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McLane Company, Inc.: No Ded. Plan Coverage Period: 01/01/2017 – 12/31/2017

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: All | Plan Type: PPO

Questions: Call 1-888-403-6089, BCBSTX at 1-866-363-7936 or visit us at www.mclaneco.com. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.mclaneco.com (click ‘Teammates’, and login to ‘eServe’) or call 1-888-403-6089 to request a copy.

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.mclaneco.com or by calling 1-888-403-6089.

Important Questions Answers Why this Matters:

What is the overall deductible?

For In-Network providers $0 Person/$0 Family For Out-of-Network providers $2,000 Person/$4,000 Family

Doesn’t apply to services that charge a copay, In-Network preventive care and prescription drugs. Copays do not count toward the deductible.

You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.

Are there other deductibles

for specific services? Yes. Per occurrence: $1,500 In-Network inpatient admission. There are no other specific deductibles.

You must pay all of the costs for these services up to the specific

deductible amount before this plan begins to pay for these services.

Is there an out-of-pocket limit on my expenses?

Yes. For In-Network providers $3,000 Person/$6,000 Family For Out-of-Network providers $6,000 Person/$12,000 Family

Separate Prescription Out-of-Pocket Max $3,000 Individual/$6,000 Family

Medical copays apply to the Medical Out-of-Pocket Max. Prescription copays apply to the Prescription Out-of-Pocket Max.

The out-of-pocket limit amount is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.

What is not included in the

out-of-pocket limit? Premiums, preauthorization penalties, balance billed charges and health care this plan doesn’t cover.

Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

Does this plan use a

network of providers?

Yes. See www.bcbstx.com or call 1-866-363-7936 for a list of participating providers.

If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.

Do I need a referral to see a

specialist? No. You don’t need a referral to see a specialist.

You can see the specialist you choose without permission from this plan.

Are there services this plan

doesn’t cover? Yes.

Some of the services this plan doesn’t cover are listed on page 5. See your policy or plan document for additional information about excluded services.

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Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.

Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible.

The amount the plan pays for covered services is based on the allowed amount. If an Out-of-Network provider charges more than the allowed amount, you may have to pay the difference. For example, if an Out-of-Network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)

This plan may encourage you to use In-Network providers by charging you lower deductibles, copayments and coinsurance amounts.

Common Medical Event

Services You May Need

Your Cost If You Use an

In-Network Provider

Your Cost If You Use an

Out-of-Network Provider

Limitations & Exceptions

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness

$30 copay/visit 30% coinsurance ---none---

Specialist visit $80 copay/visit 30% coinsurance ---none---

Other practitioner office visit $80 copay/visit 30% coinsurance Applies to chiropractic services only. Limited to 18 visits max per calendar year.

Preventive care/screening/immunization No Charge 30% coinsurance Limited coverage, see enrollment guide.

If you have a test

Diagnostic test (x-ray, blood work) $250 copay/visit 30% coinsurance Pre-authorization through AIM Specialty Health applies to all services accessed in the State of Texas for the following outpatient diagnostic imaging services (CT/CTA, MRI/MRA, SPECT/Nuclear Cardiology).

Imaging (CT/PET scans, MRIs) $250 copay/visit 30% coinsurance

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Common Medical Event

Services You May Need

Your Cost If You Use an

In-Network Provider

Your Cost If You Use an

Out-of-Network Provider

Limitations & Exceptions

If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.Express-Scripts.com 855-315-6433

Generic drugs $5 copay (retail) or $10 copay (mail) / prescription

100% coinsurance (retail only, claim reimbursement)

Not all prescription drugs are covered, such as, non-sedating antihistamines and brand proton pump inhibitors. Specialty drugs must be dispensed from Accredo (Express Scripts' specialty pharmacy). Members may receive up to 90-days' supply for maintenance drugs by using Express Scripts' mail order. Certain medications may require prior authorization or have quantity limits in place. Generic conversion: If dispensed, a brand drug when script allows a generic substitution, or if member chooses a brand, the difference in cost, as well as the applicable brand coinsurance, will apply. For additional information, please visit www.Express-Scripts.com

Preferred brand drugs

30% coinsurance (retail) ($30 min/$60 max) or $60 copay (mail) / prescription

100% coinsurance (retail only, claim reimbursement)

Non-preferred brand drugs

40% coinsurance (retail) ($60 min/$120 max) or $90 copay (mail) / prescription

100% coinsurance (retail only, claim reimbursement)

Specialty drugs See Applicable Pharmacy Category Above

See Applicable Pharmacy Category Above

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)

$500 copay/visit 30% coinsurance ---none---

Physician/surgeon fees No Charge 30% coinsurance ---none---

If you need immediate medical attention

Emergency room services $500 copay/visit 30% coinsurance ---none---

Emergency medical transportation $250 copay/visit $250 copay/visit ---none---

Urgent care $80 copay/visit 30% coinsurance ---none---

If you have a hospital stay

Facility fee (e.g., hospital room) $1,500/per admission

30% coinsurance Preauthorization is required. $750 penalty if services are not preauthorized Out-of-Network.

Physician/surgeon fee No Charge 30% coinsurance ---none---

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Common Medical Event

Services You May Need

Your Cost If You Use an

In-Network Provider

Your Cost If You Use an

Out-of-Network Provider

Limitations & Exceptions

If you have mental health, behavioral health, or substance abuse needs

Mental/Behavioral health outpatient services

$30 copay PCP/ $80 copay SPC

30% coinsurance Certain services must be preauthorized; refer to benefits booklet for details.

Mental/Behavioral health inpatient services

$1,500/per admission

30% coinsurance All services must be preauthorized. $750 penalty if services are not preauthorized Out-of-Network.

Substance use disorder outpatient services

$30 copay PCP/ $80 copay SPC

30% coinsurance Certain services must be preauthorized; refer to benefits booklet for details.

Substance use disorder inpatient services $1,500/per admission

30% coinsurance All services must be preauthorized. $750 penalty if services are not preauthorized Out-of-Network.

If you are pregnant

Prenatal and postnatal care $30 copay/visit 30% coinsurance ---none---

Delivery and all inpatient services $1,500/per admission

30% coinsurance Preauthorization is required. $750 penalty if services are not preauthorized Out-of-Network.

If you need help recovering or have other special health needs

Home health care $1,500/per admission

30% coinsurance Limited to 80 visits max, per calendar year. Preauthorization is required.

Rehabilitation services $30 copay PCP/ $80 copay SPC

30% coinsurance Limited to 60 visits max per calendar year, for speech, physical and occupational therapies. $250 copay for outpatient services. Habilitation services

$30 copay PCP/ $80 copay SPC

30% coinsurance

Skilled nursing care $1,500/per admission

30% coinsurance Limited to 60 days max, per calendar year. Preauthorization is required for inpatient treatment.

Durable medical equipment $250 copay/visit 30% coinsurance ---none---

Hospice service $1,500/per admission

30% coinsurance Preauthorization is required for inpatient treatment.

If your child needs dental or eye care

Eye exam Not Covered Not Covered ---none---

Glasses Not Covered Not Covered ---none---

Dental check-up Not Covered Not Covered ---none---

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Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)

Acupuncture

Bariatric Surgery

Brand PPI Drug Class

Cosmetic Surgery

Dental Care (Limited to Injury & TMJ Office Visits)

Hearing Aids

Long-Term Care

Non-Sedating Antihistamines Drug Class

Private-Duty Nursing

Routine Eye Care

Routine Foot Care (with the exception of person with diagnosis of diabetes)

Weight Loss Programs

Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the McLane Company, Inc. at 1-888-403-6089. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.

Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact BlueCross BlueShield of Texas at 1-800-521-2227 or visit www.bcbstx.com, or contact U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or visit www.dol.gov/ebsa/healthreform. Additionally, a consumer assistance program can help you file your appeal. Contact the Texas Department of Insurance’s Consumer Health Assistance Program at (855) 839-2427 or visit www.texashealthoptions.com.

Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)

Chiropractic Care

Infertility Treatment

(Limited to Diagnosis & Treatment

of the Underlying Condition)

Most Coverage Provided Outside the U.S.

See www.bcbstx.com.

Non-Emergency Care when Traveling Outside of the U.S.

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Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coverage.

Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides.

Language Access Services:

Spanish (Español): Para obtener asistencia en Español, llame al 1-888-403-6089.

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-888-403-6089.

Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-888-403-6089.

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-888-403-6089.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––

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Having a baby (normal delivery)

Managing type 2 diabetes (routine maintenance of

a well-controlled condition)

About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.

Amount owed to providers: $7,540 Plan pays $4,340 Patient pays $3,200

Sample care costs:

Hospital charges (mother) $2,700

Routine obstetric care $2,100

Hospital charges (baby) $900

Anesthesia $900

Laboratory tests $500

Prescriptions $200

Radiology $200

Vaccines, other preventive $40

Total $7,540

Patient pays:

Deductibles $0

Copays $3,000

Coinsurance $0

Limits or exclusions $200

Total $3,200

Amount owed to providers: $5,400 Plan pays $3,520 Patient pays $1,880

Sample care costs:

Prescriptions $2,900

Medical Equipment and Supplies $1,300

Office Visits and Procedures $700

Education $300

Laboratory tests $100

Vaccines, other preventive $100

Total $5,400

Patient pays:

Deductibles $0

Copays $1,800

Coinsurance $0

Limits or exclusions $80

Total $1,880

This is not a cost estimator.

Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different.

See the next page for important information about these examples. These numbers assume the patient has given notice of

her pregnancy to the plan. If you are pregnant and

have not given notice of your pregnancy, your costs

may be higher. For more information, please contact:

BCBSTX at 1-866-363-7936 before you go into the

hospital.

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Questions: Call 1-888-403-6089, BCBSTX at 1-866-363-7936 or visit us at www.mclaneco.com. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.mclaneco.com (click ‘Teammates’, and login to ‘eServe’) or call 1-888-403-6089 to request a copy.

Questions and answers about the Coverage Examples:

What are some of the assumptions behind the Coverage Examples?

Costs don’t include premiums.

Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan.

The patient’s condition was not an excluded or preexisting condition.

All services and treatments started and ended in the same coverage period.

There are no other medical expenses for any member covered under this plan.

Out-of-pocket expenses are based only on treating the condition in the example.

The patient received all care from in-network providers. If the patient had received care from Out-of-Network providers, costs would have been higher.

What does a Coverage Example show?

For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited.

Does the Coverage Example predict my own care needs?

No. Treatments shown are just examples.

The care you would receive for this condition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors.

Does the Coverage Example predict my future expenses?

No. Coverage Examples are not cost

estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows.

Can I use Coverage Examples to compare plans?

Yes. When you look at the Summary of

Benefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “Patient Pays” box in each example. The smaller that number, the more coverage the plan provides.

Are there other costs I should consider when comparing plans?

Yes. An important cost is the premium

you pay. Generally, the lower your premium, the more you’ll pay in out-of-pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses.