Provide Minimum Essential Coverage?The Affordable Care Act requires most people to have health care coverage that qualifies as "minimum essential coverage". This plan or policy does provideminimum essential coverage.

Does this Coverage Meet the Minimum Value Standard?The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). Thishealth coverage does meet the minimum value standard for the benefits it provides.

–––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––


6 of 8

About these CoverageExamples:These examples show how this plan mightcover medical care in given situations. Usethese examples to see, in general, how muchfinancial protection a sample patient mightget if they are covered under different plans.

This is not acost estimator.

Don’t use these examples toestimate your actual costs underthis plan. The actual care youreceive will be different from theseexamples, and the cost of that carewill also be different.

See the next page for importantinformation about these examples.

Having a baby(normal delivery)

Amount owed to providers: $7,540Plan pays $6,860Patient pays $680

Sample care costs:Hospital charges (mother) $2,700Routine obstetric care $2,100Hospital charges (baby) $900Anesthesia $900Laboratory tests $500Prescriptions $200Radiology $200Vaccines, other preventive $40Total $7,540

Patient pays:Deductibles $500Co-pays $30Co-insurance $0Limits or exclusions $150Total $680

Managing type 2 diabetes(routine maintenance of

a well-controlled condition)Amount owed to providers: $5,400Plan pays $3,770Patient pays $1,630

Sample care costs:Prescriptions $2,900Medical Equipment and Supplies $1,300Office Visits and Procedures $700Education $300Laboratory tests $100Vaccines, other preventive $100Total $5,400Patient pays:Deductibles $500Co-pays $530Co-insurance $520Limits or exclusions $80Total $1,630


7 of 8

Questions and answers about the Coverage Examples:What are some of theassumptions behind theCoverage Examples?• Costs don’t include premiums.

• Sample care costs are based on nationalaverages supplied by the U.S. Departmentof Health and Human Services, andaren’t specific to a particular geographicarea or health plan.

• The patient’s condition was not anexcluded or preexisting condition.

• All services and treatments started andended in the same coverage period.

• There are no other medical expenses forany member covered under this plan.

• Out-of-pocket expenses are based only ontreating the condition in the example.

• The patient received all care from in-network providers. If the patient hadreceived care from out-of-networkproviders, costs would have been higher.

What does a Coverage Exampleshow?For each treatment situation, the CoverageExample helps you see how deductibles,copayments, and coinsurance can add up. Italso helps you see what expenses might be leftup to you to pay because the service ortreatment isn’t covered or payment is limited.

Does the Coverage Examplepredict my own care needs?û No. Treatments shown are just examples.

The care you would receive for thiscondition could be different based onyour doctor’s advice, your age, howserious your condition is, and many otherfactors.

Does the Coverage Examplepredict my future expenses?û No. Coverage Examples are not cost

estimators. You can’t use the examples toestimate costs for an actual condition.They are for comparative purposes only.Your own costs will be differentdepending on the care you receive, theprices your providers charge, and thereimbursement your health plan allows.

Can I use Coverage Examplesto compare plans?ü Yes. When you look at the Summary of

Benefits and Coverage for other plans,you’ll find the same Coverage Examples.When you compare plans, check the“Patient Pays” box in each example. Thesmaller that number, the more coveragethe plan provides.

Are there other costs I shouldconsider when comparingplans?ü Yes. An important cost is the premium

you pay. Generally, the lower yourpremium, the more you’ll pay in out-of-pocket costs, such as copayments,deductibles, and coinsurance. You shouldalso consider contributions to accountssuch as health savings accounts (HSAs),flexible spending arrangements (FSAs) orhealth reimbursement accounts (HRAs)that help you pay out-of-pocket expenses.



8 of 8

Coverage Period: 07/01/2015 - 06/30/2016

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plandocument at www.hap.org or by calling 1-800-422-4641.

Important Questions Answers Why this Matters:

What is the overalldeductible?

$1,000 person / $2,000family: doesn't apply topreventive care, officevisits, urgent care,emergency care, orpharmacy.

You must pay all the costs up to the deductible amount before this plan begins to pay for coveredservices you use. Check your policy or plan document to see when the deductible starts over (usually,but not always, January 1st). See the chart starting on page 2 for how much you pay for coveredservices after you meet the deductible.

Are there otherdeductibles for specificservices?

No. You don't have to meet deductibles for specific services, but see the chart starting on page 2 for othercosts for services your plan covers.

Is there anout–of–pocket limit onmy expenses?

Yes. $6,600 person /$13,200 family

The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for yourshare of the costs of covered services. This limit helps you plan for health care expenses.

What is not included inthe out–of–pocket limit?

Premiums, Balance BilledCharges, and HealthCare this plan does notcover.

Even though you pay these expenses, they don't count toward the out-of-pocket limit.

Is there an overall annuallimit on what the planpays?

No. The chart starting on page 2 describes any limits on what the plan will pay for specific coveredservices, such as office visits.

Does this plan use anetwork of providers?

Yes. See www.hap.org orcall 1-800-422-4641 for alist of preferred providers.

If you use an in-network doctor or other health care provider, this plan will pay some or all of thecosts of covered services. Be aware, your in-network doctor or hospital may use an out-of-networkprovider for some services. Plans use the term in-network, preferred, or participating for providers intheir network. See the chart starting on page 2 for how this plan pays different kinds of providers.

Do I need a referral to seea specialist? Yes.

Written referrals are not required for specialist visits within the member's assigned network forselected services. Referrals or oral approvals are required in other instances. Further information onthe referral process can be found at www.hap.org.

Are there services thisplan doesn’t cover? Yes. Some of the services this plan doesn't cover are listed on page 5. See your policy or plan document for

additional information about excluded services.


Questions: Call 1-800-422-4641 or visit us at www.hap.org.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat http://www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-800-422-4641 to request a copy. AA001141 XR001234

1 of 8

Coverage Period: 07/01/2015 - 06/30/2016

• Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.• Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if

the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change ifyou haven’t met your deductible.

• The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than theallowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay andthe allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)

• This plan may encourage you to use participating providers by charging you lower deductibles, copayments and coinsurance amounts.




If you visit a healthcare provider’s officeor clinic

Primary care visit to treat aninjury or illness $20 copay per visit Not Covered --------------None---------------

Specialist visit $20 copay per visit Not Covered --------------None---------------

Other practitioner office visit$20 PCP Other Practitionercopay per visit/ $20 SpecialistOther Practitioner copay pervisit

Not CoveredChiropractic manipulation ofthe spine for subluxation only -35 visits per benefit yearAcupuncture Not Covered

Preventivecare/screening/immunization No Charge Not Covered Coverage information available

at www.hap.org.

If you have a test

Diagnostic test (x-ray, bloodwork) No Charge after deductible Not Covered Some services require prior

authorization.

Imaging (CT/PET scans,MRIs) No Charge after deductible Not Covered Services require prior

authorization.

If you need drugs totreat your illness orconditionMore informationabout prescriptiondrug coverage isavailable atwww.hap.org.

Generic Drugs $15 copay/prescription (retail). Not Covered

Applies to all categories below.Retail: 30 day supply for non-maintenance drugs at 1 copay;90 day supply for eligiblemaintenance drugs at 2 copays;Mail Order: 90 day supply forboth eligible maintenance andnon-maintenance drugs at 2copays

Preferred brand drugs $50 copay/prescription (retail). Not Covered

Non-preferred brand drugs $50 copay/prescription (retail). Not Covered

Specialty drugs $50 copay/prescription (retail). Not Covered


2 of 8




If you haveoutpatient surgery

Facility fee (e.g., ambulatorysurgery center) No Charge after deductible Not Covered Some services require prior

authorization.

Physician/surgeon fees No Charge after deductible Not Covered --------------None---------------

If you needimmediate medicalattention

Emergency room services $100 copay per visit $100 copay per visit Copay will be waived ifadmitted

Emergency medicaltransportation No Charge after deductible No Charge after deductible Emergency Transport Only

Urgent care $50 copay per visit $50 copay per visit --------------None---------------

If you have a hospitalstay

Facility fee (e.g., hospital room) No Charge after deductible Not Covered Some services require priorauthorization.

Physician/surgeon fee No Charge after deductible Not Covered --------------None---------------

If you have mentalhealth, behavioralhealth, or substanceabuse needs

Mental/Behavioral healthoutpatient services $20 copay per visit Not Covered


Mental/Behavioral healthinpatient services No Charge after deductible Not Covered


Substance use disorderoutpatient services $20 copay per visit Not Covered


Substance use disorderinpatient services No Charge after deductible Not Covered


If you are pregnantPrenatal and postnatal care $20 copay per visit Not Covered No Charge for Prenatal care

Delivery and all inpatientservices No Charge after deductible Not Covered Some services require prior

authorization.


3 of 8




If you need helprecovering or haveother special healthneeds

Home health care 50% coinsurance afterdeductible Not Covered Up to 60 visits per benefit

period .

Rehabilitation services $20 copay after deductible Not CoveredUp to 60 combined visits perbenefit period- May berendered at home

Habilitation services $20 copay after deductible Not Covered

Limited to Applied BehaviorAnalysis (ABA) and Physical,Speech and OccupationalTherapy services associatedwith the treatment of AutismSpectrum Disorders throughage 18. Services require priorauthorization. *See outpatientMental Health for ABA costshare amount.

Skilled nursing care 50% coinsurance afterdeductible Not Covered

Covered for authorizedservices- Up to 100 days perbenefit period

Durable medical equipment 50% coinsurance afterdeductible Not Covered

Coverage provided forapproved equipment based onHAP's guidelines. Someservices require priorauthorization.

Hospice service No Charge after deductible Not Covered Up to 210 days per lifetime

If your child needsdental or eye care

Eye exam $20 copay per visit Not Covered No Charge for preventive eyeexam

Glasses Not Covered Not Covered --------------None---------------

Dental check up Not Covered Not Covered --------------None---------------


4 of 8

Excluded Services & Other Covered Services:Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)

• Acupuncture • Hearing Aids • Private-Duty Nursing

• Cosmetic Surgery • Long-Term Care • Routine Foot Care (Only when meets Planguidelines)

• Dental Care (Adult) • Non-Emergency Care When TravelingOutside the U.S.

• Vision Hardware (Unless additional riderpurchased)

Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for theseservices.)

• Bariatric Surgery • Infertility Treatment (Only when meets Planguidelines)

• Weight Loss Programs

• Chiropractic Care • Routine Eye Care (Adult)


5 of 8

Your Rights to Continue Coverage:

If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep healthcoverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you paywhile covered under the plan. Other limitations on your rights to continue coverage may also apply.

For more information on your rights to continue coverage, contact the plan at 1-800-422-4641. You may also contact your state insurance department, theU.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health andHuman Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.

Your Grievance and Appeals Rights:

If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questionsabout your rights, this notice, or assistance, you can contact HAP at 1-800-422-4641or visit us at www.hap.org

For more information regarding grievance and appeals, contact the plan at 1-800-422-4641. You may also contact your state insurance department, the U.S.Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and HumanServices at 1-877-267-2323 x61565 or www.cciio.cms.gov. Additionally, a consumer assistance program can help you file your appeal. Contact MichiganHealth Insurance Consumer Assistance Program (HICAP), Michigan Office of Financial and Insurance Regulation, P.O.Box 30220, Lansing, MI 48909,phone 1-877-999-6442, website: http://michigan.gov/ofir, e-mail [email protected].

Does this Coverage Provide Minimum Essential Coverage?The Affordable Care Act requires most people to have health care coverage that qualifies as "minimum essential coverage". This plan or policy does provideminimum essential coverage.

Does this Coverage Meet the Minimum Value Standard?The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). Thishealth coverage does meet the minimum value standard for the benefits it provides.

–––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––


6 of 8

About these CoverageExamples:These examples show how this plan mightcover medical care in given situations. Usethese examples to see, in general, how muchfinancial protection a sample patient mightget if they are covered under different plans.

This is not acost estimator.

Don’t use these examples toestimate your actual costs underthis plan. The actual care youreceive will be different from theseexamples, and the cost of that carewill also be different.

See the next page for importantinformation about these examples.

Having a baby(normal delivery)

Amount owed to providers: $7,540Plan pays $6,350Patient pays $1,190

Sample care costs:Hospital charges (mother) $2,700Routine obstetric care $2,100Hospital charges (baby) $900Anesthesia $900Laboratory tests $500Prescriptions $200Radiology $200Vaccines, other preventive $40Total $7,540

Patient pays:Deductibles $1,000Co-pays $40Co-insurance $0Limits or exclusions $150Total $1,190

Managing type 2 diabetes(routine maintenance of

a well-controlled condition)Amount owed to providers: $5,400Plan pays $3,120Patient pays $2,280

Sample care costs:Prescriptions $2,900Medical Equipment and Supplies $1,300Office Visits and Procedures $700Education $300Laboratory tests $100Vaccines, other preventive $100Total $5,400Patient pays:Deductibles $1,000Co-pays $680Co-insurance $520Limits or exclusions $80Total $2,280


7 of 8

Questions and answers about the Coverage Examples:What are some of theassumptions behind theCoverage Examples?• Costs don’t include premiums.

• Sample care costs are based on nationalaverages supplied by the U.S. Departmentof Health and Human Services, andaren’t specific to a particular geographicarea or health plan.

• The patient’s condition was not anexcluded or preexisting condition.

• All services and treatments started andended in the same coverage period.

• There are no other medical expenses forany member covered under this plan.

• Out-of-pocket expenses are based only ontreating the condition in the example.

• The patient received all care from in-network providers. If the patient hadreceived care from out-of-networkproviders, costs would have been higher.

What does a Coverage Exampleshow?For each treatment situation, the CoverageExample helps you see how deductibles,copayments, and coinsurance can add up. Italso helps you see what expenses might be leftup to you to pay because the service ortreatment isn’t covered or payment is limited.

Does the Coverage Examplepredict my own care needs?û No. Treatments shown are just examples.

The care you would receive for thiscondition could be different based onyour doctor’s advice, your age, howserious your condition is, and many otherfactors.

Does the Coverage Examplepredict my future expenses?û No. Coverage Examples are not cost

estimators. You can’t use the examples toestimate costs for an actual condition.They are for comparative purposes only.Your own costs will be differentdepending on the care you receive, theprices your providers charge, and thereimbursement your health plan allows.

Can I use Coverage Examplesto compare plans?ü Yes. When you look at the Summary of

Benefits and Coverage for other plans,you’ll find the same Coverage Examples.When you compare plans, check the“Patient Pays” box in each example. Thesmaller that number, the more coveragethe plan provides.

Are there other costs I shouldconsider when comparingplans?ü Yes. An important cost is the premium

you pay. Generally, the lower yourpremium, the more you’ll pay in out-of-pocket costs, such as copayments,deductibles, and coinsurance. You shouldalso consider contributions to accountssuch as health savings accounts (HSAs),flexible spending arrangements (FSAs) orhealth reimbursement accounts (HRAs)that help you pay out-of-pocket expenses.



8 of 8

Coverage Period: 07/01/2015 - 06/30/2016

0701089218

ADN Administrators, Inc. PO Box 610 Southfield, MI 48037 248-901-3705

Utica Community Schools Dental Benefits Plan Group # 9210 Skilled Trade, Bus Drivers, Mechanics, Operations, Grounds, Warehouse, Secretaries

The Plan-at-a-Glance PPO Networks: ADN Dental Network, Michigan Dental Plan, DenteMax

Maximum Benefits Plan year July 1

st through June 30

th

Annual Maximum $1000 per eligible individual for covered class I, II and III services.

Class I Preventive Services – 90% In-Network / 75% Out-of-Network

Oral Examinations Twice per plan year Bitewing X-Rays Once per plan year Prophylaxis/Periodontal Maintenance Twice per plan year Topical Application of Fluoride Twice per plan year to age 19 Full-Mouth Series or Panoramic X-Rays Once per 60 months All Other X-Rays Space Maintainers Under age 16, initial appliance only, one bilateral per arch or One unilateral per quadrant, per lifetime

Class II Restorative Services – 85% In-Network / 75% Out-of-Network

Composite and Amalgam fillings Once per tooth surface per 12 months Root Canal Therapy / Endodontics Periodontal Root Planing Once per quadrant per 24 months Periodontal Surgery Limitations apply based on service Oral Surgery and Extractions General Anesthesia or IV Sedation With covered oral surgery Consultations Once per specialty per 12 months Inlays, Onlays, Crowns** Once per permanent tooth in 60 months Denture Repair or Adjustment Denture Reline or Rebase Once per 24 months, per arch Addition of Teeth to Partial Dentures Occlusal Guards Once per lifetime, only within 6 months following Osseous Surgery

Class III Major Services – 50% In-Network / 50% Out-of-Network

Complete and Partial Removable Dentures** Once per arch per 60 months Fixed Partial Dentures (Bridges)** Once per arch per 60 months

Class IV Orthodontic Services – Not Covered

Not Covered

Sealants Implants and Restorations over implants TMJ/TMD Treatment, Therapy, Appliances

Deductible – None Missing Tooth Clause – None 12 Month Billing Limitation Waiting Periods – None **Porcelain and ceramic facings are not covered for posterior teeth, alternate benefit applies COB – Standard **Prosthetics are considered on seat/delivery date

**Note – Quotes of benefits do not constitute a guarantee of payment. Covered benefits may have limitations or exclusions affecting plan payment. Refer to plan booklet for additional coverage details and limitation. Predetermination is strongly encouraged for all non-emergency dental treatment exceeding $300.00 in charges. The treatment plan should be submitted to ADN prior to beginning any treatment.

Schedule of Vision Benefits NVA2

*Standard Lens Allowance is included. **Pre-approval from NVA required

National Vision Administrators, L.L.C.

Co-payment $6.50 Exam / $18 Lenses Participating Provider

Non-Participating Provider

Examination Once Every Plan Year

Covered 100% After $6.50 copay

Reimbursed Amount Up to $28.50 (OD) Up to $38.50 (MD)

Lenses Once Every Plan Year

Single Vision Bifocal Trifocal Lenticular

Oversized Rimless Mounting Blended Bifocal Photochromatic Transitions Polarized / Laminated*

Tints / Color Coatings*

Standard Glass or Plastic Covered 100% After $18 copay

Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100%

Covered 100%

Up to $29 Up to $51 Up to $63 Up to $75

N/A N/A N/A N/A N/A

Up to $47 (SV) Up to $81 (BI) Up to $101 (Tri) Up to $119(Lent) Up to $33 (SV) Up to $61 (Bi) Up to $75 (Tri) Up to $89 (Lent)

Frame Once Every Plan Year

Retail Allowance Up to $65

Up to $44

Contact Lenses Once Every Plan Year Elective Contact Lenses Medically Necessary**

In lieu of Lenses & Frame

Up to $90 Retail Covered 100%

In lieu of Lenses & Frame

Up to $90 Up to $175

Utica Community Schools New Vision Administrator Effective July 1, 2008

Plan Year July 1st

Summary of Vision Care Benefits

National Vision Administrators, L.L.C. (NVA) has been contracted by your group to offer a comprehensive vision care plan to you and your eligible family members. Founded in January of 1979, NVA manages vision benefit services for more than seven million lives nationwide.

How Your Vision Care Program Works

When scheduling your appointment, please notify the NVA participating provider of your choice that your vision coverage is administered by NVA.

The provider will contact NVA to verify eligibility. At the time of your appointment, simply present your NVA identification card

to the provider or indicate clearly that your benefit is administered by NVA. A vision claim form is not required at an NVA participating provider.

The provider will inform you of your eligibility status prior to rendering services.

Be sure to inform the provider of your medical history and any prescription or over-the-counter medications you may be taking.

To verify your benefit eligibility prior to calling or visiting your eye care provider, please visit our website at www.e-nva.com or contact NVA’s Customer Service Department toll-free at 1.800.672.7723.

Eligibility: Eligible members and dependents are entitled to receive a vision examination and one (1) pair of lenses and a frame or contact lenses and

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Additional professional services related to contact lenses (also known as fitting fees) would be included in the contact lens allowance shown above. Lens options purchased from a participating NVA provider will be provided to the member at the amounts listed in the fixed option pricing list below:

$10 Standard Scratch-Resistant Coating $55 High Index $12 Ultraviolet Coating $25 Polycarbonate (Single Vision) $40 Standard Anti-Reflective $30 Polycarbonate (Multi-Focal) $50 Progressive Lenses Standard

Options not listed will be priced by NVA providers at their R&C retail price less 20%. Every Day Low Prices will be provided at Retail Locations where available. Doctors affiliated with Retail Locations are not employees; therefore, participation for exams varies.

Insurance coverage provided by National Guardian Life Insurance Company (NGLIC), 2E Gilman, Madison, WI 53703. Policy NVIGRP2002. NGLIC is not affiliated with the Guardian Life Insurance Company of America, a/k/a The Guardian or Guardian Life. A full description of your coverage, its limitations, exclusions and conditions is contained in the Insurance Policy issued to your Plan Sponsor at its place of business. That full description in the form of a Certificate of Coverage can be made available to you by requesting it from your Plan Sponsor.

This document is intended as a program overview only and is not a certified document of the individual plan parameters.

contact lens evaluation/fitting once every plan year.

Customer Service: To verify eligibility, locate a participating provider and receive answers to all your vision care related inquiries, please call NVA’s Customer Service Department toll-free at 1.800.672.7723 (TDD: 973.574.2599).

NVA’s Interactive Voice Response (IVR) system is available twenty-four (24) hours per day, seven (7) days per week. The IVR allows you to locate a participating provider in your area, check eligibility as well as the status of your claim(s).

An NVA Customer Service Representative can be contacted Monday - Friday 8:00am - 6:00pm (EST) & Saturdays 8:30am - 5:00pm (EST)

National Vision Administrators, L.L.C. ▫ PO Box 2187 ▫ Clifton, NJ 07015

Web: www.e-nva.com ▫ Toll-Free: 1.800.672.7723

This document has been printed on recycled paper.

NVA® is a registered mark of National Vision Administrators, L.L.C

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Benefits at Participating Providers: Highlights of your vision care benefit:

The option of receiving services in- or out-of-network Extensive national provider network

Enhanced in-network benefits: 100% covered Vision examination (after copay if applicable) 100% covered standard spectacle lenses (after copay if applicable) Frame allowance covers countless fashionable frames in full Allowance towards the cost of contact lenses and fitting fees No claim forms.

NVA participating providers submit their claims directly to NVA. In the event you obtain services from a non-participating provider, you must submit your itemized receipt along with a completed reimbursement form to NVA to acquire reimbursement. You may obtain a Direct Reimbursement Claim Form from the NVA Web-Site: www.e-nva.com. Examinations: A comprehensive eye examination is covered which includes a case history, examination for pathology or anomalies, visual acuity (clearness of vision), refraction, and Tonometry testing (glaucoma). Comprehensive eye examinations can aid in the early detection of ocular diseases and other serious medical conditions. Lenses: NVA provides coverage in full for standard glass or plastic eyeglass lenses of any size. Frames: Select any frame from the participating provider’s inventory. Any amount in excess of your plan allowance is the member’s responsibility. Frame choices vary from office to office. Contact Lenses: Elective contact lenses are covered in lieu of all other materials (i.e. spectacle lenses and frames). Additional professional services related to contact lenses (also known as fitting fees) are covered under the contact lens allowance. The contact lens benefit includes all types of contact lenses such as hard, soft, gas permeable and disposable lenses. Medically necessary contact lenses may be covered with prior authorization when prescribed for: post cataract surgery, correction of extreme visual acuity problems that cannot be corrected to 20/70 with spectacle lenses, Anisometropia or Keratoconus. Discounts: There will be a twenty-percent (20%) discount off additional purchases of lenses and frames, excluding contacts at the time of service. Non-Participating Providers: You will be responsible for one hundred percent (100%) of the cost at the time of service at a non-participating provider. To obtain direct reimbursement according to your plan design, you can print a claim form from www.e-nva.com. Please complete this form and submit along with an original or copy of the itemized receipt. If you cannot print the claim form you may submit receipts along with a letter containing the member’s full name, patient’s full name, address, ID# and sponsoring organization to NVA’s Clifton, NJ office.

Remember, obtaining vision care services from a non-participating provider will result in greater out-of-pocket expense.

Exclusions / Limitations: No payment is made for Medical or surgical treatments / Rx drugs or OTC medications / non-prescription lenses / two pair of glasses in lieu of bifocals / subnormal visual aids / vision examination or materials required for employment / replacement of lost, stolen, broken or damaged lenses/contact lenses or frames except at normal intervals when service would otherwise be available / services or materials provided by Federal, State, local government or Worker's compensation / examination, procedures training or materials not listed as a covered service / industrial safety lenses and safety frames with or without side shields / parts or repair of frame / sunglasses. Participating providers are not contractually obligated to offer sale prices in addition to outlined coverage. Regardless of medical or optical necessity, vision benefits are not available more frequently than specified in your policy. Laser Eye Surgery: If you are nearsighted, farsighted or affected by astigmatism, and are interested in laser eye surgery, NVA offers a network of providers and significant discounts off reasonable and customary charges. The benefit is easy to use and there are:

No claims forms to fill out No deductibles to meet No waiting period for coverage No need for reimbursements

Laser surgery providers can be located online at www.e-nva.com. Contact Fill: NVA provides you with the convenience and savings of Contact Fill, our mail order contact lens replacement service. You may access Contact Fill’s services online at www.contactfill.com or by calling them toll-free at 866.234.1393. Contact Fill provides contact lens wearers with significant savings packaged with the convenience of home delivery. Plan discounts applicable at participating retail locations do not apply to purchases made through Contact Fill due to the already low prices. Plan Specific Details Online: The NVA website is easy to use and provides the most up to date information for program participants:

• Locate a nearby participating provider by name, zip code, or City/State • Verify eligibility for you or a dependent • View benefit program and specific details • Review claims • Print ID cards (when allowable) • Nominate a non-participating provider to join the NVA network

If you are not a registered subscriber, you can still search our providers online by selecting the “Find a Provider” link on our home page. Be sure to choose the NVA Network 2 vision plan from the drop down box and enter in your search parameters. It’s that easy! The following providers are not in the network – Sears, Target, JC Penny, Pearle Vision, Optical Boutique at Macy’s, 20 / 20 Vision Center, Service Optical, Tropical Optical and Boscov’s Optical.

Documents

Health Alliance Plan · Skilled nursing care 50% coinsurance after deductible Not Covered Covered for authorized services- Up to 100 days per benefit period Durable medical equipment