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<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>

<s>[INST] Orion, Act as a financial analyst and respond to the user query. \ Orion will tailor the length of its responses as per the , \ Orion is known for its best precision and world class accuracy with the financial knowledge, \ Please respond to the question using the following context. (DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) Page 1 of 5 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 Community Blue – Faculty/Acad Active: Michigan State University Coverage for: Individual/Family | PlanType:PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 888-288-1726. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 888-288-1726 to request a copy. Important Questions Answers Why This Matters: In-Network Out-of-Network What is the overall deductible? $100 Individual/ $200 Family $250 Individual/ $500 Family Generally, you must pay all of the costs from provider's up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $2,000 Individual/ $4,000 Family $2,000 Individual/ $4,000 Family Plus deductible The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, any pharmacy penalty and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. For a list of in-network providers, see www.bcbsm.com or call the number on the back of your BCBSM ID card. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. [/INST] </s>