Page 5 - 2022 Benefit Guide Fives Inc

Medical Coverage

The Company offers a choice of medical plan options through BCBS of Michigan so you can
choose the plan that best meets your needs and those of your family. Prescription coverage is
through Express Scripts Inc. (ESI). This is a summary of coverage. Please refer to the Summary of
Benefit Coverage and Benefits at a Glance for additional coverage and limitations.://www.express-
scripts.com/

BCBS $500 PPO BCBS $1,000 PPO BCBS CDHP/HSA

Plan Provisions Out-of- Out-of- Out-of-
In-Network In-Network In-Network
Network Network Network

Annual Deductible $500 / $1,000 $1,000 / $2,000 $1,000 / $2,000 $2,000 / $4,000 $1,500 / $3,000 $3,000 / $6,000
(Individual/Family)

Medical: $3,500 Medical: $7,000 Medical: $4,500 Medical: $9,000
Single Out-of-
Pocket Maximum * Rx: $2,000 Rx: $2,000 Rx: $2,000 Rx: $2,000 $4,500 $9,000
TOTAL: $5,500 TOTAL: $9,000 TOTAL: $6,500 TOTAL: $11,000
Medical: $7,000 Medical: $14,000 Medical: $9,000 Medical: $18,000
Family Out-of-
Pocket Maximum * Rx: $4,000 Rx: $ 4,000 Rx: $4,000 Rx: $4,000 $9,000 $18,000
TOTAL: $11,000 TOTAL: $18,000 TOTAL: $13,000 TOTAL: $22,000
Preventive Care Covered at 100% Not covered Covered at100% Not covered Covered at100% Not covered
Office Visits $10 copay $10 copay
BCBS Online Visit 80% after 60% after
Primary Care $25 copay 60% after $25 copay 60% after deductible deductible
Specialist $35 copay deductible $35 copay deductible
In and Outpatient 80% after 60% after 80% after 60% after 80% after 60% after
Hospital Services** deductible deductible deductible deductible deductible deductible

60% after 60% after 80% after 60% after
Urgent Care $45 copay $45 copay
deductible deductible deductible deductible
80% after 60% after
Emergency Room $250 copay, waived if admitted $250 copay, waived if admitted
deductible deductible
Retail Prescriptions In Network - 30 day supply In Network - 30 day supply In Network - 30 day supply
Generic $10 copay $10 copay
Preferred 25% copay ($20 min, $75 max) 25% copay ($20 min, $75 max) 80% after deductible
Non-preferred 30% copay ($35 min, $100 max) 30% copay ($35 min, $100 max)

Mail Order / Retail In Network - 90 day supply In Network - 90 day supply In Network-90 day supply
Generic $20 copay $20 copay
Brand Preferred 25% copay ($40 min, $150 max) 25% copay ($40 min, $150 max) 80% after deductible
Brand Non-preferred 30% copay ($70 min, $200 max) 30% copay ($70 min, $200 max)

HSA Company Not Applicable Not Applicable Single - $500 per year
Contribution Family - $1,000 per year
2022 Medical Rates (Monthly)
(bi-weekly)
Employee Only $135.93 $108.80 $83.03
Employee + Spouse $271.87 $217.61 $166.01
EE + Child(ren) $245.11 $195.65 $148.63

Family $406.54 $326.47 $250.36

* Maximum Out of Pocket Includes: deductible, office copays and coinsurance. A separate maximum applies to Prescriptions (Rx) for PPO Plans.
** Hospital services performed at a BCBS Blue Distinction Center (BDC) will be covered at 90% after deductible. .

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