Page 9 - 2013 Allied Printing Benefit & Notices

Allied Printing Co., Inc. 2013

Preventive services are covered at 100% in network with no deductible on both plans. The benefit
summaries on the following pages show an abbreviated list of preventive benefits we cover.

Both plans have an out-of-pocket maximum. Once you have spent this out-of-pocket amount on
coinsurance following your deductible, the plan will pay 100% of any medical charge which would
otherwise have a coinsurance for the remainder of the plan year. The plan Summary of Benefits
Coverage (SBC) explains these out of pocket maximum and can be found in this booklet.
DRAFT

Patient Protection Notice

The Allied Printing HMO Group Health Plan through Blue Care Network (BCN) requires the designation
of a primary care provider. You have the right to designate any primary care provider who participates in
our network and who is available to accept you or your family members. Until you make this designation,
BCN designates one for you. For information on how to select a primary care provider, and for a list of
the participating primary care providers, contact the BCN website at www.miBCN.com or call
800.662.6667.

For children, you may designate a participating pediatrician as the primary care provider.

You do not need prior authorization from BCN or from any other person (including a primary care
provider) in order to obtain access to obstetrical or gynecological care from a health care professional in
our network who specializes in obstetrics or gynecology. The health care professional, however, may be
required to comply with certain procedures, including obtaining prior authorization for certain services,
following a pre-approved treatment plan, or procedures for making referrals. For a list of participating
health care professionals who specialize in obstetrics or gynecology, contact the BCN website at
www.miBCN.com or call 800.662.6667.

Waiver of Medical Coverage – Opt Out Option

You may elect to waive medical coverage from Allied Printing if you have and can provide proof of
existing coverage from another source (spouse, parent, etc). When proof of coverage is provided to
Human Resources and validated, you will be eligible to enroll in the dental and vision plans. The Opt Out
Option does not provide a monetary subsidy to the eligible employee.

Should you suffer a HIPAA status change event, you may be added to Allied Printing’s medical plan mid-
year only if notification is given to Human Resources no later than 31 days of the event.

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