Classic Blue Indemnity Plan BluePPO J Simply Blue HDHP

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1 1 Deductible $200/600 $200/600 None $750/2250 $5,500/$11,000 $5,500/$11,000 4 th Quarter carry Over Yes Yes n/a n/a n/a n/a 20% 20% None 30% 0% 0% Maximum member $200/600 $200/600 None $2000/6000 None None cost (max coins) (max coins) Lifetime Maximum None None None None None None Network BCBS Indemnity BluePPO Blue Maximum Out of pocket n/a n/a $5,250/$9,600 $6,350/$12,700 $5,500/$11,000 $5,500/$11,000 Inpatient Hospital Inpatient Stay CIF after $200 copay $200 copay by member Maternity CIF after $200 copay $200 copay by member copay (** Pre copay * (** Pre Routine Newborn Nursery Care CIF 80% of charges CIF IP Mental Health CIF after $200 copay $200 copay by member IP Detox & Rehabilitation CIF after $200 copay $200 copay by member copay (** Pre copay (** Pre (** Pre (** Pre

2 2 IP Physical Rehabilitation Skilled Nursing CIF after $200 copay Not Covered (30 days) CIF after $200 copay (100 days) $200 copay by member (30 days) $200 copay by member (100 days) copay (60 days per calendar year) (** Pre copay (120 days per calendar year) (** Pre Outpatient Hospital Emergency Room CIF CIF $50 copay (waived if admitted) (120 days per calendar year) (** Pre $50 copay (waived if admitted) Outpatient Surgery CIF 80% of charges $20 copay Pre -Admission Testing CIF 80% of charges CIF X-Rays & other radiology services CIF 80% of charges $20 copay (Pre- Authorization MRI, CAT, PET scans) (Pre-Authorization MRI, CAT, PET scans) Routine Mammography Services CIF 80% of charges CIF CIF Routine Cervical Cancer Screening CIF 80% of charges CIF CIF

3 3 Radiation Therapy CIF 80% of charges CIF Hospice CIF 80% of charges CIF Home Health Care CIF (60 days) 80% of charges CIF $50 Ded/25% Coins, BB OP Treatment of Alcohol & Substance Abuse Professional Services (Physician) Surgery CIF CIF to allowed amount Assistance at Surgery CIF CIF to allowed amount Voluntary Second Opinion CIF CIF to allowed amount Maternity Care CIF CIF to allowed amount Anesthesia Services CIF CIF to allowed amount CIF 80% of charges $20 copay CIF CIF $20 copay CIF CIF

4 4 Doctor Visits in a hospital CIF CIF to allowed amount CIF Well Child Care CIF CIF to allowed amount CIF CIF CIF CIF X-Rays & Radiology Services CIF CIF to allowed amount Routine Mammography Services CIF CIF to allowed amount Routine Cervical Cancer Screening CIF CIF to allowed amount Laboratory Tests CIF CIF to allowed amount Radiation Therapy CIF CIF to allowed amount $20 copay (Pre- Authorization MRI, CAT, PET scans) (Pre-Authorization MRI, CAT, PET scans) CIF CIF CIF CIF CIF CIF Physician Office Visits Ded/Coins Ded/Coin, BB $20 copay

5 5 Speech Therapy CIF CIF to allowed amount $20 copay OT, RT 45 per year) OT, RT 45 per year) Cardiac Rehabilitation CIF 1 program per lifetime 80% of charges 1 program per lifetime $20 copay Chiropractic Care Ded/Coins $20 copay Chemotherapy CIF CIF Immunizations - Adult CIF CIF CIF Diabetic Supplies & Equipment CIF $20 copay Home Care Ded/Coins CIF $50 Ded/25% Coins, BB Durable Medical Equipment / Prosthetics / Medical Supplies Ded/Coins 20% coins (** Pre Outpatient Mental Health CIF CIF to allowed amount, BB (** Pre $20 copay

6 6 Allergy Testing Ded/Coins $20 copay Allergy Treatments Ded/Coins CIF Kidney Dialysis CIF CIF to allowed amount Physical & Occupational Therapy CIF (unlimited) Free Standing Urgent Care CIF CIF to allowed amount Routine Adult Physicals CIF CIF to allowed amount Ambulance Ground CIF CIF to allowed amount CIF $20 copay OT, RT 45 / year.) OT, RT 45 / year.) -45 $25 copay -45 CIF CIF $20 copay

7 7 Ambulance Air CIF CIF to allowed amount $20 copay Pulmonary Rehabilitation CIF CIF $20 copay Dental Coverage Accidental injury to sound and natural teeth only, covered based on type of service provided. Accidental injury to sound and natural teeth only, covered based on type of service provided, BB may apply. $20 copay for OV, $50 at ER, accidental injury to sound, natural teeth and for care due to congenital disease or anomaly for OV, $50 at ER, accidental injury to sound, natural teeth and for care due to congenital disease or anomaly at ER- accidental injury to sound, natural teeth and for care due to congenital disease or anomaly at ER- accidental injury to sound, natural teeth and for care due to congenital disease or anomaly Pre-Existing Conditions Covered Covered Covered Covered Covered Covered Prescription Rx Not Covered under Not Covered under Not Covered under Not Covered under Coverage Excellus, covered Excellus, covered Excellus, covered Excellus, covered under ESI. under ESI. under ESI. under ESI.