1. Blue Cross Blue Shield of Michigan/Blue Care Network Rate Quote
New Policy
Agency: Gadaleto Ramsby Client: Bear Manor Properties Group(Subgroup)/Suffix(Class) Specific Data
Group/Suffix: 0 0 Effective Date: 8/1/2008
BCBSM Area: 4
Agent:
Grand Rapids MI 49506 County: Kent Rate Qtr: 2008Q3
Assoc: None
Zip: 49506 Total Eligibles: 3
Group SIC/Industry 6512 Nonresidential building operators BCN Region: West: BC, GR, WS Customer Size: 3
Type: Association Suffix/Class Size: 3
BCBSM: Class4 BCN: Class 4
Rates
One Two Med. Fam. Total
Person Person Family Suppl. Cont. Premium
Medical and/or Drug Enrollment 0 0 3 0 0
Flexible Blue Plans:
Flex Blue 3 - 20% Copay-$1,000/$2,000 OutOfPocket $149.60 $336.60 $403.92 $160.12 $74.80 $1,211.76
OCSM-24 - Osteopathic and Chiropractic Spinal Manipulation $3.73 $8.39 $10.07 N/A $1.86 $30.21
FB-PCM500 - Adds $500 Coverage for Preventive Care $6.76 $15.21 $18.26 N/A $3.38 $54.78
FB-RM100 - Removes Copay & Deductible for Mammography Services $0.19 $0.44 $0.52 N/A $0.10 $1.56
XVA - Excludes Voluntary Abortion Coverage ($0.45) ($1.02) ($1.22) N/A ($0.22) ($3.66)
Blue Advantage - RX Discount Plan $0.87 $1.96 $2.35 $2.35 $0.44 $7.05
Flex Blue 3 - 20% Copay-$1,000/$2,000 OutOfPocket Requires RX Plan $153.81 $346.08 $415.29 $160.12 $76.91 $1,245.87
OCSM-24 - Osteopathic and Chiropractic Spinal Manipulation $3.83 $8.63 $10.35 N/A $1.92 $31.05
FB-PCM500 - Adds $500 Coverage for Preventive Care $6.76 $15.21 $18.26 N/A $3.38 $54.78
FB-RM100 - Removes Copay & Deductible for Mammography Services $0.19 $0.44 $0.52 N/A $0.10 $1.56
XVA - Excludes Voluntary Abortion Coverage ($0.45) ($1.02) ($1.22) N/A ($0.22) ($3.66)
PCD - Prescription Contraceptive Devices $0.03 $0.08 $0.09 N/A $0.02 $0.27
CI - Contraceptive Injections $0.00 $0.00 $0.00 N/A $0.00 $0.00
Flex Blue RX Plan $35.31 $79.46 $95.35 $209.68 $17.66 $286.05
Flex Blue RX Plan Closed Formulary Rider ($11.22) ($25.25) ($30.30) N/A ($5.60) ($90.90)
PDCM - Prescription Contraceptive Medications $0.52 $1.17 $1.40 N/A $0.26 $4.20
Blue Cross Blue Shield of Michigan and Blue Care Network
Copyright Silver Creek Programmers, 2007
are independent licensees of the Blue Cross Blue Shield Association
Page 1 of 4 Printed at 6/12/2008 10:23:31 AM

2. Blue Cross Blue Shield of Michigan/Blue Care Network Rate Quote
New Policy
Rates
One Two Med. Fam. Total
Person Person Family Suppl. Cont. Premium
XED - Excludes Elective Drugs ($1.00) ($2.26) ($2.71) ($6.11) ($0.49) ($8.13)
FB-PREV - $500 Benefit w/No Copay or Deductible on Listed Preventive Rx $2.33 $5.24 $6.28 N/A $1.16 $18.84
RX90 - Retail Purchase 2X for 90-day Refill $0.00 $0.00 $0.00 N/A $0.00 $0.00
RX $10/$60 Copay w/Mail Order 2X $29.28 $65.89 $79.06 $83.47 $14.64 $237.18
PDCM - Prescription Contraceptive Medications $0.44 $0.98 $1.18 N/A $0.22 $3.54
XED - Excludes Elective Drugs ($0.82) ($1.86) ($2.24) ($2.42) ($0.41) ($6.72)
FB-PREV - $500 Benefit w/No Copay or Deductible on Listed Preventive Rx $2.33 $5.24 $6.28 N/A $1.16 $18.84
RX90 - Retail Purchase 2X for 90-day Refill $0.00 $0.00 $0.00 N/A $0.00 $0.00
RX $10/$40 Copay Closed Formulary w/Mail Order 2X $27.04 $60.84 $73.01 $72.76 $13.52 $219.03
PDCM - Prescription Contraceptive Medications $0.26 $0.58 $0.70 N/A $0.13 $2.10
XED - Excludes Elective Drugs ($0.50) ($1.13) ($1.36) ($2.10) ($0.24) ($4.08)
FB-PREV - $500 Benefit w/No Copay or Deductible on Listed Preventive Rx $2.33 $5.24 $6.28 N/A $1.16 $18.84
RX $15/40% $40 min $100 max Copay Closed Formulary w/MOPD2X $23.86 $53.69 $64.43 $57.85 $11.93 $193.29
PDCM - Prescription Contraceptive Medications $0.19 $0.42 $0.51 N/A $0.09 $1.53
XED - Excludes Elective Drugs ($0.37) ($0.85) ($1.03) ($1.67) ($0.18) ($3.09)
FB-PREV - $500 Benefit w/No Copay or Deductible on Listed Preventive Rx $2.33 $5.24 $6.28 N/A $1.16 $18.84
RX $15/$50/50% $70 min $100 max Copay w/MOPD2X $24.28 $54.62 $65.55 $59.90 $12.14 $196.65
PDCM - Prescription Contraceptive Medications $0.21 $0.47 $0.56 N/A $0.10 $1.68
XED - Excludes Elective Drugs ($0.93) ($2.10) ($2.52) ($1.73) ($0.46) ($7.56)
FB-PREV - $500 Benefit w/No Copay or Deductible on Listed Preventive Rx $2.33 $5.24 $6.28 N/A $1.16 $18.84
RX $20/$60/50% $80 min $100 max Copay w/MOPD2X $21.79 $49.04 $58.85 $48.31 $10.90 $176.55
PDCM - Prescription Contraceptive Medications $0.16 $0.35 $0.42 N/A $0.08 $1.26
XED - Excludes Elective Drugs ($0.28) ($0.65) ($0.78) ($1.40) ($0.14) ($2.34)
FB-PREV - $500 Benefit w/No Copay or Deductible on Listed Preventive Rx $2.33 $5.24 $6.28 N/A $1.16 $18.84
Flex Blue 3 - 20% Copay-$2,000/$4,000 OutOfPocket $140.16 $315.37 $378.44 $160.12 $70.08 $1,135.32
OCSM-24 - Osteopathic and Chiropractic Spinal Manipulation $3.49 $7.86 $9.44 N/A $1.75 $28.32
FB-PCM500 - Adds $500 Coverage for Preventive Care $6.76 $15.21 $18.26 N/A $3.38 $54.78
Blue Cross Blue Shield of Michigan and Blue Care Network
Copyright Silver Creek Programmers, 2007
are independent licensees of the Blue Cross Blue Shield Association
Page 2 of 4 Printed at 6/12/2008 10:23:31 AM

3. Blue Cross Blue Shield of Michigan/Blue Care Network Rate Quote
New Policy
Rates
One Two Med. Fam. Total
Person Person Family Suppl. Cont. Premium
FB-RM100 - Removes Copay & Deductible for Mammography Services $0.19 $0.44 $0.52 N/A $0.10 $1.56
XVA - Excludes Voluntary Abortion Coverage ($0.45) ($1.02) ($1.22) N/A ($0.22) ($3.66)
Blue Advantage - RX Discount Plan $0.87 $1.96 $2.35 $2.35 $0.44 $7.05
Flex Blue 3 - 20% Copay-$2,000/$4,000 OutOfPocket Requires RX Plan $143.50 $322.87 $387.45 $160.12 $71.75 $1,162.35
OCSM-24 - Osteopathic and Chiropractic Spinal Manipulation $3.57 $8.03 $9.64 N/A $1.79 $28.92
FB-PCM500 - Adds $500 Coverage for Preventive Care $6.76 $15.21 $18.26 N/A $3.38 $54.78
FB-RM100 - Removes Copay & Deductible for Mammography Services $0.19 $0.44 $0.52 N/A $0.10 $1.56
XVA - Excludes Voluntary Abortion Coverage ($0.45) ($1.02) ($1.22) N/A ($0.22) ($3.66)
PCD - Prescription Contraceptive Devices $0.03 $0.08 $0.09 N/A $0.02 $0.27
CI - Contraceptive Injections $0.00 $0.00 $0.00 N/A $0.00 $0.00
Flex Blue RX Plan $32.95 $74.13 $88.96 $209.68 $16.47 $266.88
Flex Blue RX Plan Closed Formulary Rider ($10.47) ($23.57) ($28.28) N/A ($5.23) ($84.84)
PDCM - Prescription Contraceptive Medications $0.49 $1.10 $1.32 N/A $0.24 $3.96
XED - Excludes Elective Drugs ($0.93) ($2.10) ($2.52) ($6.11) ($0.46) ($7.56)
FB-PREV - $500 Benefit w/No Copay or Deductible on Listed Preventive Rx $2.33 $5.24 $6.28 N/A $1.16 $18.84
RX90 - Retail Purchase 2X for 90-day Refill $0.00 $0.00 $0.00 N/A $0.00 $0.00
RX $10/$60 Copay w/Mail Order 2X $26.50 $59.63 $71.55 $83.47 $13.25 $214.65
PDCM - Prescription Contraceptive Medications $0.38 $0.86 $1.04 N/A $0.19 $3.12
XED - Excludes Elective Drugs ($0.76) ($1.72) ($2.06) ($2.42) ($0.37) ($6.18)
FB-PREV - $500 Benefit w/No Copay or Deductible on Listed Preventive Rx $2.33 $5.24 $6.28 N/A $1.16 $18.84
RX90 - Retail Purchase 2X for 90-day Refill $0.00 $0.00 $0.00 N/A $0.00 $0.00
RX $10/$40 Copay Closed Formulary w/Mail Order 2X $24.12 $54.27 $65.13 $72.76 $12.06 $195.39
PDCM - Prescription Contraceptive Medications $0.26 $0.58 $0.70 N/A $0.13 $2.10
XED - Excludes Elective Drugs ($0.50) ($1.13) ($1.36) ($2.10) ($0.24) ($4.08)
FB-PREV - $500 Benefit w/No Copay or Deductible on Listed Preventive Rx $2.33 $5.24 $6.28 N/A $1.16 $18.84
RX $15/40% $40 min $100 max Copay Closed Formulary w/MOPD2X $20.77 $46.73 $56.07 $57.85 $10.38 $168.21
PDCM - Prescription Contraceptive Medications $0.19 $0.42 $0.51 N/A $0.09 $1.53
Blue Cross Blue Shield of Michigan and Blue Care Network
Copyright Silver Creek Programmers, 2007
are independent licensees of the Blue Cross Blue Shield Association
Page 3 of 4 Printed at 6/12/2008 10:23:31 AM

4. Blue Cross Blue Shield of Michigan/Blue Care Network Rate Quote
New Policy
Rates
One Two Med. Fam. Total
Person Person Family Suppl. Cont. Premium
XED - Excludes Elective Drugs ($0.37) ($0.85) ($1.03) ($1.67) ($0.18) ($3.09)
FB-PREV - $500 Benefit w/No Copay or Deductible on Listed Preventive Rx $2.33 $5.24 $6.28 N/A $1.16 $18.84
RX $15/$50/50% $70 min $100 max Copay w/MOPD2X $21.22 $47.74 $57.28 $59.90 $10.61 $171.84
PDCM - Prescription Contraceptive Medications $0.21 $0.47 $0.56 N/A $0.10 $1.68
XED - Excludes Elective Drugs ($0.93) ($2.10) ($2.52) ($1.73) ($0.46) ($7.56)
FB-PREV - $500 Benefit w/No Copay or Deductible on Listed Preventive Rx $2.33 $5.24 $6.28 N/A $1.16 $18.84
RX $20/$60/50% $80 min $100 max Copay w/MOPD2X $18.60 $41.84 $50.21 $48.31 $9.30 $150.63
PDCM - Prescription Contraceptive Medications $0.16 $0.35 $0.42 N/A $0.08 $1.26
XED - Excludes Elective Drugs ($0.28) ($0.65) ($0.78) ($1.40) ($0.14) ($2.34)
FB-PREV - $500 Benefit w/No Copay or Deductible on Listed Preventive Rx $2.33 $5.24 $6.28 N/A $1.16 $18.84
BCBSM/BCN has the right to adjust rates if any of the assumptions or calculations used in the quoting process are incorrect.
BCN Medical CCF = 0.8950, Drug CCF = 0.8950
Cross CCF = 0.6907, Shield CCF = 0.6907, Master CCF = 0.6907
Drug CCF = 0.6500, Dental CCF = 1.0000, Vision CCF = 1.0000
Final rates will be determined by BCBSM/BCN underwriting based on the actual enrollment of your group with BCBSM/BCN coverage, and
will include a review of group participation.
BCN Rates are subject to Office of Financial and Insurance Bureau approval.
BCN Medical Single Factor = 1.1687
BCBSM no longer markets Master Medical 65 as part of its supplemental coverage. If you choose to make any change in your medical benefit plan,
and Master Medical 65 is a part of your coverage, Master Medical 65 will no longer be a part of your Medicare supplemental coverage.
Blue Cross Blue Shield of Michigan and Blue Care Network
Copyright Silver Creek Programmers, 2007
are independent licensees of the Blue Cross Blue Shield Association
Page 4 of 4 Printed at 6/12/2008 10:23:31 AM