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It is not a contract. Additional limitations and ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 0 66.35 Tm (exclusions may apply. Payment amounts are based on BCBSM's approved amount, less any applicable deductible and/or copay. If there is a ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 0 57.15 Tm (discrepancy between this Benefits-at-a-Glance and any applicable plan document, the plan document will control. ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 0 38.75 Tm (BCBSM provides administrative claims services only. Your employer or plan sponsor is financially responsible for claims. ) Tj ET EMC /Span <>BDC BT /F7 8 Tf 1 0 0 1 0 20.36 Tm (Note:) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 20.44 20.36 Tm ( A list of services that require approval ) Tj ET EMC /Span <>BDC BT /F7 8 Tf 1 0 0 1 158.28 20.36 Tm (before) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 182.73 20.36 Tm ( they are provided is available online at \() Tj ET EMC /Span <>BDC 0 0 1 rg BT /F3 8 Tf 1 0 0 1 325.93 20.36 Tm (https://www.bcbsm.com/importantinfo) Tj ET EMC /Artifact <> BDC 2 J 0.586 w [] 0 d 0 0 1 RG 326.22 19.22 m 458.57 19.22 l S 1 w [] 0 d EMC /Span <>BDC 0 0 0 rg BT /F3 8 Tf 1 0 0 1 458.86 20.36 Tm (\). Select ) Tj ET EMC /Span <>BDC BT /F7 8 Tf 1 0 0 1 490.43 20.36 Tm (Approving ) Tj ET EMC /Span <>BDC BT /F7 8 Tf 1 0 0 1 0 11.16 Tm (covered Services) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 65.82 11.16 Tm (. ) Tj ET EMC Q q Q q 1 0 0 1 36 446.14 cm Q q Q q 1 0 0 1 36 194.21 cm /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 20.7 w -1.45 241.58 m 542.6 241.58 l S 1 w 0.83922 0.84314 0.9098 RG 17.25 w -1.45 222.61 m 269.85 222.61 l S 1 w 17.25 w 270.35 222.61 m 418.9 222.61 l S 1 w 17.25 w 419.4 222.61 m 542.6 222.61 l S 1 w 1 1 1 RG 22.4 w -1.45 202.79 m 269.85 202.79 l S 1 w 0.92941 0.95294 0.99608 RG 22.4 w 270.35 202.79 m 418.9 202.79 l S 1 w 0.96078 0.96078 0.96078 RG 22.4 w 419.4 202.79 m 542.6 202.79 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 191.09 m 542.6 191.09 l S 1 1 1 RG 86.79 w -1.45 147.19 m 269.85 147.19 l S 1 w 0.92941 0.95294 0.99608 RG 86.79 w 270.35 147.19 m 418.9 147.19 l S 1 w 0.96078 0.96078 0.96078 RG 86.79 w 419.4 147.19 m 542.6 147.19 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 103.29 m 542.6 103.29 l S 1 1 1 RG 42.8 w -1.45 81.39 m 269.85 81.39 l S 1 w 0.92941 0.95294 0.99608 RG 42.8 w 270.35 81.39 m 418.9 81.39 l S 1 w 0.96078 0.96078 0.96078 RG 42.8 w 419.4 81.39 m 542.6 81.39 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 59.5 m 542.6 59.5 l S 1 1 1 RG 42.8 w -1.45 37.6 m 269.85 37.6 l S 1 w 0.92941 0.95294 0.99608 RG 42.8 w 270.35 37.6 m 418.9 37.6 l S 1 w 0.96078 0.96078 0.96078 RG 42.8 w 419.4 37.6 m 542.6 37.6 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 15.7 m 542.6 15.7 l S 1 1 1 RG 13.2 w -1.45 8.6 m 269.85 8.6 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 8.6 m 542.6 8.6 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 1.5 m 542.6 1.5 l S EMC /Span <>BDC 1 1 1 rg BT /F7 12 Tf 1 0 0 1 2.9 237.62 Tm (Member's responsibility \(deductibles, copays, coinsurance and dollar maximums\) ) Tj ET EMC /Span <>BDC 0.2 0.2 0.2 rg BT /F7 9 Tf 1 0 0 1 2.9 219.64 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F7 9 Tf 1 0 0 1 274.45 219.64 Tm (In-Network ) Tj ET EMC /Span <>BDC BT /F7 9 Tf 1 0 0 1 422.3 221.09 Tm (Out-of-Network ) Tj ET EMC /Span <>BDC BT /F7 8 Tf 1 0 0 1 2.9 204.74 Tm (Deductibles) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 48.24 204.74 Tm ( - per calendar year ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 204.74 Tm ($500 per member ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 195.54 Tm ($1,000 per family ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 204.74 Tm ($1,000 per member ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 195.54 Tm ($2,000 per family ) Tj ET EMC q n 2.9 191.59 m 546.95 191.59 l 546.95 190.59 l 2.9 190.59 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F7 8 Tf 1 0 0 1 2.9 181.34 Tm (Copays ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 172.14 Tm ( Fixed Dollar Copays ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 181.34 Tm ($40 copay for : ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 172.14 Tm ( Facility Urgent care services ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 162.94 Tm ( Professional Urgent care services ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 153.75 Tm ( Office visits ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 144.55 Tm ( Chiropractic spinal manipulations ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 135.35 Tm ( Allergy testing ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 126.15 Tm ( Allergy therapy ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 116.95 Tm ($250 copay for : ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 107.75 Tm ( Facility medical emergency ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 181.34 Tm ($250 copay for : ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 172.14 Tm ( Facility medical emergency ) Tj ET EMC q n 2.9 103.79 m 546.95 103.79 l 546.95 102.79 l 2.9 102.79 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F7 8 Tf 1 0 0 1 2.9 93.55 Tm (Coinsurance ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 84.35 Tm ( Percent Coinsurance ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 93.55 Tm (20% up to a maximum of: ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 84.35 Tm ($2,000 per member ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 75.15 Tm ($4,000 per family ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 93.55 Tm (40% ) Tj ET EMC /Span <>BDC BT /F7 8 Tf 1 0 0 1 422.3 82.35 Tm (Note:) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 442.74 82.35 Tm ( Services without a network ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 73.15 Tm (are covered at the in-network ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 63.95 Tm (level. ) Tj ET EMC q n 2.9 60 m 546.95 60 l 546.95 59 l 2.9 59 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F7 8 Tf 1 0 0 1 2.9 49.75 Tm (Annual out-of-pocket maximums ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 49.75 Tm ($6,350 per member ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 40.55 Tm ($12,700 per family ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 29.36 Tm (Includes Deductible, Coinsurance and ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 20.16 Tm (Copays ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 49.75 Tm ($12,700 per member ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 40.55 Tm ($25,400 per family ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 29.36 Tm (Includes Deductible and ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 20.16 Tm (Coinsurance ) Tj ET EMC q n 2.9 16.2 m 546.95 16.2 l 546.95 15.2 l 2.9 15.2 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F7 8 Tf 1 0 0 1 2.9 5.96 Tm (Lifetime dollar maximum ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 5.96 Tm (Unlimited ) Tj ET EMC q n 2.9 2 m 546.95 2 l 546.95 1 l 2.9 1 l h W n Q /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG 270.1 231.23 m 270.1 191.59 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 190.59 m 270.1 103.79 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 102.79 m 270.1 59.99 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 58.99 m 270.1 16.2 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 15.2 m 270.1 2 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 231.23 m 419.15 191.59 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 190.59 m 419.15 103.79 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 102.79 m 419.15 59.99 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 58.99 m 419.15 16.2 l S 1 w [] 0 d 0.5 w [] 0 d 542.85 251.93 m 542.85 1 l S 1 w [] 0 d EMC q n 0 1 m 612 1 l 612 0 l 0 0 l h W n Q Q q Q q 1 0 0 1 36 103.84 cm /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 20.7 w -1.45 60.24 m 542.6 60.24 l S 1 w 0.83922 0.84314 0.9098 RG 17.25 w -1.45 41.26 m 269.85 41.26 l S 1 w 17.25 w 270.35 41.26 m 418.9 41.26 l S 1 w 17.25 w 419.4 41.26 m 542.6 41.26 l S 1 w 1 1 1 RG 13.2 w -1.45 26.04 m 269.85 26.04 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 26.04 m 418.9 26.04 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 26.04 m 542.6 26.04 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 18.94 m 542.6 18.94 l S EMC /Span <>BDC 1 1 1 rg BT /F7 12 Tf 1 0 0 1 2.9 56.27 Tm (Preventive Care Services ) Tj ET EMC /Span <>BDC 0.2 0.2 0.2 rg BT /F7 9 Tf 1 0 0 1 2.9 38.29 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F7 9 Tf 1 0 0 1 274.45 38.29 Tm (In-Network ) Tj ET EMC /Span <>BDC BT /F7 9 Tf 1 0 0 1 422.3 39.74 Tm (Out-of-Network ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 23.39 Tm (Health Maintenance Exam - beginning age 4; one per calendar year ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 23.39 Tm (Covered - 100% ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 23.39 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 19.44 m 546.95 19.44 l 546.95 18.44 l 2.9 18.44 l h W n Q /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG 270.1 49.88 m 270.1 19.44 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 49.88 m 419.15 19.44 l S 1 w [] 0 d 0.5 w [] 0 d 542.85 70.58 m 542.85 18.44 l S 1 w [] 0 d EMC Q q Q Q endstream endobj 44 0 obj <>>>>> endobj 45 0 obj <> endobj 47 0 obj <> endobj 48 0 obj <> endobj 49 0 obj <> endobj 50 0 obj <> endobj 51 0 obj <> endobj 52 0 obj <> endobj 53 0 obj <> endobj 55 0 obj <> endobj 56 0 obj <> endobj 57 0 obj <> endobj 58 0 obj <> endobj 59 0 obj <> endobj 60 0 obj <> endobj 61 0 obj <> endobj 62 0 obj <> endobj 63 0 obj <> endobj 64 0 obj <> endobj 65 0 obj <> endobj 66 0 obj <> endobj 67 0 obj <> endobj 68 0 obj <> endobj 69 0 obj <> endobj 70 0 obj <> endobj 71 0 obj <> endobj 72 0 obj <> endobj 73 0 obj <> endobj 74 0 obj <> endobj 75 0 obj <> endobj 76 0 obj <> endobj 77 0 obj <> endobj 78 0 obj <> endobj 79 0 obj <> endobj 80 0 obj <> endobj 81 0 obj <> endobj 82 0 obj [ 44 0 R /XYZ 38.9 492.04 0] endobj 83 0 obj [ 44 0 R /XYZ 38.9 492.04 0] endobj 84 0 obj <> endobj 86 0 obj <> endobj 87 0 obj <> endobj 88 0 obj <> endobj 89 0 obj <> endobj 90 0 obj <> endobj 91 0 obj <> endobj 92 0 obj <> endobj 93 0 obj <> endobj 94 0 obj <> endobj 95 0 obj <> endobj 96 0 obj <> endobj 97 0 obj <> endobj 98 0 obj <> endobj 99 0 obj <> endobj 100 0 obj <> endobj 101 0 obj <> endobj 102 0 obj <> endobj 103 0 obj <> endobj 104 0 obj <> endobj 105 0 obj [ 44 0 R /XYZ 38.9 341.92 0] endobj 106 0 obj [ 44 0 R /XYZ 38.9 341.92 0] endobj 107 0 obj <> endobj 109 0 obj <> endobj 110 0 obj <> endobj 111 0 obj <> endobj 112 0 obj <> endobj 113 0 obj <> endobj 114 0 obj <> endobj 115 0 obj <> endobj 116 0 obj <> endobj 117 0 obj <> endobj 118 0 obj <> endobj 119 0 obj <> endobj 120 0 obj <> endobj 121 0 obj <> endobj 122 0 obj <> endobj 123 0 obj <> endobj 124 0 obj <> endobj 125 0 obj <> endobj 126 0 obj <> endobj 127 0 obj [ 44 0 R /XYZ 38.9 203 0] endobj 128 0 obj [ 44 0 R /XYZ 38.9 202.99 0] endobj 129 0 obj <> endobj 131 0 obj <> endobj 132 0 obj <> endobj 133 0 obj <> endobj 134 0 obj <> endobj 135 0 obj <> endobj 136 0 obj <> endobj 137 0 obj <> endobj 138 0 obj <> endobj 139 0 obj <> endobj 140 0 obj <> endobj 141 0 obj <> endobj 142 0 obj <> endobj 143 0 obj <>stream q 0 0 612 792 re W n /Artifact <> BDC q 1 0 0 1 36 755.3 cm q n 0 0.7 m 612 0.7 l 612 0 l 0 0 l h W n Q Q q Q EMC /Artifact <> BDC q 1 0 0 1 36 36 cm 0 0 0 rg BT /F3 7 Tf 1 0 0 1 61.82 61.51 Tm (Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. ) Tj ET BT /F3 7 Tf 1 0 0 1 0 53.46 Tm (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 ) Tj ET BT /F3 7 Tf 1 0 0 1 0 45.41 Tm (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 ) Tj ET BT /F3 7 Tf 1 0 0 1 0 37.36 Tm (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 ) Tj ET BT /F3 7 Tf 1 0 0 1 0 29.31 Tm (charge. ) Tj ET BT /F3 7 Tf 1 0 0 1 0 21.26 Tm (Page ) Tj ET BT /F3 7 Tf 1 0 0 1 18.29 21.26 Tm (2) Tj ET BT /F3 7 Tf 1 0 0 1 22.19 21.26 Tm ( of ) Tj ET BT /F3 7 Tf 1 0 0 1 31.91 21.26 Tm (6 ) Tj ET BT /F3 7 Tf 1 0 0 1 251.68 21.26 Tm (G10192023 ) Tj ET BT /F3 8 Tf 1 0 0 1 486.61 20.36 Tm (000019424595 ) Tj ET Q q Q EMC q 1 0 0 1 36 515.27 cm /Artifact <> BDC 0.83922 0.84314 0.9098 RG 0 J 17.25 w -1.45 231.41 m 269.85 231.41 l S 1 w 17.25 w 270.35 231.41 m 418.9 231.41 l S 1 w 17.25 w 419.4 231.41 m 542.6 231.41 l S 1 w 1 1 1 RG 22.4 w -1.45 211.59 m 269.85 211.59 l S 1 w 0.92941 0.95294 0.99608 RG 22.4 w 270.35 211.59 m 418.9 211.59 l S 1 w 0.96078 0.96078 0.96078 RG 22.4 w 419.4 211.59 m 542.6 211.59 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 199.89 m 542.6 199.89 l S 1 1 1 RG 22.4 w -1.45 188.19 m 269.85 188.19 l S 1 w 0.92941 0.95294 0.99608 RG 22.4 w 270.35 188.19 m 418.9 188.19 l S 1 w 0.96078 0.96078 0.96078 RG 22.4 w 419.4 188.19 m 542.6 188.19 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 176.49 m 542.6 176.49 l S 1 1 1 RG 13.2 w -1.45 169.39 m 269.85 169.39 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 169.39 m 418.9 169.39 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 169.39 m 542.6 169.39 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 162.29 m 542.6 162.29 l S 1 1 1 RG 22.4 w -1.45 150.59 m 269.85 150.59 l S 1 w 0.92941 0.95294 0.99608 RG 22.4 w 270.35 150.59 m 418.9 150.59 l S 1 w 0.96078 0.96078 0.96078 RG 22.4 w 419.4 150.59 m 542.6 150.59 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 138.89 m 542.6 138.89 l S 1 1 1 RG 13.2 w -1.45 131.79 m 269.85 131.79 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 131.79 m 418.9 131.79 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 131.79 m 542.6 131.79 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 124.69 m 542.6 124.69 l S 1 1 1 RG 13.2 w -1.45 117.59 m 269.85 117.59 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 117.59 m 418.9 117.59 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 117.59 m 542.6 117.59 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 110.49 m 542.6 110.49 l S 1 1 1 RG 13.2 w -1.45 103.39 m 269.85 103.39 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 103.39 m 418.9 103.39 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 103.39 m 542.6 103.39 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 96.29 m 542.6 96.29 l S 1 1 1 RG 79.59 w -1.45 56 m 269.85 56 l S 1 w 0.92941 0.95294 0.99608 RG 79.59 w 270.35 56 m 418.9 56 l S 1 w 0.96078 0.96078 0.96078 RG 79.59 w 419.4 56 m 542.6 56 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 15.7 m 542.6 15.7 l S 1 1 1 RG 13.2 w -1.45 8.6 m 269.85 8.6 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 8.6 m 418.9 8.6 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 8.6 m 542.6 8.6 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 1.5 m 542.6 1.5 l S EMC /Artifact <> BDC 0.2 0.2 0.2 rg BT /F7 9 Tf 1 0 0 1 2.9 228.44 Tm (Benefits ) Tj ET BT /F7 9 Tf 1 0 0 1 274.45 228.44 Tm (In-Network ) Tj ET BT /F7 9 Tf 1 0 0 1 422.3 229.89 Tm (Out-of-Network ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 213.54 Tm (Routine Physical Related Test X-Rays, EKG and lab procedures ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 204.34 Tm (performed as part of the health maintenance exam ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 213.54 Tm (Covered - 100% ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 213.54 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 200.39 m 546.95 200.39 l 546.95 199.39 l 2.9 199.39 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 190.14 Tm (Annual Gynecological Exam - two per calendar year, in addition to health ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 180.95 Tm (maintenance exam ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 190.14 Tm (Covered - 100% ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 190.14 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 176.99 m 546.95 176.99 l 546.95 175.99 l 2.9 175.99 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 166.75 Tm (Pap Smear Screening - one per calendar year ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 166.75 Tm (Covered - 100% ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 166.75 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 162.79 m 546.95 162.79 l 546.95 161.79 l 2.9 161.79 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 152.55 Tm (Mammography Screening - one per calendar year ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 143.35 Tm (includes 3D Mammography ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 152.55 Tm (Covered - 100% ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 152.55 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 139.39 m 546.95 139.39 l 546.95 138.39 l 2.9 138.39 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 129.15 Tm (Contraceptive Methods and Counseling ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 129.15 Tm (Covered - 100% ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 129.15 Tm (Not Covered ) Tj ET EMC q n 2.9 125.19 m 546.95 125.19 l 546.95 124.19 l 2.9 124.19 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 114.95 Tm (Prostate Specific Antigen \(PSA\) screening - one per calendar year ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 114.95 Tm (Covered - 100% ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 114.95 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 110.99 m 546.95 110.99 l 546.95 109.99 l 2.9 109.99 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 100.75 Tm (Endoscopic Exams - one per calendar year ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 100.75 Tm (Covered - 100% ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 100.75 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 96.79 m 546.95 96.79 l 546.95 95.79 l 2.9 95.79 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 86.55 Tm (Well Child Care ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 75.35 Tm ( 8 visits, birth through 12 months ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 66.15 Tm ( 6 visits, 13 months through 23 months ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 56.95 Tm ( 6 visits, 24 months through 35 months ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 47.75 Tm ( 2 visits, 36 months through 47 months ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 29.36 Tm (Visits beyond 47 months are limited to one per member per calendar year ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 20.16 Tm (under the health maintenance exam benefit ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 86.55 Tm (Covered - 100% ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 86.55 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 16.2 m 546.95 16.2 l 546.95 15.2 l 2.9 15.2 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 5.96 Tm (Immunizations - pediatric and adult ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 5.96 Tm (Covered - 100% ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 5.96 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 2 m 546.95 2 l 546.95 1 l 2.9 1 l h W n Q /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG 270.1 240.03 m 270.1 200.38 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 199.39 m 270.1 176.99 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 175.99 m 270.1 162.79 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 161.79 m 270.1 139.39 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 138.39 m 270.1 125.19 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 124.19 m 270.1 110.99 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 109.99 m 270.1 96.79 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 95.79 m 270.1 16.2 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 15.2 m 270.1 2 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 240.03 m 419.15 200.38 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 199.39 m 419.15 176.99 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 175.99 m 419.15 162.79 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 161.79 m 419.15 139.39 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 138.39 m 419.15 125.19 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 124.19 m 419.15 110.99 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 109.99 m 419.15 96.79 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 95.79 m 419.15 16.2 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 15.2 m 419.15 2 l S 1 w [] 0 d 0.5 w [] 0 d 542.85 240.03 m 542.85 1 l S 1 w [] 0 d EMC q n 0 1 m 612 1 l 612 0 l 0 0 l h W n Q Q q Q q 1 0 0 1 36 365.14 cm /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 20.7 w -1.45 119.99 m 542.6 119.99 l S 1 w 0.83922 0.84314 0.9098 RG 17.25 w -1.45 101.02 m 269.85 101.02 l S 1 w 17.25 w 270.35 101.02 m 418.9 101.02 l S 1 w 17.25 w 419.4 101.02 m 542.6 101.02 l S 1 w 1 1 1 RG 13.2 w -1.45 85.79 m 269.85 85.79 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 85.79 m 418.9 85.79 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 85.79 m 542.6 85.79 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 78.69 m 542.6 78.69 l S 1 1 1 RG 13.2 w -1.45 71.6 m 269.85 71.6 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 71.6 m 418.9 71.6 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 71.6 m 542.6 71.6 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 64.5 m 542.6 64.5 l S 1 1 1 RG 33.6 w -1.45 47.2 m 269.85 47.2 l S 1 w 0.92941 0.95294 0.99608 RG 33.6 w 270.35 47.2 m 418.9 47.2 l S 1 w 0.96078 0.96078 0.96078 RG 33.6 w 419.4 47.2 m 542.6 47.2 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 29.9 m 542.6 29.9 l S 1 1 1 RG 13.2 w -1.45 22.8 m 269.85 22.8 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 22.8 m 418.9 22.8 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 22.8 m 542.6 22.8 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 15.7 m 542.6 15.7 l S 1 1 1 RG 13.2 w -1.45 8.6 m 269.85 8.6 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 8.6 m 418.9 8.6 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 8.6 m 542.6 8.6 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 1.5 m 542.6 1.5 l S EMC /Span <>BDC 1 1 1 rg BT /F7 12 Tf 1 0 0 1 2.9 116.03 Tm (Physician Office Services ) Tj ET EMC /Span <>BDC 0.2 0.2 0.2 rg BT /F7 9 Tf 1 0 0 1 2.9 98.05 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F7 9 Tf 1 0 0 1 274.45 98.05 Tm (In-Network ) Tj ET EMC /Span <>BDC BT /F7 9 Tf 1 0 0 1 422.3 99.5 Tm (Out-of-Network ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 83.15 Tm (Office Visits ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 83.15 Tm (Covered - 100% after $40 copay ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 83.15 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 79.19 m 546.95 79.19 l 546.95 78.19 l 2.9 78.19 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 68.95 Tm (Telemedicine Visits ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 68.95 Tm (Covered - 100% after $40 copay ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 68.95 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 65 m 546.95 65 l 546.95 64 l 2.9 64 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 54.75 Tm (Blue Cross Online Visits ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 43.55 Tm (Note: Online Medical visits by a non-BCBSM selected vendor are not ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 34.36 Tm (covered. ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 54.75 Tm (Covered - 100% after $40 copay ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 54.75 Tm (Not Covered ) Tj ET EMC q n 2.9 30.4 m 546.95 30.4 l 546.95 29.4 l 2.9 29.4 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 20.16 Tm (Office Consultations ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 20.16 Tm (Covered - 100% after $40 copay ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 20.16 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 16.2 m 546.95 16.2 l 546.95 15.2 l 2.9 15.2 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 5.96 Tm (Pre-Surgical Consultations ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 5.96 Tm (Covered - 80% after deductible ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 5.96 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 2 m 546.95 2 l 546.95 1 l 2.9 1 l h W n Q /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG 270.1 109.64 m 270.1 79.19 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 78.19 m 270.1 65 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 63.99 m 270.1 30.4 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 29.4 m 270.1 16.2 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 15.2 m 270.1 2 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 109.64 m 419.15 79.19 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 78.19 m 419.15 65 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 63.99 m 419.15 30.4 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 29.4 m 419.15 16.2 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 15.2 m 419.15 2 l S 1 w [] 0 d 0.5 w [] 0 d 542.85 130.34 m 542.85 1 l S 1 w [] 0 d EMC q n 0 1 m 612 1 l 612 0 l 0 0 l h W n Q Q q Q q 1 0 0 1 36 226.22 cm /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 20.7 w -1.45 108.79 m 542.6 108.79 l S 1 w 0.83922 0.84314 0.9098 RG 17.25 w -1.45 89.82 m 269.85 89.82 l S 1 w 17.25 w 270.35 89.82 m 418.9 89.82 l S 1 w 17.25 w 419.4 89.82 m 542.6 89.82 l S 1 w 1 1 1 RG 22.4 w -1.45 70 m 269.85 70 l S 1 w 0.92941 0.95294 0.99608 RG 22.4 w 270.35 70 m 418.9 70 l S 1 w 0.96078 0.96078 0.96078 RG 22.4 w 419.4 70 m 542.6 70 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 58.3 m 542.6 58.3 l S 1 1 1 RG 13.2 w -1.45 51.2 m 269.85 51.2 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 51.2 m 418.9 51.2 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 51.2 m 542.6 51.2 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 44.1 m 542.6 44.1 l S 1 1 1 RG 13.2 w -1.45 37 m 269.85 37 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 37 m 418.9 37 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 37 m 542.6 37 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 29.9 m 542.6 29.9 l S 1 1 1 RG 13.2 w -1.45 22.8 m 269.85 22.8 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 22.8 m 418.9 22.8 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 22.8 m 542.6 22.8 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 15.7 m 542.6 15.7 l S 1 1 1 RG 13.2 w -1.45 8.6 m 269.85 8.6 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 8.6 m 418.9 8.6 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 8.6 m 542.6 8.6 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 1.5 m 542.6 1.5 l S EMC /Span <>BDC 1 1 1 rg BT /F7 12 Tf 1 0 0 1 2.9 104.83 Tm (Emergency Medical Care ) Tj ET EMC /Span <>BDC 0.2 0.2 0.2 rg BT /F7 9 Tf 1 0 0 1 2.9 86.85 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F7 9 Tf 1 0 0 1 274.45 86.85 Tm (In-Network ) Tj ET EMC /Span <>BDC BT /F7 9 Tf 1 0 0 1 422.3 88.3 Tm (Out-of-Network ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 71.95 Tm (Hospital Emergency Room ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 62.75 Tm (Qualified medical emergency ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 71.95 Tm (Covered - 100% after $250 copay; copay ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 62.75 Tm (waived if admitted ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 71.95 Tm (Covered - 100% after $250 ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 62.75 Tm (copay; copay waived if admitted ) Tj ET EMC q n 2.9 58.8 m 546.95 58.8 l 546.95 57.8 l 2.9 57.8 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 48.55 Tm (Non-Emergency use of the Emergency Room ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 48.55 Tm (Not Covered ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 48.55 Tm (Not Covered ) Tj ET EMC q n 2.9 44.6 m 546.95 44.6 l 546.95 43.6 l 2.9 43.6 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 34.36 Tm (Facility Urgent Care Services ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 34.36 Tm (Covered - 100% after $40 copay ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 34.36 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 30.4 m 546.95 30.4 l 546.95 29.4 l 2.9 29.4 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 20.16 Tm (Physician Urgent Care Services ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 20.16 Tm (Covered - 100% after $40 copay ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 20.16 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 16.2 m 546.95 16.2 l 546.95 15.2 l 2.9 15.2 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 5.96 Tm (Ambulance Services - Medically Necessary Transport ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 5.96 Tm (Covered - 80% after deductible ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 5.96 Tm (Covered - 80% after deductible ) Tj ET EMC q n 2.9 2 m 546.95 2 l 546.95 1 l 2.9 1 l h W n Q /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG 270.1 98.44 m 270.1 58.8 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 57.8 m 270.1 44.6 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 43.6 m 270.1 30.4 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 29.4 m 270.1 16.2 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 15.2 m 270.1 2 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 98.44 m 419.15 58.8 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 57.8 m 419.15 44.6 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 43.6 m 419.15 30.4 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 29.4 m 419.15 16.2 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 15.2 m 419.15 2 l S 1 w [] 0 d 0.5 w [] 0 d 542.85 119.14 m 542.85 1 l S 1 w [] 0 d EMC q n 0 1 m 612 1 l 612 0 l 0 0 l h W n Q Q q Q q 1 0 0 1 36 124.9 cm /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 20.7 w -1.45 71.2 m 542.6 71.2 l S 1 w 0.83922 0.84314 0.9098 RG 17.25 w -1.45 52.22 m 269.85 52.22 l S 1 w 17.25 w 270.35 52.22 m 418.9 52.22 l S 1 w 17.25 w 419.4 52.22 m 542.6 52.22 l S 1 w 1 1 1 RG 13.2 w -1.45 37 m 269.85 37 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 37 m 418.9 37 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 37 m 542.6 37 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 29.9 m 542.6 29.9 l S 1 1 1 RG 13.2 w -1.45 22.8 m 269.85 22.8 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 22.8 m 418.9 22.8 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 22.8 m 542.6 22.8 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 15.7 m 542.6 15.7 l S 1 1 1 RG 13.2 w -1.45 8.6 m 269.85 8.6 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 8.6 m 418.9 8.6 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 8.6 m 542.6 8.6 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 1.5 m 542.6 1.5 l S EMC /Span <>BDC 1 1 1 rg BT /F7 12 Tf 1 0 0 1 2.9 67.23 Tm (Diagnostic Services ) Tj ET EMC /Span <>BDC 0.2 0.2 0.2 rg BT /F7 9 Tf 1 0 0 1 2.9 49.25 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F7 9 Tf 1 0 0 1 274.45 49.25 Tm (In-Network ) Tj ET EMC /Span <>BDC BT /F7 9 Tf 1 0 0 1 422.3 50.7 Tm (Out-of-Network ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 34.36 Tm (MRI, MRA, PET and CAT Scans and Nuclear Medicine ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 34.36 Tm (Covered - 80% after deductible ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 34.36 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 30.4 m 546.95 30.4 l 546.95 29.4 l 2.9 29.4 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 20.16 Tm (Diagnostic Tests, X-rays, Laboratory & Pathology ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 20.16 Tm (Covered - 80% after deductible ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 20.16 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 16.2 m 546.95 16.2 l 546.95 15.2 l 2.9 15.2 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 5.96 Tm (Radiation Therapy and Chemotherapy ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 5.96 Tm (Covered - 80% after deductible ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 5.96 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 2 m 546.95 2 l 546.95 1 l 2.9 1 l h W n Q /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG 270.1 60.85 m 270.1 30.4 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 29.4 m 270.1 16.2 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 15.2 m 270.1 2 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 60.85 m 419.15 30.4 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 29.4 m 419.15 16.2 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 15.2 m 419.15 2 l S 1 w [] 0 d 0.5 w [] 0 d 542.85 81.54 m 542.85 1 l S 1 w [] 0 d EMC q n 0 1 m 612 1 l 612 0 l 0 0 l h W n Q Q q Q Q endstream endobj 144 0 obj <>>>>> endobj 145 0 obj [ 144 0 R /XYZ 38.9 751.85 0] endobj 146 0 obj [ 144 0 R /XYZ 38.9 751.85 0] endobj 147 0 obj <> endobj 149 0 obj <> endobj 150 0 obj <> endobj 151 0 obj <> endobj 152 0 obj <> endobj 153 0 obj <> endobj 154 0 obj <> endobj 155 0 obj <> endobj 156 0 obj <> endobj 157 0 obj <> endobj 158 0 obj [ 144 0 R /XYZ 38.9 664.73 0] endobj 159 0 obj [ 144 0 R /XYZ 38.9 664.72 0] endobj 160 0 obj <> endobj 162 0 obj <> endobj 163 0 obj <> endobj 164 0 obj <> endobj 165 0 obj <> endobj 166 0 obj <> endobj 167 0 obj <> endobj 168 0 obj <> endobj 169 0 obj <> endobj 170 0 obj <> endobj 171 0 obj [ 144 0 R /XYZ 38.9 568.4 0] endobj 172 0 obj [ 144 0 R /XYZ 38.9 568.4 0] endobj 173 0 obj <> endobj 175 0 obj <> endobj 176 0 obj <> endobj 177 0 obj <> endobj 178 0 obj <> endobj 179 0 obj <> endobj 180 0 obj <> endobj 181 0 obj <> endobj 182 0 obj <> endobj 183 0 obj <> endobj 184 0 obj <> endobj 185 0 obj <> endobj 186 0 obj <> endobj 187 0 obj <> endobj 188 0 obj [ 144 0 R /XYZ 38.9 455.88 0] endobj 189 0 obj [ 144 0 R /XYZ 38.9 455.88 0] endobj 190 0 obj <> endobj 192 0 obj <> endobj 193 0 obj <> endobj 194 0 obj <> endobj 195 0 obj <> endobj 196 0 obj <> endobj 197 0 obj <> endobj 198 0 obj <> endobj 199 0 obj <> endobj 200 0 obj <> endobj 201 0 obj <> endobj 202 0 obj <> endobj 203 0 obj <> endobj 204 0 obj <> endobj 205 0 obj <> endobj 206 0 obj <> endobj 207 0 obj <> endobj 208 0 obj <> endobj 209 0 obj <> endobj 210 0 obj <> endobj 211 0 obj <> endobj 212 0 obj [ 144 0 R /XYZ 38.9 303.76 0] endobj 213 0 obj [ 144 0 R /XYZ 38.9 303.76 0] endobj 214 0 obj <> endobj 216 0 obj <> endobj 217 0 obj <> endobj 218 0 obj <> endobj 219 0 obj <> endobj 220 0 obj <> endobj 221 0 obj <> endobj 222 0 obj <> endobj 223 0 obj <> endobj 224 0 obj <> endobj 225 0 obj <> endobj 226 0 obj [ 144 0 R /XYZ 38.9 196.23 0] endobj 227 0 obj [ 144 0 R /XYZ 38.9 196.23 0] endobj 228 0 obj <>stream q 0 0 612 792 re W n /Artifact <> BDC q 1 0 0 1 36 755.3 cm q n 0 0.7 m 612 0.7 l 612 0 l 0 0 l h W n Q Q q Q EMC /Artifact <> BDC q 1 0 0 1 36 36 cm 0 0 0 rg BT /F3 7 Tf 1 0 0 1 61.82 61.51 Tm (Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. ) Tj ET BT /F3 7 Tf 1 0 0 1 0 53.46 Tm (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 ) Tj ET BT /F3 7 Tf 1 0 0 1 0 45.41 Tm (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 ) Tj ET BT /F3 7 Tf 1 0 0 1 0 37.36 Tm (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 ) Tj ET BT /F3 7 Tf 1 0 0 1 0 29.31 Tm (charge. ) Tj ET BT /F3 7 Tf 1 0 0 1 0 21.26 Tm (Page ) Tj ET BT /F3 7 Tf 1 0 0 1 18.29 21.26 Tm (3) Tj ET BT /F3 7 Tf 1 0 0 1 22.19 21.26 Tm ( of ) Tj ET BT /F3 7 Tf 1 0 0 1 31.91 21.26 Tm (6 ) Tj ET BT /F3 7 Tf 1 0 0 1 251.68 21.26 Tm (G10192023 ) Tj ET BT /F3 8 Tf 1 0 0 1 486.61 20.36 Tm (000019424595 ) Tj ET Q q Q EMC q 1 0 0 1 36 687.95 cm /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 20.7 w -1.45 57 m 542.6 57 l S 1 w 0.83922 0.84314 0.9098 RG 17.25 w -1.45 38.02 m 269.85 38.02 l S 1 w 17.25 w 270.35 38.02 m 418.9 38.02 l S 1 w 17.25 w 419.4 38.02 m 542.6 38.02 l S 1 w 1 1 1 RG 13.2 w -1.45 22.8 m 269.85 22.8 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 22.8 m 418.9 22.8 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 22.8 m 542.6 22.8 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 15.7 m 542.6 15.7 l S 1 1 1 RG 13.2 w -1.45 8.6 m 269.85 8.6 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 8.6 m 418.9 8.6 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 8.6 m 542.6 8.6 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 1.5 m 542.6 1.5 l S EMC /Span <>BDC 1 1 1 rg BT /F7 12 Tf 1 0 0 1 2.9 53.03 Tm (Maternity Services Provided by a Physician ) Tj ET EMC /Span <>BDC 0.2 0.2 0.2 rg BT /F7 9 Tf 1 0 0 1 2.9 35.05 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F7 9 Tf 1 0 0 1 274.45 35.05 Tm (In-Network ) Tj ET EMC /Span <>BDC BT /F7 9 Tf 1 0 0 1 422.3 36.5 Tm (Out-of-Network ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 20.16 Tm (Prenatal and Postnatal Care Visits ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 20.16 Tm (Covered - 100% ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 20.16 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 16.2 m 546.95 16.2 l 546.95 15.2 l 2.9 15.2 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 5.96 Tm (Delivery and Nursery Care ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 5.96 Tm (Covered - 80% after deductible ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 5.96 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 2 m 546.95 2 l 546.95 1 l 2.9 1 l h W n Q /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG 270.1 46.65 m 270.1 16.2 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 15.2 m 270.1 2 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 46.65 m 419.15 16.2 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 15.2 m 419.15 2 l S 1 w [] 0 d 0.5 w [] 0 d 542.85 67.35 m 542.85 1 l S 1 w [] 0 d EMC q n 0 1 m 612 1 l 612 0 l 0 0 l h W n Q Q q Q q 1 0 0 1 36 591.63 cm /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 20.7 w -1.45 66.2 m 542.6 66.2 l S 1 w 0.83922 0.84314 0.9098 RG 17.25 w -1.45 47.22 m 269.85 47.22 l S 1 w 17.25 w 270.35 47.22 m 418.9 47.22 l S 1 w 17.25 w 419.4 47.22 m 542.6 47.22 l S 1 w 1 1 1 RG 22.4 w -1.45 27.4 m 269.85 27.4 l S 1 w 0.92941 0.95294 0.99608 RG 22.4 w 270.35 27.4 m 418.9 27.4 l S 1 w 0.96078 0.96078 0.96078 RG 22.4 w 419.4 27.4 m 542.6 27.4 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 15.7 m 542.6 15.7 l S 1 1 1 RG 13.2 w -1.45 8.6 m 269.85 8.6 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 8.6 m 418.9 8.6 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 8.6 m 542.6 8.6 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 1.5 m 542.6 1.5 l S EMC /Span <>BDC 1 1 1 rg BT /F7 12 Tf 1 0 0 1 2.9 62.23 Tm (Hospital Care ) Tj ET EMC /Span <>BDC 0.2 0.2 0.2 rg BT /F7 9 Tf 1 0 0 1 2.9 44.25 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F7 9 Tf 1 0 0 1 274.45 44.25 Tm (In-Network ) Tj ET EMC /Span <>BDC BT /F7 9 Tf 1 0 0 1 422.3 45.7 Tm (Out-of-Network ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 29.36 Tm (Semi-Private Room, Inpatient Physician Care, General Nursing Care, ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 20.16 Tm (Hospital Services and Supplies ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 29.36 Tm (Covered - 80% after deductible ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 29.36 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 16.2 m 546.95 16.2 l 546.95 15.2 l 2.9 15.2 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 5.96 Tm (Inpatient Medical Care ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 5.96 Tm (Covered - 80% after deductible ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 5.96 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 2 m 546.95 2 l 546.95 1 l 2.9 1 l h W n Q /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG 270.1 55.85 m 270.1 16.2 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 15.2 m 270.1 2 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 55.85 m 419.15 16.2 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 15.2 m 419.15 2 l S 1 w [] 0 d 0.5 w [] 0 d 542.85 76.54 m 542.85 1 l S 1 w [] 0 d EMC q n 0 1 m 612 1 l 612 0 l 0 0 l h W n Q Q q Q q 1 0 0 1 36 479.11 cm /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 20.7 w -1.45 82.4 m 542.6 82.4 l S 1 w 0.83922 0.84314 0.9098 RG 17.25 w -1.45 63.42 m 269.85 63.42 l S 1 w 17.25 w 270.35 63.42 m 418.9 63.42 l S 1 w 17.25 w 419.4 63.42 m 542.6 63.42 l S 1 w 1 1 1 RG 13.2 w -1.45 48.2 m 269.85 48.2 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 48.2 m 418.9 48.2 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 48.2 m 542.6 48.2 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 41.1 m 542.6 41.1 l S 1 1 1 RG 13.2 w -1.45 34 m 269.85 34 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 34 m 418.9 34 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 34 m 542.6 34 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 26.9 m 542.6 26.9 l S 1 1 1 RG 24.4 w -1.45 14.2 m 269.85 14.2 l S 1 w 0.92941 0.95294 0.99608 RG 24.4 w 270.35 14.2 m 418.9 14.2 l S 1 w 0.96078 0.96078 0.96078 RG 24.4 w 419.4 14.2 m 542.6 14.2 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 1.5 m 542.6 1.5 l S EMC /Span <>BDC 1 1 1 rg BT /F7 12 Tf 1 0 0 1 2.9 78.43 Tm (Alternatives to Hospital Care ) Tj ET EMC /Span <>BDC 0.2 0.2 0.2 rg BT /F7 9 Tf 1 0 0 1 2.9 60.45 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F7 9 Tf 1 0 0 1 274.45 60.45 Tm (In-Network ) Tj ET EMC /Span <>BDC BT /F7 9 Tf 1 0 0 1 422.3 61.9 Tm (Out-of-Network ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 45.56 Tm (Hospice Care ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 45.56 Tm (Covered - 80% after deductible ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 45.56 Tm (Covered - 80% after deductible ) Tj ET EMC q n 2.9 41.6 m 546.95 41.6 l 546.95 40.6 l 2.9 40.6 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 31.36 Tm (Home Health Care ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 31.36 Tm (Covered - 80% after deductible ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 31.36 Tm (Covered - 80% after deductible ) Tj ET EMC q n 2.9 27.4 m 546.95 27.4 l 546.95 26.4 l 2.9 26.4 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 17.16 Tm (Skilled Nursing ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 5.96 Tm (Limited to 120 days per calendar year ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 17.16 Tm (Covered - 80% after deductible ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 17.16 Tm (Covered - 80% after deductible ) Tj ET EMC q n 2.9 2 m 546.95 2 l 546.95 1 l 2.9 1 l h W n Q /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG 270.1 72.04 m 270.1 41.6 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 40.6 m 270.1 27.4 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 26.4 m 270.1 2 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 72.04 m 419.15 41.6 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 40.6 m 419.15 27.4 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 26.4 m 419.15 2 l S 1 w [] 0 d 0.5 w [] 0 d 542.85 92.75 m 542.85 1 l S 1 w [] 0 d EMC q n 0 1 m 612 1 l 612 0 l 0 0 l h W n Q Q q Q q 1 0 0 1 36 326.99 cm /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 20.7 w -1.45 121.99 m 542.6 121.99 l S 1 w 0.83922 0.84314 0.9098 RG 17.25 w -1.45 103.02 m 269.85 103.02 l S 1 w 17.25 w 270.35 103.02 m 418.9 103.02 l S 1 w 17.25 w 419.4 103.02 m 542.6 103.02 l S 1 w 1 1 1 RG 13.2 w -1.45 87.79 m 269.85 87.79 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 87.79 m 418.9 87.79 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 87.79 m 542.6 87.79 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 80.69 m 542.6 80.69 l S 1 1 1 RG 13.2 w -1.45 73.6 m 269.85 73.6 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 73.6 m 418.9 73.6 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 73.6 m 542.6 73.6 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 66.5 m 542.6 66.5 l S 1 1 1 RG 24.4 w -1.45 53.8 m 269.85 53.8 l S 1 w 0.92941 0.95294 0.99608 RG 24.4 w 270.35 53.8 m 418.9 53.8 l S 1 w 0.96078 0.96078 0.96078 RG 24.4 w 419.4 53.8 m 542.6 53.8 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 41.1 m 542.6 41.1 l S 1 1 1 RG 24.4 w -1.45 28.4 m 269.85 28.4 l S 1 w 0.92941 0.95294 0.99608 RG 24.4 w 270.35 28.4 m 418.9 28.4 l S 1 w 0.96078 0.96078 0.96078 RG 24.4 w 419.4 28.4 m 542.6 28.4 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 15.7 m 542.6 15.7 l S 1 1 1 RG 13.2 w -1.45 8.6 m 269.85 8.6 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 8.6 m 418.9 8.6 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 8.6 m 542.6 8.6 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 1.5 m 542.6 1.5 l S EMC /Span <>BDC 1 1 1 rg BT /F7 12 Tf 1 0 0 1 2.9 118.03 Tm (Surgical Services ) Tj ET EMC /Span <>BDC 0.2 0.2 0.2 rg BT /F7 9 Tf 1 0 0 1 2.9 100.05 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F7 9 Tf 1 0 0 1 274.45 100.05 Tm (In-Network ) Tj ET EMC /Span <>BDC BT /F7 9 Tf 1 0 0 1 422.3 101.5 Tm (Out-of-Network ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 85.15 Tm (Surgery \(includes related surgical services\) ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 85.15 Tm (Covered - 80% after deductible ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 85.15 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 81.19 m 546.95 81.19 l 546.95 80.19 l 2.9 80.19 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 70.95 Tm (Bariatric Surgery ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 70.95 Tm (Covered - 80% after deductible ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 70.95 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 67 m 546.95 67 l 546.95 66 l 2.9 66 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 56.75 Tm (Sterilization - male reproductive organs ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 45.55 Tm (excludes reversal sterilization ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 56.75 Tm (Covered - 80% after deductible ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 56.75 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 41.6 m 546.95 41.6 l 546.95 40.6 l 2.9 40.6 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 31.36 Tm (Sterilization - female reproductive organs ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 20.16 Tm (excludes reversal sterilization ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 31.36 Tm (Covered - 100% ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 31.36 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 16.2 m 546.95 16.2 l 546.95 15.2 l 2.9 15.2 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 5.96 Tm (Elective Abortions ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 5.96 Tm (Covered - 80% after deductible ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 5.96 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 2 m 546.95 2 l 546.95 1 l 2.9 1 l h W n Q /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG 270.1 111.64 m 270.1 81.19 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 80.19 m 270.1 67 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 66 m 270.1 41.6 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 40.6 m 270.1 16.2 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 15.2 m 270.1 2 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 111.64 m 419.15 81.19 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 80.19 m 419.15 67 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 66 m 419.15 41.6 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 40.6 m 419.15 16.2 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 15.2 m 419.15 2 l S 1 w [] 0 d 0.5 w [] 0 d 542.85 132.34 m 542.85 1 l S 1 w [] 0 d EMC q n 0 1 m 612 1 l 612 0 l 0 0 l h W n Q Q q Q q 1 0 0 1 36 219.46 cm /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 20.7 w -1.45 77.4 m 542.6 77.4 l S 1 w 0.83922 0.84314 0.9098 RG 17.25 w -1.45 58.42 m 269.85 58.42 l S 1 w 17.25 w 270.35 58.42 m 418.9 58.42 l S 1 w 17.25 w 419.4 58.42 m 542.6 58.42 l S 1 w 1 1 1 RG 33.6 w -1.45 33 m 269.85 33 l S 1 w 0.92941 0.95294 0.99608 RG 33.6 w 270.35 33 m 418.9 33 l S 1 w 0.96078 0.96078 0.96078 RG 33.6 w 419.4 33 m 542.6 33 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 15.7 m 542.6 15.7 l S 1 1 1 RG 13.2 w -1.45 8.6 m 269.85 8.6 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 8.6 m 418.9 8.6 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 8.6 m 542.6 8.6 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 1.5 m 542.6 1.5 l S EMC /Span <>BDC 1 1 1 rg BT /F7 12 Tf 1 0 0 1 2.9 73.43 Tm (Human Organ Transplants ) Tj ET EMC /Span <>BDC 0.2 0.2 0.2 rg BT /F7 9 Tf 1 0 0 1 2.9 55.45 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F7 9 Tf 1 0 0 1 274.45 55.45 Tm (In-Network ) Tj ET EMC /Span <>BDC BT /F7 9 Tf 1 0 0 1 422.3 56.9 Tm (Out-of-Network ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 40.56 Tm (Specified Organ Transplants ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 29.36 Tm (In designated facilities only, when coordinated through BCBSM Human ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 20.16 Tm (Organ Transplant Program \(800-242-3504\) ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 40.56 Tm (Covered - 80% after deductible ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 40.56 Tm (Not covered except in designated ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 31.36 Tm (facilities ) Tj ET EMC q n 2.9 16.2 m 546.95 16.2 l 546.95 15.2 l 2.9 15.2 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 5.96 Tm (Kidney, Cornea, Bone Marrow and Skin ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 5.96 Tm (Covered - 80% after deductible ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 5.96 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 2 m 546.95 2 l 546.95 1 l 2.9 1 l h W n Q /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG 270.1 67.04 m 270.1 16.2 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 15.2 m 270.1 2 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 67.04 m 419.15 16.2 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 15.2 m 419.15 2 l S 1 w [] 0 d 0.5 w [] 0 d 542.85 87.75 m 542.85 1 l S 1 w [] 0 d EMC q n 0 1 m 612 1 l 612 0 l 0 0 l h W n Q Q q Q q 1 0 0 1 36 103.84 cm /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 20.7 w -1.45 85.49 m 542.6 85.49 l S 1 w 0.83922 0.84314 0.9098 RG 17.25 w -1.45 66.52 m 269.85 66.52 l S 1 w 17.25 w 270.35 66.52 m 418.9 66.52 l S 1 w 17.25 w 419.4 66.52 m 542.6 66.52 l S 1 w 1 1 1 RG 13.2 w -1.45 51.29 m 269.85 51.29 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 51.29 m 418.9 51.29 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 51.29 m 542.6 51.29 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 44.19 m 542.6 44.19 l S 1 1 1 RG 13.2 w -1.45 37.09 m 269.85 37.09 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 37.09 m 418.9 37.09 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 37.09 m 542.6 37.09 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 29.99 m 542.6 29.99 l S 1 1 1 RG 13.2 w -1.45 22.9 m 269.85 22.9 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 22.9 m 418.9 22.9 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 22.9 m 542.6 22.9 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 15.79 m 542.6 15.79 l S EMC /Span <>BDC 1 1 1 rg BT /F7 12 Tf 1 0 0 1 2.9 81.53 Tm (Behavioral Health Services \(Mental Health and Substance Use Disorder\) ) Tj ET EMC /Span <>BDC 0.2 0.2 0.2 rg BT /F7 9 Tf 1 0 0 1 2.9 63.54 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F7 9 Tf 1 0 0 1 274.45 63.54 Tm (In-Network ) Tj ET EMC /Span <>BDC BT /F7 9 Tf 1 0 0 1 422.3 64.99 Tm (Out-of-Network ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 48.65 Tm (Inpatient Mental Health Care and Substance Use Disorder Treatment ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 48.65 Tm (Covered - 80% after deductible ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 48.65 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 44.69 m 546.95 44.69 l 546.95 43.69 l 2.9 43.69 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 34.45 Tm (Outpatient Mental Health Care and Substance Use Disorder Treatment ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 34.45 Tm (Covered - 100% after $40 copay ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 34.45 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 30.49 m 546.95 30.49 l 546.95 29.49 l 2.9 29.49 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 20.25 Tm (Telemedicine Mental Health Care ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 20.25 Tm (Covered - 100% after $40 copay ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 20.25 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 16.29 m 546.95 16.29 l 546.95 15.29 l 2.9 15.29 l h W n Q /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG 270.1 75.14 m 270.1 44.69 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 43.69 m 270.1 30.49 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 29.49 m 270.1 16.29 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 75.14 m 419.15 44.69 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 43.69 m 419.15 30.49 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 29.49 m 419.15 16.29 l S 1 w [] 0 d 0.5 w [] 0 d 542.85 95.84 m 542.85 15.29 l S 1 w [] 0 d EMC Q q Q Q endstream endobj 229 0 obj <>>>>> endobj 230 0 obj <> endobj 232 0 obj <> endobj 233 0 obj <> endobj 234 0 obj <> endobj 235 0 obj <> endobj 236 0 obj <> endobj 237 0 obj <> endobj 238 0 obj <> endobj 239 0 obj <> endobj 240 0 obj <> endobj 241 0 obj <> endobj 242 0 obj <> endobj 243 0 obj <> endobj 244 0 obj <> endobj 246 0 obj <> endobj 247 0 obj <> endobj 248 0 obj <> endobj 249 0 obj [ 229 0 R /XYZ 38.9 679.23 0] endobj 250 0 obj [ 229 0 R /XYZ 38.9 679.23 0] endobj 251 0 obj <> endobj 253 0 obj <> endobj 254 0 obj <> endobj 255 0 obj <> endobj 256 0 obj <> endobj 257 0 obj <> endobj 258 0 obj <> endobj 259 0 obj <> endobj 260 0 obj <> endobj 261 0 obj <> endobj 262 0 obj <> endobj 263 0 obj <> endobj 264 0 obj <> endobj 265 0 obj <> endobj 266 0 obj <> endobj 267 0 obj [ 229 0 R /XYZ 38.9 491.11 0] endobj 268 0 obj [ 229 0 R /XYZ 38.9 491.11 0] endobj 269 0 obj <> endobj 271 0 obj <> endobj 272 0 obj <> endobj 273 0 obj <> endobj 274 0 obj <> endobj 275 0 obj <> endobj 276 0 obj <> endobj 277 0 obj <> endobj 278 0 obj <> endobj 279 0 obj <> endobj 280 0 obj <> endobj 281 0 obj <> endobj 282 0 obj <> endobj 283 0 obj <> endobj 284 0 obj <> endobj 285 0 obj <> endobj 286 0 obj <> endobj 287 0 obj <> endobj 288 0 obj <> endobj 289 0 obj <> endobj 290 0 obj <> endobj 291 0 obj <> endobj 292 0 obj <> endobj 293 0 obj <> endobj 294 0 obj <> endobj 295 0 obj [ 229 0 R /XYZ 38.9 314.59 0] endobj 296 0 obj [ 229 0 R /XYZ 38.9 314.59 0] endobj 297 0 obj <>stream q 0 0 612 792 re W n /Artifact <> BDC q 1 0 0 1 36 755.3 cm q n 0 0.7 m 612 0.7 l 612 0 l 0 0 l h W n Q Q q Q EMC /Artifact <> BDC q 1 0 0 1 36 36 cm 0 0 0 rg BT /F3 7 Tf 1 0 0 1 61.82 61.51 Tm (Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. ) Tj ET BT /F3 7 Tf 1 0 0 1 0 53.46 Tm (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 ) Tj ET BT /F3 7 Tf 1 0 0 1 0 45.41 Tm (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 ) Tj ET BT /F3 7 Tf 1 0 0 1 0 37.36 Tm (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 ) Tj ET BT /F3 7 Tf 1 0 0 1 0 29.31 Tm (charge. ) Tj ET BT /F3 7 Tf 1 0 0 1 0 21.26 Tm (Page ) Tj ET BT /F3 7 Tf 1 0 0 1 18.29 21.26 Tm (4) Tj ET BT /F3 7 Tf 1 0 0 1 22.19 21.26 Tm ( of ) Tj ET BT /F3 7 Tf 1 0 0 1 31.91 21.26 Tm (6 ) Tj ET BT /F3 7 Tf 1 0 0 1 251.68 21.26 Tm (G10192023 ) Tj ET BT /F3 8 Tf 1 0 0 1 486.61 20.36 Tm (000019424595 ) Tj ET Q q Q EMC q 1 0 0 1 36 702.45 cm /Artifact <> BDC 0.83922 0.84314 0.9098 RG 0 J 17.25 w -1.45 44.22 m 269.85 44.22 l S 1 w 17.25 w 270.35 44.22 m 418.9 44.22 l S 1 w 17.25 w 419.4 44.22 m 542.6 44.22 l S 1 w 1 1 1 RG 33.6 w -1.45 18.8 m 269.85 18.8 l S 1 w 0.92941 0.95294 0.99608 RG 33.6 w 270.35 18.8 m 418.9 18.8 l S 1 w 0.96078 0.96078 0.96078 RG 33.6 w 419.4 18.8 m 542.6 18.8 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 1.5 m 542.6 1.5 l S EMC /Artifact <> BDC 0.2 0.2 0.2 rg BT /F7 9 Tf 1 0 0 1 2.9 41.25 Tm (Benefits ) Tj ET BT /F7 9 Tf 1 0 0 1 274.45 41.25 Tm (In-Network ) Tj ET BT /F7 9 Tf 1 0 0 1 422.3 42.7 Tm (Out-of-Network ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 26.36 Tm (Blue Cross Online Mental Health Care ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 15.16 Tm (Note: Online Mental Health visits by a non-BCBSM selected vendor are ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 5.96 Tm (not covered. ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 26.36 Tm (Covered - 100% after $40 copay ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 26.36 Tm (Not Covered ) Tj ET EMC q n 2.9 2 m 546.95 2 l 546.95 1 l 2.9 1 l h W n Q /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG 270.1 52.85 m 270.1 2 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 52.85 m 419.15 2 l S 1 w [] 0 d 0.5 w [] 0 d 542.85 52.85 m 542.85 1 l S 1 w [] 0 d EMC q n 0 1 m 612 1 l 612 0 l 0 0 l h W n Q Q q Q q 1 0 0 1 36 514.34 cm /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 20.7 w -1.45 157.99 m 542.6 157.99 l S 1 w 0.83922 0.84314 0.9098 RG 17.25 w -1.45 139.02 m 269.85 139.02 l S 1 w 17.25 w 270.35 139.02 m 418.9 139.02 l S 1 w 17.25 w 419.4 139.02 m 542.6 139.02 l S 1 w 1 1 1 RG 79.59 w -1.45 90.59 m 269.85 90.59 l S 1 w 0.92941 0.95294 0.99608 RG 79.59 w 270.35 90.59 m 418.9 90.59 l S 1 w 0.96078 0.96078 0.96078 RG 79.59 w 419.4 90.59 m 542.6 90.59 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 50.3 m 542.6 50.3 l S 1 1 1 RG 33.6 w -1.45 33 m 269.85 33 l S 1 w 0.92941 0.95294 0.99608 RG 33.6 w 270.35 33 m 418.9 33 l S 1 w 0.96078 0.96078 0.96078 RG 33.6 w 419.4 33 m 542.6 33 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 15.7 m 542.6 15.7 l S 1 1 1 RG 13.2 w -1.45 8.6 m 269.85 8.6 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 8.6 m 418.9 8.6 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 8.6 m 542.6 8.6 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 1.5 m 542.6 1.5 l S EMC /Span <>BDC 1 1 1 rg BT /F7 12 Tf 1 0 0 1 2.9 154.03 Tm (Autism Spectrum Disorders, Diagnoses and Treatment ) Tj ET EMC /Span <>BDC 0.2 0.2 0.2 rg BT /F7 9 Tf 1 0 0 1 2.9 136.04 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F7 9 Tf 1 0 0 1 274.45 136.04 Tm (In-Network ) Tj ET EMC /Span <>BDC BT /F7 9 Tf 1 0 0 1 422.3 137.49 Tm (Out-of-Network ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 121.15 Tm (Applied Behavior Analysis \(ABA\) ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 109.95 Tm (Pre-authorization required ) Tj ET EMC /Span <>BDC BT /F7 8 Tf 1 0 0 1 2.9 91.55 Tm (Note: ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 25.56 91.55 Tm (Prior to seeking ABA treatment, the member must be evaluated by ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 82.35 Tm (an interdisciplinary team including, but not limited to, a physician, ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 73.15 Tm (behavioral health specialist, and a speech and language specialist for the ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 63.95 Tm (services to be authorized. This interdisciplinary evaluation can be ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 54.75 Tm (performed at an approved autism evaluation center \(AAEC\). ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 121.15 Tm (Covered - 80% after deductible ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 121.15 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 50.8 m 546.95 50.8 l 546.95 49.8 l 2.9 49.8 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 40.56 Tm (Physical, Occupational and Speech Therapy ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 29.36 Tm (Physical, Occupational and Speech therapy with an autism diagnosis is ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 20.16 Tm (unlimited ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 40.56 Tm (Covered - 80% after deductible ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 40.56 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 16.2 m 546.95 16.2 l 546.95 15.2 l 2.9 15.2 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 5.96 Tm (Nutritional Counseling ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 5.96 Tm (Covered - 80% after deductible ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 5.96 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 2 m 546.95 2 l 546.95 1 l 2.9 1 l h W n Q /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG 270.1 147.64 m 270.1 50.8 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 49.8 m 270.1 16.2 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 15.2 m 270.1 2 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 147.64 m 419.15 50.8 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 49.8 m 419.15 16.2 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 15.2 m 419.15 2 l S 1 w [] 0 d 0.5 w [] 0 d 542.85 168.34 m 542.85 1 l S 1 w [] 0 d EMC q n 0 1 m 612 1 l 612 0 l 0 0 l h W n Q Q q Q q 1 0 0 1 36 337.82 cm /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 20.7 w -1.45 146.39 m 542.6 146.39 l S 1 w 0.83922 0.84314 0.9098 RG 17.25 w -1.45 127.42 m 269.85 127.42 l S 1 w 17.25 w 270.35 127.42 m 418.9 127.42 l S 1 w 17.25 w 419.4 127.42 m 542.6 127.42 l S 1 w 1 1 1 RG 13.2 w -1.45 112.19 m 269.85 112.19 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 112.19 m 418.9 112.19 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 112.19 m 542.6 112.19 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 105.09 m 542.6 105.09 l S 1 1 1 RG 31.6 w -1.45 88.79 m 269.85 88.79 l S 1 w 0.92941 0.95294 0.99608 RG 31.6 w 270.35 88.79 m 418.9 88.79 l S 1 w 0.96078 0.96078 0.96078 RG 31.6 w 419.4 88.79 m 542.6 88.79 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 72.5 m 542.6 72.5 l S 1 1 1 RG 13.2 w -1.45 65.4 m 269.85 65.4 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 65.4 m 418.9 65.4 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 65.4 m 542.6 65.4 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 58.3 m 542.6 58.3 l S 1 1 1 RG 13.2 w -1.45 51.2 m 269.85 51.2 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 51.2 m 418.9 51.2 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 51.2 m 542.6 51.2 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 44.1 m 542.6 44.1 l S 1 1 1 RG 13.2 w -1.45 37 m 269.85 37 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 37 m 418.9 37 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 37 m 542.6 37 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 29.9 m 542.6 29.9 l S 1 1 1 RG 13.2 w -1.45 22.8 m 269.85 22.8 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 22.8 m 418.9 22.8 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 22.8 m 542.6 22.8 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 15.7 m 542.6 15.7 l S 1 1 1 RG 13.2 w -1.45 8.6 m 269.85 8.6 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 8.6 m 418.9 8.6 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 8.6 m 542.6 8.6 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 1.5 m 542.6 1.5 l S EMC /Span <>BDC 1 1 1 rg BT /F7 12 Tf 1 0 0 1 2.9 142.43 Tm (Other Covered Services ) Tj ET EMC /Span <>BDC 0.2 0.2 0.2 rg BT /F7 9 Tf 1 0 0 1 2.9 124.44 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F7 9 Tf 1 0 0 1 274.45 124.44 Tm (In-Network ) Tj ET EMC /Span <>BDC BT /F7 9 Tf 1 0 0 1 422.3 125.9 Tm (Out-of-Network ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 109.55 Tm (Cardiac Rehabilitation ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 109.55 Tm (Covered - 80% after deductible ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 109.55 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 105.59 m 546.95 105.59 l 546.95 104.59 l 2.9 104.59 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 95.35 Tm (Chiropractic Spinal Manipulation Services ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 76.95 Tm (Limited to a maximum of 24 visits per calendar year ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 95.35 Tm (Covered - 100% after $40 copay ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 95.35 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 73 m 546.95 73 l 546.95 72 l 2.9 72 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 62.75 Tm (Durable Medical Equipment ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 62.75 Tm (Covered - 80% after deductible ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 62.75 Tm (Covered - 80% after deductible ) Tj ET EMC q n 2.9 58.8 m 546.95 58.8 l 546.95 57.8 l 2.9 57.8 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 48.56 Tm (Prosthetic and Orthotic Devices ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 48.56 Tm (Covered - 80% after deductible ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 48.56 Tm (Covered - 80% after deductible ) Tj ET EMC q n 2.9 44.6 m 546.95 44.6 l 546.95 43.6 l 2.9 43.6 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 34.36 Tm (Private Duty Nursing Care ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 34.36 Tm (Covered - 50% after deductible ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 34.36 Tm (Covered - 50% after deductible ) Tj ET EMC q n 2.9 30.4 m 546.95 30.4 l 546.95 29.4 l 2.9 29.4 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 20.16 Tm (Allergy Testing and Therapy ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 20.16 Tm (Covered - 100% after $40 copay ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 20.16 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 16.2 m 546.95 16.2 l 546.95 15.2 l 2.9 15.2 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 5.96 Tm (Facility Clinic Visit ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 5.96 Tm (Covered - 100% after $40 copay ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 5.96 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 2 m 546.95 2 l 546.95 1 l 2.9 1 l h W n Q /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG 270.1 136.04 m 270.1 105.59 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 104.59 m 270.1 73 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 72 m 270.1 58.8 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 57.8 m 270.1 44.6 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 43.6 m 270.1 30.4 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 29.4 m 270.1 16.2 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 15.2 m 270.1 2 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 136.04 m 419.15 105.59 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 104.59 m 419.15 73 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 72 m 419.15 58.8 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 57.8 m 419.15 44.6 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 43.6 m 419.15 30.4 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 29.4 m 419.15 16.2 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 15.2 m 419.15 2 l S 1 w [] 0 d 0.5 w [] 0 d 542.85 156.74 m 542.85 1 l S 1 w [] 0 d EMC q n 0 1 m 612 1 l 612 0 l 0 0 l h W n Q Q q Q q 1 0 0 1 36 103.84 cm /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 20.7 w -1.45 203.85 m 542.6 203.85 l S 1 w 0.83922 0.84314 0.9098 RG 17.25 w -1.45 184.87 m 269.85 184.87 l S 1 w 17.25 w 270.35 184.87 m 418.9 184.87 l S 1 w 17.25 w 419.4 184.87 m 542.6 184.87 l S 1 w 1 1 1 RG 24.4 w -1.45 164.05 m 269.85 164.05 l S 1 w 0.92941 0.95294 0.99608 RG 24.4 w 270.35 164.05 m 418.9 164.05 l S 1 w 0.96078 0.96078 0.96078 RG 24.4 w 419.4 164.05 m 542.6 164.05 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 151.35 m 542.6 151.35 l S EMC /Span <>BDC 1 1 1 rg BT /F7 12 Tf 1 0 0 1 2.9 199.88 Tm (Therapy Services ) Tj ET EMC /Span <>BDC 0.2 0.2 0.2 rg BT /F7 9 Tf 1 0 0 1 2.9 181.9 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F7 9 Tf 1 0 0 1 274.45 181.9 Tm (In-Network ) Tj ET EMC /Span <>BDC BT /F7 9 Tf 1 0 0 1 422.3 183.35 Tm (Out-of-Network ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 167.01 Tm (Physical, Occupational and Speech Therapy ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 155.81 Tm (Limited to a combined maximum of 60 visits per calendar year ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 167.01 Tm (Covered - 80% after deductible ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 422.3 167.01 Tm (Covered - 60% after deductible ) Tj ET EMC q n 2.9 151.85 m 546.95 151.85 l 546.95 150.85 l 2.9 150.85 l h W n Q /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG 270.1 193.5 m 270.1 151.85 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 193.5 m 419.15 151.85 l S 1 w [] 0 d 0.5 w [] 0 d 542.85 214.2 m 542.85 150.85 l S 1 w [] 0 d EMC q n 0 150.85 m 612 150.85 l 612 149.85 l 0 149.85 l h W n Q Q q Q Q endstream endobj 298 0 obj <>/Font<>>>>> endobj 299 0 obj <> endobj 301 0 obj <> endobj 302 0 obj <> endobj 303 0 obj <> endobj 304 0 obj <> endobj 305 0 obj <> endobj 306 0 obj <> endobj 307 0 obj <> endobj 308 0 obj <>/Pg 298 0 R /K[<>]/Type/StructElem/Alt(Blue Cross Blue Shield of Michigan. A nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.\n)/S/Figure/Lang(en_US)/P 309 0 R >> endobj 309 0 obj <> endobj 310 0 obj <> endobj 311 0 obj <> endobj 312 0 obj <> endobj 313 0 obj <> endobj 314 0 obj <> endobj 315 0 obj <> endobj 317 0 obj <> endobj 319 0 obj [ 298 0 R /XYZ 38.9 455.57 0] endobj 320 0 obj [ 298 0 R /XYZ 38.9 455.57 0] endobj 321 0 obj <>stream q 0 0 612 792 re W n /Artifact <> BDC q 1 0 0 1 36 755.3 cm q n 0 0.7 m 612 0.7 l 612 0 l 0 0 l h W n Q Q q Q EMC /Artifact <> BDC q 1 0 0 1 36 36 cm 0 0 0 rg BT /F3 7 Tf 1 0 0 1 61.82 27.66 Tm (Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. ) Tj ET BT /F3 7 Tf 1 0 0 1 0 3.56 Tm (Page ) Tj ET BT /F3 7 Tf 1 0 0 1 18.29 3.56 Tm (5) Tj ET BT /F3 7 Tf 1 0 0 1 22.19 3.56 Tm ( of ) Tj ET BT /F3 7 Tf 1 0 0 1 31.91 3.56 Tm (6 ) Tj ET BT /F3 8 Tf 1 0 0 1 249.34 2.66 Tm (G10192023 ) Tj ET BT /F3 7 Tf 1 0 0 1 493.28 3.56 Tm (000019424595 ) Tj ET q n 0 0.7 m 612 0.7 l 612 0 l 0 0 l h W n Q Q q Q EMC q 1 0 0 1 36 541.81 cm q 1 0 0 1 0 121.89 cm q n 0 0 m 540 0 l 540 91.6 l 0 91.6 l h W n /Figure <>BDC q 540 0 0 91.6 0 0 cm /img5283 Do Q EMC Q Q q Q /Span <>BDC 0 0 0 rg BT /F7 14 Tf 1 0 0 1 0 100.02 Tm (ϳԹ ) Tj ET EMC /Span <>BDC BT /F7 14 Tf 1 0 0 1 0 83.92 Tm (Group Number: 71705 Package Code\(s\): 011 ) Tj ET EMC /Span <>BDC BT /F7 14 Tf 1 0 0 1 0 67.82 Tm (Division Code\(s\): 1000, 1100 ) Tj ET EMC /Span <>BDC BT /F7 14 Tf 1 0 0 1 0 51.72 Tm (Prescription Drugs ) Tj ET EMC /Span <>BDC BT /F7 14 Tf 1 0 0 1 0 35.62 Tm (Effective Date:) Tj ET EMC /Span <>BDC BT /F7 14 Tf 1 0 0 1 97.26 35.62 Tm ( ) Tj ET EMC /Span <>BDC BT /F7 14 Tf 1 0 0 1 101.15 35.62 Tm (08/01/2023 ) Tj ET EMC /Span <>BDC BT /F7 14 Tf 1 0 0 1 0 19.52 Tm (Benefits-at-a-glance ) Tj ET EMC Q q Q q 1 0 0 1 36 459.02 cm /Span <>BDC 0 0 0 rg BT /F3 8 Tf 1 0 0 1 0 75.55 Tm (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 ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 0 66.35 Tm (exclusions may apply. Payment amounts are based on BCBSM's approved amount, less any applicable deductible and/or copay. If there is a ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 0 57.15 Tm (discrepancy between this Benefits-at-a-Glance and any applicable plan document, the plan document will control. ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 0 38.75 Tm (BCBSM provides administrative claims services only. Your employer or plan sponsor is financially responsible for claims. ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 0 20.36 Tm (Your prescription drug copays, including mail order copays, may be subject to the same annual out-of-pocket maximum required under your medical ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 0 11.16 Tm (coverage. ) Tj ET EMC Q q Q q 1 0 0 1 36 74 cm /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 20.7 w -1.45 374.67 m 542.6 374.67 l S 1 w 0.83922 0.84314 0.9098 RG 17.25 w -1.45 355.7 m 286.25 355.7 l S 1 w 17.25 w 286.75 355.7 m 542.6 355.7 l S 1 w 1 1 1 RG 88.67 w -1.45 302.24 m 286.25 302.24 l S 1 w 0.92941 0.95294 0.99608 RG 88.79 w 286.5 302.3 m 542.6 302.3 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 256.9 m 542.6 256.9 l S 1 w 1 1 1 RG 31.47 w -1.45 240.29 m 286.25 240.29 l S 1 w 0.92941 0.95294 0.99608 RG 31.6 w 286.5 240.35 m 542.6 240.35 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 223.56 m 542.6 223.56 l S 1 w 1 1 1 RG 68.27 w -1.45 188.55 m 286.25 188.55 l S 1 w 0.92941 0.95294 0.99608 RG 68.39 w 286.5 188.61 m 542.6 188.61 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 153.41 m 542.6 153.41 l S 1 w 1 1 1 RG 86.67 w -1.45 109.2 m 286.25 109.2 l S 1 w 0.92941 0.95294 0.99608 RG 86.79 w 286.5 109.27 m 542.6 109.27 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 64.87 m 542.6 64.87 l S 1 w 1 1 1 RG 31.6 w -1.45 48.19 m 286.25 48.19 l S 1 w 0.92941 0.95294 0.99608 RG 31.72 w 286.5 48.26 m 542.6 48.26 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 31.4 m 542.6 31.4 l S 1 w 1 1 1 RG 22.4 w -1.45 19.32 m 286.25 19.32 l S 1 w 0.92941 0.95294 0.99608 RG 22.52 w 286.5 19.39 m 542.6 19.39 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 7.12 m 542.6 7.12 l S 1 w EMC /Span <>BDC 1 1 1 rg BT /F7 12 Tf 1 0 0 1 2.9 370.71 Tm (Member's responsibility \(copays and coinsurance amounts\) ) Tj ET EMC /Span <>BDC 0.2 0.2 0.2 rg BT /F7 9 Tf 1 0 0 1 2.9 352.72 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F7 9 Tf 1 0 0 1 290.85 352.72 Tm (Coverage ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 337.33 Tm (Retail - 30-day supply ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 337.46 Tm ($15 copay - Generic drugs ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 328.26 Tm ($40 copay - Preferred brand drugs ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 319.06 Tm ($80 copay - Non-Preferred brand drugs ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 309.86 Tm (20% coinsurance - Generic and Preferred Specialty drugs $200 ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 300.66 Tm (maximum ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 291.46 Tm (20% coinsurance - Non-Preferred Specialty drugs $300 maximum ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 271.06 Tm (Prescriptions and refills obtained from a non-network pharmacy are ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 261.86 Tm (reimbursed at 75% of the approved amount, less the members copay. ) Tj ET EMC q n 2.9 257.53 m 546.95 257.53 l 546.95 256.53 l 2.9 256.53 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 246.79 Tm (Retail and Mail Order - 90-day supply ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 246.91 Tm ($30 copay - Generic drugs ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 237.71 Tm ($80 copay - Preferred brand drugs ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 228.51 Tm ($160 copay - Non-Preferred brand drugs ) Tj ET EMC q n 2.9 224.18 m 546.95 224.18 l 546.95 223.18 l 2.9 223.18 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 213.44 Tm (Specialty Drugs ) Tj ET EMC /Span <>BDC BT /F7 8 Tf 1 0 0 1 2.9 195.04 Tm (Exclusive Specialty Network) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 110.95 195.04 Tm (: We only cover specialty drugs when obtained ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 185.84 Tm (from our exclusive specialty pharmacy network. Covered drugs will be subject ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 176.64 Tm (to the members cost-share requirements. If a member obtains specialty drugs ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 167.44 Tm (from any other provider, they may be responsible for the total cost. ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 213.56 Tm (Retail 30-day: ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 204.37 Tm (20% coinsurance - Generic and Preferred Specialty drugs $200 ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 195.17 Tm (maximum ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 185.97 Tm (20% coinsurance - Non-Preferred Specialty drugs $300 maximum ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 167.57 Tm (Members are restricted to a 30-day supply and certain specialty drugs ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 158.37 Tm (are limited to only a 15-day supply for each fill. ) Tj ET EMC q n 2.9 154.04 m 546.95 154.04 l 546.95 153.04 l 2.9 153.04 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 143.29 Tm (High-Cost Drug Discount Optimization Program ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 143.42 Tm (Prescription drug manufacturers provide coupon programs for certain ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 134.22 Tm (pharmaceuticals. Your benefit plan requires you to enroll in BCBSM- ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 125.02 Tm (approved coupon programs when available for select medications. This ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 115.82 Tm (benefit may lower the cost sharing typically required for these drugs. ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 106.62 Tm (Your out-of-pocket expense for these drugs will be no more than your ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 97.42 Tm (cost sharing. When a coupon is used, only the amount you paid for the ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 88.22 Tm (prescription will apply towards your annual out-of-pocket maximum. ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 79.03 Tm (Note - Adjustments may be required to accurately reflect your annual ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 69.83 Tm (out-of-pocket maximum with your true out-of-pocket costs. ) Tj ET EMC q n 2.9 65.49 m 546.95 65.49 l 546.95 64.49 l 2.9 64.49 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 54.75 Tm (Adult and childhood select preventive immunizations as recommended by the ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 45.55 Tm (USPSTF, ACIP, HRSA or other sources as recognized by BCBSM that are in ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 36.35 Tm (compliance with the provisions of the PPACA ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 54.88 Tm (Covered - 100% ) Tj ET EMC q n 2.9 32.02 m 546.95 32.02 l 546.95 31.02 l 2.9 31.02 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F7 8 Tf 1 0 0 1 2.9 21.28 Tm (Oral and Injectable Contraceptives ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 12.08 Tm (Retail and Mail Order ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 21.4 Tm (Covered - 100% for Generic and Select Brand name drugs; other ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 12.21 Tm (Brand name drugs are subject to the applicable copay/coinsurance ) Tj ET EMC q n 2.9 7.75 m 546.95 7.75 l 546.95 6.75 l 2.9 6.75 l h W n Q /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG 286.5 364.32 m 286.5 257.9 l S 1 w [] 0 d 0.5 w [] 0 d 286.5 256.03 m 286.5 224.55 l S 1 w [] 0 d 0.5 w [] 0 d 286.5 222.68 m 286.5 154.41 l S 1 w [] 0 d 0.5 w [] 0 d 286.5 152.54 m 286.5 65.87 l S 1 w [] 0 d 0.5 w [] 0 d 286.5 63.99 m 286.5 32.4 l S 1 w [] 0 d 0.5 w [] 0 d 286.5 30.52 m 286.5 8.12 l S 1 w [] 0 d 0.5 w [] 0 d 542.85 385.02 m 542.85 6.5 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 346.82 m 542.35 346.82 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 257.65 m 542.35 257.65 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 256.28 m 286.5 256.28 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 286.75 256.28 m 542.6 256.28 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 224.3 m 542.35 224.3 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 222.93 m 286.5 222.93 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 286.75 222.93 m 542.6 222.93 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 154.16 m 542.35 154.16 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 152.79 m 286.5 152.79 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 286.75 152.79 m 542.6 152.79 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 65.62 m 542.35 65.62 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 64.24 m 286.5 64.24 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 286.75 64.24 m 542.6 64.24 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 32.15 m 542.35 32.15 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 30.77 m 286.5 30.77 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 286.75 30.77 m 542.6 30.77 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 7.87 m 542.35 7.87 l S 1 w [] 0 d EMC Q q Q Q endstream endobj 322 0 obj <>>>>> endobj 323 0 obj <> endobj 325 0 obj <> endobj 326 0 obj <> endobj 327 0 obj <> endobj 328 0 obj <> endobj 329 0 obj <> endobj 330 0 obj <> endobj 331 0 obj <> endobj 332 0 obj <> endobj 333 0 obj <> endobj 334 0 obj <> endobj 335 0 obj <> endobj 336 0 obj <> endobj 337 0 obj <> endobj 338 0 obj <> endobj 339 0 obj <> endobj 340 0 obj <> endobj 342 0 obj <> endobj 343 0 obj <> endobj 344 0 obj <> endobj 345 0 obj <> endobj 346 0 obj <> endobj 347 0 obj <> endobj 348 0 obj <> endobj 349 0 obj <> endobj 350 0 obj <> endobj 351 0 obj <> endobj 352 0 obj [ 322 0 R /XYZ 38.9 551.29 0] endobj 353 0 obj [ 322 0 R /XYZ 38.9 551.29 0] endobj 354 0 obj <> endobj 355 0 obj <> endobj 356 0 obj <> endobj 357 0 obj <> endobj 359 0 obj <> endobj 360 0 obj <> endobj 362 0 obj <> endobj 363 0 obj <> endobj 361 0 obj <> endobj 366 0 obj <>/Pg 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<> endobj 391 0 obj <> endobj 374 0 obj <> endobj 375 0 obj <> endobj 392 0 obj [ 5 0 R 8 0 R 9 0 R 10 0 R 11 0 R 12 0 R 12 0 R 12 0 R 13 0 R 15 0 R 15 0 R 15 0 R 15 0 R 15 0 R 15 0 R 15 0 R 15 0 R 15 0 R 15 0 R 15 0 R 15 0 R 15 0 R 18 0 R 20 0 R 21 0 R 22 0 R 23 0 R 23 0 R 24 0 R 24 0 R 25 0 R 25 0 R 26 0 R 26 0 R 27 0 R 27 0 R 27 0 R 27 0 R 27 0 R 27 0 R 27 0 R 27 0 R 27 0 R 28 0 R 28 0 R 29 0 R 29 0 R 30 0 R 30 0 R 30 0 R 31 0 R 32 0 R 32 0 R 32 0 R 32 0 R 33 0 R 34 0 R 34 0 R 35 0 R 35 0 R 36 0 R 36 0 R 37 0 R 37 0 R 38 0 R 39 0 R 45 0 R 47 0 R 48 0 R 49 0 R 50 0 R 51 0 R 52 0 R ] endobj 393 0 obj [ 53 0 R 53 0 R 55 0 R 56 0 R 57 0 R 57 0 R 58 0 R 59 0 R 60 0 R 61 0 R 62 0 R 63 0 R 63 0 R 64 0 R 65 0 R 66 0 R 67 0 R 68 0 R 69 0 R 70 0 R 71 0 R 72 0 R 73 0 R 74 0 R 75 0 R 76 0 R 76 0 R 76 0 R 76 0 R 76 0 R 76 0 R 77 0 R 78 0 R 79 0 R 80 0 R 81 0 R 84 0 R 86 0 R 87 0 R 88 0 R 89 0 R 90 0 R 91 0 R 92 0 R 93 0 R 94 0 R 95 0 R 96 0 R 96 0 R 97 0 R 98 0 R 99 0 R 100 0 R 101 0 R 102 0 R 103 0 R 104 0 R 107 0 R 109 0 R 110 0 R 111 0 R 112 0 R 112 0 R 113 0 R 113 0 R 114 0 R 114 0 R 115 0 R 116 0 R 117 0 R 118 0 R 119 0 R 120 0 R 121 0 R 122 0 R 123 0 R 124 0 R 125 0 R 126 0 R 129 0 R 131 0 R 132 0 R 133 0 R 134 0 R 135 0 R 136 0 R 137 0 R 138 0 R 139 0 R 140 0 R 141 0 R 142 0 R ] endobj 394 0 obj [ 147 0 R 149 0 R 150 0 R 151 0 R 152 0 R 153 0 R 154 0 R 155 0 R 156 0 R 157 0 R 160 0 R 162 0 R 163 0 R 164 0 R 165 0 R 165 0 R 166 0 R 167 0 R 168 0 R 169 0 R 170 0 R 173 0 R 175 0 R 176 0 R 177 0 R 178 0 R 179 0 R 180 0 R 181 0 R 182 0 R 183 0 R 184 0 R 185 0 R 186 0 R 187 0 R 190 0 R 192 0 R 193 0 R 194 0 R 195 0 R 196 0 R 197 0 R 198 0 R 199 0 R 200 0 R 201 0 R 202 0 R 203 0 R 204 0 R 205 0 R 206 0 R 207 0 R 208 0 R 209 0 R 210 0 R 211 0 R 214 0 R 216 0 R 217 0 R 218 0 R 219 0 R 220 0 R 220 0 R 221 0 R 222 0 R 222 0 R 223 0 R 224 0 R 225 0 R 230 0 R 232 0 R 233 0 R 234 0 R 235 0 R 236 0 R 237 0 R 238 0 R 239 0 R 240 0 R 241 0 R 242 0 R 243 0 R ] endobj 395 0 obj [ 244 0 R 246 0 R 246 0 R 247 0 R 248 0 R 251 0 R 253 0 R 254 0 R 255 0 R 256 0 R 257 0 R 257 0 R 257 0 R 257 0 R 257 0 R 257 0 R 257 0 R 258 0 R 259 0 R 260 0 R 261 0 R 261 0 R 262 0 R 263 0 R 264 0 R 265 0 R 266 0 R 269 0 R 271 0 R 272 0 R 273 0 R 274 0 R 275 0 R 276 0 R 277 0 R 277 0 R 278 0 R 279 0 R 280 0 R 281 0 R 282 0 R 283 0 R 284 0 R 285 0 R 286 0 R 287 0 R 288 0 R 289 0 R 290 0 R 291 0 R 292 0 R 293 0 R 294 0 R 299 0 R 301 0 R 302 0 R 303 0 R 304 0 R 305 0 R 306 0 R 307 0 R ] endobj 396 0 obj [ 308 0 R 310 0 R 311 0 R 312 0 R 313 0 R 314 0 R 314 0 R 314 0 R 315 0 R 317 0 R 317 0 R 317 0 R 317 0 R 317 0 R 317 0 R 323 0 R 325 0 R 326 0 R 327 0 R 328 0 R 328 0 R 328 0 R 328 0 R 328 0 R 328 0 R 329 0 R 329 0 R 330 0 R 331 0 R 331 0 R 331 0 R 332 0 R 332 0 R 332 0 R 332 0 R 332 0 R 332 0 R 333 0 R 333 0 R 333 0 R 333 0 R 333 0 R 333 0 R 334 0 R 335 0 R 335 0 R 335 0 R 335 0 R 335 0 R 335 0 R 335 0 R 335 0 R 335 0 R 336 0 R 336 0 R 336 0 R 337 0 R 338 0 R 338 0 R 339 0 R 339 0 R ] endobj 397 0 obj [ 340 0 R 342 0 R 343 0 R 344 0 R 345 0 R 346 0 R 347 0 R 348 0 R 349 0 R 350 0 R 351 0 R 351 0 R 351 0 R 351 0 R 351 0 R 351 0 R 351 0 R 354 0 R 359 0 R 362 0 R 362 0 R 362 0 R 362 0 R 362 0 R 362 0 R 362 0 R 362 0 R 362 0 R 362 0 R 362 0 R 367 0 R 370 0 R 370 0 R 370 0 R 370 0 R 370 0 R 370 0 R 370 0 R 370 0 R 370 0 R 370 0 R 370 0 R ] endobj 398 0 obj <>stream q 0 0 612 792 re W n /Artifact <> BDC q 1 0 0 1 36 755.3 cm q n 0 0.7 m 612 0.7 l 612 0 l 0 0 l h W n Q Q q Q EMC /Artifact <> BDC q 1 0 0 1 36 36 cm 0 0 0 rg BT /F3 7 Tf 1 0 0 1 61.82 27.66 Tm (Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. ) Tj ET BT /F3 7 Tf 1 0 0 1 0 3.56 Tm (Page ) Tj ET BT /F3 7 Tf 1 0 0 1 18.29 3.56 Tm (6) Tj ET BT /F3 7 Tf 1 0 0 1 22.19 3.56 Tm ( of ) Tj ET BT /F3 7 Tf 1 0 0 1 31.91 3.56 Tm (6 ) Tj ET BT /F3 8 Tf 1 0 0 1 249.34 2.66 Tm (G10192023 ) Tj ET BT /F3 7 Tf 1 0 0 1 493.28 3.56 Tm (000019424595 ) Tj ET q n 0 0.7 m 612 0.7 l 612 0 l 0 0 l h W n Q Q q Q EMC q 1 0 0 1 36 573.14 cm /Artifact <> BDC 0.83922 0.84314 0.9098 RG 0 J 17.25 w -1.45 173.54 m 286.25 173.54 l S 1 w 17.25 w 286.75 173.54 m 542.6 173.54 l S 1 w 1 1 1 RG 13.2 w -1.45 157.82 m 286.25 157.82 l S 1 w 0.92941 0.95294 0.99608 RG 13.32 w 286.5 157.88 m 542.6 157.88 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 150.21 m 542.6 150.21 l S 1 w 1 1 1 RG 13.2 w -1.45 142.74 m 286.25 142.74 l S 1 w 0.92941 0.95294 0.99608 RG 13.32 w 286.5 142.8 m 542.6 142.8 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 135.14 m 542.6 135.14 l S 1 w 1 1 1 RG 13.2 w -1.45 127.67 m 286.25 127.67 l S 1 w 0.92941 0.95294 0.99608 RG 13.32 w 286.5 127.73 m 542.6 127.73 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 120.07 m 542.6 120.07 l S 1 w 1 1 1 RG 13.2 w -1.45 112.59 m 286.25 112.59 l S 1 w 0.92941 0.95294 0.99608 RG 13.32 w 286.5 112.65 m 542.6 112.65 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 104.99 m 542.6 104.99 l S 1 w 1 1 1 RG 13.2 w -1.45 97.52 m 286.25 97.52 l S 1 w 0.92941 0.95294 0.99608 RG 13.32 w 286.5 97.58 m 542.6 97.58 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 89.92 m 542.6 89.92 l S 1 w 1 1 1 RG 86.67 w -1.45 45.71 m 286.25 45.71 l S 1 w 0.92941 0.95294 0.99608 RG 86.79 w 286.5 45.77 m 542.6 45.77 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 1.5 m 542.6 1.5 l S EMC /Artifact <> BDC 0.2 0.2 0.2 rg BT /F7 9 Tf 1 0 0 1 2.9 170.57 Tm (Benefits ) Tj ET BT /F7 9 Tf 1 0 0 1 290.85 170.57 Tm (Coverage ) Tj ET EMC /Span <>BDC BT /F7 8 Tf 1 0 0 1 2.9 155.17 Tm (Additional Services ) Tj ET EMC q n 2.9 150.84 m 546.95 150.84 l 546.95 149.84 l 2.9 149.84 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 140.1 Tm (Smoking Cessation Drugs ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 140.22 Tm (Covered ) Tj ET EMC q n 2.9 135.76 m 546.95 135.76 l 546.95 134.76 l 2.9 134.76 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 125.02 Tm (Weight Loss Drugs ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 125.15 Tm (Covered ) Tj ET EMC q n 2.9 120.69 m 546.95 120.69 l 546.95 119.69 l 2.9 119.69 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 109.95 Tm (Impotency Drugs ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 110.07 Tm (Covered ) Tj ET EMC q n 2.9 105.62 m 546.95 105.62 l 546.95 104.62 l 2.9 104.62 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 94.88 Tm (Infertility Drugs ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 95 Tm (Not Covered ) Tj ET EMC q n 2.9 90.54 m 546.95 90.54 l 546.95 89.54 l 2.9 89.54 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F7 8 Tf 1 0 0 1 2.9 79.8 Tm (Diabetic Supplies ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 79.93 Tm (Includes: ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 70.73 Tm (Needles/Syringes - Covered at 100% if an injectable prescription drug ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 61.53 Tm (was filled within the last 120 days under the BCBSM Rx benefit ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 43.13 Tm (Retail Test Strips and Lancets: ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 33.93 Tm ($40 copay ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 15.53 Tm (Mail Order Test Strips and Lancets: ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 289.4 6.33 Tm ($40 copay ) Tj ET EMC q n 2.9 2 m 546.95 2 l 546.95 1 l 2.9 1 l h W n Q /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG 286.5 182.16 m 286.5 151.21 l S 1 w [] 0 d 0.5 w [] 0 d 286.5 149.34 m 286.5 136.14 l S 1 w [] 0 d 0.5 w [] 0 d 286.5 134.26 m 286.5 121.07 l S 1 w [] 0 d 0.5 w [] 0 d 286.5 119.19 m 286.5 105.99 l S 1 w [] 0 d 0.5 w [] 0 d 286.5 104.12 m 286.5 90.92 l S 1 w [] 0 d 0.5 w [] 0 d 286.5 89.04 m 286.5 2.38 l S 1 w [] 0 d 0.5 w [] 0 d 542.85 182.16 m 542.85 1 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 164.66 m 542.35 164.66 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 150.96 m 542.35 150.96 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 149.59 m 286.5 149.59 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 286.75 149.59 m 542.6 149.59 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 135.89 m 542.35 135.89 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 134.51 m 286.5 134.51 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 286.75 134.51 m 542.6 134.51 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 120.82 m 542.35 120.82 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 119.44 m 286.5 119.44 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 286.75 119.44 m 542.6 119.44 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 105.74 m 542.35 105.74 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 104.37 m 286.5 104.37 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 286.75 104.37 m 542.6 104.37 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 90.67 m 542.35 90.67 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 89.29 m 286.5 89.29 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 286.75 89.29 m 542.6 89.29 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 2.13 m 542.35 2.13 l S 1 w [] 0 d EMC q n 0 1 m 612 1 l 612 0 l 0 0 l h W n Q Q q Q q 1 0 0 1 36 74 cm /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 20.7 w -1.45 470.39 m 542.6 470.39 l S 1 w 1 1 1 RG 105.19 w -1.45 407.45 m 131.1 407.45 l S 1 w 0.92941 0.95294 0.99608 RG 105.19 w 131.6 407.45 m 542.6 407.45 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 354.35 m 542.6 354.35 l S 1 1 1 RG 59.19 w -1.45 324.25 m 131.1 324.25 l S 1 w 0.92941 0.95294 0.99608 RG 59.19 w 131.6 324.25 m 542.6 324.25 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 294.15 m 542.6 294.15 l S EMC /Span <>BDC 1 1 1 rg BT /F7 12 Tf 1 0 0 1 2.9 466.43 Tm (Features of your prescription drug plan ) Tj ET EMC /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 450.8 Tm (Preferred Therapy Program ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 134.5 450.8 Tm (A step-therapy approach that encourages physicians to prescribe generic, generic alternative or over-the-counter ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 134.5 441.6 Tm (medications before prescribing a more expensive brand-name drug. It applies only to prescriptions being filled for ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 134.5 432.4 Tm (the first time of a targeted medication. Before filling your initial prescription for select, high-cost, brand-name drugs, ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 134.5 423.2 Tm (the pharmacy will contact your physician to suggest a generic alternative. A list of select brand-name drugs ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 134.5 414 Tm (targeted for the preferred therapy program is available at bcbsm.com/pharmacy, along with the preferred ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 134.5 404.8 Tm (medications. ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 134.5 395.61 Tm (If our records indicate you have already tried the preferred medication\(s\), we will authorize the prescription. lf we ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 134.5 386.41 Tm (have no record of you trying the preferred medication\(s\), you may be liable for the entire cost of the brand-name ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 134.5 377.21 Tm (drug unless you first try the preferred medication\(s\) or your physician obtains prior authorization from BCBSM. ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 134.5 368.01 Tm (These provisions affect all targeted brand- name drugs, whether they are dispensed by a retail pharmacy or ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 134.5 358.81 Tm (through a mail order provider. ) Tj ET EMC q n 2.9 354.85 m 546.95 354.85 l 546.95 353.85 l 2.9 353.85 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 344.61 Tm (Prior authorization/step therapy ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 134.5 344.61 Tm (A process that requires a physician to obtain approval from BCBSM ) Tj ET EMC /Span <>BDC BT /F7 8 Tf 1 0 0 1 375.95 344.61 Tm (before) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 400.4 344.61 Tm ( select prescription drugs \(drugs ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 134.5 335.41 Tm (identified by BCBSM as requiring prior authorization\) will be covered. ) Tj ET EMC /Span <>BDC BT /F7 8 Tf 1 0 0 1 380.4 335.41 Tm (Step Therapy) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 431.07 335.41 Tm (, an initial step in the Prior ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 134.5 326.21 Tm (Authorization process, applies criteria to select drugs to determine if a less costly prescription drug may be used for ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 134.5 317.01 Tm (the same drug therapy. This also applies to mail order drugs. Claims that do not meet Step Therapy criteria require ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 134.5 307.81 Tm (prior authorization. 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