Health Insurance Costs and Coverage

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**Renewal Benefits and Rates - Medical**
Member Level Rated & Billed	BluePreferred PPO HSA Compatible Silver Plan - $2,300 Ded¹ (APHMB021-J) Prescription Drug (RXCMB366)	BlueChoice Plus HSA Compatible Silver Plan - $2,300 Ded¹ (ATHMB016-G) Prescription Drug (RXCMB367)	BlueChoice Advantage HSA Compatible Silver Plan - $2,300 Ded¹ (AAHMB02P-CP) Prescription Drug (RXCMB367)
Non-Preventive Doctor Copay (PCP/Specialist)	PCP: Deductible, then $25 Copay per visit SPEC: Deductible, then $70 Copay per visit	PCP: Deductible, then $90 Copay per visit SPEC: Deductible, then $90 Copay per visit	PCP: Deductible, then $25 Copay per visit SPEC: Deductible, then $70 Copay per visit	PCP: Deductible, then $90 Copay per visit SPEC: Deductible, then $90 Copay per visit	PCP: Deductible, then $25 Copay per visit SPEC: Deductible, then $70 Copay per visit	PCP: Deductible, then $90 Copay per visit SPEC: Deductible, then $90 Copay per visit
Preventive Doctor Copay (PCP/Specialist)	No Charge	Deductible, then No Charge	No Charge	Deductible, then No Charge	No Charge	Deductible, then No Charge
Inpatient Charge per Admission	Deductible, then $500 Copay per Admission	Deductible, then $600 Copay per Admission	Deductible, then $500 Copay per Admission	Deductible, then $600 Copay per Admission	Deductible, then $500 Copay per Admission	Deductible, then $600 Copay per Admission
Deductible (Individual/Family)	$2,300/$4,600	$4,600/$9,200	$2,300/$4,600	$4,600/$9,200	$2,300/$4,600	$4,600/$9,200
Coinsurance (Insurance/Member)	None	None	None	None	None	None
Out-of-Pocket Maximum (Individual/Family)	$8,450/$16,900	$16,900/$33,800	$8,450/$16,900	$16,900/$33,800	$8,450/$16,900	$16,900/$33,800
Emergency Room	Deductible, then $500 Copay per visit	Paid as In-Network	Deductible, then $500 Copay per visit	Paid as In-Network	Deductible, then $500 Copay per visit	Paid as In-Network
Pediatric Dental	Included	Included	Included	Included	Included	Included
Pediatric Vision	Included	Included	Included	Included	Included	Included
Maximum Benefit	None	None	None	None	None	None
Prescription Drug Highlights	PPACA Prescription Drug	PPACA Prescription Drug	PPACA Prescription Drug
Off Exchange	Integrated Drug (RXCMB366-GM)	Integrated Drug (RXCMB367-GM)	Integrated Drug (RXCMB367-GM)
Deductible	$2,300/$4,600 Combined with Medical	$2,300/$4,600 Combined with Medical	$2,300/$4,600 Combined with Medical
Copay (Retail)	$15/$50/$70	$15/$50/$70	$15/$50/$70
Copay (Mail)	$30/$100/$140	$30/$100/$140	$30/$100/$140
Preferred Specialty	Specialty - Ded then 50% up to $100 (Tier 4)	Specialty - Ded then 50% up to $100 (Tier 4)	Specialty - Ded then 50% up to $100 (Tier 4)
Non-Preferred Specialty	Ded then 50% up to $150 (Tier 5)	Ded then 50% up to $150 (Tier 5)	Ded then 50% up to $150 (Tier 5)
¹ Refer to the Issuing Company table for complete information on the issuer's legal name for this product.

**Renewal Benefits and Rates - Medical**
Member Level Rated & Billed	BluePreferred PPO HSA Compatible Silver Plan - $2,300 Ded¹ (APHMB021-J) Prescription Drug (RXCMB366)		BlueChoice Plus HSA Compatible Silver Plan - $2,300 Ded¹ (ATHMB016-G) Prescription Drug (RXCMB367)		BlueChoice Advantage HSA Compatible Silver Plan - $2,300 Ded¹ (AAHMB02P-CP) Prescription Drug (RXCMB367)
Off Exchange	Member Pays		Member Pays		Member Pays
Health Plan Highlights	In-network	Out-of-network	In-network	Out-of-network	In-network	Out-of-network
Non-Preventive Doctor Copay (PCP/Specialist)	PCP: Deductible, then $25 Copay per visit SPEC: Deductible, then $70 Copay per visit	PCP: Deductible, then $90 Copay per visit SPEC: Deductible, then $90 Copay per visit	PCP: Deductible, then $25 Copay per visit SPEC: Deductible, then $70 Copay per visit	PCP: Deductible, then $90 Copay per visit SPEC: Deductible, then $90 Copay per visit	PCP: Deductible, then $25 Copay per visit SPEC: Deductible, then $70 Copay per visit	PCP: Deductible, then $90 Copay per visit SPEC: Deductible, then $90 Copay per visit
Preventive Doctor Copay (PCP/Specialist)	No Charge	Deductible, then No Charge	No Charge	Deductible, then No Charge	No Charge	Deductible, then No Charge
Inpatient Charge per Admission	Deductible, then $500 Copay per Admission	Deductible, then $600 Copay per Admission	Deductible, then $500 Copay per Admission	Deductible, then $600 Copay per Admission	Deductible, then $500 Copay per Admission	Deductible, then $600 Copay per Admission
Deductible (Individual/Family)	$2,300/$4,600	$4,600/$9,200	$2,300/$4,600	$4,600/$9,200	$2,300/$4,600	$4,600/$9,200
Coinsurance (Insurance/Member)	None	None	None	None	None	None
Out-of-Pocket Maximum (Individual/Family)	$8,450/$16,900	$16,900/$33,800	$8,450/$16,900	$16,900/$33,800	$8,450/$16,900	$16,900/$33,800
Emergency Room	Deductible, then $500 Copay per visit	Paid as In-Network	Deductible, then $500 Copay per visit	Paid as In-Network	Deductible, then $500 Copay per visit	Paid as In-Network
Pediatric Dental	Included	Included	Included	Included	Included	Included
Pediatric Vision	Included	Included	Included	Included	Included	Included
Maximum Benefit	None	None	None	None	None	None
Prescription Drug Highlights	PPACA Prescription Drug		PPACA Prescription Drug		PPACA Prescription Drug
Off Exchange	Integrated Drug (RXCMB366-GM)		Integrated Drug (RXCMB367-GM)		Integrated Drug (RXCMB367-GM)
Deductible	$2,300/$4,600 Combined with Medical		$2,300/$4,600 Combined with Medical		$2,300/$4,600 Combined with Medical
Copay (Retail)	$15/$50/$70		$15/$50/$70		$15/$50/$70
Copay (Mail)	$30/$100/$140		$30/$100/$140		$30/$100/$140
Preferred Specialty	Specialty - Ded then 50% up to $100 (Tier 4)		Specialty - Ded then 50% up to $100 (Tier 4)		Specialty - Ded then 50% up to $100 (Tier 4)
Non-Preferred Specialty	Ded then 50% up to $150 (Tier 5)		Ded then 50% up to $150 (Tier 5)		Ded then 50% up to $150 (Tier 5)
¹ Refer to the Issuing Company table for complete information on the issuer's legal name for this product.

Age Band	BluePreferred PPO HSA Compatible Silver Plan - $2,300 Ded	BlueChoice Plus HSA Compatible Silver Plan - $2,300 Ded	BlueChoice Advantage HSA Compatible Silver Plan - $2,300 Ded
0-14	$378.44	$332.26	$354.02
15	$412.08	$361.80	$385.49
16	$424.94	$373.09	$397.52
17	$437.80	$384.38	$409.55
18	$451.65	$396.54	$422.51
19	$465.50	$408.70	$435.47
20	$479.85	$421.30	$448.89
21	$494.69	$434.33	$462.77
22	$494.69	$434.33	$462.77
23	$494.69	$434.33	$462.77
24	$494.69	$434.33	$462.77
25	$496.67	$436.07	$464.62
26	$506.56	$444.75	$473.88
27	$518.44	$455.18	$484.98
28	$537.73	$472.12	$503.03
29	$553.56	$486.02	$517.84
30	$561.47	$492.96	$525.24
31	$573.35	$503.39	$536.35
32	$585.22	$513.81	$547.46
33	$592.64	$520.33	$554.40
34	$600.55	$527.28	$561.80
35	$604.51	$530.75	$565.50
36	$608.47	$534.23	$569.21
37	$612.43	$537.70	$572.91
38	$616.38	$541.18	$576.61
39	$624.30	$548.12	$584.02
40	$632.21	$555.07	$591.42
41	$644.09	$565.50	$602.53
42	$655.46	$575.49	$613.17
43	$671.29	$589.39	$627.98
44	$691.08	$606.76	$646.49
45	$714.33	$627.17	$668.24
46	$742.04	$651.50	$694.16
47	$773.20	$678.86	$723.31
48	$808.82	$710.13	$756.63
49	$843.94	$740.97	$789.49
50	$883.52	$775.71	$826.51
51	$922.60	$810.03	$863.07
52	$965.63	$847.81	$903.33
53	$1,009.17	$886.03	$944.05
54	$1,056.16	$927.29	$988.01
55	$1,103.16	$968.56	$1,031.98
56	$1,154.11	$1,013.29	$1,079.64
57	$1,205.56	$1,058.46	$1,127.77
58	$1,260.47	$1,106.67	$1,179.14
59	$1,287.68	$1,130.56	$1,204.59
60	$1,342.59	$1,178.77	$1,255.96
61	$1,390.08	$1,220.47	$1,300.38
62	$1,421.24	$1,247.83	$1,329.54
63	$1,460.32	$1,282.14	$1,366.10
64	$1,484.07	$1,302.99	$1,388.31
65+	$1,484.07	$1,302.99	$1,388.31