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Tj ET EMC /Span <>BDC BT /F3 9 Tf 1 0 0 1 393.84 508.01 Tm ( Additional limitations and exclusions may ) Tj ET EMC /Span <>BDC BT /F3 9 Tf 1 0 0 1 0 497.68 Tm (apply to covered services. For a complete description of benefits, please see the applicable Blue Care Network certificates and riders. Payment amounts are based ) Tj ET EMC /Span <>BDC BT /F3 9 Tf 1 0 0 1 0 487.36 Tm (on the Blue Care Network approved amount, less any applicable deductible, coinsurance and/or copay amounts required by the plan. If there is a discrepancy ) Tj ET EMC /Span <>BDC BT /F3 9 Tf 1 0 0 1 0 477.03 Tm (between this Benefits-at-a-Glance and any applicable plan documents, the plan document will control. This coverage is provided pursuant to a contract entered into ) Tj ET EMC /Span <>BDC BT /F3 9 Tf 1 0 0 1 0 466.7 Tm (in the state of Michigan and shall be construed under the jurisdiction and according to the laws of the state of Michigan. 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However, one individual Member cannot contribute more than ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 270.38 Tm (the individual Deductible amount toward the family Deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 265.26 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 253.86 Tm (Coinsurance ) Tj ET EMC /Span <>BDC BT /F4 10 Tf 1 0 0 1 -0.25 242.28 Tm (Note:) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 20.7 242.28 Tm ( Coinsurance applies once the deductible has been met ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 253.86 Tm (50% for select services as noted below ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 242.39 Tm (20% for select services as noted below ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 237.15 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 225.76 Tm (Out of Pocket Maximum - applies to deductibles, copays and ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 -0.25 214.28 Tm (coinsurance amounts for all covered services ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 225.76 Tm ($6,900 per member/$13,800 per family per benefit year ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 214.28 Tm (For members with more than one person on the contract, if the one member ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 202.81 Tm (maximum is met even if the family maximum is not, that member does not ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 191.33 Tm (pay any more cost-sharing for the rest of the year ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 186.21 Tm (Separator ) Tj ET EMC /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG -1.7 380.21 m -1.7 185.98 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 360.75 m 262.05 306.15 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 304 m 262.05 266.68 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 264.53 m 262.05 238.57 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 236.43 m 262.05 187.63 l S 1 w [] 0 d 0.5 w [] 0 d 542.6 380.21 m 542.6 185.98 l S 1 w [] 0 d 0.5 w [] 0 d -1.7 380.46 m 542.6 380.46 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 361 m 542.1 361 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 343.83 m 542.1 343.83 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 305.9 m 542.1 305.9 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 304.25 m 542.1 304.25 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 266.43 m 542.1 266.43 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 264.78 m 542.1 264.78 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 238.32 m 542.1 238.32 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 236.68 m 542.1 236.68 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 187.38 m 542.1 187.38 l S 1 w [] 0 d 0.5 w [] 0 d -1.7 185.73 m 542.6 185.73 l S 1 w [] 0 d EMC /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 18.96 w -1.45 164.02 m 542.35 164.02 l S 1 w 0.83922 0.84314 0.9098 RG 16.67 w -1.45 145.71 m 261.8 145.71 l S 1 w 16.67 w 262.3 145.71 m 542.35 145.71 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 129.68 m 542.35 129.68 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 121.42 m 542.35 121.42 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 113.16 m 542.35 113.16 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 104.9 m 542.35 104.9 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 96.64 m 542.35 96.64 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 88.38 m 542.35 88.38 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 80.12 m 542.35 80.12 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 71.86 m 542.35 71.86 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 63.6 m 542.35 63.6 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 55.34 m 542.35 55.34 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 47.08 m 542.35 47.08 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 38.81 m 542.35 38.81 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 30.55 m 542.35 30.55 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 22.29 m 542.35 22.29 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 14.03 m 542.35 14.03 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 5.77 m 542.35 5.77 l S 1 w EMC /Span <>BDC 1 1 1 rg BT /F3 14 Tf 1 0 0 1 -0.25 159.15 Tm (Preventive services ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 -0.25 141.4 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 -0.25 126.2 Tm (Health Maintenance Exam ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 126.2 Tm (100% ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 121.08 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 109.68 Tm (Annual Gynecological Exam ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 109.68 Tm (100% ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 104.55 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 93.16 Tm (Pap Smear Screening - laboratory services only ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 93.16 Tm (100% ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 88.03 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 76.64 Tm (Well-Baby and Well-Child Visits ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 76.64 Tm (100% ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 71.51 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 60.12 Tm (Immunizations ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 60.12 Tm (100% ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 54.99 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 43.59 Tm (Prostate Specific Antigen $PSA$ Screening - laboratory services only ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 43.59 Tm (100% ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 38.47 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 27.07 Tm (Routine Colonoscopy ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 27.07 Tm (100% ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 21.94 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 10.55 Tm (Mammography Screening ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 10.55 Tm (100% ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 5.42 Tm (Separator ) Tj ET EMC /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG -1.7 173.51 m -1.7 5.19 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 154.04 m 262.05 122.5 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 120.35 m 262.05 105.97 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 103.83 m 262.05 89.45 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 87.31 m 262.05 72.93 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 70.78 m 262.05 56.41 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 54.26 m 262.05 39.89 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 37.74 m 262.05 23.36 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 21.22 m 262.05 6.84 l S 1 w [] 0 d 0.5 w [] 0 d 542.6 173.51 m 542.6 5.19 l S 1 w [] 0 d 0.5 w [] 0 d -1.7 173.76 m 542.6 173.76 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 154.29 m 542.1 154.29 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 137.12 m 542.1 137.12 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 122.25 m 542.1 122.25 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 120.6 m 542.1 120.6 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 105.72 m 542.1 105.72 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 104.08 m 542.1 104.08 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 89.2 m 542.1 89.2 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 87.56 m 542.1 87.56 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 72.68 m 542.1 72.68 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 71.03 m 542.1 71.03 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 56.16 m 542.1 56.16 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 54.51 m 542.1 54.51 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 39.64 m 542.1 39.64 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 37.99 m 542.1 37.99 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 23.11 m 542.1 23.11 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 21.47 m 542.1 21.47 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 6.59 m 542.1 6.59 l S 1 w [] 0 d 0.5 w [] 0 d -1.7 4.95 m 542.6 4.95 l S 1 w [] 0 d EMC Q q Q Q endstream endobj 11 0 obj <>>>>> endobj 12 0 obj <>stream q 0 0 612 792 re W n /Artifact <> BDC EMC /Artifact <> BDC q 1 0 0 1 36 36 cm 0 0 0 rg BT /F3 6 Tf 1 0 0 1 0 23.24 Tm (_____________________________________________________________________________________________________________________________________________________________________________________________________ ) Tj ET BT /F3 8 Tf 1 0 0 1 0 10.98 Tm (Page ) Tj ET BT /F3 8 Tf 1 0 0 1 17.14 10.98 Tm (2) Tj ET BT /F3 8 Tf 1 0 0 1 20.79 10.98 Tm ( of ) Tj ET BT /F3 8 Tf 1 0 0 1 29.91 10.98 Tm (5) Tj ET BT /F4 8 Tf 1 0 0 1 215.77 10.98 Tm (bcbsm.com) Tj ET BT /F3 8 Tf 1 0 0 1 496.22 10.98 Tm (000020792947 ) Tj ET BT /F3 8 Tf 1 0 0 1 468.14 1.8 Tm (04/19/2024 06:53:26 AM ) Tj ET Q q Q EMC q 1 0 0 1 36 64.77 cm /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 18.96 w -1.45 667.82 m 542.35 667.82 l S 1 w 0.83922 0.84314 0.9098 RG 16.67 w -1.45 649.5 m 261.8 649.5 l S 1 w 16.67 w 262.3 649.5 m 542.35 649.5 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 633.48 m 542.35 633.48 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 625.22 m 542.35 625.22 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 616.96 m 542.35 616.96 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 608.7 m 542.35 608.7 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 600.43 m 542.35 600.43 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 592.17 m 542.35 592.17 l S 1 w EMC /Artifact <> BDC 1 1 1 rg BT /F3 14 Tf 1 0 0 1 -0.25 662.94 Tm (Preventive services) Tj ET BT /F3 14 Tf 1 0 0 1 99.3 662.94 Tm ( $continued$ ) Tj ET 0 0 0 rg BT /F4 12 Tf 1 0 0 1 -0.25 645.19 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 -0.25 630 Tm (Voluntary Sterilization of Female Reproductive Organs ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 630 Tm (100% ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 624.87 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 613.48 Tm (Breast Pumps $DME guidelines apply.$ ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 613.48 Tm (100% ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 608.35 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 596.95 Tm (Routine Maternity Prenatal and Postnatal Care ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 596.95 Tm (100% ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 591.83 Tm (Separator ) Tj ET EMC /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG -1.7 677.3 m -1.7 591.6 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 657.84 m 262.05 626.29 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 624.14 m 262.05 609.77 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 607.62 m 262.05 593.25 l S 1 w [] 0 d 0.5 w [] 0 d 542.6 677.3 m 542.6 591.6 l S 1 w [] 0 d 0.5 w [] 0 d -1.7 677.55 m 542.6 677.55 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 658.09 m 542.1 658.09 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 640.92 m 542.1 640.92 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 626.04 m 542.1 626.04 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 624.39 m 542.1 624.39 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 609.52 m 542.1 609.52 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 607.87 m 542.1 607.87 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 593 m 542.1 593 l S 1 w [] 0 d 0.5 w [] 0 d -1.7 591.35 m 542.6 591.35 l S 1 w [] 0 d EMC /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 18.96 w -1.45 569.64 m 542.35 569.64 l S 1 w 0.83922 0.84314 0.9098 RG 16.67 w -1.45 551.33 m 261.8 551.33 l S 1 w 16.67 w 262.3 551.33 m 542.35 551.33 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 535.3 m 542.35 535.3 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 527.04 m 542.35 527.04 l S 1 w 0.92941 0.95294 0.99608 RG 71.86 w 262.3 490.04 m 542.35 490.04 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 453.04 m 542.35 453.04 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 444.78 m 542.35 444.78 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 436.52 m 542.35 436.52 l S 1 w EMC /Span <>BDC 1 1 1 rg BT /F3 14 Tf 1 0 0 1 -0.25 564.77 Tm (Physician office services ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 -0.25 547.02 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 -0.25 531.82 Tm (PCP Office Visits ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 531.82 Tm (80% after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 526.7 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 515.3 Tm (Medical Online Visits - when performed by a BCN participating provider ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 -0.25 503.83 Tm (or BCN designated online vendor ) Tj ET EMC /Span <>BDC BT /F4 10 Tf 1 0 0 1 -0.25 492.24 Tm (Note:) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 20.7 492.24 Tm ( Not all services delivered virtually are considered an online visit ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 -0.25 480.77 Tm (but may be considered telemedicine. Telemedicine services will be ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 -0.25 469.3 Tm (subject to the applicable cost share associated with the service ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 -0.25 457.82 Tm (provided. ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 515.3 Tm (80% after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 452.69 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 441.3 Tm (Consulting Specialist Care ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 441.3 Tm (80% after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 436.17 Tm (Separator ) Tj ET EMC /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG -1.7 579.13 m -1.7 435.95 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 559.66 m 262.05 528.12 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 525.97 m 262.05 454.11 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 451.97 m 262.05 437.59 l S 1 w [] 0 d 0.5 w [] 0 d 542.6 579.13 m 542.6 435.95 l S 1 w [] 0 d 0.5 w [] 0 d -1.7 579.38 m 542.6 579.38 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 559.91 m 542.1 559.91 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 542.74 m 542.1 542.74 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 527.87 m 542.1 527.87 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 526.22 m 542.1 526.22 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 453.86 m 542.1 453.86 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 452.22 m 542.1 452.22 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 437.34 m 542.1 437.34 l S 1 w [] 0 d 0.5 w [] 0 d -1.7 435.7 m 542.6 435.7 l S 1 w [] 0 d EMC /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 18.96 w -1.45 413.99 m 542.35 413.99 l S 1 w 0.83922 0.84314 0.9098 RG 16.67 w -1.45 395.67 m 261.8 395.67 l S 1 w 16.67 w 262.3 395.67 m 542.35 395.67 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 379.65 m 542.35 379.65 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 371.39 m 542.35 371.39 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 363.13 m 542.35 363.13 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 354.87 m 542.35 354.87 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 346.61 m 542.35 346.61 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 338.34 m 542.35 338.34 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 330.08 m 542.35 330.08 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 321.82 m 542.35 321.82 l S 1 w EMC /Span <>BDC 1 1 1 rg BT /F3 14 Tf 1 0 0 1 -0.25 409.11 Tm (Emergency medical care ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 -0.25 391.36 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 -0.25 376.17 Tm (Hospital Emergency Room ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 376.17 Tm (80% after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 371.04 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 359.65 Tm (Urgent Care Center ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 359.65 Tm (80% after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 354.52 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 343.12 Tm (Retail Health Clinic ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 343.12 Tm (80% after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 338 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 326.6 Tm (Ambulance Services - medically necessary ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 326.6 Tm (80% after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 321.47 Tm (Separator ) Tj ET EMC /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG -1.7 423.47 m -1.7 321.25 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 404.01 m 262.05 372.46 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 370.31 m 262.05 355.94 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 353.79 m 262.05 339.42 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 337.27 m 262.05 322.89 l S 1 w [] 0 d 0.5 w [] 0 d 542.6 423.47 m 542.6 321.25 l S 1 w [] 0 d 0.5 w [] 0 d -1.7 423.72 m 542.6 423.72 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 404.26 m 542.1 404.26 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 387.08 m 542.1 387.08 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 372.21 m 542.1 372.21 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 370.56 m 542.1 370.56 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 355.69 m 542.1 355.69 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 354.04 m 542.1 354.04 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 339.17 m 542.1 339.17 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 337.52 m 542.1 337.52 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 322.64 m 542.1 322.64 l S 1 w [] 0 d 0.5 w [] 0 d -1.7 321 m 542.6 321 l S 1 w [] 0 d EMC /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 18.96 w -1.45 299.29 m 542.35 299.29 l S 1 w 0.83922 0.84314 0.9098 RG 16.67 w -1.45 280.97 m 261.8 280.97 l S 1 w 16.67 w 262.3 280.97 m 542.35 280.97 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 264.95 m 542.35 264.95 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 256.69 m 542.35 256.69 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 248.43 m 542.35 248.43 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 240.17 m 542.35 240.17 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 231.91 m 542.35 231.91 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 223.65 m 542.35 223.65 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 215.39 m 542.35 215.39 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 207.13 m 542.35 207.13 l S 1 w EMC /Span <>BDC 1 1 1 rg BT /F3 14 Tf 1 0 0 1 -0.25 294.42 Tm (Diagnostic services ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 -0.25 276.67 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 -0.25 261.47 Tm (Laboratory and Pathology Tests ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 261.47 Tm (80% after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 256.34 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 244.95 Tm (Diagnostic Tests and X-rays ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 244.95 Tm (80% after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 239.82 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 228.43 Tm (High Technology Radiology Imaging $MRI, MRA, CAT, PET$ ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 228.43 Tm (80% after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 223.3 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 211.9 Tm (Radiation Therapy ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 211.9 Tm (80% after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 206.78 Tm (Separator ) Tj ET EMC /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG -1.7 308.77 m -1.7 206.55 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 289.31 m 262.05 257.76 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 255.62 m 262.05 241.24 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 239.1 m 262.05 224.72 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 222.57 m 262.05 208.2 l S 1 w [] 0 d 0.5 w [] 0 d 542.6 308.77 m 542.6 206.55 l S 1 w [] 0 d 0.5 w [] 0 d -1.7 309.02 m 542.6 309.02 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 289.56 m 542.1 289.56 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 272.39 m 542.1 272.39 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 257.51 m 542.1 257.51 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 255.87 m 542.1 255.87 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 240.99 m 542.1 240.99 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 239.35 m 542.1 239.35 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 224.47 m 542.1 224.47 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 222.82 m 542.1 222.82 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 207.95 m 542.1 207.95 l S 1 w [] 0 d 0.5 w [] 0 d -1.7 206.3 m 542.6 206.3 l S 1 w [] 0 d EMC /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 18.96 w -1.45 184.59 m 542.35 184.59 l S 1 w 0.83922 0.84314 0.9098 RG 16.67 w -1.45 166.28 m 261.8 166.28 l S 1 w 16.67 w 262.3 166.28 m 542.35 166.28 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 150.26 m 542.35 150.26 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 141.99 m 542.35 141.99 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 133.73 m 542.35 133.73 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 125.47 m 542.35 125.47 l S 1 w EMC /Span <>BDC 1 1 1 rg BT /F3 14 Tf 1 0 0 1 -0.25 179.72 Tm (Maternity services provided by a physician ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 -0.25 161.97 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 -0.25 146.77 Tm (Routine Prenatal and Postnatal Care Visits ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 146.77 Tm (100% ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 141.65 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 130.25 Tm (Delivery and Nursery Care ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 130.25 Tm (80% after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 125.12 Tm (Separator ) Tj ET EMC /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG -1.7 194.08 m -1.7 124.9 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 174.61 m 262.05 143.07 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 140.92 m 262.05 126.54 l S 1 w [] 0 d 0.5 w [] 0 d 542.6 194.08 m 542.6 124.9 l S 1 w [] 0 d 0.5 w [] 0 d -1.7 194.33 m 542.6 194.33 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 174.86 m 542.1 174.86 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 157.69 m 542.1 157.69 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 142.82 m 542.1 142.82 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 141.17 m 542.1 141.17 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 126.29 m 542.1 126.29 l S 1 w [] 0 d 0.5 w [] 0 d -1.7 124.65 m 542.6 124.65 l S 1 w [] 0 d EMC /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 18.96 w -1.45 102.94 m 542.35 102.94 l S 1 w 0.83922 0.84314 0.9098 RG 16.67 w -1.45 84.62 m 261.8 84.62 l S 1 w 16.67 w 262.3 84.62 m 542.35 84.62 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 68.6 m 542.35 68.6 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 60.34 m 542.35 60.34 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 52.08 m 542.35 52.08 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 43.82 m 542.35 43.82 l S 1 w EMC /Span <>BDC 1 1 1 rg BT /F3 14 Tf 1 0 0 1 -0.25 98.07 Tm (Hospital care ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 -0.25 80.32 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 -0.25 65.12 Tm (General Nursing Care, Hospital Services and Supplies ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 65.12 Tm (80% after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 59.99 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 48.6 Tm (Outpatient Surgery ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 48.6 Tm (80% after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 43.47 Tm (Separator ) Tj ET EMC /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG -1.7 112.42 m -1.7 43.24 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 92.96 m 262.05 61.41 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 59.27 m 262.05 44.89 l S 1 w [] 0 d 0.5 w [] 0 d 542.6 112.42 m 542.6 43.24 l S 1 w [] 0 d 0.5 w [] 0 d -1.7 112.67 m 542.6 112.67 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 93.21 m 542.1 93.21 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 76.04 m 542.1 76.04 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 61.17 m 542.1 61.17 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 59.52 m 542.1 59.52 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 44.64 m 542.1 44.64 l S 1 w [] 0 d 0.5 w [] 0 d -1.7 42.99 m 542.6 42.99 l S 1 w [] 0 d EMC Q q Q Q endstream endobj 13 0 obj <>>>>> endobj 14 0 obj <>stream q 0 0 612 792 re W n /Artifact <> BDC EMC /Artifact <> BDC q 1 0 0 1 36 36 cm 0 0 0 rg BT /F3 6 Tf 1 0 0 1 0 23.24 Tm (_____________________________________________________________________________________________________________________________________________________________________________________________________ ) Tj ET BT /F3 8 Tf 1 0 0 1 0 10.98 Tm (Page ) Tj ET BT /F3 8 Tf 1 0 0 1 17.14 10.98 Tm (3) Tj ET BT /F3 8 Tf 1 0 0 1 20.79 10.98 Tm ( of ) Tj ET BT /F3 8 Tf 1 0 0 1 29.91 10.98 Tm (5) Tj ET BT /F4 8 Tf 1 0 0 1 215.77 10.98 Tm (bcbsm.com) Tj ET BT /F3 8 Tf 1 0 0 1 496.22 10.98 Tm (000020792947 ) Tj ET BT /F3 8 Tf 1 0 0 1 468.14 1.8 Tm (04/19/2024 06:53:26 AM ) Tj ET Q q Q EMC q 1 0 0 1 36 64.77 cm /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 18.96 w -1.45 667.82 m 542.35 667.82 l S 1 w 0.83922 0.84314 0.9098 RG 16.67 w -1.45 649.5 m 261.8 649.5 l S 1 w 16.67 w 262.3 649.5 m 542.35 649.5 l S 1 w 0.92941 0.95294 0.99608 RG 25.85 w 262.3 627.74 m 542.35 627.74 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 613.74 m 542.35 613.74 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 605.48 m 542.35 605.48 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 597.22 m 542.35 597.22 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 588.96 m 542.35 588.96 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 580.7 m 542.35 580.7 l S 1 w EMC /Span <>BDC 1 1 1 rg BT /F3 14 Tf 1 0 0 1 -0.25 662.94 Tm (Alternatives to hospital care ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 -0.25 645.19 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 -0.25 630 Tm (Skilled Nursing Care ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 630 Tm (80% after deductible ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 618.52 Tm (Up to 45 days per benefit year ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 613.4 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 602 Tm (Hospice Care ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 602 Tm (80% after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 596.87 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 585.48 Tm (Home Health Care ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 585.48 Tm (80% after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 580.35 Tm (Separator ) Tj ET EMC /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG -1.7 677.3 m -1.7 580.12 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 657.84 m 262.05 614.82 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 612.67 m 262.05 598.29 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 596.15 m 262.05 581.77 l S 1 w [] 0 d 0.5 w [] 0 d 542.6 677.3 m 542.6 580.12 l S 1 w [] 0 d 0.5 w [] 0 d -1.7 677.55 m 542.6 677.55 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 658.09 m 542.1 658.09 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 640.92 m 542.1 640.92 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 614.57 m 542.1 614.57 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 612.92 m 542.1 612.92 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 598.04 m 542.1 598.04 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 596.4 m 542.1 596.4 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 581.52 m 542.1 581.52 l S 1 w [] 0 d 0.5 w [] 0 d -1.7 579.88 m 542.6 579.88 l S 1 w [] 0 d EMC /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 18.96 w -1.45 558.17 m 542.35 558.17 l S 1 w 0.83922 0.84314 0.9098 RG 16.67 w -1.45 539.85 m 261.8 539.85 l S 1 w 16.67 w 262.3 539.85 m 542.35 539.85 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 523.83 m 542.35 523.83 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 515.57 m 542.35 515.57 l S 1 w 0.92941 0.95294 0.99608 RG 25.85 w 262.3 501.57 m 542.35 501.57 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 487.57 m 542.35 487.57 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 479.31 m 542.35 479.31 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 471.05 m 542.35 471.05 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 462.79 m 542.35 462.79 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 454.53 m 542.35 454.53 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 446.27 m 542.35 446.27 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 438.01 m 542.35 438.01 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 429.74 m 542.35 429.74 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 421.48 m 542.35 421.48 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 413.22 m 542.35 413.22 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 404.96 m 542.35 404.96 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 396.7 m 542.35 396.7 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 388.44 m 542.35 388.44 l S 1 w 0.92941 0.95294 0.99608 RG 25.85 w 262.3 374.44 m 542.35 374.44 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 360.44 m 542.35 360.44 l S 1 w EMC /Span <>BDC 1 1 1 rg BT /F3 14 Tf 1 0 0 1 -0.25 553.29 Tm (Surgical services ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 -0.25 535.54 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 -0.25 520.35 Tm (Surgery - included all related surgical services and anesthesia. ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 520.35 Tm (80% after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 515.22 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 503.83 Tm (Voluntary Sterilization of Male Reproductive Organs - see Preventive ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 -0.25 492.35 Tm (Services for Voluntary Sterilization of Female Reproductive Organs ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 503.83 Tm (50% after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 487.22 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 475.83 Tm (Elective Abortion $One procedure per two-year period of membership$ ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 475.83 Tm (Not covered ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 470.7 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 459.31 Tm (Human Organ Transplants $subject to medical criteria$ ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 459.31 Tm (80% after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 454.18 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 442.79 Tm (Reduction Mammoplasty $subject to medical criteria$ ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 442.79 Tm (50% after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 437.66 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 426.26 Tm (Male Mastectomy $subject to medical criteria$ ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 426.26 Tm (50% after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 421.14 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 409.74 Tm (Temporomandibular Joint Syndrome $subject to medical criteria$ ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 409.74 Tm (50% after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 404.61 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 393.22 Tm (Orthognathic Surgery $subject to medical criteria$ ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 393.22 Tm (50% after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 388.09 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 376.7 Tm (Weight Reduction Procedures $subject to medical criteria$ - Limited to ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 -0.25 365.22 Tm (one procedure per lifetime ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 376.7 Tm (50% after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 360.09 Tm (Separator ) Tj ET EMC /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG -1.7 567.65 m -1.7 359.87 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 548.18 m 262.05 516.64 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 514.49 m 262.05 488.64 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 486.5 m 262.05 472.12 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 469.98 m 262.05 455.6 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 453.45 m 262.05 439.08 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 436.93 m 262.05 422.56 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 420.41 m 262.05 406.04 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 403.89 m 262.05 389.51 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 387.36 m 262.05 361.52 l S 1 w [] 0 d 0.5 w [] 0 d 542.6 567.65 m 542.6 359.87 l S 1 w [] 0 d 0.5 w [] 0 d -1.7 567.9 m 542.6 567.9 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 548.43 m 542.1 548.43 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 531.27 m 542.1 531.27 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 516.39 m 542.1 516.39 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 514.74 m 542.1 514.74 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 488.39 m 542.1 488.39 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 486.75 m 542.1 486.75 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 471.87 m 542.1 471.87 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 470.23 m 542.1 470.23 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 455.35 m 542.1 455.35 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 453.7 m 542.1 453.7 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 438.83 m 542.1 438.83 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 437.18 m 542.1 437.18 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 422.31 m 542.1 422.31 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 420.66 m 542.1 420.66 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 405.79 m 542.1 405.79 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 404.14 m 542.1 404.14 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 389.26 m 542.1 389.26 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 387.61 m 542.1 387.61 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 361.27 m 542.1 361.27 l S 1 w [] 0 d 0.5 w [] 0 d -1.7 359.62 m 542.6 359.62 l S 1 w [] 0 d EMC /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 18.96 w -1.45 337.91 m 542.35 337.91 l S 1 w 0.83922 0.84314 0.9098 RG 16.67 w -1.45 319.6 m 261.8 319.6 l S 1 w 16.67 w 262.3 319.6 m 542.35 319.6 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 303.57 m 542.35 303.57 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 295.31 m 542.35 295.31 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 287.05 m 542.35 287.05 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 278.79 m 542.35 278.79 l S 1 w 0.92941 0.95294 0.99608 RG 37.43 w 262.3 259 m 542.35 259 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 239.21 m 542.35 239.21 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 230.95 m 542.35 230.95 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 222.69 m 542.35 222.69 l S 1 w EMC /Span <>BDC 1 1 1 rg BT /F3 14 Tf 1 0 0 1 -0.25 333.04 Tm (Behavioral health services $mental health and substance use disorder treatment$ ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 -0.25 315.29 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 -0.25 300.09 Tm (Inpatient Mental Health Care ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 300.09 Tm (80% after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 294.96 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 283.57 Tm (Residential Substance Use Disorder ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 283.57 Tm (80% after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 278.44 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 267.05 Tm (Outpatient Mental Health Care includes online and telemedicine visits ) Tj ET EMC /Span <>BDC BT /F4 10 Tf 1 0 0 1 -0.25 255.47 Tm (Note:) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 20.7 255.47 Tm ( For diagnostic and therapeutic services, see the Diagnostic ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 -0.25 243.99 Tm (Services section above for applicable cost sharing. ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 267.05 Tm (80% after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 238.86 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 227.47 Tm (Outpatient Substance Use Disorder ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 227.47 Tm (80% after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 222.34 Tm (Separator ) Tj ET EMC /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG -1.7 347.39 m -1.7 222.12 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 327.93 m 262.05 296.39 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 294.24 m 262.05 279.86 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 277.72 m 262.05 240.29 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 238.14 m 262.05 223.76 l S 1 w [] 0 d 0.5 w [] 0 d 542.6 347.39 m 542.6 222.12 l S 1 w [] 0 d 0.5 w [] 0 d -1.7 347.64 m 542.6 347.64 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 328.18 m 542.1 328.18 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 311.01 m 542.1 311.01 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 296.14 m 542.1 296.14 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 294.49 m 542.1 294.49 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 279.61 m 542.1 279.61 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 277.97 m 542.1 277.97 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 240.04 m 542.1 240.04 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 238.39 m 542.1 238.39 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 223.51 m 542.1 223.51 l S 1 w [] 0 d 0.5 w [] 0 d -1.7 221.87 m 542.6 221.87 l S 1 w [] 0 d EMC /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 18.96 w -1.45 200.16 m 542.35 200.16 l S 1 w 0.83922 0.84314 0.9098 RG 16.67 w -1.45 181.84 m 261.8 181.84 l S 1 w 16.67 w 262.3 181.84 m 542.35 181.84 l S 1 w 0.92941 0.95294 0.99608 RG 71.86 w 262.3 137.08 m 542.35 137.08 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 100.08 m 542.35 100.08 l S 1 w 0.92941 0.95294 0.99608 RG 37.32 w 262.3 80.34 m 542.35 80.34 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 60.61 m 542.35 60.61 l S 1 w 0.92941 0.95294 0.99608 RG 25.85 w 262.3 46.61 m 542.35 46.61 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 32.61 m 542.35 32.61 l S 1 w EMC /Span <>BDC 1 1 1 rg BT /F3 14 Tf 1 0 0 1 -0.25 195.28 Tm (Autism spectrum disorders, diagnoses and treatment ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 -0.25 177.54 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 -0.25 162.34 Tm (Applied behavioral analysis $ABA$ treatment ) Tj ET EMC /Span <>BDC BT /F4 10 Tf 1 0 0 1 -0.25 150.76 Tm (Note: ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 22.98 150.76 Tm (Prior to seeking ABA treatment, the member must be evaluated ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 -0.25 139.28 Tm (by an interdisciplinary team including, but not limited to, a physician, ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 -0.25 127.81 Tm (behavioral health specialist, and a speech and language specialist for ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 -0.25 116.33 Tm (the services to be authorized. This interdisciplinary evaluation can be ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 -0.25 104.86 Tm (performed at an approved autism evaluation center $AAEC$ ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 162.34 Tm (80% after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 99.73 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 88.33 Tm (Outpatient physical therapy, speech therapy and occupational therapy ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 -0.25 76.86 Tm (for autism spectrum disorder. Unlimited visits for PT/OT/ST with autism ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 -0.25 65.39 Tm (spectrum disorder diagnosis. ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 88.33 Tm (80% after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 60.26 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 48.86 Tm (Other covered services, including mental health services, for autism ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 -0.25 37.39 Tm (spectrum disorder ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 48.86 Tm (See your outpatient mental health, medical office visit and preventive ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 37.39 Tm (benefit. ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 32.26 Tm (Separator ) Tj ET EMC /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG -1.7 209.64 m -1.7 32.04 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 190.18 m 262.05 101.15 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 99 m 262.05 61.68 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 59.53 m 262.05 33.68 l S 1 w [] 0 d 0.5 w [] 0 d 542.6 209.64 m 542.6 32.04 l S 1 w [] 0 d 0.5 w [] 0 d -1.7 209.89 m 542.6 209.89 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 190.43 m 542.1 190.43 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 173.26 m 542.1 173.26 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 100.9 m 542.1 100.9 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 99.25 m 542.1 99.25 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 61.43 m 542.1 61.43 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 59.78 m 542.1 59.78 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 33.43 m 542.1 33.43 l S 1 w [] 0 d 0.5 w [] 0 d -1.7 31.78 m 542.6 31.78 l S 1 w [] 0 d EMC Q q Q Q endstream endobj 15 0 obj <>>>>> endobj 16 0 obj <>stream q 0 0 612 792 re W n /Artifact <> BDC EMC /Artifact <> BDC q 1 0 0 1 36 36 cm 0 0 0 rg BT /F3 6 Tf 1 0 0 1 0 23.24 Tm (_____________________________________________________________________________________________________________________________________________________________________________________________________ ) Tj ET BT /F3 8 Tf 1 0 0 1 0 10.98 Tm (Page ) Tj ET BT /F3 8 Tf 1 0 0 1 17.14 10.98 Tm (4) Tj ET BT /F3 8 Tf 1 0 0 1 20.79 10.98 Tm ( of ) Tj ET BT /F3 8 Tf 1 0 0 1 29.91 10.98 Tm (5) Tj ET BT /F4 8 Tf 1 0 0 1 215.77 10.98 Tm (bcbsm.com) Tj ET BT /F3 8 Tf 1 0 0 1 496.22 10.98 Tm (000020792947 ) Tj ET BT /F3 8 Tf 1 0 0 1 468.14 1.8 Tm (04/19/2024 06:53:26 AM ) Tj ET Q q Q EMC q 1 0 0 1 36 64.77 cm /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 18.96 w -1.45 667.82 m 542.35 667.82 l S 1 w 0.83922 0.84314 0.9098 RG 16.67 w -1.45 649.5 m 261.8 649.5 l S 1 w 16.67 w 262.3 649.5 m 542.35 649.5 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 633.48 m 542.35 633.48 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 625.22 m 542.35 625.22 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 616.96 m 542.35 616.96 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 608.7 m 542.35 608.7 l S 1 w 0.92941 0.95294 0.99608 RG 25.85 w 262.3 594.7 m 542.35 594.7 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 580.7 m 542.35 580.7 l S 1 w 0.92941 0.95294 0.99608 RG 37.32 w 262.3 560.96 m 542.35 560.96 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 541.23 m 542.35 541.23 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 532.97 m 542.35 532.97 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 524.71 m 542.35 524.71 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 516.45 m 542.35 516.45 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 508.18 m 542.35 508.18 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 499.92 m 542.35 499.92 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 491.66 m 542.35 491.66 l S 1 w 0.92941 0.95294 0.99608 RG 48.91 w 262.3 466.14 m 542.35 466.14 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 440.61 m 542.35 440.61 l S 1 w 0.92941 0.95294 0.99608 RG 25.85 w 262.3 426.61 m 542.35 426.61 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 412.61 m 542.35 412.61 l S 1 w EMC /Span <>BDC 1 1 1 rg BT /F3 14 Tf 1 0 0 1 -0.25 662.94 Tm (Other services ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 -0.25 645.19 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 -0.25 630 Tm (Allergy Testing and Therapy ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 630 Tm (80% after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 624.87 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 613.48 Tm (Allergy Injections ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 613.48 Tm (80% after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 608.35 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 596.95 Tm (Chiropractic Spinal Manipulation - when referred ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 596.95 Tm (80% after deductible ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 585.48 Tm (Limited to 30 visits per benefit year ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 580.35 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 568.96 Tm (Outpatient Physical, Speech and Occupational Therapy - subject to ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 -0.25 557.48 Tm (meaningful improvement within 60 days ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 568.96 Tm (80% after deductible ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 557.48 Tm (Limited to 60 visits per benefit year for any combination of outpatient ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 546.01 Tm (rehabilitation therapies. ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 540.88 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 529.49 Tm (Infertility Counseling and Treatment ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 529.49 Tm (50% after deductible $excludes in-vitro fertilization$ ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 524.36 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 512.96 Tm (Durable Medical Equipment ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 512.96 Tm (50% after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 507.84 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 496.44 Tm (Prosthetic and Orthotic Appliances ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 496.44 Tm (50% after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 491.31 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 479.92 Tm (Diabetic Supplies ) Tj ET EMC /Span <>BDC BT /F4 10 Tf 1 0 0 1 -0.25 468.34 Tm (Note:) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 20.7 468.34 Tm ( Certain diabetic supplies are covered through the pharmacy ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 -0.25 456.86 Tm (benefit if you have BCN pharmacy coverage. Applicable prescription ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 -0.25 445.39 Tm (drug cost-sharing will apply. ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 479.92 Tm (80% after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 440.26 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 428.87 Tm (Hearing Aid ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 428.87 Tm (Hearing aid evaluation and monaural hearing aid covered every 36 months ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 417.39 Tm (up to a $1,500 benefit maximum. ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 412.26 Tm (Separator ) Tj ET EMC /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG -1.7 677.3 m -1.7 412.04 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 657.84 m 262.05 626.29 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 624.14 m 262.05 609.77 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 607.62 m 262.05 581.77 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 579.63 m 262.05 542.3 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 540.15 m 262.05 525.78 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 523.63 m 262.05 509.26 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 507.11 m 262.05 492.73 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 490.59 m 262.05 441.68 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 439.53 m 262.05 413.68 l S 1 w [] 0 d 0.5 w [] 0 d 542.6 677.3 m 542.6 412.04 l S 1 w [] 0 d 0.5 w [] 0 d -1.7 677.55 m 542.6 677.55 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 658.09 m 542.1 658.09 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 640.92 m 542.1 640.92 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 626.04 m 542.1 626.04 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 624.39 m 542.1 624.39 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 609.52 m 542.1 609.52 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 607.87 m 542.1 607.87 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 581.52 m 542.1 581.52 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 579.88 m 542.1 579.88 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 542.05 m 542.1 542.05 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 540.4 m 542.1 540.4 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 525.53 m 542.1 525.53 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 523.88 m 542.1 523.88 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 509.01 m 542.1 509.01 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 507.36 m 542.1 507.36 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 492.48 m 542.1 492.48 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 490.84 m 542.1 490.84 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 441.43 m 542.1 441.43 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 439.78 m 542.1 439.78 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 413.43 m 542.1 413.43 l S 1 w [] 0 d 0.5 w [] 0 d -1.7 411.79 m 542.6 411.79 l S 1 w [] 0 d EMC /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 18.96 w -1.45 390.08 m 542.35 390.08 l S 1 w 0.83922 0.84314 0.9098 RG 16.67 w -1.45 371.76 m 261.8 371.76 l S 1 w 16.67 w 262.3 371.76 m 542.35 371.76 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 355.74 m 542.35 355.74 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 347.48 m 542.35 347.48 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 339.22 m 542.35 339.22 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 330.96 m 542.35 330.96 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 322.7 m 542.35 322.7 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 314.44 m 542.35 314.44 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 306.18 m 542.35 306.18 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 297.92 m 542.35 297.92 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 289.65 m 542.35 289.65 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 281.39 m 542.35 281.39 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 273.13 m 542.35 273.13 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 264.87 m 542.35 264.87 l S 1 w 0.92941 0.95294 0.99608 RG 37.32 w 262.3 245.13 m 542.35 245.13 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 225.4 m 542.35 225.4 l S 1 w 0.92941 0.95294 0.99608 RG 14.38 w 262.3 217.14 m 542.35 217.14 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 208.88 m 542.35 208.88 l S 1 w 0.92941 0.95294 0.99608 RG 25.85 w 262.3 194.88 m 542.35 194.88 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 180.88 m 542.35 180.88 l S 1 w 0.92941 0.95294 0.99608 RG 37.32 w 262.3 161.15 m 542.35 161.15 l S 1 w 0.86275 0.86275 0.86275 RG 1.15 w -1.45 141.41 m 542.35 141.41 l S 1 w EMC /Span <>BDC 1 1 1 rg BT /F3 14 Tf 1 0 0 1 -0.25 385.21 Tm (Prescription drugs ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 -0.25 367.46 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 -0.25 352.26 Tm (Preferred Generic Tier ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 352.26 Tm ($10 copay after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 347.13 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 335.74 Tm (Nonpreferred Generic Tier ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 335.74 Tm ($30 copay after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 330.61 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 319.22 Tm (Preferred Brand Tier ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 319.22 Tm ($60 copay after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 314.09 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 302.69 Tm (Nonpreferred Brand Tier ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 302.69 Tm ($80 copay after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 297.57 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 286.17 Tm (Preferred Specialty Tier ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 286.17 Tm (20% coinsurance $max $200$ after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 281.04 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 269.65 Tm (Nonpreferred Specialty Tier ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 269.65 Tm (20% coinsurance $max $300$ after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 264.52 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 253.13 Tm (Contraceptives ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 253.13 Tm (Women's Contraceptives - Preferred Generic - 100%, Non-Preferred ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 241.65 Tm (Generic- $30 copay after deductible, Preferred Brand- $60 copay after ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 230.18 Tm (deductible, Non-Preferred Brand - $80 copay after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 225.05 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 213.66 Tm (Drugs for the Treatment of Sexual Dysfunction ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 213.66 Tm (50% coinsurance after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 208.53 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 197.14 Tm (Mail Order Prescription Drugs ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 197.14 Tm (30 day supply or less - applicable tiered copay/coinsurance, 31-90 day ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 185.66 Tm (supply - 3x's the 30 day copay/coinsurance minus $10 after deductible ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 180.53 Tm (Separator ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F3 10 Tf 1 0 0 1 -0.25 169.14 Tm (Diabetic Supplies ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 169.14 Tm (Select diabetic supplies and equipment are covered, applicable cost sharing ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 157.66 Tm (will apply. Cost sharing may not apply to certain preferred glucometers as ) Tj ET EMC /Span <>BDC BT /F3 10 Tf 1 0 0 1 263.5 146.19 Tm (defined on the drug list. ) Tj ET EMC /Span <>BDC 0.86275 0.86275 0.86275 rg BT /F3 1 Tf 1 0 0 1 -1.45 141.06 Tm (Separator ) Tj ET EMC /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG -1.7 399.56 m -1.7 140.83 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 380.1 m 262.05 348.55 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 346.41 m 262.05 332.03 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 329.89 m 262.05 315.51 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 313.36 m 262.05 298.99 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 296.84 m 262.05 282.47 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 280.32 m 262.05 265.94 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 263.8 m 262.05 226.47 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 224.32 m 262.05 209.95 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 207.8 m 262.05 181.95 l S 1 w [] 0 d 0.5 w [] 0 d 262.05 179.81 m 262.05 142.48 l S 1 w [] 0 d 0.5 w [] 0 d 542.6 399.56 m 542.6 140.83 l S 1 w [] 0 d 0.5 w [] 0 d -1.7 399.81 m 542.6 399.81 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 380.35 m 542.1 380.35 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 363.18 m 542.1 363.18 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 348.3 m 542.1 348.3 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 346.66 m 542.1 346.66 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 331.78 m 542.1 331.78 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 330.14 m 542.1 330.14 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 315.26 m 542.1 315.26 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 313.61 m 542.1 313.61 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 298.74 m 542.1 298.74 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 297.09 m 542.1 297.09 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 282.22 m 542.1 282.22 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 280.57 m 542.1 280.57 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 265.69 m 542.1 265.69 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 264.05 m 542.1 264.05 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 226.22 m 542.1 226.22 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 224.57 m 542.1 224.57 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 209.7 m 542.1 209.7 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 208.05 m 542.1 208.05 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 181.7 m 542.1 181.7 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 180.06 m 542.1 180.06 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 142.23 m 542.1 142.23 l S 1 w [] 0 d 0.5 w [] 0 d -1.7 140.59 m 542.6 140.59 l S 1 w [] 0 d EMC Q q Q Q endstream endobj 17 0 obj <>>>>> endobj 6 0 obj <> endobj 7 0 obj <> endobj 8 0 obj <> endobj 21 0 obj <> endobj 22 0 obj <> endobj 23 0 obj <> endobj 24 0 obj <> endobj 25 0 obj <> endobj 26 0 obj <> endobj 27 0 obj <> endobj 28 0 obj <> endobj 29 0 obj <> endobj 30 0 obj <> endobj 31 0 obj <> endobj 32 0 obj <> endobj 33 0 obj <> endobj 34 0 obj <> endobj 35 0 obj <> endobj 36 0 obj <> endobj 37 0 obj <> endobj 38 0 obj <> endobj 39 0 obj <> endobj 40 0 obj <> endobj 41 0 obj <> endobj 42 0 obj <> endobj 43 0 obj <> endobj 44 0 obj <> endobj 45 0 obj <> endobj 46 0 obj <> endobj 47 0 obj <> endobj 48 0 obj <> endobj 49 0 obj <> endobj 50 0 obj <> endobj 51 0 obj <> endobj 52 0 obj <> endobj 53 0 obj <> endobj 54 0 obj <> endobj 55 0 obj 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