Common use of Benefits Coverage Clause in Contracts

Benefits Coverage. Surgery-includes related surgical services and medically necessary facility services by a participating ambulatory surgery facility 90% after deductible Presurgical consultations • 100% (no deductible or copay/coinsurance) when obtained from a participating provider • 90% after deductible when obtained from a nonparticipating provider Voluntary sterilization for males Note: For voluntary sterilizations for females, see "Preventive care services." 90% after deductible Voluntary Abortions 90% after deductible Removal of impacted and partial bony impacted teeth - includes surgery and related anesthesia 90% after deductible Human organ transplants Benefits Coverage Specified human organ transplants-must be in a designated facility and coordinated through the BCBSM Human Organ Transplant Program (0-000-000-0000) 100% (no deductible or copay/coinsurance) Bone marrow transplants-must be coordinated through the BCBSM Human Organ Transplant Program (0-000-000-0000) 90% after deductible Specified oncology clinical trials Note: BCBSM covers clinical trials in compliance with PPACA. 90% after deductible Kidney, cornea and skin transplants 90% after deductible Mental health care and substance abuse treatment Benefits Coverage Inpatient mental health care and inpatient substance abuse treatment 90% after deductible, unlimited days Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a "low access area" by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and the provider's charge. Benefits Coverage Residential psychiatric treatment facility: • covered mental health services must be performed in a residential psychiatric treatment facility • treatment must be preauthorized • subject to medical criteria 90% after deductible Outpatient mental health care 90% after deductible Outpatient substance abuse treatment-in approved facilities only 90% after deductible Autism spectrum disorders, diagnoses and treatment Benefits Coverage Applied behavioral analysis (ABA) treatment - when rendered by an approved board-certified behavioral analyst - is covered through age 18, subject to preauthorization Note: Diagnosis of an autism spectrum disorder and a treatment recommendation for ABA services must be obtained by a BCBSM approved autism evaluation center (AAEC) prior to seeking ABA treatment. 90% after deductible Outpatient physical therapy, speech therapy, occupational therapy, nutritional counseling for autism spectrum disorder 90% after deductible Other covered services, including mental health services, for autism spectrum disorder 90% after deductible Other covered services Benefits Coverage Outpatient Diabetes Management Program (ODMP) Note: Screening services required under the provisions of PPACA are covered at 100% of approved amount with no cost-sharing when rendered by a participating provider. Note: When you purchase your diabetic supplies via mail order you will lower your out-of-pocket costs. • 90% after deductible for diabetes medical supplies • 100% (no deductible or copay/coinsurance) for diabetes self- management training Allergy testing and therapy 90% after deductible Chiropractic spinal manipulation and osteopathic manipulative therapy 90% after deductible, limited to a combined 38-visit maximum per member per calendar year Outpatient physical, speech and occupational therapy- provided for Rehabilitation 90% after deductible Durable medical equipment Note: DME items required under the provisions of PPACA are covered at 100% of approved amount with no in-network cost-sharing when rendered by an in-network provider. For a list of covered DME items required under PPACA, call BCBSM. 90% after deductible Prosthetic and orthotic appliances 90% after deductible Private duty nursing 90% after deductible Hair prosthesis and accessories: • covered only when the hair loss is the result of either chemptherapy and/or radiation treatment for malignant and non-malignant conditions, trichotillomania or alopecia • subject to medical and benefit criteria 90% after deductible Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a "low access area" by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and the provider's charge. BERRIEN COUNTY 007015910/0003/0007/0010/0011 D, O, S, T POLC/TRIAL COURT/FOP Comprehensive Major Medical (CMM) ASC Effective Date: On or after January 2017 Benefits-at-a-glance This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and exclusions may apply. Payment amounts are based on BCBSM's approved amount, less any applicable deductible and/or copay/coinsurance. For a complete description of benefits please see the applicable BCBSM certificates and riders, if your group is underwritten or any other plan documents your group uses, if your group is self-funded. If there is a discrepancy between this Benefits-at-a-Glance and any applicable plan document, the plan document will control. Specialty Pharmaceutical Drugs - The mail order pharmacy for specialty drugs is Walgreens Specialty Pharmacy, LLC, an independent company. Specialty prescription drugs (such as Enbrel® and Humira® ) are used to treat complex conditions such as rheumatoid arthritis, multiple sclerosis and cancer. These drugs require special handling, administration or monitoring. Walgreens Specialty Pharmacy will handle mail order prescriptions only for specialty drugs while many in-network retail pharmacies will continue to dispense specialty drugs (check with your local pharmacy for availability). Other mail order prescription medications can continue to be sent to Express Scripts. (Express Scripts is an independent company providing pharmacy benefit services for Blues members.) A list of specialty drugs is available on our Web site at xxxxx.xxx/xxxxxxxx. If you have any questions, please call Walgreens Specialty Pharmacy customer service at 0-000-000-0000. We will not pay for more than a 30-day supply of a covered prescription drug that BCBSM defines as a "specialty pharmaceutical" whether or not the drug is obtained from a 90-Day Retail Network provider or mail-order provider. We may make exceptions if a member requires more than a 30-day supply. BCBSM reserves the right to limit the quantity of select specialty drugs to no more than a 15-day supply for each fill. Your copay/coinsurance will be reduced by one-half for each fill once applicable deductibles have been met. Select Controlled Substance Drugs - BCBSM will limit the initial fill of select controlled substances to a 15-day supply. The member will be responsible for only one-half of their cost-sharing requirement typically imposed on a 30-day fill. Subsequent fills of the same medication will be eligible to be filled as prescribed, subject to the applicable cost-sharing requirement. Select controlled substances affected by this prescription drug requirement are available online at xxxxx.xxx/xxxxxxxx. Member's responsibility (copays and coinsurance amounts) Note: Your prescription drug copays and coinsurance amounts, including mail order copay and coinsurance amounts, are subject to the same annual out-of-pocket maximum required under your medical coverage. The following prescription drug expenses will not apply to your annual out-of-pocket maximum. • any difference between the Maximum Allowable Cost and BCBSM's approved amount for a covered brand name drug • the 25% member liability for covered drugs obtained from an out-of-network pharmacy Benefits Coverage Out-of-network pharmacy Copay You pay $15 copay You pay $15 copay plus an additional 25% of BCBSM approved amount for the drug Brand name prescription drugs You pay $30 copay You pay $30 copay plus an additional 25% of BCBSM approved amount for the drug Mail order (home delivery) prescription drugs Copay for up to a 90 day supply: • You pay $15 copay • You pay $30 copay for brand name drugs Not covered Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Note: An in-network pharmacy is a Preferred Rx pharmacy in Michigan or an Express Scripts pharmacy outside Michigan. Express Scripts is an independent company providing pharmacy benefit services for Blues members. An out-of-network pharmacy is a pharmacy NOT in the Preferred Rx or Express Scripts networks. Note: Over-the-counter (OTC) drugs are drugs that do not require a prescription under federal law. They are identified by BCBSM as select prescription drugs. A prescription for the select OTC drug is required from the member's physician. In some cases, over-the- counter drugs may need to be tried before BCBSM will approve use of other drugs. Covered services Benefits Coverage Out-of-network pharmacy FDA-approved drugs 100% of approved amount less plan copay/coinsurance 75% of approved amount less plan copay/coinsurance Prescribed over-the-counter drugs - when covered by BCBSM 100% of approved amount less plan copay/coinsurance 75% of approved amount less plan copay/coinsurance State-controlled drugs 100% of approved amount less plan copay/coinsurance 75% of approved amount less plan copay/coinsurance FDA-approved generic and select brand-name prescription preventive drugs, supplements and vitamins as required by PPACA (non-self- administered drugs are not covered) 100% of approved amount 75% of approved amount Other FDA-approved brand-name prescription preventive drugs, supplements and vitamins as required by PPACA (non-self-administered drugs are not covered) 100% of approved amount less plan copay/coinsurance 75% of approved amount less plan copay/coinsurance FDA-approved generic and select brand name prescription contraceptive medication (non-self- administered drugs are not covered) 100% of approved amount 75% of approved amount Other FDA-approved brand name prescription contraceptive medication (non-self-administered drugs are not covered) 100% of approved amount less plan copay/coinsurance 75% of approved amount less plan copay/coinsurance Disposable needles and syringes - when dispensed with insulin or other covered injectable legend drugs Note: Needles and syringes have no copay/ coinsurance. 100% of approved amount less plan copay/coinsurance for the insulin or other covered injectable legend drug 75% of approved amount less plan copay/coinsurance for the insulin or other covered injectable legend drug Note: An in-network pharmacy is a Preferred Rx pharmacy in Michigan or an Express Scripts pharmacy outside Michigan. Express Scripts is an independent company providing pharmacy benefit services for Blues members. An out-of-network pharmacy is a pharmacy NOT in the Preferred Rx or Express Scripts networks. Note: Over-the-counter (OTC) drugs are drugs that do not require a prescription under federal law. They are identified by BCBSM as select prescription drugs. A prescription for the select OTC drug is required from the member's physician. In some cases, over-the- counter drugs may need to be tried before BCBSM will approve use of other drugs Features of your prescription drug plan Drug interchange and generic copay/ coinsurance waiver BCBSM's drug interchange and generic copay/ coinsurance waiver programs encourage physicians to prescribe a less-costly generic equivalent. If your physician rewrites your prescription for the recommended generic or OTC alternate drug, you will only have to pay a generic copay/ coinsurance. In select cases BCBSM may waive the initial copay/ coinsurance after your prescription has been rewritten. BCBSM will notify you if you are eligible for a waiver. Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Features of your prescription drug plan Prescription drug preferred therapy A step-therapy approach that encourages physicians to prescribe generic, generic alternative or over-the- counter medications before prescribing a more expensive brand-name drug. It applies only to prescriptions being filled for the first time of a targeted medication. Before filling your initial prescription for select, high-cost, brand-name drugs, the pharmacy will contact your physician to suggest a generic alternative. A list of select brand-name drugs targeted for the preferred therapy program is available at xxxxx.xxx/xxxxxxxx, along with the preferred medications. If our records indicate you have already tried the preferred medication(s), we will authorize the prescription. If we have no record of you trying the preferred medication(s), you may be liable for the entire cost of the brand-name drug unless you first try the preferred medication(s) or your physician obtains prior authorization from BCBSM. These provisions affect all targeted brand-name drugs, whether they are dispensed by a retail pharmacy or through a mail order provider. Quantity limits To stay consistent with FDA approved labeling for drugs, some medications may have quantity limits. Clinical Drug List A continually updated list of FDA-approved medications that represent each therapeutic class. The drugs on the list are chosen by the BCBSM Pharmacy and Therapeutics Committee for their effectiveness, safety, uniqueness and cost efficiency. The goal of the drug list is to provide members with the greatest therapeutic value at the lowest possible cost. This document can also be accessed on the County website at: Xxxxxxxxxxxxx.xxx/Xxxxxxxxxxx/Xxxxxxxxx/Xxxxxxxx Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. For the Court: Dated Xxxx X. Xxxxx, Trial Court Chief Judge For the Union Dated Union Representative

Benefits Coverage. Surgery-includes related surgical services and medically necessary facility services by a participating ambulatory surgery facility 90% after deductible Presurgical consultations •  100% (no deductible or copay/coinsurance) when obtained from a participating provider •  90% after deductible when obtained from a nonparticipating provider Voluntary sterilization for males Note: For voluntary sterilizations for females, see "Preventive care services." 90% after deductible Voluntary Abortions 90% after deductible Removal of impacted and partial bony impacted teeth - includes surgery and related anesthesia 90% after deductible Human organ transplants Benefits Coverage Specified human organ transplants-must be in a designated facility and coordinated through the BCBSM Human Organ Transplant Program (0-000-000-0000) 100% (no deductible or copay/coinsurance) Bone marrow transplants-must be coordinated through the BCBSM Human Organ Transplant Program (0-000-000-0000) 90% after deductible Specified oncology clinical trials Note: BCBSM covers clinical trials in compliance with PPACA. 90% after deductible Kidney, cornea and skin transplants 90% after deductible Mental health care and substance abuse treatment Benefits Coverage Inpatient mental health care and inpatient substance abuse treatment 90% after deductible, unlimited days Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a "low access area" by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and the provider's charge. Benefits Coverage Residential psychiatric treatment facility: •  covered mental health services must be performed in a residential psychiatric treatment facility •  treatment must be preauthorized •  subject to medical criteria 90% after deductible Outpatient mental health care 90% after deductible Outpatient substance abuse treatment-in approved facilities only 90% after deductible Autism spectrum disorders, diagnoses and treatment Benefits Coverage Applied behavioral analysis (ABA) treatment - when rendered by an approved board-certified behavioral analyst - is covered through age 18, subject to preauthorization Note: Diagnosis of an autism spectrum disorder and a treatment recommendation for ABA services must be obtained by a BCBSM approved autism evaluation center (AAEC) prior to seeking ABA treatment. 90% after deductible Outpatient physical therapy, speech therapy, occupational therapy, nutritional counseling for autism spectrum disorder 90% after deductible Other covered services, including mental health services, for autism spectrum disorder 90% after deductible Other covered services Benefits Coverage Outpatient Diabetes Management Program (ODMP)  90% after deductible for diabetes medical supplies Note: Screening services required under the provisions of PPACA are covered at 100% of approved amount with no cost-sharing when rendered by a participating provider.  100% (no deductible or copay/coinsurance) for diabetes self- management training Note: When you purchase your diabetic supplies via mail order you will lower your out-of-pocket costs. • 90% after deductible for diabetes medical supplies • 100% (no deductible or copay/coinsurance) for diabetes self- management training Allergy testing and therapy 90% after deductible Chiropractic spinal manipulation and osteopathic manipulative therapy 90% after deductible, limited to a combined 38-visit maximum per member per calendar year Outpatient physical, speech Rehabilitation and occupational therapy- provided for Rehabilitation 90% after deductible Durable medical equipment Note: DME items required under the provisions of PPACA are covered at 100% of approved amount with no in-network cost-sharing when rendered by an in-network provider. For a list of covered DME items required under PPACA, call BCBSM. 90% after deductible Prosthetic and orthotic appliances 90% after deductible Private duty nursing 90% after deductible Hair prosthesis and accessories: •  covered only when the hair loss is the result of either chemptherapy and/or radiation treatment for malignant and non-malignant conditions, trichotillomania or alopecia •  subject to medical and benefit criteria 90% after deductible Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a "low access area" by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and the provider's charge. BERRIEN COUNTY 007015910/0003/0007/0010/0011 D, O, S, T POLC/TRIAL COURT/FOP Comprehensive Major Medical (CMM) ASC Effective Date: On or after January 2017 Benefits-at-a-glance This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and exclusions may apply. Payment amounts are based on BCBSM's approved amount, less any applicable deductible and/or copay/coinsurance. For a complete description of benefits please see the applicable BCBSM certificates and riders, if your group is underwritten or any other plan documents your group uses, if your group is self-funded. If there is a discrepancy between this Benefits-at-a-Glance and any applicable plan document, the plan document will control. Specialty Pharmaceutical Drugs - The mail order pharmacy for specialty drugs is Walgreens Specialty Pharmacy, LLC, an independent company. Specialty prescription drugs (such as Enbrel® and Humira® ) are used to treat complex conditions such as rheumatoid arthritis, multiple sclerosis and cancer. These drugs require special handling, administration or monitoring. Walgreens Specialty Pharmacy will handle mail order prescriptions only for specialty drugs while many in-network retail pharmacies will continue to dispense specialty drugs (check with your local pharmacy for availability). Other mail order prescription medications can continue to be sent to Express Scripts. (Express Scripts is an independent company providing pharmacy benefit services for Blues members.) A list of specialty drugs is available on our Web site at xxxxx.xxx/xxxxxxxx. If you have any questions, please call Walgreens Specialty Pharmacy customer service at 0-000-000-0000. We will not pay for more than a 30-day supply of a covered prescription drug that BCBSM defines as a "specialty pharmaceutical" whether or not the drug is obtained from a 90-Day Retail Network provider or mail-order provider. We may make exceptions if a member requires more than a 30-day supply. BCBSM reserves the right to limit the quantity of select specialty drugs to no more than a 15-day supply for each fill. Your copay/coinsurance will be reduced by one-half for each fill once applicable deductibles have been met. Select Controlled Substance Drugs - BCBSM will limit the initial fill of select controlled substances to a 15-day supply. The member will be responsible for only one-half of their cost-sharing requirement typically imposed on a 30-day fill. Subsequent fills of the same medication will be eligible to be filled as prescribed, subject to the applicable cost-sharing requirement. Select controlled substances affected by this prescription drug requirement are available online at xxxxx.xxx/xxxxxxxx. Member's responsibility (copays and coinsurance amounts) Note: Your prescription drug copays and coinsurance amounts, including mail order copay and coinsurance amounts, are subject to the same annual out-of-pocket maximum required under your medical coverage. The following prescription drug expenses will not apply to your annual out-of-pocket maximum. •  any difference between the Maximum Allowable Cost and BCBSM's approved amount for a covered brand name drug •  the 25% member liability for covered drugs obtained from an out-of-network pharmacy Benefits Coverage Out-of-network pharmacy Copay You pay $15 copay You pay $15 copay plus an additional 25% of BCBSM approved amount for the drug Brand name prescription drugs You pay $30 copay You pay $30 copay plus an additional 25% of BCBSM approved amount for the drug Mail order (home delivery) prescription drugs Copay for up to a 90 day supply: •  You pay $15 copay •  You pay $30 copay for brand name drugs Not covered Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Note: An in-network pharmacy is a Preferred Rx pharmacy in Michigan or an Express Scripts pharmacy outside Michigan. Express Scripts is an independent company providing pharmacy benefit services for Blues members. An out-of-network pharmacy is a pharmacy NOT in the Preferred Rx or Express Scripts networks. Note: Over-the-counter (OTC) drugs are drugs that do not require a prescription under federal law. They are identified by BCBSM as select prescription drugs. A prescription for the select OTC drug is required from the member's physician. In some cases, over-the- counter drugs may need to be tried before BCBSM will approve use of other drugs. Covered services Benefits Coverage Out-of-network pharmacy FDA-approved drugs 100% of approved amount less plan copay/coinsurance 75% of approved amount less plan copay/coinsurance Prescribed over-the-counter drugs - when covered by BCBSM 100% of approved amount less plan copay/coinsurance 75% of approved amount less plan copay/coinsurance State-controlled drugs 100% of approved amount less plan copay/coinsurance 75% of approved amount less plan copay/coinsurance FDA-approved generic and select brand-name prescription preventive drugs, supplements and vitamins as required by PPACA (non-self- administered drugs are not covered) 100% of approved amount 75% of approved amount Other FDA-approved brand-name prescription preventive drugs, supplements and vitamins as required by PPACA (non-self-administered drugs are not covered) 100% of approved amount less plan copay/coinsurance 75% of approved amount less plan copay/coinsurance FDA-approved generic and select brand name prescription contraceptive medication (non-self- administered drugs are not covered) 100% of approved amount 75% of approved amount Other FDA-approved brand name prescription contraceptive medication (non-self-administered drugs are not covered) 100% of approved amount less plan copay/coinsurance 75% of approved amount less plan copay/coinsurance Disposable needles and syringes - when dispensed with insulin or other covered injectable legend drugs Note: Needles and syringes have no copay/ coinsurance. 100% of approved amount less plan copay/coinsurance for the insulin or other covered injectable legend drug 75% of approved amount less plan copay/coinsurance for the insulin or other covered injectable legend drug Note: An in-network pharmacy is a Preferred Rx pharmacy in Michigan or an Express Scripts pharmacy outside Michigan. Express Scripts is an independent company providing pharmacy benefit services for Blues members. An out-of-network pharmacy is a pharmacy NOT in the Preferred Rx or Express Scripts networks. Note: Over-the-counter (OTC) drugs are drugs that do not require a prescription under federal law. They are identified by BCBSM as select prescription drugs. A prescription for the select OTC drug is required from the member's physician. In some cases, over-the- counter drugs may need to be tried before BCBSM will approve use of other drugs Features of your prescription drug plan Drug interchange and generic copay/ coinsurance waiver BCBSM's drug interchange and generic copay/ coinsurance waiver programs encourage physicians to prescribe a less-costly generic equivalent. If your physician rewrites your prescription for the recommended generic or OTC alternate drug, you will only have to pay a generic copay/ coinsurance. In select cases BCBSM may waive the initial copay/ coinsurance after your prescription has been rewritten. BCBSM will notify you if you are eligible for a waiver. Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Features of your prescription drug plan Prescription drug preferred therapy A step-therapy approach that encourages physicians to prescribe generic, generic alternative or over-the- counter medications before prescribing a more expensive brand-name drug. It applies only to prescriptions being filled for the first time of a targeted medication. Before filling your initial prescription for select, high-cost, brand-name drugs, the pharmacy will contact your physician to suggest a generic alternative. A list of select brand-name drugs targeted for the preferred therapy program is available at xxxxx.xxx/xxxxxxxx, along with the preferred medications. If our records indicate you have already tried the preferred medication(s), we will authorize the prescription. If we have no record of you trying the preferred medication(s), you may be liable for the entire cost of the brand-name drug unless you first try the preferred medication(s) or your physician obtains prior authorization from BCBSM. These provisions affect all targeted brand-name drugs, whether they are dispensed by a retail pharmacy or through a mail order provider. Quantity limits To stay consistent with FDA approved labeling for drugs, some medications may have quantity limits. Clinical Drug List A continually updated list of FDA-approved medications that represent each therapeutic class. The drugs on the list are chosen by the BCBSM Pharmacy and Therapeutics Committee for their effectiveness, safety, uniqueness and cost efficiency. The goal of the drug list is to provide members with the greatest therapeutic value at the lowest possible cost. This document can also be accessed on the County website at: Xxxxxxxxxxxxx.xxx/Xxxxxxxxxxx/Xxxxxxxxx/Xxxxxxxx Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. For the Court: Dated Xxxx X. Xxxxx, Trial Court Chief Judge For the Union Dated Union Representative

Benefits Coverage. Surgery-includes related surgical Laboratory and pathology services and medically necessary facility services by a participating ambulatory surgery facility 90% after deductible Presurgical consultations • Diagnostic tests and x-rays 90% after deductible Therapeutic radiology 90% after deductible Maternity services provided by a physician or certified nurse midwife Benefits Coverage Prenatal care visits 100% (no deductible or copay/coinsurance) when obtained from a participating provider • Postnatal care 90% after deductible when obtained from a nonparticipating provider Voluntary sterilization for males Note: For voluntary sterilizations for females, see "Preventive Delivery and nursery care services." 90% after deductible Voluntary Abortions 90% after deductible Removal of impacted and partial bony impacted teeth - includes surgery and related anesthesia 90% after deductible Human organ transplants Hospital Care Benefits Coverage Specified human organ transplants-Semiprivate room, inpatient physician care, general nursing care, hospital services and supplies Note: Nonemergency services must be rendered in a designated facility and coordinated through the BCBSM Human Organ Transplant Program (0-000-000-0000) 100% (no deductible or copay/coinsurance) Bone marrow transplants-must be coordinated through the BCBSM Human Organ Transplant Program (0-000-000-0000) 90% after deductible Specified oncology clinical trials Note: BCBSM covers clinical trials in compliance with PPACAparticipating hospital. 90% after deductible Kidney, cornea and skin transplants 90% after deductible Mental health care and substance abuse treatment Benefits Coverage Inpatient mental health care and inpatient substance abuse treatment 90% after deductible, unlimited days Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a "low access area" by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and the provider's charge. Benefits Coverage Residential psychiatric treatment facility: • covered mental health services must be performed in a residential psychiatric treatment facility • treatment must be preauthorized • subject to medical criteria Inpatient consultations 90% after deductible Outpatient mental health care 90% after deductible Outpatient substance abuse treatment-in approved facilities only 90% after deductible Autism spectrum disorders, diagnoses and treatment Benefits Coverage Applied behavioral analysis (ABA) treatment - when rendered by an approved board-certified behavioral analyst - is covered through age 18, subject to preauthorization Note: Diagnosis of an autism spectrum disorder and a treatment recommendation for ABA services must be obtained by a BCBSM approved autism evaluation center (AAEC) prior to seeking ABA treatment. 90% after deductible Outpatient physical therapy, speech therapy, occupational therapy, nutritional counseling for autism spectrum disorder 90% after deductible Other covered services, including mental health services, for autism spectrum disorder 90% after deductible Other covered services Benefits Coverage Outpatient Diabetes Management Program (ODMP) Note: Screening services required under the provisions of PPACA are covered at 100% of approved amount with no cost-sharing when rendered by a participating provider. Note: When you purchase your diabetic supplies via mail order you will lower your out-of-pocket costs. • 90% after deductible for diabetes medical supplies • 100% (no deductible or copay/coinsurance) for diabetes self- management training Allergy testing and therapy 90% after deductible Chiropractic spinal manipulation and osteopathic manipulative therapy 90% after deductible, limited to a combined 38-visit maximum per member per calendar year Outpatient physical, speech and occupational therapy- provided for Rehabilitation 90% after deductible Durable medical equipment Note: DME items required under the provisions of PPACA are covered at 100% of approved amount with no in-network cost-sharing when rendered by an in-network provider. For a list of covered DME items required under PPACA, call BCBSM. 90% after deductible Prosthetic and orthotic appliances 90% after deductible Private duty nursing 90% after deductible Hair prosthesis and accessories: • covered only when the hair loss is the result of either chemptherapy and/or radiation treatment for malignant and non-malignant conditions, trichotillomania or alopecia • subject to medical and benefit criteria Chemotherapy 90% after deductible Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a "low access area" by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and the provider's charge. BERRIEN COUNTY 007015910/0003/0007/0010/0011 D, O, S, T POLC/TRIAL COURT/FOP Comprehensive Major Medical Alternatives to hospital care Benefits Coverage Skilled nursing care-must be in a participating skilled nursing facility 90% after deductible Hospice care 100% (CMM) ASC Effective Date: On no deductible or after January 2017 Benefits-at-a-glance This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and exclusions may apply. Payment amounts are based on BCBSM's approved amount, less any applicable deductible and/or copay/coinsurance. For coinsurance),up to 28 pre-hospice counseling visits before electing hospice services; when elected, four 90-day periods-provided through a complete description of benefits please see the applicable BCBSM certificates participating hospice program only; limited to dollar maximum that is reviewed and ridersadjusted periodically (after reaching dollar maximum, if your group is underwritten member transitions into individual case management) Home health care: • must be medically necessary • must be provided by a participating home health care agency 90% after deductible, limited to a maximum 100-visits per member per calendar year Infusion therapy: • must be medically necessary • must be given by a participating Home Infusion Therapy (HIT) provider or any other plan documents your group uses, if your group is selfin a participating freestanding Ambulatory Infusion Center (AIC) • may use drugs that require preauthorization-funded. If there is a discrepancy between this Benefits-at-a-Glance and any applicable plan document, the plan document will control. Specialty Pharmaceutical Drugs - The mail order pharmacy for specialty drugs is Walgreens Specialty Pharmacy, LLC, an independent company. Specialty prescription drugs (such as Enbrel® and Humira® ) are used to treat complex conditions such as rheumatoid arthritis, multiple sclerosis and cancer. These drugs require special handling, administration or monitoring. Walgreens Specialty Pharmacy will handle mail order prescriptions only for specialty drugs while many in-network retail pharmacies will continue to dispense specialty drugs (check consult with your local pharmacy for availability). Other mail order prescription medications can continue to be sent to Express Scripts. (Express Scripts is an independent company providing pharmacy benefit services for Blues members.) A list of specialty drugs is available on our Web site at xxxxx.xxx/xxxxxxxx. If you have any questions, please call Walgreens Specialty Pharmacy customer service at 0-000-000-0000. We will not pay for more than a 30-day supply of a covered prescription drug that BCBSM defines as a "specialty pharmaceutical" whether or not the drug is obtained from a doctor 90-Day Retail Network provider or mail-order provider. We may make exceptions if a member requires more than a 30-day supply. BCBSM reserves the right to limit the quantity of select specialty drugs to no more than a 15-day supply for each fill. Your copay/coinsurance will be reduced by one-half for each fill once applicable deductibles have been met. Select Controlled Substance Drugs - BCBSM will limit the initial fill of select controlled substances to a 15-day supply. The member will be responsible for only one-half of their cost-sharing requirement typically imposed on a 30-day fill. Subsequent fills of the same medication will be eligible to be filled as prescribed, subject to the applicable cost-sharing requirement. Select controlled substances affected by this prescription drug requirement are available online at xxxxx.xxx/xxxxxxxx. Member's responsibility (copays and coinsurance amounts) Note: Your prescription drug copays and coinsurance amounts, including mail order copay and coinsurance amounts, are subject to the same annual out-of-pocket maximum required under your medical coverage. The following prescription drug expenses will not apply to your annual out-of-pocket maximum. • any difference between the Maximum Allowable Cost and BCBSM's approved amount for a covered brand name drug • the 25% member liability for covered drugs obtained from an out-of-network pharmacy Benefits Coverage Out-of-network pharmacy Copay You pay $15 copay You pay $15 copay plus an additional 25% of BCBSM approved amount for the drug Brand name prescription drugs You pay $30 copay You pay $30 copay plus an additional 25% of BCBSM approved amount for the drug Mail order (home delivery) prescription drugs Copay for up to a 90 day supply: • You pay $15 copay • You pay $30 copay for brand name drugs Not covered Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Note: An in-network pharmacy is a Preferred Rx pharmacy in Michigan or an Express Scripts pharmacy outside Michigan. Express Scripts is an independent company providing pharmacy benefit services for Blues members. An out-of-network pharmacy is a pharmacy NOT in the Preferred Rx or Express Scripts networks. Note: Over-the-counter (OTC) drugs are drugs that do not require a prescription under federal law. They are identified by BCBSM as select prescription drugs. A prescription for the select OTC drug is required from the member's physician. In some cases, over-the- counter drugs may need to be tried before BCBSM will approve use of other drugs. Covered services Benefits Coverage Out-of-network pharmacy FDA-approved drugs 100% of approved amount less plan copay/coinsurance 75% of approved amount less plan copay/coinsurance Prescribed over-the-counter drugs - when covered by BCBSM 100% of approved amount less plan copay/coinsurance 75% of approved amount less plan copay/coinsurance State-controlled drugs 100% of approved amount less plan copay/coinsurance 75% of approved amount less plan copay/coinsurance FDA-approved generic and select brand-name prescription preventive drugs, supplements and vitamins as required by PPACA (non-self- administered drugs are not covered) 100% of approved amount 75% of approved amount Other FDA-approved brand-name prescription preventive drugs, supplements and vitamins as required by PPACA (non-self-administered drugs are not covered) 100% of approved amount less plan copay/coinsurance 75% of approved amount less plan copay/coinsurance FDA-approved generic and select brand name prescription contraceptive medication (non-self- administered drugs are not covered) 100% of approved amount 75% of approved amount Other FDA-approved brand name prescription contraceptive medication (non-self-administered drugs are not covered) 100% of approved amount less plan copay/coinsurance 75% of approved amount less plan copay/coinsurance Disposable needles and syringes - when dispensed with insulin or other covered injectable legend drugs Note: Needles and syringes have no copay/ coinsurance. 100% of approved amount less plan copay/coinsurance for the insulin or other covered injectable legend drug 75% of approved amount less plan copay/coinsurance for the insulin or other covered injectable legend drug Note: An in-network pharmacy is a Preferred Rx pharmacy in Michigan or an Express Scripts pharmacy outside Michigan. Express Scripts is an independent company providing pharmacy benefit services for Blues members. An out-of-network pharmacy is a pharmacy NOT in the Preferred Rx or Express Scripts networks. Note: Over-the-counter (OTC) drugs are drugs that do not require a prescription under federal law. They are identified by BCBSM as select prescription drugs. A prescription for the select OTC drug is required from the member's physician. In some cases, over-the- counter drugs may need to be tried before BCBSM will approve use of other drugs Features of your prescription drug plan Drug interchange and generic copay/ coinsurance waiver BCBSM's drug interchange and generic copay/ coinsurance waiver programs encourage physicians to prescribe a less-costly generic equivalent. If your physician rewrites your prescription for the recommended generic or OTC alternate drug, you will only have to pay a generic copay/ coinsurance. In select cases BCBSM may waive the initial copay/ coinsurance after your prescription has been rewritten. BCBSM will notify you if you are eligible for a waiver. Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Features of your prescription drug plan Prescription drug preferred therapy A step-therapy approach that encourages physicians to prescribe generic, generic alternative or over-the- counter medications before prescribing a more expensive brand-name drug. It applies only to prescriptions being filled for the first time of a targeted medication. Before filling your initial prescription for select, high-cost, brand-name drugs, the pharmacy will contact your physician to suggest a generic alternative. A list of select brand-name drugs targeted for the preferred therapy program is available at xxxxx.xxx/xxxxxxxx, along with the preferred medications. If our records indicate you have already tried the preferred medication(s), we will authorize the prescription. If we have no record of you trying the preferred medication(s), you may be liable for the entire cost of the brand-name drug unless you first try the preferred medication(s) or your physician obtains prior authorization from BCBSM. These provisions affect all targeted brand-name drugs, whether they are dispensed by a retail pharmacy or through a mail order provider. Quantity limits To stay consistent with FDA approved labeling for drugs, some medications may have quantity limits. Clinical Drug List A continually updated list of FDA-approved medications that represent each therapeutic class. The drugs on the list are chosen by the BCBSM Pharmacy and Therapeutics Committee for their effectiveness, safety, uniqueness and cost efficiency. The goal of the drug list is to provide members with the greatest therapeutic value at the lowest possible cost. This document can also be accessed on the County website at: Xxxxxxxxxxxxx.xxx/Xxxxxxxxxxx/Xxxxxxxxx/Xxxxxxxx Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. For the Court: Dated Xxxx X. Xxxxx, Trial Court Chief Judge For the Union Dated Union Representativedeductible Surgical services

Benefits Coverage. Surgery-includes related surgical Laboratory and pathology services and medically necessary facility services by a participating ambulatory surgery facility 90% after deductible Presurgical consultations • Diagnostic tests and x-rays 90% after deductible Therapeutic radiology 90% after deductible Maternity services provided by a physician or certified nurse midwife Benefits Coverage Prenatal care visits 100% (no deductible or copay/coinsurance) when obtained from a participating provider • Postnatal care 90% after deductible when obtained from a nonparticipating provider Voluntary sterilization for males Note: For voluntary sterilizations for females, see "Preventive Delivery and nursery care services." 90% after deductible Voluntary Abortions 90% after deductible Removal of impacted and partial bony impacted teeth - includes surgery and related anesthesia 90% after deductible Human organ transplants Hospital Care Benefits Coverage Specified human organ transplants-Semiprivate room, inpatient physician care, general nursing care, hospital services and supplies Note: Nonemergency services must be rendered in a designated facility and coordinated through the BCBSM Human Organ Transplant Program (0-000-000-0000) 100% (no deductible or copay/coinsurance) Bone marrow transplants-must be coordinated through the BCBSM Human Organ Transplant Program (0-000-000-0000) 90% after deductible Specified oncology clinical trials Note: BCBSM covers clinical trials in compliance with PPACAparticipating hospital. 90% after deductible Kidney, cornea and skin transplants 90% after deductible Mental health care and substance abuse treatment Benefits Coverage Inpatient mental health care and inpatient substance abuse treatment 90% after deductible, unlimited days Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a "low access area" by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and the provider's charge. Benefits Coverage Residential psychiatric treatment facility: • covered mental health services must be performed in a residential psychiatric treatment facility • treatment must be preauthorized • subject to medical criteria Inpatient consultations 90% after deductible Outpatient mental health care 90% after deductible Outpatient substance abuse treatment-in approved facilities only 90% after deductible Autism spectrum disorders, diagnoses and treatment Benefits Coverage Applied behavioral analysis (ABA) treatment - when rendered by an approved board-certified behavioral analyst - is covered through age 18, subject to preauthorization Note: Diagnosis of an autism spectrum disorder and a treatment recommendation for ABA services must be obtained by a BCBSM approved autism evaluation center (AAEC) prior to seeking ABA treatment. 90% after deductible Outpatient physical therapy, speech therapy, occupational therapy, nutritional counseling for autism spectrum disorder 90% after deductible Other covered services, including mental health services, for autism spectrum disorder 90% after deductible Other covered services Benefits Coverage Outpatient Diabetes Management Program (ODMP) Note: Screening services required under the provisions of PPACA are covered at 100% of approved amount with no cost-sharing when rendered by a participating provider. Note: When you purchase your diabetic supplies via mail order you will lower your out-of-pocket costs. • 90% after deductible for diabetes medical supplies • 100% (no deductible or copay/coinsurance) for diabetes self- management training Allergy testing and therapy 90% after deductible Chiropractic spinal manipulation and osteopathic manipulative therapy 90% after deductible, limited to a combined 38-visit maximum per member per calendar year Outpatient physical, speech and occupational therapy- provided for Rehabilitation 90% after deductible Durable medical equipment Note: DME items required under the provisions of PPACA are covered at 100% of approved amount with no in-network cost-sharing when rendered by an in-network provider. For a list of covered DME items required under PPACA, call BCBSM. 90% after deductible Prosthetic and orthotic appliances 90% after deductible Private duty nursing 90% after deductible Hair prosthesis and accessories: • covered only when the hair loss is the result of either chemptherapy and/or radiation treatment for malignant and non-malignant conditions, trichotillomania or alopecia • subject to medical and benefit criteria Chemotherapy 90% after deductible Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Services from a provider for which there is no Michigan PPO network and services from an out-of-network provider in a geographic area of Michigan deemed a "low access area" by BCBSM for that particular provider specialty are covered at the in-network benefit level. Cost-sharing may differ when you obtain covered services outside of Michigan. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and the provider's charge. BERRIEN COUNTY 007015910/0003/0007/0010/0011 D, O, S, T POLC/TRIAL COURT/FOP Comprehensive Major Medical Alternatives to hospital care Benefits Coverage Skilled nursing care-must be in a participating skilled nursing facility 90% after deductible Hospice care 100% (CMM) ASC Effective Date: On no deductible or after January 2017 Benefits-at-a-glance This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and exclusions may apply. Payment amounts are based on BCBSM's approved amount, less any applicable deductible and/or copay/coinsurance. For coinsurance),up to 28 pre-hospice counseling visits before electing hospice services; when elected, four 90-day periods-provided through a complete description of benefits please see the applicable BCBSM certificates participating hospice program only; limited to dollar maximum that is reviewed and ridersadjusted periodically (after reaching dollar maximum, if your group is underwritten member transitions into individual case management) Home health care:  must be medically necessary  must be provided by a participating home health care agency 90% after deductible, limited to a maximum 100-visits per member per calendar year Infusion therapy:  must be medically necessary  must be given by a participating Home Infusion Therapy (HIT) provider or any other plan documents your group uses, if your group is selfin a participating freestanding Ambulatory Infusion Center (AIC)  may use drugs that require preauthorization-funded. If there is a discrepancy between this Benefits-at-a-Glance and any applicable plan document, the plan document will control. Specialty Pharmaceutical Drugs - The mail order pharmacy for specialty drugs is Walgreens Specialty Pharmacy, LLC, an independent company. Specialty prescription drugs (such as Enbrel® and Humira® ) are used to treat complex conditions such as rheumatoid arthritis, multiple sclerosis and cancer. These drugs require special handling, administration or monitoring. Walgreens Specialty Pharmacy will handle mail order prescriptions only for specialty drugs while many in-network retail pharmacies will continue to dispense specialty drugs (check consult with your local pharmacy for availability). Other mail order prescription medications can continue to be sent to Express Scripts. (Express Scripts is an independent company providing pharmacy benefit services for Blues members.) A list of specialty drugs is available on our Web site at xxxxx.xxx/xxxxxxxx. If you have any questions, please call Walgreens Specialty Pharmacy customer service at 0-000-000-0000. We will not pay for more than a 30-day supply of a covered prescription drug that BCBSM defines as a "specialty pharmaceutical" whether or not the drug is obtained from a doctor 90-Day Retail Network provider or mail-order provider. We may make exceptions if a member requires more than a 30-day supply. BCBSM reserves the right to limit the quantity of select specialty drugs to no more than a 15-day supply for each fill. Your copay/coinsurance will be reduced by one-half for each fill once applicable deductibles have been met. Select Controlled Substance Drugs - BCBSM will limit the initial fill of select controlled substances to a 15-day supply. The member will be responsible for only one-half of their cost-sharing requirement typically imposed on a 30-day fill. Subsequent fills of the same medication will be eligible to be filled as prescribed, subject to the applicable cost-sharing requirement. Select controlled substances affected by this prescription drug requirement are available online at xxxxx.xxx/xxxxxxxx. Member's responsibility (copays and coinsurance amounts) Note: Your prescription drug copays and coinsurance amounts, including mail order copay and coinsurance amounts, are subject to the same annual out-of-pocket maximum required under your medical coverage. The following prescription drug expenses will not apply to your annual out-of-pocket maximum. • any difference between the Maximum Allowable Cost and BCBSM's approved amount for a covered brand name drug • the 25% member liability for covered drugs obtained from an out-of-network pharmacy Benefits Coverage Out-of-network pharmacy Copay You pay $15 copay You pay $15 copay plus an additional 25% of BCBSM approved amount for the drug Brand name prescription drugs You pay $30 copay You pay $30 copay plus an additional 25% of BCBSM approved amount for the drug Mail order (home delivery) prescription drugs Copay for up to a 90 day supply: • You pay $15 copay • You pay $30 copay for brand name drugs Not covered Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Note: An in-network pharmacy is a Preferred Rx pharmacy in Michigan or an Express Scripts pharmacy outside Michigan. Express Scripts is an independent company providing pharmacy benefit services for Blues members. An out-of-network pharmacy is a pharmacy NOT in the Preferred Rx or Express Scripts networks. Note: Over-the-counter (OTC) drugs are drugs that do not require a prescription under federal law. They are identified by BCBSM as select prescription drugs. A prescription for the select OTC drug is required from the member's physician. In some cases, over-the- counter drugs may need to be tried before BCBSM will approve use of other drugs. Covered services Benefits Coverage Out-of-network pharmacy FDA-approved drugs 100% of approved amount less plan copay/coinsurance 75% of approved amount less plan copay/coinsurance Prescribed over-the-counter drugs - when covered by BCBSM 100% of approved amount less plan copay/coinsurance 75% of approved amount less plan copay/coinsurance State-controlled drugs 100% of approved amount less plan copay/coinsurance 75% of approved amount less plan copay/coinsurance FDA-approved generic and select brand-name prescription preventive drugs, supplements and vitamins as required by PPACA (non-self- administered drugs are not covered) 100% of approved amount 75% of approved amount Other FDA-approved brand-name prescription preventive drugs, supplements and vitamins as required by PPACA (non-self-administered drugs are not covered) 100% of approved amount less plan copay/coinsurance 75% of approved amount less plan copay/coinsurance FDA-approved generic and select brand name prescription contraceptive medication (non-self- administered drugs are not covered) 100% of approved amount 75% of approved amount Other FDA-approved brand name prescription contraceptive medication (non-self-administered drugs are not covered) 100% of approved amount less plan copay/coinsurance 75% of approved amount less plan copay/coinsurance Disposable needles and syringes - when dispensed with insulin or other covered injectable legend drugs Note: Needles and syringes have no copay/ coinsurance. 100% of approved amount less plan copay/coinsurance for the insulin or other covered injectable legend drug 75% of approved amount less plan copay/coinsurance for the insulin or other covered injectable legend drug Note: An in-network pharmacy is a Preferred Rx pharmacy in Michigan or an Express Scripts pharmacy outside Michigan. Express Scripts is an independent company providing pharmacy benefit services for Blues members. An out-of-network pharmacy is a pharmacy NOT in the Preferred Rx or Express Scripts networks. Note: Over-the-counter (OTC) drugs are drugs that do not require a prescription under federal law. They are identified by BCBSM as select prescription drugs. A prescription for the select OTC drug is required from the member's physician. In some cases, over-the- counter drugs may need to be tried before BCBSM will approve use of other drugs Features of your prescription drug plan Drug interchange and generic copay/ coinsurance waiver BCBSM's drug interchange and generic copay/ coinsurance waiver programs encourage physicians to prescribe a less-costly generic equivalent. If your physician rewrites your prescription for the recommended generic or OTC alternate drug, you will only have to pay a generic copay/ coinsurance. In select cases BCBSM may waive the initial copay/ coinsurance after your prescription has been rewritten. BCBSM will notify you if you are eligible for a waiver. Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Features of your prescription drug plan Prescription drug preferred therapy A step-therapy approach that encourages physicians to prescribe generic, generic alternative or over-the- counter medications before prescribing a more expensive brand-name drug. It applies only to prescriptions being filled for the first time of a targeted medication. Before filling your initial prescription for select, high-cost, brand-name drugs, the pharmacy will contact your physician to suggest a generic alternative. A list of select brand-name drugs targeted for the preferred therapy program is available at xxxxx.xxx/xxxxxxxx, along with the preferred medications. If our records indicate you have already tried the preferred medication(s), we will authorize the prescription. If we have no record of you trying the preferred medication(s), you may be liable for the entire cost of the brand-name drug unless you first try the preferred medication(s) or your physician obtains prior authorization from BCBSM. These provisions affect all targeted brand-name drugs, whether they are dispensed by a retail pharmacy or through a mail order provider. Quantity limits To stay consistent with FDA approved labeling for drugs, some medications may have quantity limits. Clinical Drug List A continually updated list of FDA-approved medications that represent each therapeutic class. The drugs on the list are chosen by the BCBSM Pharmacy and Therapeutics Committee for their effectiveness, safety, uniqueness and cost efficiency. The goal of the drug list is to provide members with the greatest therapeutic value at the lowest possible cost. This document can also be accessed on the County website at: Xxxxxxxxxxxxx.xxx/Xxxxxxxxxxx/Xxxxxxxxx/Xxxxxxxx Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. For the Court: Dated Xxxx X. Xxxxx, Trial Court Chief Judge For the Union Dated Union Representativedeductible Surgical services