2020 Large Group Benefits Brochure

20 Large Group Benefits 20 Health plans designed for flexibility and savings

Improving care in every community Personalized member engagement

with a robust portfolio that delivers programs that to help your employees make smart decisions drive higher-quality health care and lower costs. about their health care expenses.

Purposeful innovation Tailored health plan solutions

to change the way health care is designed, that are comprehensive and flexible to meet delivered, and experienced for our members. your business’ unique needs. Table of contents

Smarter, Better Health Care...... 1 Improving care in every community...... 3 Personalized member engagement...... 5 Purposeful innovation...... 10 Tailored health plan solutions...... 11 51 – 99 health plans...... 22 Copay Deductible/Copay Deductible/Coinsurance HSA-qualified Choice Advantage Tiered Network 100+ health plans...... 38 Copay Deductible/Copay Deductible/Coinsurance HSA-qualified Choice Advantage What’s not covered...... 49 Important plan details...... 50 Underwriting summary...... 51 Prescription drug plans...... 53 Dental plans...... 55

Vision plans...... 57 SMARTER, BETTER HEALTH CARE

Keep your employees healthy and protect your bottom line with a tailored network and health plan solution from Independence Blue Cross (Independence). Whether you need medical and prescription drug coverage or want to add extra benefits, we have a health plan for you.

The Power of Blue With the power of the Blues, we can deliver comprehensive health coverage solutions to you.*

1 in 3 Americans Largest provider network 106 million members carry a Blue Card (96% of hospitals, 95% of doctors)

* Based on data from the Blue Cross Blue Shield Association. Health plans overview

Quick guide to your benefits solutions Independence has everything you need to create a tailored health plan solution to keep your business and employees as healthy as possible. Build the plan that best meets your needs.

51 – 99 customers 100+ customers

Protect employees' health • 58 plans • 168 plans • PPO, DPOS, POS • PPO, DPOS, POS • Tiered Network plans • Copay, deductible, and coinsurance plans • Copay, deductible, and coinsurance plans • Health Savings Account (HSA) • Health Savings Account (HSA) • Biotech/Specialty & Infusion Health plans — pg. 22 – 48 • Biotech/Specialty & Infusion Site of Service benefits Site of Service benefits • Choice Advantage plans with additional • Choice Advantage plans with additional Site of Service benefits Site of Service benefits • Preventive Plus colonoscopy benefit • Preventive Plus colonoscopy benefit • Lab Site of Service benefits (PPO plans only) • Lab Site of Service benefits (PPO plans only)

• HSA available with qualified plans • HSA available with qualified plans • HRA option with all plans except HSA-qualified plans • HRA option with all plans except HSA-qualified plans Spending accounts — pg. 19 • FSA for medical or dependent care available with any plan* • Coverage is required • Coverage is optional • Value formulary • Value formulary Prescription drug — pg. 53 – 54 • 3 plans • 20 plans • HSA-qualified plans have built-in prescription • HSA-qualified plans have built-in prescription drug coverage drug coverage • Available to all customers • Available to all customers Dental — pg. 55 – 56 • Sample PPO plans included for comparison • Sample PPO plans included for comparison • Additional PPO plans available • Additional customizable PPO plans available • All DPOS/POS medical plans have built-in eye • All DPOS/POS medical plans have built-in eye exams and can be paired with vision plans to exams and can be paired with vision plans to Vision — pg. 57 – 58 cover glasses or contacts cover glasses or contacts • PPO medical plans can be paired with vision plans • PPO medical plans can be paired with vision plans that cover exams as well as glasses or contacts that cover exams as well as glasses or contacts • Included for all fully-insured customers • Included for all fully-insured customers Telemedicine — pg. 16 • Available to self-funded customers • Available to self-funded customers

Employee assistance program — pg. 20 • Personal Life ManagementSM • Personal Life ManagementSM

Protect employees' wealth • Life insurance • Life insurance Guardian supplemental • Disability insurance • Disability insurance insurance — pg. 20 • Accident, critical illness, and cancer insurance • Accident, critical illness, and cancer insurance • Hospital indemnity insurance • Hospital indemnity insurance

Give employees peace of mind • Available to fully-insured customers at no cost • Available to fully-insured customers at no cost The College Tuition Benefit — pg. 16 upon renewal upon renewal • Available to self-funded customers • Available to self-funded customers International health • 2 plans to choose from (short- or long-term travel) • 2 plans to choose from (short- or long-term travel) insurance — pg. 21

Lower your financial risk Stop loss — pg. 21 • Not available • Available for self-funded customers

* HSAs can only be paired with a limited-purpose FSA to cover eligible vision and dental expenses. 2020 Large Group Plans | Independence Blue Cross 2 Improving care in EVERY COMMUNITY Making health care work better in the communities we serve by working together with providers to improve the quality and affordability of the care delivered to your employees.

Value-based programs provide quality and savings Independence is a leader in driving value-based health care through our Facilitated Health Networks (FHN). Instead of paying providers for volume, this approach rewards providers based on quality and outcomes.

% % BETTER DECREASE 32 1 21 2 in pediatric prevention in avoidable ER visits per 1,000

% 18 MORE PROVIDERS in a value-based contract than the national average3

1 Based on 2017 HEDIS National Average 2 Based on internal data 3 Health Care Payment Learning & Action Network. Measuring Progress: Adoption of Alternative Payment Models in Commercial, Medicaid, Medicare Advantage, and Medicare Fee-for-Service Programs. October 22, 2018 Improving care in every community

Health care value optimization Driving value in medical management As stewards of your dollar, we regularly review programs, In recent years, Independence has optimized our medical processes, and policies — using industry benchmarks and management savings to ensure members receive high-quality best practice standards — to identify and address outliers health care in the safest setting. As a result, we are: in health care costs and utilization. Once we identify new • Driving evidence-based care initiatives, we embed them into our utilization management and claim payment policies. • Reducing the number of unnecessary procedures and related costs from potential complications • Embedding pharmacy benefits with medical benefits to provide the safest, most appropriate care

Network Management and reimbursement administration

Medical/Pharmacy Policy

Health Care Value Optimization

Utilization Management

Payment Optimization

% FHN success story: Penn Medicine CUT We collaborate with the University of Pennsylvania Health System (Penn Medicine) 25 to ensure our members receive quality health care at an affordable price. in hospital readmissions rates after the first year

Preventing readmissions Real-time data Face-to-face with doctors Payment models incentivize doctors Exchanging data helps give a We hold quarterly meetings with Penn to deliver quality care, preventing complete view of patients' health Medicine doctors to provide tools to unnecessary readmissions. and identify gaps in care. help them maximize cost efficiencies.

2020 Large Group Plans | Independence Blue Cross 4 Personalized MEMBER ENGAGEMENT A positive and engaging employee and member experience is about getting members to understand and use their benefits to make smart decisions about their health and care expenses. Engaging with members helps them:

Better understand Improve their health Make informed health Use self-service tools and maximize their and well-being care decisions and resources health benefits

Members can access the following tools anytime, anywhere on ibx.com or through the IBX mobile app.

Tools for members' health Tools for members' wealth • Achieve Well-being • Healthy Lifestyles reimbursements • Telemedicine services • Care Cost Estimator • Find a Doctor tool • Price a Drug tool • Behavioral health resources • Blue 365® discount • Blue Insider SM savings • Spending accounts

The IBX mobile app is a top-rated app in both the Apple and Google Play stores. Personalized member engagement

Industry-leading member experience Keeping members connected With two-thirds of our subscribers digitally engaged It all starts with the member ID card, which invites in IBX Wire® or email, our award-winning engagement members to call to confirm receipt. Then, we reach strategy delivers customized content that guides members out to members throughout the year with personalized to the right tools and resources for their needs. By engaging information depending on where they are in their health early and often, we’re not only driving better health care journey. Messages are also prioritized so that outcomes but also driving a healthier, more productive members receive the most vital ones first. workforce for your business.

Clinical Messages PRIORITY Onboarding Messages PRIORITY • Gaps in care • Site of Service education • Medication adherence 01 • Self-service tips 02 • Discharge follow-up • Welcome by product • Preventive health reminders

FREQUENCY BASED FREQUENCY ON CLINICAL NEEDS 2 TIMES PER MONTH 2

PRIORITY General Engagement Transactional Triggers AS • Digital newsletters • ID card updates ELIGIBLE • How to find a provider 03 • Appeals status • Deals and discounts • Benefits coordination

FREQUENCY FREQUENCY 2 2 TIMES PER MONTH UNLIMITED

Engagement drives powerful results 42% 14% 11% MORE LIKELY LESS LIKELY MORE TO BE COMPLIANT WITH TO USE THE ER FOR COMPLIANT WITH THEIR MEDICATION REGIMEN NON-EMERGENT REASONS PREVENTIVE SCREENINGS

2020 Large Group Plans | Independence Blue Cross 6 Helping members Achieve with Independence The prevalence of chronic conditions and unhealthy lifestyle choices are key factors in rising health care costs and, ultimately, your bottom line. Whether your employees are generally healthy or need a little more support, our Achieve Well-being and Achieve Better Health programs are tailored to meet their specific needs.

Achieve Well-being Achieve Better Health

Self-service tools to help employees stay healthy Care management programs for extra health support

• Engaging online tools that make it easy for members to achieve • 24/7 access to a registered nurse Health Coach their well-being goals • Resources and support for members with chronic conditions • Personalized action plan includes ongoing activities and reminders • Case managers to help members with serious illnesses • Ability to sync with fitness apps and devices for progress, biometrics, or conditions personal challenges, and inviting friends • Targeted clinical messaging to help members Achieve Better Health • Up to $450 in reimbursements for gym workouts, weight management, and tobacco cessation programs • Maternity program support to pregnant members

Focusing on behavioral health Cognitive behavioral therapies are available to your employees on ibx.com.* These confidential and free online programs help them balance work and home responsibilities. They can:

Create a personal health plan Receive online self- View helpful tips Find local providers based on a quick screening paced care on demand and articles who offer tele-behavioral health capabilities

* Available to members who have employee assistance program benefits through Magellan Behavioral Health. 7 Invest in your employees

Invest in your strongest asset — your employees We provide tools to help you We give you the tools and resources to build a customized build a customized worksite worksite well-being program that promotes more engaged, productive, and healthier employees. After all, your well-being program, which employees are your company’s greatest asset, and their health can dramatically affect your workplace. can include:

Use your wellness credits for on-site services Seminars and videos Creating a culture of well-being in your workplace starts by reinforcing the idea of year-round wellness. Employers in our Large Group market (51+) are eligible for wellness Incentives and rewards credits every year to help implement a program for their organization. You can use your wellness credits on pre- selected vendors who provide services for on-site biometric Ready-made well-being challenges screenings, chair massages, fitness challenges, nutrition counseling, stress workshops, and much more.

Operational wellness plans

Assessments

Toolkits and communication templates

Visit wellbeing.ibx.com for tools to build your customized well-being program.

Service excellence Our customer service center provides outstanding support to members. Our services include:

Agents who receive extensive State-of-the-art technology Live, in-person support Concierge solutions that training on members’ needs that helps agents give that's available at are available for buy-up quick, efficient service Independence LIVE

2020 Large Group Plans | Independence Blue Cross 8 Helping make health care coverage easier to manage Administer your health benefits efficiently and securely through ibx.com. Sign in to access enrollment, billing, reporting, marketing tools, and our latest news.

PAY WITH eBILL This secure and convenient service allows you to pay and view invoices. You can choose to make a one-time payment at any time right up until your premium due date. Or, you can set up a recurring monthly payment from one or multiple bank accounts.

MANAGE ACCOUNT Add or remove an employee and change employee or dependent information. CREATE INDEX REPORTS FOR 100+ Easily get detailed and actionable insights about health care trends and cost drivers.

COMPREHENSIVE TOOLKITS Access self-service toolkits to help you promote Independence capabilities and services to your employees.

IBX.COM

9 Inspiring PURPOSEFUL INNOVATION Making health care work better means disrupting the status quo and pioneering new ways to improve health care for our members. As market leaders, we are inspired to develop new ways to improve health care. Our focus is always on members, their health, and innovative ways of doing things that will help make the health care experience more convenient, effective, and affordable.

Quil Through our new partnership with Comcast, we've developed a platform that empowers individuals with customized health-related content through multiple digital channels, supporting them through their health care journey, and helping them answer the question of what's next.

Innovation center Located at our headquarters in Philadelphia, it’s a two-floor, high-tech center that leverages design-thinking principles to unleash innovative solutions. It is also available for customers and partners to solve specific challenges.

Investing in new ventures, partnerships, and technologies We help to make a better and more sustainable health care system by nurturing the country’s most promising health-related startups. We also forge powerful partnerships that foster public-private collaborations and improve quality, lower costs, and promote health care innovation.

Blue Cross Blue Shield Health of America This report is a source of insights, information, and powerful stories highlighting how Blue Cross Blue Shield companies are leading the way to better health care — and better health — for America. To view the reports, visit bcbs.com/the-health-of-america. Tailored HEALTH PLAN SOLUTIONS No one knows your business better than you do. That’s why we work with you to design a comprehensive and flexible benefits solution that meets your unique needs. Our health plan options are designed to create a comprehensive benefits solution tailored to the needs of your business and employees.

For you For members • Plans at every price point • Coverage in and out of network • Cost-sharing flexibility • Affordable cost-sharing • Employee satisfaction and retention • More choices and control Tailored health plan solutions

Health plans to fit your needs and budget Choose from our portfolio of standard health plans and innovative options — Tiered Networks, Choice Advantage with Site of Service (SoS) benefits, or an HSA-qualified plan with an HSA. Our plans give members choices and affordable access to care at a premium that works for you.

Plan options

PPO POS DPOS • Copay • Copay • Copay • Deductible/Copay • Deductible/Copay • Deductible/Copay • HSA • Choice Advantage (SoS) • Choice Advantage (SoS) • Tiered Network • Deductible/Coinsurance

Plans offer both in- and out-of-network coverage We offer a wide variety of PPO, Direct Point-of-Service (POS), and POS plans, many of which are available at the same cost-sharing across each product type to give you a range of premiums.

Personal Choice® PPO Keystone Direct POS Keystone POS

Access to more than 60,000 doctors X X X

Select a primary care physician X X

No specialist referrals needed X X1 for the highest level of benefits

In-network benefits nationwide X

24/7 telemedicine access X X X

Away from Home Care® for those temporarily X X living outside the coverage area

Emergency and urgent care access worldwide X X X

1 Members with a Direct POS plan need a referral from their PCP for certain services: Routine X-rays, spinal manipulations, physical/occupational therapy, and acupuncture. For lab work, members should use the designated site selected by their PCP for the lowest out-of-pocket costs. 2020 Large Group Plans | Independence Blue Cross 12 Tiered Network plans Members can save on hospital Our Tiered Network plans offer cost savings for you and your and outpatient services employees. The PPO Tiered Network plans offer members Out-of-pocket savings are based on the provider's tier. the option to save on out-of-pocket costs for hospital and Members can choose between tier 1 and tier 2 hospitals or certain outpatient services. outpatient facilities when they access care. We’ve made it easy for members to determine a hospital or outpatient facility tier when they search on ibx.com. Here’s a look at the types of providers and services that are subject to tiering. In-network tier 1 $ • Inpatient hospital admissions for medical and maternity care • Outpatient surgery at ambulatory In-network tier 2 $$ surgical centers • Hospital-based outpatient radiology centers • Hospital-based outpatient labs Out-of-network $$$

All other services are not subject to tiering. Member cost sharing for these services is the same at any in-network provider.

13 Members save with Tiered Networks

Members save with tier 1 hospitals. Here is a listing of our tier 1 and tier 2 hospitals by county.

Tier 1 and Tier 2 hospitals by county

Tier 1 - ($) Tier 2 — ($$)

Bucks Bucks Aria Health — Bucks County Campus St. Mary Medical Center Doylestown Hospital Grand View Hospital Lower Bucks Hospital St. Luke’s Health Network — Quakertown Campus

Chester Chester Brandywine Hospital Chester County Hospital Jennersville Hospital Main Line Health — Paoli Hospital Phoenixville Hospital

Delaware Delaware Crozer-Chester Medical Center Main Line Health — Riddle Hospital Delaware County Memorial Hospital Mercy Fitzgerald Hospital Springfield Hospital Taylor Hospital

Montgomery Montgomery Abington Memorial Hospital Albert Einstein Medical Center — Montgomery Campus Holy Redeemer Hospital and Medical Center Main Line Health — Bryn Mawr Hospital Lansdale Hospital Main Line Health — Lankenau Medical Center Pottstown Memorial Medical Center Suburban Community Hospital

Philadelphia Philadelphia Aria Health — Frankford Campus Albert Einstein Medical Center Aria Health — Torresdale Campus Albert Einstein Medical Center — Germantown Campus Chestnut Hill Hospital Children's Hospital of Philadelphia Methodist Hospital Fox Chase Cancer Center Roxborough Memorial Hospital Hospital of the University of Pennsylvania Thomas Jefferson University Hospital Jeanes Hospital Mercy Philadelphia Hospital Nazareth Hospital Penn Presbyterian Medical Center Pennsylvania Hospital Shriner's Hospital for Children St. Christopher's Hospital for Children Temple — Northeast Campus Temple University Hospital

Tier assignments are accurate as of the date of publication. They are reviewed annually and are subject to change. Members can visit ibx.com for the most up-to-date information. 2020 Large Group Plans | Independence Blue Cross 14 Site of Service benefits and Choice Advantage plans Our Site of Service (SoS) benefits give members choices services in the privacy of their home or doctor's office when accessing certain services. Members save money instead of an outpatient hospital setting. on out-of-pocket costs and you save on overall costs based Our Choice Advantage plans build on our existing SoS on where care is received. benefits to offer members even more opportunity to save All health plans now include SoS benefits for biotech/ on out-of-pocket costs. Some of the additional SoS benefits specialty injectables and infusion services. Members can include routine and complex radiology and pathology. pay less and feel more comfortable with receiving these

Covered SoS services

Choice Advantage PPO Choice Advantage POS/DPOS All other plans

Biotech Specialty Injectables X X X

Infusion X X X

Lab/pathology X X (PPO plans only)

Preventive colonoscopy X X X

Outpatient surgery X X

Physical/occupational therapy X X (PPO plans only)

Routine/complex radiology X

NEW

All health plans now include a site of service benefit for biotech/specialty injectables and infusion services, which gives members the option to save their health care dollars based on where these services are provided.

15 Additional health plan benefits

Telemedicine The College Tuition Benefit® Telemedicine is a benefit offered with all plans and provides One way to help attract and retain talent is through The members with easy access to care. Telemedicine is a great College Tuition Benefit, which is included with all plans alternative when a member's PCP is unavailable. Members at no additional cost to you. It works like a scholarship may experience lower medical costs, reduced ER and program, where subscribers can earn SAGE Scholars urgent care utilization for non-emergencies, and decreased Tuition Rewards® to help offset the cost of a four-year absenteeism when they take advantage of this benefit. undergraduate education at a participating college or university nationwide. MDLIVE, a leading telemedicine vendor, offers secure, 24/7 access to board-certified physicians via secure video chat, • Subscribers can sponsor students who are part over the telephone, or through the mobile app. Signing up of their immediate or extended family — children, is easy with Sophie, a virtual assistant who guides members grandchildren, nieces, nephews, stepchildren, and godchildren.* through the registration processes. • One Tuition Rewards point is equal to a $1 guaranteed minimum discount off of the full price of tuition. • When subscribers register for the program they earn % 2,000 points, and students receive 500 Tuition Rewards OF PATIENTS points upon enrollment. Subscribers also receive an 96 additional 2,500 points in year four. did not take any further actions in accessing care for that The College Tuition Benefit is a great retention tool for same condition you, because the longer your employee stays with your company and keeps their Independence coverage, the % more your employee can accrue. 82 OF CASES Tuition Rewards points grow each year did not require any further action within the next 7 days Year 7 17,000 pts

Year 6 15,000 pts % 97PATIENT SATISFACTION Year 5 13,000 pts Year 4 11,000 pts**

Year 3 6,500 pts

Year 2 4,500 pts

* Subject to certain restrictions. ** Includes additional 2,500 2020 Large Group Plans | Independence Blue Cross 16 Power of one: Medical and pharmacy together Choosing Independence to manage both your medical and pharmacy benefits gives us a holistic view of your employees’ health and utilization so we can help coordinate all aspects of their health care.

Our prescription drug plans are powered by a national, Specialty pharmacy drugs top-three Pharmacy Benefit Manager (PBM), and Specialty drug spending continues to outpace all other managed by FutureScripts®. As partners, we are able to: health care costs. Our specialty pharmacy program • Provide greater savings and lower total spend offers a holistic approach to care that goes beyond the • Improve employee health person’s specialty prescriptions and treatment. Our therapy management programs and experienced pharmacy and • Utilize one member ID card and member portal nurse clinical management teams help improve member • Deliver value health outcomes while reducing overall costs of care. While drug prices continue to rise at an alarming rate, our prescription drug plans provide members with safe Most Cost Effective Setting program and affordable access to covered medications through: Specialty drugs are expensive, and for those who have rare and serious conditions requiring newer medications • PreCheck MyScript. A digital tool that allows the prescribing physician to determine the most and emerging technologies, our Most Cost Effective affordable medication options for members. Setting program helps members receive the appropriate medication in their home, provider’s office, or infusion • Rebates at point-of-sale. Where applicable rebates are provided directly to members with deductibles center, where it costs three to four times less than if they or coinsurance plans to reduce out-of-pocket costs. received it in a hospital. • Online and mobile tools. Members access drug pricing tools to help them identify lower-cost alternatives. These tools also provide messaging regarding NEW FOR 2020! medication adherence and generic drug availability. Most of our prescription drug plans now allow members to get a 90-day supply of maintenance medication at any For our Prescription Drug plans, see page 53. Walgreens in addition to mail service. 90 DAY SUPPLY

17 Pharmacy benefits

Specialty drug savings with Briova Rx® SPECIALT Y STRATEGIES COST EFFECTIVE With the help of our specialty drug partner, BriovaRx, DRUGS* SETTING PROGRAM** members receive expert, personalized 24/7 support from pharmacists and nurses experienced in treating rare, complex, and chronic diseases. BriovaRx’s hands-on approach to personalized care includes:

• Online resources and videos $400B Clinically • Condition, clinical, and lifestyle support Estimated appropriate drugs 57 DRUGS currently covered • Side effect management National Spend for members • Tracking the impact of an intervention • Measuring disease progression 9%+ NATIONAL Safe, cost-effective $105M health care spend treatment setting in savings Video consultations Real-time, face-to-face video consultations with an expert clinician or patient care coordinator from a secure online patient portal.

Support bundles Free therapy support kit to help patients manage their condition and any treatment side effects.

Support community Patients receive tailored videos based on their condition and treatment regimen by email and can view them on any device; emails are sent throughout the course of treatment to provide continued encouragement and answer common questions a patient might have while taking the medication.

Combating the opioid crisis Independence has improved prescribing habits by adding five-day supply limits, introducing enhanced pre-authorization policies, and setting up system alerts to call attention to possible misuse. We have created programs that give those suffering from addiction access to effective community-based opioid treatment and prevention as well as doctors in our Medication Assisted Treatment (MAT) network. We are also implementing new strategies by building better integration with behavioral health services and offering alternative pain management therapies, like acupuncture, in plan benefits. By tracking claims data over a five-year period, Independence has seen a major reduction in the number of members using opioids, claims processed, and opioid dosages prescribed.

% REDUCTION % DECREASE 40 in opioid users** 46 in opioid prescriptions**

*Nationally by 2020 | ** Based on internal analytics. 2020 Large Group Plans | Independence Blue Cross 18 Spending accounts offer tax advantages and more control over health care spending With tax advantages for both employers and employees, spending accounts make a smart addition to your health plans. You can choose to offer an HSA with one of our HSA-qualified plans, or you can add an HRA or FSA1 to any other eligible health plan.

BlueSaver® HSA, HRA, and FSA

Encourage your employees to take more control over planning and paying for eligible health care expenses and help them get the most out of their health care dollars.

For employers For employees • Flexibility to choose plans that fit your budget • Tax advantages and more control over health care • Tax-advantaged spending accounts to help spending decisions lower your health care costs • Easy access through ibx.com • Easy online account maintenance and reporting • Integration of spending accounts and health claims • Convenient funding methods • Streamlined payments including debit card

HSA HRA Medical FSA1,2 Allows employers to choose lower premium Another way to help employees offset Offered as a standalone account or plans with higher deductibles while giving health care expenses, but the employer with HRA/HSA,3 giving employees Why employers offer employees a way to save for qualified contributes tax-advantaged funds only a way to pay for qualified medical medical expenses as well as future health when claims are paid, owns the account, expenses, including some that may care expenses and can define eligible categories not be covered by insurance

Compatible with HSA-qualified high-deductible health plans Any plan except HSA plans Any plan3

Who owns the account Employee Employer Employer

Who funds the account Employer and/or employee Employer Employee in most circumstances

Who establishes IRS Employer and Independence IRS with employer option to contribution rules establish lower limits Qualified medical expenses Qualified medical expenses as Qualified medical expenses Helps pay for4 determined by employer

Yes Employer option Employer option of partial Funds carry over carry-over or grace period

Portable Yes No No

1 Available to 100+ customers only. 2 Dependent care FSA also available. 3 Employers participating in an HSA can only elect a limited-purpose health care FSA. 4 Refer to IRS Publication 502 for a complete list of qualified medical and dental expenses. If account funds are used for non-qualified medical expenses, they are subject to the current tax rate and may be subject to a 20 percent penalty. Independence does not provide legal or tax advice. Consult your legal and/or tax advisor for rules regarding the tax advantages of spending accounts. 19 Additional Specialty Services

Additional benefits Our comprehensive suite of ancillary products provides a holistic approach to managing your employees' health and wealth while reducing the total cost of care.

Dental Guardian supplemental insurance Our dental plans encourage prevention, early diagnosis, and Our suite of seven Guardian-sponsored products provide treatment of conditions before they become costly problems. your employees with financial safety and security from Administered by United Concordia, all plans focus on an unexpected illness or injury. flexibility, network access, and simple plan administration. • Life insurance • Can match almost any PPO plan to limit disruption • Short- and long-term disability insurance • National network of 127,000 unique dentists and • Accident, critical illness, and cancer insurance 410,000 total locations focus on deep discounts • Hospital indemnity insurance • Annual maximum roll over and Preventive Incentive control out-of-pocket costs Employee assistance program • No waiting periods or preexisting condition clauses on most plans Help your employees work through personal matters quickly, easily, and confidentially with Personal Life ManagementSM For a sample of dental plans, see page 55. provided by Integrated Behavioral Health. • Live counseling and support for legal and financial Vision services, child care and elder care, adoption, and education planning Administered by Davis Vision®, our vision plans go beyond • Custom training for workplace performance and safety access to eye exams and eye wear. Regular eye exams can help detect more serious medical conditions like diabetes • Help managing mandatory referrals and and heart disease, as well as the effects of harmful blue worksite incidents light exposure from everyday cell phone and computer use.

• National network of more than 84,000 points of access • Low to no copay or frame allowance options • Exclusive $50 frame allowance enhancement at Visionworks* • Fixed pricing on all cosmetic options and anti-reflective coatings which protect against blue light exposure • Access to exclusive EPIC Hearing discounts on exams, hearing aids, and more

For our vision plans, see page 57.

* Visionworks enhancement available on most plans 2020 Large Group Plans | Independence Blue Cross 20 Stop loss Through HM Insurance Group (HMIG), stop loss insurance will help lower your financial risk by protecting your self-funded business against large or catastrophic claims.

• Transparent administration between medical and stop loss • Competitive pricing and flexible funding options to manage cash flow

International health insurance, available through GeoBlue®

• Short- or long-term coverage worldwide (less than 180 days or more than 6 months) • English-speaking, Western-trained physicians in over 190 countries • 24/7 concierge-level assistance plus an app to help members find care anywhere in the world

Boost your employee retention and acquisition efforts Ask your broker, consultant, or Independence account executive about adding these ancillary products to complete your benefits package.

21 51+ HEALTH PLANS PLANS FOR 51 PLUS CUSTOMERS 51 – 99 health plans

51-99 HEALTH PLANS

Copay health plans Deductible/copay health plans Give employees the predictability of fixed Balance lower premiums with predictable out-of-pocket costs out-of-pocket costs

• No deductible or coinsurance for in-network services • Copays for the most commonly used services • PPO options for more flexibility; DPOS and POS • Can be paired with a health reimbursement account options for affordability to help employees pay for deductible expenses • Built-in vision exams with DPOS and POS • Built-in vision exams with DPOS and POS

Deductible/coinsurance health plans HSA-qualified health plans Offer more control over health care choices Offer employees more control over their health care dollars

• Coinsurance on most services including but not limited • Option to save on taxes with an HSA to doctor visits, inpatient hospital admissions, and • The flexibility of a PPO, at a lower premium outpatient surgical procedures • Integrated prescription drug coverage

Choice Advantage health plans Tiered Network plans Offer employees options to save on health care Offer more choice and savings

• Members can save on care by visiting designated or • Personal Choice® PPO hospitals and facility freestanding sites instead of hospital-based sites providers are grouped into two tiers, based on cost • Plans available with and without deductibles and and quality measures coinsurance for in-network services • Members pay less when they choose tier 1 providers, but the choice is theirs • Members can save on hospital and outpatient services

NEW FOR ALL PLANS!

All plans now include a biotech/specialty injectables and infusion benefit, which means members will pay less when a drug is administered in the home or doctor’s office as opposed to an outpatient setting. Personal Choice PPO Personal Choice PPO Personal Choice PPO Keystone DPOS Keystone DPOS Keystone DPOS Copay Health Plans Keystone POS Keystone POS Keystone POS $50/$80/$500+$250 1 $40/$70/$500 1 $30/$60/$400 1

Benefits per contract year You pay in-network You pay in-network You pay in-network

Deductible — individual/family $0 $0 $0

Coinsurance 0% 0% 0% Out-of-pocket maximum — individual/family3 $7,900/$15,800 $7,900/$15,800 $7,900/$15,800

Preventive services4 Preventive care for adults and children $0 $0 $0

Preventive colonoscopy for colorectal cancer screening — $0/$750 $0/$750 $0/$750 Preventive Plus Providers/Hospital-based22

Physician services Primary care office visit/retail clinic $50 $40 $30

Specialist office visit $80 $70 $60 DPOS/POS — $405 DPOS/POS — $405 DPOS/POS — $405 Eye exam PPO — Not covered PPO — Not covered PPO — Not covered Telemedicine $40 $40 $30

Urgent care $100 $100 $100

Spinal manipulations (20 visits per year) $806,7 $706,7 $606,7

Physical/occupational therapy (30 visits per year) $806,7 $706,7 $606,7 Freestanding/Hospital-based

Hospital/other medical services Inpatient hospital services8/professional services $500 per day for days 1-5, $500 per day10/$0 $400 per day10/$0 (includes maternity) $250 per day for days 6-109/$0

Emergency room (not waived if admitted)11 $300 $300 $300

Observation room (waived if admitted) $300 $300 $300

Routine radiology/diagnostic — Freestanding/Hospital-based20 $807 $707 $607

MRI/MRA, CT/CTA scan, PET scan — $300 $300 $200 Freestanding/Hospital-based Biotech/specialty injectables — home or office/outpatient $150/$300 $150/$300 $150/$300 Infusion — home or office/outpatient $50/$100 $40/$80 $30/$60 Durable medical equipment/prosthetics 50% 50% 50% Mental health, serious mental illness, and substance abuse $80/$500 per day for days 1-5, $70/$500 per day10 $60/$400 per day10 — outpatient/inpatient8 $250 per day for days 6-109 Outpatient surgery — Ambulatory surgical center/Hospital-based $500 $500 $400 $0 (POS/DPOS) $0 (POS/DPOS) $0 (POS/DPOS) Outpatient lab/pathology — Freestanding/Hospital-based $0/$160 (PPO) $0/$140 (PPO) $0/$120 (PPO)

Prescription drugs Low-cost generic drugs Generic drugs See prescription drug plans on See prescription drug plans on See prescription drug plans on Preferred brand drugs pages 53 – 54 pages 53 – 54 pages 53 – 54 Non-preferred drugs Self-administered specialty drugs

Out-of-network18,19 You pay 0ut-of-network You pay 0ut-of-network You pay 0ut-of-network $2,500/$5,000 (PPO/DPOS) $2,500/$5,000 (PPO/DPOS) $2,500/$5,000 (PPO/DPOS) Deductible 5,000/$10,000 (POS) 5,000/$10,000 (POS) 5,000/$10,000 (POS) Coinsurance 50% after ded 50% after ded 50% after ded $10,000/$20,000 (PPO/DPOS) $10,000/$20,000 (PPO/DPOS) $10,000/$20,000 (PPO/DPOS) Out-of-pocket maximum — individual/family21 $30,000/$60,000 (POS) $30,000/$60,000 (POS) $30,000/$60,000 (POS)

23 Personal Choice PPO Keystone DPOS Personal Choice PPO Keystone POS $15/$35/$150 1 $20/$40/$250 1

You pay in-network You pay in-network

$0 $0

0% 0% $7,900/$15,800 $7,900/$15,800

$0 $0

$0/$750 $0/$750

$20 $15

$40 $35 DPOS/POS — $355 Not covered PPO — Not covered $20 $15

$85 $70

$406,7 $356

$250 per day10/$0 $150 per day10/$0

$250 $200

$407 $35

$80 $70

$100/$200 $100/$200 $20/$40 $15/$30 50% 50%

$40/$250 per day10 $35/$150 per day10

$250 $150 $0 (POS/DPOS) $0 (POS/DPOS) $0/$80 (PPO) $0/$70 (PPO)

See prescription drug plans on pages 53 – 54 See prescription drug plans on pages 53 – 54

You pay 0ut-of-network You pay 0ut-of-network $2,500/$5,000 (PPO/DPOS) $2,500/$5,000 5,000/$10,000 (POS) 50% after ded 50% after ded $10,000/$20,000 (PPO/DPOS) $10,000/$20,000 $30,000/$60,000 (POS)

Footnotes begin on page 50 | ded = Deductible 2020 Large Group Plans | Independence Blue Cross 24 Personal Choice PPO Keystone POS Keystone DPOS Deductible/Copay Health Plans $3,500/$20/$40/70% 1 Keystone POS $2,000/$30/$60/80% 1

Benefits per contract year You pay in-network You pay in-network

Deductible — individual/family $3,500/$7,000 $2,000/$4,000

Coinsurance 30% 20%

Out-of-pocket maximum — individual/family3 $7,900/$15,800 $7,900/$15,800

Preventive services4 Preventive care for adults and children 0% no ded 0% no ded

Preventive colonoscopy for colorectal cancer screening — $0/$750 no ded $0/$750 no ded Preventive Plus Providers/Hospital-based22

Physician services Primary care office visit/retail clinic $20 no ded $30 no ded

Specialist office visit $40 no ded $60 no ded DPOS/POS — $40 no ded5 Eye exam $35 no ded5 PPO — Not covered Telemedicine $20 no ded $30 no ded

Urgent care $85 no ded $100 no ded

Spinal manipulations (20 visits per year) $40 no ded7 $60 no ded6,7

Physical/occupational therapy (30 visits per year) Freestanding/Hospital-based $40 no ded7 $60 no ded6,7

Hospital/other medical services

Inpatient hospital services8/professional services (includes maternity) 30% after ded/30% after ded 20% after ded/20% after ded

Emergency room (not waived if admitted)11 $250 after ded $300 after ded

Observation room (waived if admitted) 30% after ded 20% after ded

Routine radiology/diagnostic — Freestanding/Hospital-based20 $40 no ded7 $60 no ded7

MRI/MRA, CT/CTA scan, PET scan — Freestanding/Hospital-based $80 no ded $200 no ded

Biotech/specialty injectables — home or office/outpatient $100 no ded/$200 no ded $150 no ded/$300 no ded

Infusion — home or office/outpatient 30% after ded/50% after ded 20% after ded/40% after ded

Durable medical equipment/prosthetics 30% after ded 20% after ded

Mental health, serious mental illness, and substance abuse $40 no ded/30% after ded $60 no ded/20% after ded — outpatient/inpatient8

Outpatient surgery — Ambulatory surgical center/Hospital-based 30% after ded 20% after ded

$60 no ded (POS/DPOS) Outpatient lab/pathology — Freestanding/Hospital-based $40 no ded $60 no ded/$120 no ded (PPO)

Prescription drugs Low-cost generic drugs Generic drugs See prescription drug plans on See prescription drug plans on Preferred brand drugs pages 53 – 54 pages 53 – 54 Non-preferred drugs Self-administered specialty drugs

Out-of-network18,19 You pay 0ut-of-network You pay 0ut-of-network Deductible $5,000/$10,000 $5,000/$10,000 Coinsurance 50% after ded 50% after ded $10,000/$20,000 (PPO/DPOS) Out-of-pocket maximum — individual/family21 $30,000/$60,000 $30,000/$60,000 (POS)

25 Personal Choice PPO Personal Choice PPO Personal Choice PPO Keystone DPOS Keystone DPOS Keystone DPOS Keystone POS Keystone POS Keystone POS $3,000/$30/$60/90% 1 $4,000/$30/$60/90% 1 $5,000/$30/$60/90% 1

You pay in-network You pay in-network You pay in-network

$3,000/$6,000 $4,000/$8,000 $5,000/$10,000

10% 10% 10%

$7,900/$15,800 $7,900/$15,800 $7,900/$15,800

0% no ded 0% no ded 0% no ded

$0/$750 no ded $0/$750 no ded $0/$750 no ded

$30 no ded $30 no ded $30 no ded

$60 no ded $60 no ded $60 no ded DPOS/POS — $40 no ded5 DPOS/POS — $40 no ded5 DPOS/POS — $40 no ded5 PPO — Not covered PPO — Not covered PPO — Not covered $30 no ded $30 no ded $30 no ded

$100 no ded $100 no ded $100 no ded

$60 no ded6,7 $60 no ded6,7 $60 no ded6,7

10% after ded/10% after ded 10% after ded/10% after ded 10% after ded/10% after ded

$300 after ded $300 after ded $300 after ded

10% after ded 10% after ded 10% after ded

$60 no ded7 $60 no ded7 $60 no ded7

$200 no ded $200 no ded $200 no ded

$150 no ded/$300 no ded $150 no ded/$300 no ded $150 no ded/$300 no ded

10% after ded/30% after ded 10% after ded/30% after ded 10% after ded/ 30% after ded

10% after ded 10% after ded 10% after ded

$60 no ded/10% after ded $60 no ded/10% after ded $60 no ded/10% after ded

10% after ded 10% after ded 10% after ded

$60 no ded (POS/DPOS) $60 no ded (POS/DPOS) $60 no ded (POS/DPOS) $60 no ded/$120 no ded (PPO) $60 no ded/$120 no ded (PPO) $60 no ded/$120 no ded (PPO)

See prescription drug plans on pages 53 – 54 See prescription drug plans on pages 53 – 54 See prescription drug plans on pages 53 – 54

You pay 0ut-of-network You pay 0ut-of-network You pay 0ut-of-network $5,000/$10,000 $6,000/$12,000 $7,500/$15,000 50% after ded 50% after ded 50% after ded $10,000/$20,000 (PPO/DPOS) $12,000/$24,000 (PPO/DPOS) $15,000/$30,000 (PPO/DPOS) $30,000/$60,000 (POS) $30,000/$60,000 (POS) $30,000/$60,000 (POS)

Footnotes begin on page 50 | ded = Deductible 2020 Large Group Plans | Independence Blue Cross 26 Personal Choice PPO Personal Choice PPO Keystone DPOS Deductible/Copay Health Plans $1,500/$20/$40/100% 1 Keystone POS $2,500/$30/$60/100% 1

Benefits per contract year You pay in-network You pay in-network

Deductible — individual/family $1,500/$3,000 $2,500/$5,000

Coinsurance 0% 0%

Out-of-pocket maximum — individual/family3 $7,900/$15,800 $7,900/$15,800

Preventive services4 Preventive care for adults and children 0% no ded 0% no ded

Preventive colonoscopy for colorectal cancer screening — $0/$750 no ded $0/$750 no ded Preventive Plus Providers/Hospital-based22

Physician services Primary care office visit/retail clinic $20 no ded $30 no ded

Specialist office visit $40 no ded $60 no ded DPOS/POS — $40 no ded5 Eye exam Not covered PPO — Not covered

Telemedicine $20 no ded $30 no ded

Urgent care $85 no ded $100 no ded

Spinal manipulations (20 visits per year) $40 no ded6 $60 no ded6,7

Physical/occupational therapy (30 visits per year) Freestanding/Hospital-based $40 no ded6 $60 no ded6,7

Hospital/other medical services Inpatient hospital services8/professional services 0% after ded/0% after ded 0% after ded/0% after ded (includes maternity) Emergency room (not waived if admitted)11 $250 after ded $300 after ded

Observation room (waived if admitted) $250 after ded $300 after ded

Routine radiology/diagnostic — Freestanding/Hospital-based20 $40 no ded $60 no ded7

MRI/MRA, CT/CTA scan, PET scan — Freestanding/Hospital-based $80 no ded $200 no ded

Biotech/specialty injectables — home or office/outpatient $100 no ded/$200 no ded $150 no ded/$300 no ded

Infusion — home or office/outpatient 0% after ded/20% after ded 0% after ded/20% after ded

Durable medical equipment/prosthetics 0% after ded 0% after ded

Mental health, serious mental illness, and substance abuse $40 no ded/0% after ded $60 no ded/0% after ded — outpatient/inpatient8

Outpatient surgery — Ambulatory surgical center/Hospital-based 0% after ded 0% after ded

$60 no ded (POS/DPOS) Outpatient lab/pathology — Freestanding/Hospital-based $40 no ded/$80 no ded $60 no ded/$120 no ded (PPO)

Prescription drugs Low-cost generic drugs Generic drugs Preferred brand drugs See prescription drug plans on See prescription drug plans on pages 53 – 54 pages 53 – 54 Non-preferred drugs

Self-administered specialty drugs

27 Personal Choice PPO Personal Choice PPO Keystone DPOS Keystone DPOS Personal Choice PPO Keystone POS Keystone POS $6,000/$20/$40/100% 1 $3,000/$30/$60/100% 1 $5,000/$40/$70/100% 1

You pay in-network You pay in-network You pay in-network

$3,000/$6,000 $5,000/$10,000 $6,000/$12,000

0% 0% 0%

$7,900/$15,800 $7,900/$15,800 $7,900/$15,800

0% no ded 0% no ded 0% no ded

$0/$750 no ded $0/$750 no ded $0/$750 no ded

$30 no ded $40 no ded $20 no ded

$60 no ded $70 no ded $40 no ded DPOS/POS — $40 no ded5 DPOS/POS — $40 no ded5 Not covered PPO — Not covered PPO — Not covered

$30 no ded $40 no ded $20 no ded

$100 no ded $100 no ded $85 no ded

$60 no ded6,7 $70 no ded6,7 $40 no ded6

0% after ded/0% after ded 0% after ded/0% after ded 0% after ded/0% after ded

$300 after ded $300 after ded $250 after ded

$60 no ded7 $70 no ded7 $40 no ded

$200 no ded $300 no ded $80 no ded

$150 no ded/$300 no ded $150 no ded/$300 no ded $100 no ded/$200 no ded

0% after ded/20% after ded 0% after ded/20% after ded 0% after ded/20% after ded

0% after ded 0% after ded 0% after ded

$60 no ded/0% after ded $70 no ded/0% after ded $40 no ded/0% after ded

0% after ded 0% after ded 0% after ded

$60 no ded (POS/DPOS) $70 no ded (POS/DPOS) $40 no ded (POS/DPOS) $60 no ded/$120 no ded (PPO) $70 no ded/$140 no ded (PPO) $40 no ded/$80 no ded (PPO)

See prescription drug plans on pages 53 – 54 See prescription drug plans on pages 53 – 54 See prescription drug plans on pages 53 – 54

You pay 0ut-of-network You pay 0ut-of-network You pay 0ut-of-network $5,000/$10,000 $7,500/$15,000 $9,000/$18,000 50% after ded 50% after ded 50% after ded $10,000/$20,000 (PPO/DPOS) $15,000/$30,000 (PPO/DPOS) $18,000/$36,000 $30,000/$60,000 (POS) $30,000/$60,000 (POS)

Footnotes begin on page 50 | ded = Deductible 2020 Large Group Plans | Independence Blue Cross 28 Deductible/Coinsurance Health Plan

Benefits per contract year

Deductible — individual/family

Coinsurance

Out-of-pocket maximum — individual/family3

Preventive services4 Preventive care for adults and children

Preventive colonoscopy for colorectal cancer screening — Preventive Plus Providers/Hospital-based22

Physician services Primary care office visit/retail clinic

Specialist office visit

Eye exam

Telemedicine

Urgent care

Spinal manipulations (20 visits per year)

Physical/occupational therapy (30 visits per year) Freestanding/Hospital-based

Hospital/other medical services

Inpatient hospital services8/professional services (includes maternity)

Emergency room (not waived if admitted)11

Observation room (waived if admitted)

Routine radiology/diagnostic — Freestanding/Hospital-based20

MRI/MRA, CT/CTA scan, PET scan — Freestanding/Hospital-based

Biotech/specialty injectables — home or office/outpatient

Infusion — home or office/outpatient

Durable medical equipment/prosthetics

Mental health, serious mental illness, and substance abuse — outpatient/inpatient8

Outpatient surgery — Ambulatory surgical center/Hospital-based

Outpatient lab/pathology — Freestanding/Hospital-based

Prescription drugs12,14 Low-cost generic drugs13,15,16 Generic drugs13,16 Preferred brand drugs13,16 Non-preferred drugs13,16

Self-administered specialty drugs17

Out-of-network18,19 Deductible Coinsurance

Out-of-pocket maximum — individual/family21

29 Personal Choice PPO PPO $4000/90% w Int Rx

You pay in-network

$4,000/$8,000

10%

$7,900/$15,800

0% no ded

$0 no ded/$750 no ded

10% after ded

Not covered

0% no ded

10% after ded

10% after ded6

10% after ded/10% after ded

10% after ded

10% after ded/30% after ded

10% after ded

10% after ded/10% after ded

10% after ded

10% after ded/20% after ded

$5 after ded $20 after ded $40 after ded $70 after ded

50% up to $500 after ded

You pay 0ut-of-network $6,000/$12,000 50% after ded

$12,000/$24,000

Footnotes begin on page 50 | ded = Deductible 2020 Large Group Plans | Independence Blue Cross 30 Personal Choice PPO Personal Choice PPO Personal Choice PPO HSA-qualified Health Plans $2,000/80% 2 $3,000/80% 2 $5,000/80% 2

Benefits per contract year You pay in-network You pay in-network You pay in-network

Deductible — individual/family $2,000 /$4,000 $3,000/$6,000 $5,000/$10,000

Coinsurance 20% 20% 20% Out-of-pocket maximum — individual/family3 $6,750/$13,500 $6,750/$13,500 $6,750/$13,500

Preventive services4 Preventive care for adults and children 0% no ded 0% no ded 0% no ded

Preventive colonoscopy for colorectal cancer screening — $0/$750 no ded $0/$750 no ded $0/$750 no ded Preventive Plus Providers/Hospital-based22

Physician services Primary care office visit/retail clinic 20% after ded 20% after ded 20% after ded

Specialist office visit 20% after ded 20% after ded 20% after ded

Eye exam Not covered Not covered Not covered

Telemedicine 20% after ded 20% after ded 20% after ded

Urgent care 20% after ded 20% after ded 20% after ded

Spinal manipulations (20 visits per year) 20% after ded6 20% after ded6 20% after ded6

Physical/occupational therapy (30 visits per year) 20% after ded6 20% after ded6 20% after ded6 Freestanding/Hospital-based

Hospital/other medical services Inpatient hospital services8/professional services 20% after ded/20% after ded 20% after ded/20% after ded 20% after ded/20% after ded (includes maternity)

Emergency room (not waived if admitted)11 20% after ded 20% after ded 20% after ded

Observation room (waived if admitted) 20% after ded 20% after ded 20% after ded

Routine radiology/diagnostic — Freestanding/Hospital-based20 20% after ded 20% after ded 20% after ded

MRI/MRA, CT/CTA scan, PET scan — 20% after ded 20% after ded 20% after ded Freestanding/Hospital-based

Biotech/specialty injectables — home or office/outpatient 20% after ded/40% after ded 20% after ded/40% after ded 20% after ded/40% after ded

Infusion — home or office/outpatient 20% after ded/40% after ded 20% after ded/40% after ded 20% after ded/40% after ded

Durable medical equipment/prosthetics 20% after ded 20% after ded 20% after ded

Mental health, serious mental illness, and substance abuse 20% after ded/20% after ded 20% after ded/20% after ded 20% after ded/20% after ded — outpatient/inpatient8

Outpatient surgery — 20% after ded 20% after ded 20% after ded Ambulatory surgical center/Hospital-based

Outpatient lab/pathology — Freestanding/Hospital-based 20% after ded/30% after ded 20% after ded/30% after ded 20% after ded/30% after ded

Prescription drugs12,14 Low-cost generic drugs13,15,16 $5 after ded $5 after ded $5 after ded Generic drugs13,16 $20 after ded $20 after ded $20 after ded Preferred brand drugs13,16 $40 after ded $40 after ded $40 after ded Non-preferred drugs13,16 $70 after ded $70 after ded $70 after ded

Self-administered specialty drugs17 50% up to $500 after ded 50% up to $500 after ded 50% up to $500 after ded

Out-of-network18,19 You pay 0ut-of-network You pay 0ut-of-network You pay 0ut-of-network Deductible $5,000/$10,000 $5,000/$10,000 $7,500/$15,000 Coinsurance 50% after ded 50% after ded 50% after ded Out-of-pocket maximum — individual/family21 $10,000/$20,000 $10,000/$20,000 $15,000/$30,000

31 Personal Choice PPO Personal Choice PPO Personal Choice PPO Personal Choice PPO $2,500/90% 2 $5,000/70% 2 $3,000/90% 2 $4,000/90% 2

You pay in-network You pay in-network You pay in-network You pay in-network

$2,500 /$5,000 $5,000/$10,000 $3,000/$6,000 $4,000 /$8,000

10% 30% 10% 10% $6,750/$13,500 $6,750/$13,500 $6,750/$13,500 $6,750/$13,500

0% no ded 0% no ded 0% no ded 0% no ded

$0/$750 no ded $0 no ded/$750 no ded $0/$750 no ded $0/$750 no ded