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SummaryofBenefitsandCoverage: …

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018-12/31/2018. SM. : Blue Choice Preferred Bronze PPO 201 Two $40 PCP Visits Coverage for: Individual/Family Plan Type: 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 2018 or by calling 1-800-538-8833.

Limitations,Exceptions,&OtherImportant Information WhatYouWillPay ServicesYouMayNeed Common MedicalEvent Non-Participating Provider(Youwillpaythe most)

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1 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018-12/31/2018. SM. : Blue Choice Preferred Bronze PPO 201 Two $40 PCP Visits Coverage for: Individual/Family Plan Type: 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 2018 or by calling 1-800-538-8833.

2 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 Reports-and-Other-Resources/ or call 1-855-756-4448 to request a copy. Important Questions Answers Why This Matters: What is the overall Individual: Generally, you must pay all of the costs from providers up to the deductible amount before deductible? Participating $5,500 this plan begins to pay. If you have other family members on the plan, each family member Non-Participating $15,000 must meet their own individual deductible until the total amount of deductible expenses paid Family: by all family members meets the overall family deductible.

3 Participating $14,700. Non-Participating $45,000. Are there services covered Yes. Deductibles don't apply to This plan covers some items and services even if you haven't yet met the deductible amount. before you meet your certain preventive care & certain But a copayment or coinsurance may apply. For example, this plan covers certain preventive deductible? copayments. services without cost-sharing and before you meet your deductible. See a list of covered preventive services at Are there other No. You don't have to meet deductibles for specific services. deductibles for specific services? What is the out-of-pocket Individual: The out-of-pocket limit is the most you could pay in a year for covered services.

4 If you have limit for this plan? Participating $7,350 other family members in this plan, they have to meet their own out-of-pocket limits until the Non-Participating Unlimited overall family out-of-pocket limit has been met. Family: Participating $14,700. Non-Participating Unlimited What is not included in the Premiums, balance-billed Even though you pay these expenses, they don't count toward the out-of-pocket limit. out-of-pocket limit? charges, and health care this plan doesn't cover. Will you pay less if you use See or call This plan uses a provider network. You will pay less if you use a provider in the plan's network.

5 A network provider? 1-800-538-8833 for a list of You will pay the most if you use an out-of-network provider, and you might receive a bill from Participating providers. a provider for the difference between the provider's charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to No. You don't need a referral to You can see the specialist you choose without a referral. see a specialist? see a Specialist. Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association SBC IL Non-HMO IND-2018 1 of 7.

6 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. What You Will Pay Common Participating Provider Non-Participating Limitations, Exceptions, & Other Important Services You May Need Medical Event (You will pay the least) Provider (You will pay the Information most). Primary care visit to treat an $40/visit; deductible does 50% coinsurance Deductible and coinsurance applies after first injury or illness not apply 2 office visits. Virtual visits may be available, please refer to your plan policy for more If you visit a health care details.

7 Provider's office or Specialist visit 50% coinsurance 50% coinsurance None. clinic Preventive care/screening/ No Charge, deductible 50% coinsurance You may have to pay for services that aren't immunization does not apply preventive. Ask your provider if the services needed are preventive. * Then check what your plan will pay for. Diagnostic test (x-ray, blood Hospital - 50% 50% coinsurance work) coinsurance None. Non-Hospital - 40%. coinsurance If you have a test Imaging (CT/PET scans, MRIs) Hospital - 50% 50% coinsurance Preauthorization is required for certain coinsurance services. *See benefit booklet for more Non-Hospital - 40%.

8 Details. coinsurance Preferred generic drugs Retail Preferred - Retail - $20/prescription Limited to a 30-day supply at retail (or a If you need drugs to $10/prescription deductible does not apply 90-day supply at a network of select retail treat your illness or Non-Preferred pharmacies). Up to a 90-day supply at mail condition $20/prescription order. Specialty drugs limited to a 30-day More information about Mail - $30/prescription supply. Payment of the difference between prescription drug deductible does not apply the cost of a brand name drug and a generic coverage is available at Non-preferred generic drugs Retail Preferred - Retail - $30/prescription may also be required if a generic drug is $20/prescription deductible does not apply available.

9 All Out-of-Network prescriptions com/content/dam/ Non-Preferred are subject to a 50% additional charge after prime/memberportal/ $30/prescription the applicable copay/coinsurance. Additional forms/AuthorForms/ Mail - $60/prescription charge will not apply to any deductible or HIM/2018 deductible does not apply out-of-pocket amounts. You may be eligible to synchronize your prescription refills, *For more information about limitations and exceptions, see the plan or policy document at 2 of 7. What You Will Pay Common Participating Provider Non-Participating Limitations, Exceptions, & Other Important Services You May Need Medical Event (You will pay the least) Provider (You will pay the Information most).

10 Preferred brand drugs Preferred - 30% 35% coinsurance coinsurance/. Non-Preferred - 35%. coinsurance Non-preferred brand drugs Preferred - 35% 40% coinsurance *please see your benefit booklet for details. coinsurance/. Non-Preferred - 40%. coinsurance Preferred specialty drugs 45% coinsurance 45% coinsurance Non-Preferred specialty drugs 50% coinsurance 50% coinsurance Facility fee ( , ambulatory Hospital - $600/visit plus $1,500/visit plus 50%. Abortions not covered, except where a surgery center) 50% coinsurance coinsurance pregnancy is the result of rape or incest, or If you have outpatient Non-Hospital - $600/visit for a pregnancy which, as certified by a surgery plus 40% coinsurance physician, places the woman in danger of Physician/surgeon fees $200/visit plus 50% 50% coinsurance death unless an abortion is performed.