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Blue Care Network

Medical Coverage Contract

Premium Plan

Blue Care Network


Core Plan

Blue Care Network


Core Plus Plan

Blue Care Network

Pharmacy Coverage Contract Documents

(All Plans)

Group Enrollment & Coverage Agreement

Blue Care Network Region: Hospital Market & Large Groups

Group ID:

Part C

Company Name (Full Legal Name): DETROIT PUBLIC SCHOOLS COMMUNITY DISTRICT 00103623

Federal Tax ID Number: 386019629

Sub Group(s) Covered:

1007-0003 1009 -0004 1107-0003 1207-0003

Requested Effective Date: January 1, 2018Blue Care Network Certificate/Rider Options

MEDICAL/SURG. Package: Non-Standard HMO Med/Surg

Certificates

Enhanced

Classic Large Group

Standard

Classic Large Group

Riders

Enhanced

6600PM CR10% CO20 D500 ER100

UR40 WDEDFC 15ECM 40RP AS5

FOCUS OMRR SN120Standard

6600PM CR20% CO30 D2000 ER150

UR45 WDEDFC 2KECM 45RP AS5

FOCUS OMRR SN120

PRESCRIP. DRUG Package: Non-Standard Drug

Certificates

Riders

Enhanced

MOPD2X 7255C SPRX0C Standard

MOPD2X 15306C SPRX0C

Are you using HealthEquity to coordinate your HSA? (response required) [ ] Yes [ ] No

SELECTED PACKAGES & OPTIONAL RIDERS

Medical/Surg. Prescription Drug Dental Vision

CLSSLG Add 6600PM Add CR10% Add CO20 Add D500 Add ER100 Add UR40

Page 1

Part C January 1, 2017 (r2) Distribution: Underwriting Sales Office 1 Sales Office 2 Membership & Billing



Group ID:

Part C con't (2)



Sub Group(s) Covered: 1007-0003 1009-0004 1107-0003 1207-0003

Requested Effective Date: January 1, 2018

Add SN120F Add CLSSLG Add 6600PM Add CR20% Add CO30 Add D2000 Add ER150 Add UR45 Add WDEDFC Add 2KECM Add 45RP Add AS5 Add FOCUS Add OMRR Add SN120F

Mail Identification Cards to: Send Bill to: [X] Group [ ] Sub Group [ ] Contract Contract

[Blue Cross Blue Shield of Michigan/Blue Care Network Use Only]

Business Type: Benefit Change

Effective Date:

Billing Cycle Date:

Rate Renewal Date:

BCBSM Inventory Date:

Sales Office Code:

Mail Code:

Territory Code:

SIC Code:

County Code:

January 1, 2018

01

655

BH

082

8211

Control Code:

January 1, 2018

November 16, 2016 BH

BCN Inventory Date: November 1, 2017

517H

Cluster Code: D720



Group ID:

Part C con't (3)





GROUP REIMBURSEMENT POLICY ACKNOWLEDGEMENT

Group Decision Maker signature ______________________________________________ Date _______________________________ Group Decision Maker Name (Print) _________________________________________________ As agent of this group, in addition to the statement above, I also certify that I am not offering and will not offer any of the above described reimbursement arrangements for this customer when the customer has purchased one of the above plans. I understand that failure to adhere to this certification can result in termination of the agent’s contract with BCBSM/BCN; nonpayment of commissions; or other penalties identified by BCBSM/BCN. Agent signature __________________________________________________ Date _______________________________ Agent name (Print) ___________________________________________________

By signing this document, Group agrees that deductibles, coinsurance, and copayments under - Simply Blue - Simply Blue Routine Care Simply Blue HSA (may be paired with an HSA only, to which the Employer may contribute) Healthy Blue Achieve Community Blue Plan 19 Community Blue Plan 20 All BCN plans, except: - BCN HRA is allowed on BCN deductible products - BCN HSA can be paired with an HSA account, to which the employer may contribute Any BCN prescription drug coverage Any BCBSM prescription drug coverage*

*Applies to groups of 101 or more FTEs with fewer than 100 enrolled. will not be reimbursed by any third party administrator, any employer-funded reimbursement arrangement or any fully-insured plan (whether employer or employee funded). Rules for Flexible Spending Accounts (FSAs): Employee-funded FSAs are allowed for all plans. Employer FSA contributions of up to $250 per contract are allowed, with the following exceptions: BCBSM’s Healthy Blue Achieve and BCN’s Healthy Blue Living. Group understands that failure to adhere to this agreement could result in Blue Cross Blue Shield of Michigan or Blue Care Network taking either of the following actions: (1) refuse to renew the group’s coverage; or (2) terminate the group’s coverage. BCN may adjust the premiums for the coverage.



Group ID:

Part C con't (6)





LARGE GROUP PRESCRIPTION DRUG ACKNOWLEDGEMENT

Group Decision Maker signature ______________________________________________ Date _______________________________

Group Decision Maker Name (Print) _________________________________________________

BCBSM Group number/suffixes; BCN Group number/subgroups/classes___________________________________________________

___________________________________________________________________________________________________________

As an authorized agent of Group, I certify that the information stated above is true and accurate and that Group is in compliance with BCBSM’s and BCN’s above stated policy. I understand that if my certification is incorrect or if Group fails to adhere to BCBSM’s above stated policy, termination of my contract with BCBSM or BCN, as applicable, nonpayment of commissions, or other penalties identified by BCBSM or BCN may result.

Agent signature __________________________________________________ Date _______________________________ Agent name (Print) ___________________________________________________

Group, a “large employer” as defined by the Patient Protection and Affordable Care Act, as amended (“PPACA”), understands and acknowledges that in connection with health care coverage (“Health Care Coverage”) underwritten by Blue Cross Blue Shield of Michigan (“BCBSM”) or Blue Care Network of Michigan (“BCN”), as applicable, Group does not have prescription drug benefits provided through BCBSM or BCN. Group represents and warrants that if it has any prescription drug coverage (“Rx Coverage”), the sum of the out-of-pocket maximum amount payable for essential health benefits by a participant (a) under such Rx Coverage and (b) under any other coverage that is not part of the Health Care Coverage will never exceed for any plan year the difference between (i) the out-of-pocket maximum amount permitted by PPACA and (ii) the out-of-pocket maximum amount payable by a participant for the Health Care Coverage so long as the Health Care Coverage remains effective. Group further understands and acknowledges that PPACA requires it to cover certain prescription drugs, supplements, and devices, including, but not limited to, women’s contraceptives (“PPACA Rx”) beginning with Group’s plan year on or after August 1, 2012. Group acknowledges that it is accepting BCBSM’s or BCN’s, as applicable, limited drug benefits certificate, which only provides PPACA Rx, for Group’s selected medical plan(s). Alternatively, if Group declines PPACA Rx from BCBSM or BCN as initialed below, Group represents and warrants that Group has Rx Coverage and that such Rx Coverage includes PPACA Rx. BCBSM or BCN only guarantees minimum actuarial value if a BCBSM/BCN drug plan is purchased with the medical plan. The group should consult with their benefits consultant for compliance. Group agrees that should the information in this Large Group Prescription Drug Acknowledgment change or become incorrect, or should Group fail to immediately inform BCBSM or BCN, as applicable, in writing that Group is using another drug carrier, Group will indemnify and hold BCBSM or BCN, as applicable, harmless for any fines, costs (including attorney fees) expenses, liabilities or financial penalties that are imposed on BCBSM or BCN that result from BCBSM’s or BCN’s reliance on the information in this Large Group Prescription Drug Acknowledgment. Group represents and warrants that, as noted and initialed below, it either (i) has no Rx Coverage from another vendor (and is taking PPACA Rx from BCBSM or BCN,as applicable) or (ii) has Rx Coverage from another vendor and is either accepting or declining PPACA Rx from BCBSM or BCN:

Yes Initials No Rx Coverage - PPACA Rx provided by BCBSM/BCN 3rd Party Rx Coverage - accept PPACA Rx 3rd Party Rx Coverage - decline PPACA Rx

Group represents and warrants that the information contained in this Large Group Prescription Drug Acknowledgement shall remain true and accurate so long as the Health Care Coverage remains effective.


Blue Care Network Region: Hospital Market & Large Groups Group ID:

Part C




1307-0005 1309-0006 1407-0005 1507-0005

Requested Effective Date: January 1, 2018 Blue Care Network Certificate/Rider Options


Certificates Enhanced

Classic Large Group Standard

Classic Large Group

Riders Enhanced

AS5 DME5 ER100 20MHSA SNU UR50 OMRR WR1000 6600PM P&O5 FOCUS 100MSR CO20 OPRH Standard

AS5 DME5 ER100 20MHSA P&O5 SNU UR50 OMRR WR1000 WDEDFC FOCUS 6600PM D500 CO20 OPRH


Certificates

Riders Enhanced


MOPD2X 5254C SPRX0C Are you using HealthEquity to coordinate your HSA? (response required) [ ] Yes [ ] No



The Group agrees with all terms as stipulated in this Group Enrollment and Coverage Agreement (Parts A, B & C), on the Enrollment Change of Status Form, and in the specified Blue Care Network Certificate(s) and Rider(s). By signing this form, I confirm that I understand Blue Care Network will not send hardcopy certificate and riders to subscribers in my group.These documents are available to members at anytime via the member secured services area of the BCN website, MiBCN.com. Members may also request a hardcopy by calling Customer Service at 1-800-662-6667. If you require BCN to send your subscribers hard copies of their certificate and riders, check this box

Signature of Group Executive on behalf of the Group and the Group Health Plan: _____________________________________________ Date: __________ Signature of BCBSM Rep: _____________________________________________ Date: __________ Signature of Agent: _____________________________________________ Date: __________ Signature of Underwriter/Group Administration: _____________________________________________ Date: __________

Page 1 Part C January 1, 2017 (r2) Distribution: Underwriting Sales Office 1 Sales Office 2 Membership & Billing



Part C con't (2)








Effective Date: Billing Cycle Date:

Rate Renewal Date: BCBSM Inventory Date:

Sales Office Code: Mail Code:

Territory Code:

SIC Code: County Code:

January 1, 2018 01

655

BH 082 8211

Control Code: January 1, 2018 November 16, 2016 BH


517H Cluster Code: D720

1307-0005 1309-0006 1407-0005 1507-0005



Part C con't (3)



Sub Group(s) 1307-0005 1309-0006 1407-0005 1507-0005 Covered:




By signing this document, Group agrees that deductibles, coinsurance, and copayments under - Simply Blue - Simply Blue Routine Care

- Simply Blue HSA (may be paired with an HSA only, to which the Employer may contribute) - Healthy Blue Achieve - Community Blue Plan 19 - Community Blue Plan 20 - All BCN plans, except:

- BCN HRA is allowed on BCN deductible products - BCN HSA can be paired with an HSA account, to which the employer may contribute

- Any BCN prescription drug coverage - Any BCBSM prescription drug coverage*




Part C con't (6)








BCBSM Group number/suffixes; BCN Group number/subgroups/classes___________________________________________________ ___________________________________________________________________________________________________________








Part C




1307-0005 1309-0006 1407-0005 1507-0005

Requested Effective Date: January 1, 2018 Blue Care Network Certificate/Rider Options


Certificates Enhanced

Classic Large Group Standard

Classic Large Group

Riders Enhanced

AS5 DME5 ER100 20MHSA SNU UR50 OMRR WR1000 6600PM P&O5 FOCUS 100MSR CO20 OPRH Standard

AS5 DME5 ER100 20MHSA P&O5 SNU UR50 OMRR WR1000 WDEDFC FOCUS 6600PM D500 CO20 OPRH


Certificates

Riders Enhanced


MOPD2X 5254C SPRX0C Are you using HealthEquity to coordinate your HSA? (response required) [ ] Yes [ ] No



The Group agrees with all terms as stipulated in this Group Enrollment and Coverage Agreement (Parts A, B & C), on the Enrollment Change of Status Form, and in the specified Blue Care Network Certificate(s) and Rider(s). By signing this form, I confirm that I understand Blue Care Network will not send hardcopy certificate and riders to subscribers in my group.These documents are available to members at anytime via the member secured services area of the BCN website, MiBCN.com. Members may also request a hardcopy by calling Customer Service at 1-800-662-6667. If you require BCN to send your subscribers hard copies of their certificate and riders, check this box

Signature of Group Executive on behalf of the Group and the Group Health Plan: _____________________________________________ Date: __________ Signature of BCBSM Rep: _____________________________________________ Date: __________ Signature of Agent: _____________________________________________ Date: __________ Signature of Underwriter/Group Administration: _____________________________________________ Date: __________

Page 1 Part C January 1, 2017 (r2) Distribution: Underwriting Sales Office 1 Sales Office 2 Membership & Billing



Part C con't (2)








Effective Date: Billing Cycle Date:

Rate Renewal Date: BCBSM Inventory Date:

Sales Office Code: Mail Code:

Territory Code:

SIC Code: County Code:

January 1, 2018 01

655

BH 082 8211

Control Code: January 1, 2018 November 16, 2016 BH


517H Cluster Code: D720

1307-0005 1309-0006 1407-0005 1507-0005



Part C con't (3)







By signing this document, Group agrees that deductibles, coinsurance, and copayments under - Simply Blue - Simply Blue Routine Care

- Simply Blue HSA (may be paired with an HSA only, to which the Employer may contribute) - Healthy Blue Achieve - Community Blue Plan 19 - Community Blue Plan 20 - All BCN plans, except:

- BCN HRA is allowed on BCN deductible products - BCN HSA can be paired with an HSA account, to which the employer may contribute

- Any BCN prescription drug coverage - Any BCBSM prescription drug coverage*




Part C con't (6)








BCBSM Group number/suffixes; BCN Group number/subgroups/classes___________________________________________________ ___________________________________________________________________________________________________________




