Kalitta Companies

Group Number: 71576 Package Code(s): 040

Section Code(s): 1000, 1100
PPO - Air PPO_Rx_Vision_Hearing_Dental
Effective Date: 01/01/2023
Benefits-at-a-glance
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
exclusions may apply. Payment amounts are based on BCBSM's approved amount, less any applicable deductible and/or copay. If there is a
discrepancy between this Benefits-at-a-Glance and any applicable plan document, the plan document will control.

BCBSM provides administrative claims services only. Your employer or plan sponsor is financially responsible for claims.

Note: A list of services that require approval before they are provided is available online at (https://www.bcbsm.com/importantinfo). Select Approving
covered Services.

Member's responsibility (deductibles, copays, coinsurance and dollar maximums)

Benefits In-Network Out-of-Network
Deductibles - per calendar year $200 per member $200 per member
$600 per family $600 per family
Copays $10 copay for : $250 copay for :
• Fixed Dollar Copays • Facility Urgent care services • Facility medical emergency
• Professional Urgent care services
• Office visits
• Chiropractic spinal manipulations
$250 copay for :
• Facility medical emergency
Coinsurance 20% up to a maximum of: 40%
• Percent Coinsurance $1,000 per member Note: Services without a network
$2,000 per family are covered at the in-network
level.
Annual out-of-pocket maximums $2,000 per member $4,000 per member
$4,000 per family $8,000 per family
Includes Deductible, Coinsurance and Includes Deductible and
Copays Coinsurance
Lifetime dollar maximum Unlimited

Preventive Care Services

Benefits In-Network Out-of-Network
Health Maintenance Exam - beginning age 4; one per calendar year Covered - 100% Covered - 60% after deductible
Routine Physical Related Test X-Rays, EKG and lab procedures Covered - 100% Covered - 60% after deductible
performed as part of the health maintenance exam

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
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
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
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
charge.
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 Annual Gynecological Exam - two per calendar year, in addition to health Covered - 100% Covered - 60% after deductible
maintenance exam
Pap Smear Screening - one per calendar year Covered - 100% Covered - 60% after deductible
Mammography Screening - one per calendar year Covered - 100% Covered - 60% after deductible
includes 3D Mammography
Contraceptive Methods and Counseling Covered - 100% Not Covered
Prostate Specific Antigen (PSA) screening - one per benefit period Covered - 100% Covered - 60% after deductible
Endoscopic Exams - one per benefit period Covered - 100% Covered - 60% after deductible
Well Child Care Covered - 100% Covered - 60% after deductible
• 8 visits, birth through 12 months
• 6 visits, 13 months through 23 months
• 6 visits, 24 months through 35 months
• 2 visits, 36 months through 47 months

Visits beyond 47 months are limited to one per member per calendar year
under the health maintenance exam benefit
Immunizations - pediatric and adult Covered - 100% Covered - 60% after deductible

Physician Office Services

Benefits In-Network Out-of-Network
Office Visits Covered - 100% after $10 copay Covered - 60% after deductible
Telemedicine Visits Covered - 100% after $10 copay Covered - 60% after deductible
Virtual Care - Online Medical Visits Covered - 100% Not Covered

Note: Online Medical visits by a non-BCBSM selected vendor are not

covered
Office Consultations Covered - 100% Covered - 60% after deductible
Pre-Surgical Consultations Covered - 100% Covered - 60% after deductible

Emergency Medical Care

Benefits In-Network Out-of-Network
Hospital Emergency Room Covered - 100% after $250 copay; copay Covered - 100% after $250
Qualified medical emergency waived if admitted copay; copay waived if admitted
Non-Emergency use of the Emergency Room Not Covered Not Covered
Facility Urgent Care Services Covered - 100% after $10 copay Covered - 60% after deductible
Physician Urgent Care Services Covered - 100% after $10 copay Covered - 60% after deductible
Ambulance Services - Medically Necessary Transport Covered - 80% after deductible Covered - 80% after deductible

Diagnostic Services
Benefits In-Network Out-of-Network
MRI, MRA, PET and CAT Scans and Nuclear Medicine Covered - 100% Covered - 60% after deductible
Diagnostic Tests, X-rays, Laboratory & Pathology Covered - 100% Covered - 60% after deductible
Radiation Therapy and Chemotherapy Covered - 100% Covered - 60% after deductible

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
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
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
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
charge.
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 Maternity Services Provided by a Physician
Benefits In-Network Out-of-Network
Prenatal and Postnatal Care Visits Covered - 100% Covered - 60% after deductible
Delivery and Nursery Care Covered - 80% after deductible Covered - 60% after deductible

Hospital Care
Benefits In-Network Out-of-Network
Semi-Private Room, Inpatient Physician Care, General Nursing Care, Covered - 80% after deductible Covered - 60% after deductible
Hospital Services and Supplies
Inpatient Medical Care Covered - 80% after deductible Covered - 60% after deductible

Alternatives to Hospital Care

Benefits In-Network Out-of-Network
Hospice Care Covered - 100% Covered - 100%
Home Health Care Covered - 100% Covered - 100%
Limited to a maximum of 100 visits per calendar year
Skilled Nursing Covered - 100% Covered - 100%
Limited to 100 days per benefit period

Surgical Services
Benefits In-Network Out-of-Network
Surgery (includes related surgical services) Covered - 80% after deductible Covered - 60% after deductible
Bariatric Surgery Covered - 80% after deductible Not Covered
Blue Distinction Centers only
Sterilization - males only Covered - 100% after $10 copay Covered - 60% after deductible
excludes reversal sterilization
Sterilization - females only Covered - 100% Covered - 60% after deductible
excludes reversal sterilization
Elective Abortions Covered - 80% after deductible Covered - 60% after deductible

Human Organ Transplants

Benefits In-Network Out-of-Network
Specified Organ Transplants Covered - 100% Not covered except in designated
In designated facilities only, when coordinated through BCBSM Human facilities
Organ Transplant Program (800-242-3504)
Kidney, Cornea, Bone Marrow and Skin Covered - 80% after deductible Covered - 60% after deductible

Behavioral Health Services (Mental Health and Substance Use Disorder)

Benefits In-Network Out-of-Network
Inpatient Mental Health Care and Substance Use Disorder Treatment Covered - 80% after deductible Covered - 60% after deductible
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
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
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
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
charge.
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 Outpatient Mental Health Care and Substance Use Disorder Treatment Covered - 100% after $10 copay Covered - 60% after deductible
Telemedicine Mental Health Care Covered - 100% after $10 copay Covered - 60% after deductible
Virtual Care – Online Mental Health Visits Covered - 100% Not Covered

Note: Online Mental Health visits by a non-BCBSM selected vendor are

not covered

Autism Spectrum Disorders, Diagnoses and Treatment

Benefits In-Network Out-of-Network
Applied Behavior Analysis (ABA) Covered - 80% after deductible Covered - 60% after deductible
Pre-authorization required

Note: Diagnosis of an autism spectrum disorder and a treatment

recommendation for ABA services must be obtained by an approved
autism evaluation center (AAEC) prior to seeking ABA treatment.
Physical, Occupational and Speech Therapy Covered - 80% after deductible Covered - 60% after deductible
Physical, Occupational and Speech therapy with an autism diagnosis is
unlimited
Nutritional Counseling Covered - 80% after deductible Covered - 60% after deductible

Other Covered Services

Benefits In-Network Out-of-Network
Cardiac Rehabilitation Covered - 80% after deductible Covered - 60% after deductible
Chiropractic Spinal Manipulation Covered - 100% after $10 copay Covered - 60% after deductible
Limited to a maximum of 26 visits per calendar year
Durable Medical Equipment Covered - 80% after deductible Covered - 60% after deductible
Prosthetic and Orthotic Devices Covered - 80% after deductible Covered - 60% after deductible
Private Duty Nursing Care Covered - 80% after deductible Covered - 60% after deductible
Limited to 60 days per calendar year
Allergy Testing and Therapy Covered - 100% Covered - 60% after deductible
Facility Clinic Visit Covered - 100% after $10 copay Covered - 60% after deductible

Therapy Services
Benefits In-Network Out-of-Network
Physical, Occupational and Speech Therapy Covered - 100% after $10 copay Covered - 60% after deductible
Limited to a combined maximum of 60 visits per calendar year

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
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
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
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
charge.
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Kalitta Companies
Group Number: 71576 Package Code(s): 040
Section Code(s): 1000, 1100
Hearing Care Coverage
Effective Date: 01/01/2016
Benefits-at-a-glance
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
exclusions may apply. Payment amounts are based on BCBSM's approved amount, less any applicable deductible and/or copay. If there is a
discrepancy between this Benefits-at-a-Glance and any applicable plan document, the plan document will control.

BCBSM provides administrative claims services only. Your employer or plan sponsor is financially responsible for claims.

Member's responsibility (coinsurance and benefit maximum)

Benefits Participating Provider Non-Participating Provider
Coinsurance No Coinsurance Not Covered
Benefit Maximum $5,000

Covered services
To be payable, hearing care benefits must be received from a participating provider and in the order listed.

Benefits Participating Provider Non-Participating Provider

Frequency Limitation Once every 36 months
Audiometric Exam Covered - 100% Not Covered
Hearing Aid Evaluation Covered - 100% Not Covered
Hearing Aid Covered - 100% Not Covered

Limited to a maximum of $5,000

Member may be responsible for the difference in cost between our

approved amount and the charge of the hearing aid.
Hearing Aid Conformity Test Covered - 100% Not Covered

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

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Kalitta Companies
Group Number: 71576 Package Code(s): 040
Section Code(s): 1000, 1100
Prescription Drugs
Effective Date: 01/01/2017
Benefits-at-a-glance
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
exclusions may apply. Payment amounts are based on BCBSM's approved amount, less any applicable deductible and/or copay. If there is a
discrepancy between this Benefits-at-a-Glance and any applicable plan document, the plan document will control.

BCBSM provides administrative claims services only. Your employer or plan sponsor is financially responsible for claims.

Your prescription drug copays, including mail order copays, may be subject to the same annual out-of-pocket maximum required under your medical
coverage.

Member's responsibility (copays and coinsurance amounts)

Benefits Coverage
Retail - 30-day supply $10 copay - Generic drugs
$25 copay - Preferred brand drugs
$50 copay - Non-Preferred brand drugs

Prescriptions and refills obtained from a non-network pharmacy are

reimbursed at 75% of the approved amount, less the member’s copay.
Retail and Mail Order - 90-day supply $20 copay - Generic drugs
$50 copay - Preferred brand drugs
$100 copay - Non-Preferred brand drugs
Specialty Drugs – 30-day supply $10 copay - Generic drugs
Retail and Mail Order $25 copay - Preferred brand drugs
$50 copay - Non-Preferred brand drugs

Members are restricted to a 30-day supply at both retail and mail order
and certain specialty drugs are limited to only a 15-day supply for each
fill.
Adult and childhood select preventive immunizations as recommended by the Covered - 100%
USPSTF, ACIP, HRSA or other sources as recognized by BCBSM that are in
compliance with the provisions of the PPACA
Oral and Injectable Contraceptives Covered - 100% for Generic and Select Brand name drugs; other
Retail and Mail Order Brand name drugs are subject to the applicable copay/coinsurance
Additional Services
Smoking Cessation Drugs Covered
Weight Loss Drugs Not Covered
Impotency Drugs Not Covered
Infertility Drugs Not Covered

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

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 Diabetic Supplies Includes:
Needles/Syringes - Covered at 100% if an injectable prescription drug
was filled within the last 120 days under the BCBSM Rx benefit

Retail Test Strips and Lancets:

$10 copay

Mail Order Test Strips and Lancets:

$20 copay

Features of your prescription drug plan

Prior authorization/step therapy A process that requires a physician to obtain approval from BCBSM before select prescription drugs (drugs
identified by BCBSM as requiring prior authorization) will be covered. Step Therapy, an initial step in the Prior
Authorization process, applies criteria to select drugs to determine if a less costly prescription drug may be used for
the same drug therapy. This also applies to mail order drugs. Claims that do not meet Step Therapy criteria require
prior authorization. Details about which drugs require Prior Authorization or Step Therapy are available online at
bcbsm.com/pharmacy.
Mandatory maximum allowable If your prescription is filled by a network pharmacy, and the pharmacist fills it with a brand-name drug for which a
cost drugs generic equivalent is available, you MUST pay the difference in cost between the BCBSM approved amount for
the brand-name drug dispensed and the maximum allowable cost for the generic drug plus your applicable copay
regardless of whether you or your physician requests the brand name drug. Exception: If your physician requests
and receives authorization for a non-preferred brand-name drug with a generic equivalent from BCBSM and writes
“Dispense as Written” or “DAW” on the prescription order, you pay only your applicable copay.
Note: This MAC difference will not be applied toward your annual in-network deductible, nor your annual
coinsurance/copay maximum.

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

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Kalitta Companies
Group Number: 71576 Package Code(s): 040
Section Code(s): 1000, 1100
Dental Coverage - Blue Dental PPO Plus
Effective Date: 10/01/2013
Benefits-at-a-glance
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
exclusions may apply. Payment amounts are based on BCBSM's approved amount, less any applicable deductible and/or copay. If there is a
discrepancy between this Benefits-at-a-Glance and any applicable plan document, the plan document will control.

Network access information - With Blue Dental PPO Plus, members can choose any licensed dentist anywhere. However, they'll save the most
money when they choose a dentist who is a member of the Blue Dental PPO network.

Blue Dental PPO network - Blue Dental members have unmatched access to PPO dentists through the Blue Dental PPO network, which offers
more than 130,000 dentist locations nationwide. PPO dentists agree to accept our approved amount as full payment for covered services -
members pay only their applicable coinsurance and deductible amounts. Members also receive discounts on noncovered services when they use
PPO dentists (in states where permitted by law). To find a PPO dentist near you, please visit mibluedentist.com or call 1-888-826-8152.

A dentist location is any place a member can see a dentist to receive high-quality dental care. For example, one dentist practicing in two offices
would be two dentist locations.

Blue Par SelectSM arrangement - Most non-PPO dentists accept our Blue Par Select arrangement, which means they participate with the Blues on
a “per claim” basis. Members should ask their dentists if they participate with BCBSM before every treatment. Blue Par Select dentists accept our
approved amount as full payment for covered services - members pay only applicable coinsurance and deductibles. To find a dentist who may
participate with BCBSM, please visit mibluedentist.com.

Note: Members who go to non-participating dentists are responsible for any difference between our approved amount and the dentist's charge.

Member's responsibility (deductible, coinsurance and dollar maximums)

Benefits Coverage
Benefit Period Calendar Year
Deductible $50 Individual, $100 Family - Applies to Class II & Class III
Class I services 0%
Class II services 20%
Class III services 50%
Class IV services 50%
Dollar Maximums - Annual Maximum $1,000 per member Class I, II & III services
Lifetime Orthodontic Maximum $2,000 per member

Class I services
Benefits Coverage

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

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 Periodic Oral Exams Covered - 100%, twice per calendar year
Prophylaxis (Teeth Cleaning) Covered - 100%, twice per calendar year
Bitewing X-Rays Covered - 100%, twice per calendar year
Full-mouth or Panoramic X-Rays Covered - 100%, once every 60 months
Fluoride Treatment Covered - 100%, once per calendar year, up to and including age 18
Space Maintainers Covered - 100%, once per quadrant per lifetime, up to and including age 18
Palliative Emergency Treatment Covered - 100%
Sealants Covered - 100%, once per tooth every 36 months, 1st and 2nd permanent molars, up to
and including age 19
Occlusal Biteguards Covered - 100%, once every 12 months

Class II services
Benefits Coverage
Fillings - permanent teeth Covered - 80% after deductible, once per tooth per surface every 24 months
Fillings - primary teeth Covered - 80% after deductible, once per tooth per surface every 12 months
Root Canal Therapy Covered - 80% after deductible, once per tooth per lifetime
Periodontal Scaling and Root Planing Covered - 80% after deductible, once per quadrant every 24 months
Occlusal Adjustment Covered - 80% after deductible, up to five times in a 60 month period
General Anesthesia or IV Sedation with oral surgery Covered - 80% after deductible
Oral Surgery Covered - 80% after deductible
Relining or Rebasing of Partials or Dentures Covered - 80% after deductible, once per arch every 36 months
Tissue Conditioning Covered - 80% after deductible, once per arch every 36 months
Repair to Existing Partials or Dentures Covered - 80% after deductible, six months or more after denture is delivered

Class III services

Benefits Coverage
Removable Dentures - Complete and Partials Covered - 50% after deductible, once per arch every 60 months
Fixed Bridges Covered - 50% after deductible, once per tooth every 60 months age 16 and older
Implants Covered - 50% after deductible, once per tooth per lifetime age 16 and older
Inlays, Onlays, Crowns and Veneers - permanent teeth Covered - 50% after deductible, once every 60 months
Recementing of Inlays, Onlays, Crowns, Bridges and Covered - 50% after deductible, three per calendar year
Veneers

Class IV services - Orthodontic services for dependents up to and including age 18

Benefits Coverage
Orthodontic Services Covered - 50%
Cephalometric Films and Oral Facial Photos Covered - 50%
Habit Breaking Appliances Covered - 50%
Full-Banding Treatment Covered - 50%
Minor Tooth Guidance Appliances Covered - 50%

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

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Kalitta Companies
Group Number: 71576 Package Code(s): 040
Section Code(s): 1000, 1100
Vision Coverage - Blue Signature VSP
Effective Date: 02/01/2019
Benefits-at-a-glance
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
exclusions may apply. Payment amounts are based on BCBSM's approved amount, less any applicable deductible and/or copay. If there is a
discrepancy between this Benefits-at-a-Glance and any applicable plan document, the plan document will control.

BCBSM provides administrative claims services only. Your employer or plan sponsor is financially responsible for claims.

Blue Vision benefits are provided by Vision Service Plan (VSP), the largest provider of vision care in the nation. There are more than 3,000 VSP
provider locations in Michigan and 53,000 locations nationwide. To find a VSP provider, call 1-800-877-7195 or visit VSP's Web site at
www.vsp.com.

Member's responsibility (copayments)

Benefits VSP Provider Out-of-Network Provider
Eye Exam No Copay Reimbursement up to $35
Lenses and/or frames Not Covered Not Covered
Medically necessary contact lenses Not Covered Not Covered

Eye exams
Benefits VSP Provider Out-of-Network Provider
Covers a complete eye exam by an ophthalmologist or optometrist. The Covered - no copay Covered - reimbursement up to
exam includes refraction, glaucoma testing and other tests necessary to $35
determine the overall visual health of the patient.
One per calendar year

Lenses and frames

Benefits VSP Provider Out-of-Network Provider
Single vision, bifocal, trifocal or lenticular lenses in glass or plastic. Not Covered Not Covered
Note: Additional pairs of prescription glasses and non-covered lens
options are discounted when purchased from a VSP provider.
Covers standard eyeglass frames. A wide selection of quality frames is Not Covered Not Covered
fully covered by VSP up to the frame allowance. Members should ask their
doctor which frames are covered in full. Members may select a more
expensive frame and pay a cost controlled price difference.

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

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 Contact Lenses: Members may obtain either eyeglasses or contact lenses, but not both
Benefits VSP Provider Out-of-Network Provider
Elective contact lenses (prescribed, but not medically necessary) may be Not Covered Not Covered
chosen instead of spectacle lenses and a frame.
Therapeutic contact lenses (medically necessary) Not Covered Not Covered

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

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Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

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