Medical Plan Options - Retirees Age 65 or Over/ Disabled Participants with Medicare Coverage

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1 Program Name U of M Retiree Plan with Group MedicareBlue SM Rx Group Platinum Blue SM Plan C with Group MedicareBlue SM Rx Freedom Plan & Freedom Plan & Type of Policy Coordinates with Medicare and includes Medicare Prescription Drug Plan Drug Plan Drug Coverage Drug Coverage Monthly Premium $ $ $ $ How Plan Works with Medicare and Medicare Assignment U of M Retiree Plan pays after applying U of M Retiree Plan inpatient deductible and. You pay Medicare Part B annual deductibles. home health care expenses. For most in-network claims, Blue Cross pays Medicare Part B provider expenses. home health care expenses. pays Medicare Part B provider expenses. home health care expenses. pays Medicare Part B provider expenses. Medicare Assignment You are encouraged to use BCBS network providers, but you do not assign your Medicare benefits to Blue Cross. You are allowed to use your Medicare benefits outside of the BCBS network. You are encouraged to use BCBS network providers, but you do not assign your Medicare benefits to Blue Cross. You are allowed to use your Medicare benefits outside of the BCBS network. Freedom members are encouraged to use network providers, but are able to use Medicare benefits outside of the Freedom network. Retiree National Choice members may see any provider who accepts Medicare. Freedom members are encouraged to use network providers, but are able to use Medicare benefits outside of the Freedom network. Retiree National Choice members may see any provider who accepts Medicare. Outpatient Hospital Outpatient Surgery after $75 copay after $75 copay Lab/X-Ray, CT scan, MRI, other outpatient diagnostic tests of remaining balance after Medicare Part B deductible is met Lab services at and all other services at $15 Lab services at and all other services at $30 copay Emergency Services after $50 copay after $50 copay after $100 copay Ambulance after $75 copay 80% 10 Open Enrollment

2 Urgent Care Visit Inpatient Part B annual deductible $183 for 2017/subject to change for 2018 Hospital for each Medicare-covered stay. No limit on number of days covered by plan Skilled Nursing. No 3-day hospital stay requirement 100 days per benefit period 100 days per benefit period 100 days per benefit period Mental Health up to 190 days of inpatient psychiatric hospital care in a lifetime. This limitation does not apply to inpatient psychiatric services furnished in a general hospital Chemical Dependency Outpatient Medical Preventive Physician Office Visit Part B annual deductible $183 for 2017/subject to change for 2018 after $20 copay after $15 copay after: Primary Care $20 copay/ Specialist $30 copay 12 Open Enrollment

3 Medications Delivered in Physician Office Setting and Paid under Medicare Part B after $20 copay after $15 copay (If Part B drugs are billed separately, coverage is 80%) after Primary Care $20 copay/specialist $30 copay (If Part B drugs are billed separately, coverage is 80%) Routine Eye and Hearing Exams Outpatient Mental Health after $20 copay after $15 individual/ $7.50 group after $30 individual/ $15 group Outpatient Chemical Dependency Chiropractic Care Podiatry Physical & Occupational Therapy Speech & Language Therapy Home Health Care Medical Equipment DME Prosthetics after $20 copay after $30 copay 80% 90% 80% Hearing Aids 80% for hearing aids every 3 years $450 plan coverage limit for hearing aids every year 80% coverage for 1 selected hearing aid for each ear every 3 years. No implantable devices No coverage. Discounts available 14 Open Enrollment

4 Prescription Drugs Generic Drugs Retail Formulary Brand Drugs Retail Non-preferred Formulary Brand Retail $10 copay $10 copay $10 copay $10 copay $30 copay $25 copay $30 copay $35 copay $50 copay $60 copay $30 copay $70 copay Specialty Drugs $50 copay $50 copay 75% coverage Supplemental Drugs Covered at generic and brand copays shown above Covered at generic and brand copays shown above Mail Order 3-month supply for 2 copays through mail order or if using Preferred Extended Network (PXT) within Group MedicareBlue Rx pharmacy network 3-month supply for 2 copays through mail order or if using Preferred Extended Network (PXT) within Group Medicare- Blue Rx pharmacy network 3-month supply for 2 copays 3-month supply for 2 copays Benefits in the Medicare Coverage Gap (Between $3,750 total prescription costs and $5,000 total outof-pocket expenses) coverage after $10 generic copay, $30 brand copay or $50 non-preferred brand and specialty copays. 25% for supplemental drugs coverage after $10 generic copay, $25 brand copay or $60 non-preferred brand copay. 25% for specialty and supplemental drugs coverage after $10 generic, $30 brand, or $50 specialty copay coverage after $10 generic copay. Participants will pay 35% for their brand or specialty medications Catastrophic Level (after $5,000 in total out-of-pocket expenses) Member cost will be the greater of $3.35 for covered generic or multisource preferred brand drugs and $8.35 for all other covered drugs, or 5% of the cost of the drug Member cost will be the greater of $3.35 for covered generic or multi-source preferred brand drugs and $8.35 for all other covered drugs, or 5% of the cost of covered drugs The lesser of 5% or the above copays Member cost will be the greater of 5% of drug cost or $3.35 copay for generic drugs, and $8.35 copay for brand/ formulary drugs Wellness Benefits Fitness Club Membership Fitness discount that credits your fitness center account $20 a month for membership fees when you work out 12 times a month Silver & Fit Exercise and Healthy Aging Program provides a fitness club membership at participating facilities or home exercise kits Fitness club membership provided at no cost for participating facilities. You may also request a home exercise kit. Nurseline 24-hour Nurse Line 24-hour Nurse Line Free access to registered nurses 24/7 through the CareLine SM nurse line Other Wellness Benefits Stop Smoking Program Wellness Discount Marketplace blue365deals.com/bcbsmn Stop Smoking support Up to $125 limit for non-medicare covered eyewear every year Wellness Discount Marketplace blue365deals.com/bcbsmn Free, unlimited number of virtuwell visits for Freedom Plan members Healthy discounts on hearing aids, eating services, delivery services, fitness equipment and much more Up to 35% discount off eyewear 16 Open Enrollment

5 Travel and Out-of-Area Benefits Travel benefits No limitations May travel out of the service area and within the United States for 9 months, no activation of benefit required May be out of the service area for up to 9 consecutive months annually; benefits are activated by calling Member Services May be out of the service area for up to 9 consecutive months annually; benefits are activated by calling Member Services Option to live outside of service area Yes No Yes, through Yes, through Maximums Annual Out-of-Pocket $863 that includes $680 plus $183 (for 2017) Part B deductible (Pharmacy copays do not apply). Part B deductible subject to change in 2018 $3,000. This amount does not include Medicare Part D copays/ $3,000 (Pharmacy copays do not apply) $3,000 (Pharmacy copays do not apply) Lifetime Unlimited Unlimited Unlimited Unlimited 18 Open Enrollment