Western Pennsylvania Region Benefit Portfolio for Small Groups Effective January 1, 2018

WESTERN PENNSYLVANIA REGION BENEFIT PORTFOLIO For Small Groups Efective January 1, 2018

(27606) HIGHMARKBCBS.COM this page was left blank intentionally TABLE OF CONTENTS

INTRODUCTION PAGE 1 2018 Highmark Portfolio Overview by County Essential Health Benefits Categories Metal Levels Finding a Provider Access to Quality Care & 2018 Provider Network Blue Cross Blue Shield Difference

PPO BLUE PAGE 6 Product Description, Service Area Map & Provider Network Benefit Grids — Service Areas: Zone C – All 29 Counties of Western PA: Allegheny, Armstrong, Beaver, Butler, Fayette, Greene, Indiana, Lawrence, Washington, Westmoreland, Crawford, Erie, McKean, Mercer, Warren, Bedford, Blair, Cambria, Centre,Clearfield, Huntingdon, Jefferson, Somerset, Cameron, Clarion, Elk, Forest, Potter, and Venango

COMMUNITY BLUE FLEX PAGE 16 Product Description, Service Area Map & Provider Network Benefit Grids — Service Areas: Zone A: Allegheny, Armstrong, Beaver, Butler, Crawford, Erie, Fayette, Greene, Indiana, Lawrence, McKean, Mercer, Warren, Washington and Westmoreland Zone B: Bedford, Blair, Cambria, Cameron, Centre, Clarion, Clearfield, Elk, Forest, Huntingdon, Jefferson, Potter, Somerset, and Venango Zone G: PA Mountains Healthcare Region available in Armstrong, Blair, Cameron, Clarion, Crawford, Forest, Huntingdon, Jefferson, Indiana, Lawrence, McKean, Potter, and Somerset Zone H: Penn Highlands Region available in Centre, Clearfield, Elk, and Jefferson

CONNECT BLUE & CONEMAUGH REGION CONNECT BLUE PAGE 32 Product Description, Service Area Map & Provider Network Benefit Grids — Service Areas: Zone J: Allegheny, Beaver, Butler, Erie, Washington, and Westmoreland Zone Y: Blair, Cambria and Somerset

PEDIATRIC DENTAL & VISION BENEFIT INFO PAGE 40 Pediatric Dental: benefits apply to Qualified High Deductible Health Plans (QHDHP) Pediatric Dental: benefits apply to Non-QHDHPs Pediatric Vision: benefits apply to Qualified High Deductible Health Plans (QHDHP) Pediatric Vision: benefits apply to Non-QHDHPs INTRODUCTION

At Highmark we believe one size never fts all. That’s why we ofer a range of fexible, high-performing network solutions built specifcally to meet the unique needs of Small Groups (with 50 or fewer full-time, part-time, and seasonal employees). Choosing health coverage is one of the most important decisions to make each year and Highmark understands the importance of providing reliable, afordable health coverage that provides peace of mind. The result of our broad network of providers and superior customer service is a health plan that has been trusted for more than 85 years by generations of satisfed members. To provide you with the information and tools you need, and to make it easier for you to present the Highmark beneft options to your clients, we created this 2018 Product Portfolio. It was designed for easier viewing of all of the health plan options by putting the most important facts and fgures front and center (including network information and more).

2018 Highmark Portfolio Overview by County

ERIE ERIE MCKEAN MCKEAN WARREN POTTER WARREN POTTER CRAWFORD CRAWFORD

FOREST FOREST CAMERON CAMERON VENANGO ELK VENANGO ELK MERCER MERCER CLARION JEFFERSON JEFFERSON CLARION LAWRENCE LAWRENCE BUTLER CLEARFIELD CLEARFIELD CENTRE CENTRE BUTLER ARMSTRONG BUTLER ARMSTRONG Zone A BEAVER

BEAVER INDIANA BEAVER INDIANA ALLEGHENY ERIE BLAIR BLAIR Zone B ALLEGHENY ALLEGHENY CAMBRIA CAMBRIA WESTMORELAND WESTMORELAND HUNTINGDON WESTMORELAND HUNTINGDON Zone G WASHINGTON WASHINGTON WASHINGTON PA Mountains Zone J BEDFORD Zone C BEDFORD Healthcare Region FAYETTE SOMERSET FAYETTE SOMERSET GREENE GREENE Zone H Penn Highlands Region

Premier Balance PPO $0 Platinum A Flex PPO $500/$1500 Penn Highlands Region Connect Blue EPO $100 a Community Blue Plan a Community Blue Plan Premier Balance PPO $250 Platinum A Connect Blue EPO $250 a Community Blue Plan Flex PPO PA Mountains Healthcare Region $500/$1500 Premier Balance PPO $0 Gold A a Community Blue Plan Connect Blue EPO $500 a Community Blue Plan Premier Balance PPO $250 Gold A Premier Balance PPO $0 Platinum A a Community Blue Flex Plan Connect Blue EPO $750 a Community Blue Plan Premier Balance PPO $500 A Premier Balance PPO $250 Platinum A a Community Blue Flex Plan Connect Blue EPO $900 a Community Blue Plan Premier Balance PPO $750 A Premier Balance PPO $0 Gold A a Community Blue Flex Plan Connect Blue EPO $1100 a Community Blue Plan Premier Balance PPO $1000 A Premier Balance PPO $250 Gold A a Community Blue Flex Plan Connect Blue EPO $2500 a Community Blue Plan Balance PPO $1000 A Premier Balance PPO $500 A a Community Blue Flex Plan Connect Blue EPO $3200 a Community Blue Plan Premier Balance PPO $1250 A Premier Balance PPO $750 A a Community Blue Flex Plan Premier Balance PPO $1400 A Premier Balance PPO $1000 A a Community Blue Flex Plan Premier Balance PPO $1500 A Balance PPO $1000 a Community Blue Flex Plan Premier Balance PPO $1250 A a Community Blue Flex Plan BLAIR Health Savings PPO $1500 CAMBRIA Premier Balance PPO $1400 A a Community Blue Flex Plan Balance PPO $1750 A Premier Balance PPO $1500 A a Community Blue Flex Plan Premier Balance PPO $2000 A Health Savings PPO $1500 a Community Blue Flex Plan Zone Y Balance PPO $2000 A SOMERSET Balance PPO $1750 A a Community Blue Flex Plan Premier Balance PPO $2500 A Premier Balance PPO $2000 A a Community Blue Flex Plan Health Savings PPO Embedded $2600 Balance PPO $2000 A a Community Blue Flex Plan Conemaugh Region Connect Blue EPO $0 Premier Balance PPO $3500 A Balance PPO $600 a Community Blue Flex Plan Conemaugh Region Connect Blue EPO $1000 Health Savings PPO Embedded $4000 Balance PPO $2600 a Community Blue Flex Plan Conemaugh Region Connect Blue EPO $3800 High Deductible PPO Embedded $4750 Qualified A Health Savings PPO Embedded $2600 a Community Blue Flex Plan Conemaugh Region Connect Blue EPO Embedded $5000 Health Savings PPO Embedded $5500 Health Savings PPO Embedded $3000 a Community Blue Flex Plan High Deductible PPO Embedded $6300 Qualified A Balance PPO $5000 1x a Community Blue Flex Plan Health Savings PPO Embedded $5500 a Community Blue Flex Plan Health Savings PPO Embedded $6000 a Community Blue Flex Plan

Premier Balance PPO $250 IP A a Community Blue Flex Plan Premier Balance PPO $750 IP A a Community Blue Flex Plan Premier Balance PPO $1500 IP A a Community Blue Flex Plan 1 Health Savings PPO Embedded $5500 a Community Blue Flex Plan ESSENTIAL HEALTH BENEFITS CATEGORIES

All Affordable Care Act (ACA) compliant plans must cover the following Essential Health Benefts categories to a benchmark level of coverage established by the state: • Ambulatory patient services • Emergency services • Hospitalization • Maternity and newborn care • Mental health and substance use disorder services • Prescription drugs • Rehabilitative and habilitative services and devices • Laboratory services • Preventive and wellness services and chronic disease • Pediatric services including oral and vision management

Pediatric Dental and Vision services are ofered to children under the age of 19; services include dental and vision checkups, as well as one pair of glasses per year. These services are integrated into all plans in the Small Group market. Prescription Drugs are ofered with cost sharing within all plans.

METAL LEVELS

Under health care reform, insurance companies must defne the level of health care costs a particular plan will pay (on average) for covered benefts. To make it easier to understand, the government established metal levels.

Out-of-Pocket Costs Estimated Plan Cost

Platinum Plans Lowest $$$$

Gold Plans Low $$$

Silver Plans Moderate $$

Bronze Plans High $

FINDING A PROVIDER IS EASY

There Are Several Ways to Find Providers

Search Find a Doctor on Call My Care Navigator at Call the Member Service highmarkbcbs.com 1-888-BLUE-428. number on the back of the (no login required). Members can Representatives can help Highmark ID card. use this search, no matter where members fnd a new doctor and they are to fnd all Blue Network transfer their health records. providers. Access to quality care 2018 provider

• Reliable health care coverage and member service and network information support from a health insurer with 75 years’ experience. • A network of high -performing, patient- focused care Know Your Options for Care providers and specialists. With Highmark, members will have access to the region’s leading • Allegheny Health Network (AHN) hospitals and health care providers, including those that are a part of Allegheny physicians anchor Highmark ’s western Pennsylvania Health Network, as well as other community hospitals. They’ll provider network. As an integrated health system, also have access to all UPMC facilities outside of the fve-county AHN ’s physicians, nurses, and staf are dedicated to Pittsburgh region. Members who have been diagnosed with cancer providing exceptional care across seven hospitals, 4 have in-network access to all UPMC services, facilities, doctors, and Health+Wellness Pavilions, and hundreds of care facil - joint ventures for oncology covered services through June 2019. This includes illnesses and complications resulting from cancer treatment, ities. AHN has received numerous national, regional, such as endocrinology, orthopedics, and cardiology. (The member’s and local accolades for superior outcomes, quality physician must determine that the member should be treated by a care, and positive impacts on the community. As one UPMC provider who renders oncology services.)1 of the largest health care systems serving western PA, many hospitals are ranked #1 in the market for ER Access delivering the highest quality of care in several clinical categories according to the Quantros’ CareChex® 2017 Members who seek care at any UPMC emergency room will be Hospital Quality Ratings. covered at in-network rates, including any inpatient admission and follow-up care for the emergency condition.2 • Access to nearly 720,000 providers in the BluelCross BlueiShield network across the country. “Continuation of Care” for Members in Treatment Now • Health and wellness discounts on products, services, Members who were in a continuing course of treatment for a chronic classes, and ftness facilities. or persistent condition in 2013, 2014, or 2015 with a UPMC provider or an independent provider and received care for that condition at UPMC can receive care from those providers at the in-network level of benefts through June 2019 if the care is related to, or in conjunction with, a chronic or persistent condition. This includes routine, preventive, and acute care that is received during treatment for a chronic or persistent condition. Otherwise, routine and preventive care will not be covered on an in-network basis.1 Members cannot be referred to or treated by a new UPMC doctor on an in-network basis for care related to a chronic or persistent condition or other conditions they might have or develop. A “new” UPMC doctor means a doctor they have not seen in the past. Allegheny Health Network hospitals

Erie “Balance Bill” Protection McKean Potter Warren Crawford Out-of-network UPMC providers can only bill Highmark members up to the diference between the Plan’s payment and 60% of the UPMC Forest Venango Elk Cameron provider’s billed charges for covered services. Mercer

Clarion Jefferson To view the most up-to-date information on the Butler Lawrence Clearfield Centre Consent Decree and in-network access to UPMC, Armstrong visit DiscoverHighmark.com. Beaver Indiana Allegheny Cambria Blair Huntingdon Westmoreland Bedford Washington Fayette Somerset Greene

1When members enrolled in Community Blue Flex and Connect Blue products access UPMC facilities in network for oncology/cancer services and continuation of care. The specifc terms of coverage will be according to the member’s beneft plan. Covered claims from UPMC may be processed at the lower level of benefts. 2 Emergency room and any related inpatient care is covered at the Enhanced Value Level of Benefts for Community Blue Flex products and at the Preferred Value Level of Benefts for Connect Blue. The specifc terms of coverage will be according to the member’s beneft plan. THE BLUE CROSS BLUE SHIELD® DIFFERENCE: LOCAL FOCUS, NATIONAL SCALE

Blue Cross Blue Shield One of the Most Recognized Brands in Health Insurance Blue Cross Blue Shield’s unmatched scale, both domestically and globally, makes Highmark uniquely positioned to provide the best health insurance for our members and your families, no matter where you work, live, or travel.

Nationwide 96 percent of hospitals and 93 percent of physicians in every zip code in the 50 states, as well as the District of Columbia and Puerto Rico, participate in BlueCard program.

Globally, through the BlueCard and Blue Cross Blue Shield Global Core programs, members have access to the largest network of physicians and hospitals across more than 170 countries.

Investing in Local Communities For decades, the Highmark has been investing in their communities to lead local change and improve the health of residents.

Blue Cross Blue Shield Global Core® Blue Cross Blue Shield Global Core® is a national program that BLUE CROSS BLUE SHIELD GLOBAL CORE® links participating health care providers and the independent Blue plans across the country and around the world. When you need medical help, call this number from the United States, Puerto Rico or Panama: Members are covered anywhere within the network, just as they are through their “home” plan. Plans interact through an 1-800-810-BLUE electronic network for claims processing and reimbursement. From other locations call 1-804-673-1177. BCBSGlobalCore.com Blue networks are powered by Blue Cross Blue Shield Global Core® and provide: • Seamless, nationwide access to provider networks and discounts • Consistency in health care benefits wherever employees live or travel • Timely settlements, centralized decision-making, and robust reporting

Blue Cross Blue Shield Global Core® provides access to physicians and hospitals in more than 200 countries, along with value-added medical assistance and claims support services

Blue Cross Blue Sield Association (BCBSA), Blue Facts (June 2017). Retrieved from https://www.bcbs.com/sites/default/files/file-attachments/page/BCBS.Facts__0.pdf 9/5/17 this page was left blank intentionally

5 WESTERN PENNSYLVANIA REGION

PPO BLUE

For Small Groups

Efective January 1, 2018

6 PPO BLUE

Highmark ofers multiple plan designs within Preferred Provider Organization (PPO) plans at all metal levels.

In this type of health plan, members pay less if they use providers in the plan’s network. They can also use providers outside of the plan’s network, but will generally have higher out-of-pocket costs.

Outside western Pennsylvania, providers that participate in their local Blue Cross and/or Blue Shield PPO network, or Blue Card® program are covered in network.

SERVICE AREA

ERIE MCKEAN WARREN POTTER CRAWFORD

FOREST CAMERON VENANGO ELK MERCER JEFFERSON CLARION LAWRENCE CLEARFIELD CENTRE BUTLER ARMSTRONG

BEAVER INDIANA

BLAIR ALLEGHENY CAMBRIA WESTMORELAND HUNTINGDON Zone C WASHINGTON

BEDFORD FAYETTE SOMERSET GREENE

7 PROVIDER NETWORK

PPO BLUE FACILITY LISTING

ALLEGHENY CLARION MCKEAN • Allegheny General Hospital • Clarion Hospital • Bradford Regional • Allegheny Valley Hospital CLEARFIELD Medical Center • Children’s Hospital of Pittsburgh • Penn Highlands Clearfeld • Kane Community Hospital of UPMC • Penn Highlands DuBois MERCER • Forbes Hospital CRAWFORD • Edgewood Surgical Hospital • Heritage Valley Sewickley • Grove City Medical Center • Jeferson Hospital • Meadville Medical Center • Titusville Area Hospital • Sharon Regional Health System • Ohio Valley Hospital • UPMC Horizon • St. Clair Hospital ELK POTTER • West Penn Hospital • Penn Highlands Elk • Cole Memorial • Western Psychiatric Institute ERIE and Clinic • Corry Memorial Hospital SOMERSET ARMSTRONG • Millcreek Community Hospital • Conemaugh Meyersdale Medical Center • Armstrong County Memorial • Saint Vincent Hospital • Somerset Hospital Hospital • UPMC Hamot • Chan Soon-Shiong Medical BEAVER FAYETTE Center at Windber • Heritage Valley Beaver • Highlands Hospital VENANGO • Uniontown Hospital BEDFORD • UPMC Northwest • UPMC Bedford Memorial GREENE WARREN • Washington Health BLAIR • Warren General Hospital • Nason Hospital System Greene WASHINGTON • Tyrone Hospital HUNTINGDON • Advanced Surgical Hospital • UPMC Altoona • J. C. Blair Memorial Hospital • Canonsburg Hospital BUTLER INDIANA • Monongahela Valley Hospital • Butler Memorial Hospital • Indiana Regional Medical Center • Washington Hospital CAMBRIA JEFFERSON WESTMORELAND • Conemaugh Memorial • Penn Highlands Brookville • Excela Frick Hospital Medical Center • Punxsutawney Area Hospital • Excela Latrobe Hospital • Conemaugh Miners LAWRENCE • Excela Westmoreland Hospital Medical Center • Ellwood City Hospital • UPMC Jameson

The BlueCard® Program - With the Blue Cross and Blue Shield BlueCard® network, your coverage travels with you. When you enroll in a Highmark plan, you have access to thousands of providers and hospitals nationwide. Getting access to care is as easy as presenting your Highmark identification (ID) card. Providers who participate with the local Blue Cross and Blue Shield plan, wherever you are, will recognize and honor your card. So no matter where you go, your benefits go with you.

*Provider list as of September 2017. Please refer to the online Find a Doctor tool at highmarkbcbs.com for a listing of network hospitals. 8 2018 PPO BLUE For Small Groups with 50 or fewer employees HIGHMARKBCBS.COM Basic Diagnostic Services Plan Payment Level Primary Advanced Imaging Out-of-Pocket Urgent Inpatient Emergency (standard imaging, Rx Formulary Medical Deductible (Coinsurance) Care Specialist2 Telemedicine (MRI, CAT, PET scan, Maximum1 Care Hospital Room diagnostic medical, (Comprehensive)3 After Deductible Provider etc.) lab/pathology, etc.) For Health Plans Low Cost Generic/Standard with Effective Dates Out-of- Out-of- Out-of- In-Network In-Network In-Network Generic/Brand Formulary/ Beginning January 1, 2018 Network Network Network In-Network In-Network In-Network In-Network In-Network In-Network In-Network In-Network Non-Formulary/ (2 x Family) (2 x Family) (2 x Family) (2 x Family) (2 x Family) (2 x Family) Specialty Formulary/ Specialty Non-Formulary Member Pays Plan Pays Member Pays Premier Balance PPO $3/$10/$50/ $0 $500 100% 80% $2,000 $4,000 $20 $35 $40 $15 $0 $150 $35 $75 $0 Platinum A $85/20%/30%*

ATINUM Premier Balance PPO $0 $3/$10/$50/ $250 $500 100% 80% $2,250 $4,500 $20 $35 $40 $15 $150 $35 $75 PL $250 Platinum A after ded $85/20%/30%*

Premier Balance PPO $3/$15/$55/ $0 $500 100% 80% $7,350 $14,700 $30 $75 $85 $15 $0 $300 $75 $300 $0 Gold A $90/20%/30%* Premier Balance PPO $0 $3/$15/$55/ $250 $500 100% 80% $7,350 $14,700 $30 $60 $75 $15 $300 $60 $300 $250 Gold A after ded $90/20%/30%* Premier Balance PPO $0 $3/$15/$55/ $500 $1,000 100% 80% $7,350 $14,700 $30 $60 $75 $15 $300 $60 $300 $500 A after ded $90/20%/30%* Premier Balance PPO $0 $3/$15/$55/ $750 $1,500 100% 80% $7,350 $14,700 $30 $60 $75 $15 $300 $60 $300 $750 A after ded $90/20%/30%* GOLD Premier Balance PPO $0 $3/$15/$55/ $1,000 $2,000 100% 80% $7,100 $14,200 $30 $60 $75 $15 $300 $60 $300 $1000 A after ded $90/20%/30%* Premier Balance PPO $0 $3/$15/$55/ $1,250 $2,500 100% 80% $6,850 $13,700 $30 $60 $75 $15 $300 $60 $300 $1250 A after ded $90/20%/30%* Premier Balance PPO $0 $75 $325 $3/$15/$55/ $1,400 $2,800 100% 80% $7,350 $14,700 $45 $75 $85 $15 $250 $1400 A after ded after ded after ded $90/20%/30%*

Continued on next page... ERIE *Member pays (at retail) a maximum of $350 for Specialty Formulary Rx / $500 for Specialty Non-Formulary Rx MCKEAN WARREN POTTER CRAWFORD

FOREST CAMERON VENANGO ELK MERCER JEFFERSON CLARION LAWRENCE CLEARFIELD CENTRE BUTLER ARMSTRONG

BEAVER INDIANA

BLAIR ALLEGHENY Zone C – PPO Blue CAMBRIA WESTMORELAND HUNTINGDON WASHINGTON

BEDFORD 9 10 FAYETTE SOMERSET GREENE 2018 PPO BLUE For Small Groups with 50 or fewer employees HIGHMARKBCBS.COM Basic Diagnostic Services Plan Payment Level Primary Advanced Imaging Out-of-Pocket Urgent Inpatient Emergency (standard imaging, Rx Formulary Medical Deductible (Coinsurance) Care Specialist2 Telemedicine (MRI, CAT, PET scan, Maximum1 Care Hospital Room diagnostic medical, (Comprehensive)3 After Deductible Provider etc.) For Health Plans lab/pathology, etc.) with Effective Dates Low Cost Generic/Standard Out-of- Out-of- Out-of- Beginning January 1, In-Network In-Network In-Network Generic/Brand Formulary/ Network Network Network In-Network In-Network In-Network In-Network In-Network In-Network In-Network In-Network Non-Formulary/ 2018 (2 x Family) (2 x Family) (2 x Family) (2 x Family) (2 x Family) (2 x Family) Specialty Formulary/ Specialty Non-Formulary Member Pays Plan Pays Member Pays Premier Balance PPO $0 $3/$15/$55/ $1,500 $3,000 100% 80% $6,600 $13,200 $30 $60 $75 $15 $300 $60 $300 $1500 A after ded $90/20%/30%* Premier Balance PPO $0 $3/$15/$55/ $2,000 $4,000 100% 80% $6,100 $12,200 $30 $60 $75 $15 $300 $60 $300 $2000 A after ded $90/20%/30%* Premier Balance PPO $0 $3/$15/$55/ $2,500 $5,000 100% 80% $7,350 $14,700 $45 $65 $75 $20 $250 $65 $250 $2500 A after ded $90/20%/30%* Premier Balance PPO $0 $3/$15/$55/ $3,500 $7,000 100% 80% $5,800 $11,600 $45 $65 $75 $20 $250 $65 $250 $3500 A after ded $90/20%/30%*

GOLD Balance PPO 20% $80 $350 $3/$15/$55/ $1,000 $2,000 80% 60% $5,600 $11,200 $60 $80 $90 $15 $350 $1000 A after ded after ded after ded $90/20%/30%* Balance PPO 10% $250 $3/$15/$55/ $1,750 $3,500 90% 70% $7,350 $14,700 $45 $65 $75 $20 $250 $65 $1750 A after ded after ded $90/20%/30%* Balance PPO 10% $3/$15/$55/ $2,000 $4,000 90% 70% $7,150 $14,300 $45 $65 $75 $20 $250 $65 $250 $2000 A after ded $90/20%/30%* Health Savings PPO $20 $40 $55 $0 $0 $200 $40 $200 $3/$10/$50/$85/20%/ $1,500 $3,000 100% 80% $3,000 $6,000 $15004,6 after ded after ded after ded after ded after ded after ded after ded after ded 30% after ded*

Continued on next page... *Member pays (at retail) a maximum of $350 for Specialty Formulary Rx / $500 for Specialty Non-Formulary Rx ERIE MCKEAN WARREN POTTER CRAWFORD

FOREST CAMERON VENANGO ELK MERCER JEFFERSON CLARION LAWRENCE CLEARFIELD CENTRE BUTLER ARMSTRONG

BEAVER INDIANA

BLAIR ALLEGHENY Zone C – PPO Blue CAMBRIA WESTMORELAND HUNTINGDON WASHINGTON

BEDFORD FAYETTE SOMERSET GREENE 11 12 2018 PPO BLUE For Small Groups with 50 or fewer employees HIGHMARKBCBS.COM Basic Diagnostic Services Plan Payment Level Advanced Imaging Out-of-Pocket Primary Care Urgent Inpatient Emergency (standard imaging, Rx Formulary Medical Deductible (Coinsurance) Specialist2 Telemedicine (MRI, CAT, PET scan, Maximum1 Provider Care Hospital Room diagnostic medical, (Comprehensive)3 After Deductible etc.) For Health Plans lab/pathology, etc.) with Effective Dates Low Cost Generic/Standard Out-of- Out-of- Out-of- Beginning January 1, In-Network In-Network In-Network Generic/Brand Formulary/ Network Network Network In-Network In-Network In-Network In-Network In-Network In-Network In-Network In-Network Non-Formulary/ 2018 (2 x Family) (2 x Family) (2 x Family) (2 x Family) (2 x Family) (2 x Family) Specialty Formulary/ Specialty Non-Formulary Member Pays Plan Pays Member Pays Health Savings PPO $20 $35 $75 $0 $0 $250 $35 $250 $3/$15/$55/$90/20%/ $2,600 $5,200 100% 80% $5,300 $10,600 Embedded $26004,5,6 after ded after ded after ded after ded after ded after ded after ded after ded 30% after ded* VER

SIL Health Savings PPO $0 $0 $0 $0 $0 $0 $0 $0 $0 $4,000 $8,000 100% 100% $4,000 $8,000 Embedded $40004,5,6 after ded after ded after ded after ded after ded after ded after ded after ded after ded

High Deductible PPO 40% 40% 40% 40% 40% 40% 40% 40% 40% $4,750 $9,500 60% 50% $6,550 $13,100 Embedded $4750 Qualified 4,5,6A after ded after ded after ded after ded after ded after ded after ded after ded after ded Health Savings PPO 20% 20% 20% 20% 20% 20% 20% 20% 20% $5,500 $11,000 80% 60% $6,550 $13,100 Embedded $55004,5,6 after ded after ded after ded after ded after ded after ded after ded after ded after ded BRONZE High Deductible PPO 10% 10% 10% 10% 10% 10% 10% 10% 10% $6,300 $12,600 90% 70% $6,550 $13,100 Embedded $6300 Qualified 4,5,6A after ded after ded after ded after ded after ded after ded after ded after ded after ded

*Member pays (at retail) a maximum of $350 for Specialty Formulary Rx / $500 for Specialty Non-Formulary Rx

ERIE MCKEAN WARREN POTTER CRAWFORD

FOREST CAMERON VENANGO ELK MERCER JEFFERSON CLARION LAWRENCE CLEARFIELD CENTRE BUTLER ARMSTRONG

BEAVER INDIANA

BLAIR ALLEGHENY Zone C – PPO Blue CAMBRIA WESTMORELAND HUNTINGDON WASHINGTON

BEDFORD FAYETTE SOMERSET GREENE 13 14 this page was left blank intentionally

15 WESTERN PENNSYLVANIA REGION COMMUNITY BLUE FLEX, PA MOUNTAINS HEALTHCARE, & PENN HIGHLANDS

For Small Groups

Efective January 1, 2018

16 SERVICE AREA COMMUNITY BLUE FLEX to care isaseasypresenting your identification Highmark (ID) card. Providers withthelocalBlue Cross whoparticipate andBlue Shield Highmark plan,youHighmark have access to thousands ofproviders andhospitalsnationwide at theEnhanced Value Benefit Level.Getting access The Community BlueFlex PlansOfer Two Tiers Benefts ofin-Network

The BlueCard® Program - With theBlue Cross andBlueShield BlueCard® your network, coverage travels withyou. When you enroll ina

LAWRENCE

WASHINGTON

BEAVER

GREENE

MERCER CRAWFORD SERVICE AREA

level ofbenefts. inalocalBlueplan,orBlueCard®providers program, participating are covered at theEnhanced value ofthecountiesOutside where theCommunity Blue Flex plansare ofered, received services from managing thecost ofcare andimproving thevalue ofemployers’ healthcare dollars. Healthcare that isfocused ontheoverall andimproving healthofthecommunity patients’ care, while hasdeveloped acollaborativeHighmark relationship withPA andPenn Mountains Highlands based onconvenience, pastexperience, recommendations andaccreditations, aswell ascost. at theStandarda doctor level. They doctors, canchoosein-network labs, hospitals, andotherfacilities atWhen theEnhanced they chooseadoctor level, theymay spendlessoutofpocketthaniftheyuse employees may choosefrom inthenetwork. many orhospitalsthat participate doctors The Community BlueFlex PPOplanshave two value levels ofbenefts:Enhanced andStandard. Your

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VENANGO

plan, wherever you are, willrecognize andhonoryour card. nomatter So where you go, your benefits gowith you.

FAYETTE

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providers, you will have the the have will you providers,

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POTTER

with this level. level. this with

CENTRE

Zone B Zone A Your Cost 17

Zone H — PennZone— Region H Highlands PAZone— G Healthcare Mountains Region – Highercosts for care from other Standard Value – Membersspendlesswithlower deductible Enhanced Value

in-network providers Enhanced Valueproviders and out-of-pocket costs for care from

PROVIDER NETWORK

COMMUNITY BLUE FLEX FACILITY LISTING In-Network Region County Enhanced Value Standard Value WPA Allegheny • Allegheny General Hospital • Jeferson Hospital • Allegheny Valley Hospital • Ohio Valley General Hospital • Children’s Hospital of Pittsburgh • St. Clair Hospital of UPMC • West Penn Hospital • Forbes Hospital • Western Psychiatric Institute and Clinic • Heritage Valley Sewickley

Armstrong • Armstrong County Memorial Hospital Beaver • Heritage Valley Beaver Bedford • UPMC Bedford Memorial Blair • Nason Hospital • UPMC Altoona • Tyrone Hospital Butler • Butler Memorial Hospital Cambria • Conemaugh Memorial Medical Center • Conemaugh Miners Medical Center Clarion • Clarion Hospital • Clarion Psychiatric Center Clearfeld • Penn Highlands Clearfeld • Penn Highlands DuBois Crawford • Meadville Medical Center • Titusville Area Hospital Elk • Penn Highlands Elk Erie • Corry Memorial Hospital • Saint Vincent Hospital • UPMC Hamot • Millcreek Community Hospital Fayette • Highlands Hospital • Uniontown Hospital Greene • Washington Health System Greene Huntingdon • J. C. Blair Memorial Hospital Indiana • Indiana Regional Medical Center Jeferson • Penn Highlands Brookville • Punxsutawney Area Hospital Lawrence • Ellwood City Hospital • UPMC Jameson McKean • Bradford Regional Medical Center • Kane Community Hospital Mercer • Edgewood Surgical Hospital • Sharon Regional Health System • UPMC Horizon • Grove City Medical Center Potter • Cole Memorial Hospital Somerset • Conemaugh Meyersdale • Chan Soon-Shiong Medical Medical Center Center at Windber • Somerset Hospital Venango • UPMC Northwest Warren • Warren General Hospital Washington • Advanced Surgical Hospital • Monongahela Valley Hospital • Canonsburg Hospital • Washington Hospital Westmoreland • Excela Frick Hospital • Excela Westmoreland Hospital • Excela Latrobe Hospital *Provider list as of September 2017. Please refer to the online Find a Doctor tool at highmarkbcbs.com for a listing of network hospitals. 18 2018 COMMUNITY BLUE FLEX Zone A: Allegheny, Armstrong, Beaver, Butler, Crawford, Erie, Fayette, Greene, Indiana, For Small Groups with 50 or fewer employees Lawrence, McKean, Mercer, Warren, Washington and Westmoreland Counties HIGHMARKBCBS.COM Primary Care Plan Payment Level Basic Diagnostic Services Advanced Out-of-Pocket Provider/Retail Inpatient Emergency (standard imaging, Imaging Rx Formulary Medical Deductible (Coinsurance) Clinic Specialist2 Urgent Care Telemedicine Maximum1 Hospital Room diagnostic medical, (MRI, CAT, (Comprehensive)3 After Deductible (except where For Health Plans noted) lab/pathology, etc.) PET scan, etc.) with Effective Dates Low Cost Generic/Standard In-Network Out-of- In-Network Out-of- Out-of- In-Network In-Network In-Network In-Network In-Network In-Network In-Network Beginning In-Network Enhanced/ Generic/Brand Formulary/ January 1, 2018 Network Network Network Non-Formulary/ Enhanced Standard Enhanced Standard (2 x Fam) Enhanced/ Standard (2 x Fam) (2 x Fam) (2 x Fam) Enhanced Standard Enhanced Standard Enhanced Standard Enhanced Standard Enhanced Standard Enhanced Standard Specialty Formulary/ (2x Fam) (2x Fam) (2x Fam) (2x Fam) Standard Specialty Non-Formulary Member Pays Plan Pays Member Pays Premier Balance PPO 30% $3/$10/$50/$85/ $0 Platinum A $0 $500 $1,500 100% 70% 50% $2,000 $6,000 $10 $40 $20 $60 $40 $70 $5 $0 $150 $20 $60 $40 $100 after ded 20%/30%* a Community Blue Flex Plan TINUM

A Premier Balance PPO $0 30% $3/$10/$50/$85/ PL $250 Platinum A $250 $750 $2,250 100% 70% 50% $1,700 $5,100 $10 $40 $20 $60 $40 $70 $5 $150 $20 $60 $40 $100 after ded after ded 20%/30%* a Community Blue Flex Plan Premier Balance PPO $500 40% $90 $375 $3/$15/$55/$90/ $0 Gold A $0 $5,000 $15,000 100% 60% 50% $7,350 $22,050 $25 $70 $65 $90 $75 $100 $15 $275 $65 $275 per admit after ded after ded after ded 20%/30%* a Community Blue Flex Plan Premier Balance PPO $0 30% $3/$15/$55/$90/ $250 Gold A $250 $750 $2,250 100% 70% 50% $7,350 $22,050 $25 $65 $60 $90 $75 $100 $15 $250 $60 $90 $225 $325 after ded after ded 20%/30%* a Community Blue Flex Plan Premier Balance PPO $0 30% $3/$15/$55/$90/ $500 A $500 $1,500 $4,500 100% 70% 50% $7,350 $22,050 $25 $65 $55 $90 $70 $100 $15 $225 $55 $90 $225 $325 after ded after ded 20%/30%* GOLD a Community Blue Flex Plan Premier Balance PPO $0 30% $3/$15/$55/$90/ $750 A $750 $1,500 $4,500 100% 70% 50% $7,350 $22,050 $25 $65 $55 $90 $70 $100 $15 $225 $55 $90 $225 $325 after ded after ded 20%/30%* a Community Blue Flex Plan Premier Balance PPO $0 30% $3/$15/$55/$90/ $1000 A $1,000 $2,000 $6,000 100% 70% 50% $7,350 $22,050 $25 $65 $55 $90 $70 $100 $15 $225 $55 $90 $225 $325 after ded after ded 20%/30%* a Community Blue Flex Plan

Continued on next page... *Member pays (at retail) a maximum of $350 for Specialty Formulary Rx / $500 for Specialty Non-Formulary Rx ERIE MCKEAN WARREN CRAWFORD POTTER

FOREST CAMERON VENANGO ELK MERCER CLARION JEFFERSON LAWRENCE CLEARFIELD CENTRE BUTLER ARMSTRONG

BEAVER INDIANA

BLAIR ALLEGHENY CAMBRIA

WESTMORELAND HUNTINGDON Zone A WASHINGTON

SOMERSET BEDFORD FAYETTE GREENE

19 20 2018 COMMUNITY BLUE FLEX Zone A: Allegheny, Armstrong, Beaver, Butler, Crawford, Erie, Fayette, Greene, Indiana, For Small Groups with 50 or fewer employees Lawrence, McKean, Mercer, Warren, Washington and Westmoreland Counties HIGHMARKBCBS.COM Primary Care Plan Payment Level Basic Diagnostic Services Advanced Out-of-Pocket Provider/ Inpatient Emergency (standard imaging, Imaging Rx Formulary Medical Deductible (Coinsurance) Retail Clinic Specialist2 Urgent Care Telemedicine Maximum1 Hospital Room diagnostic medical, (MRI, CAT, (Comprehensive)3 After Deductible (except where For Health Plans noted) lab/pathology, etc.) PET scan, etc.) with Effective Dates Low Cost Generic/Standard Beginning In-Network Out-of- In-Network Out-of- Out-of- In-Network In-Network In-Network In-Network In-Network In-Network In-Network In-Network Enhanced/ Generic/Brand Formulary/ January 1, 2018 Network Network Network Non-Formulary/ Enhanced Standard Enhanced Standard (2 x Fam) Enhanced/ Standard (2 x Fam) (2 x Fam) (2 x Fam) Enhanced Standard Enhanced Standard Enhanced Standard Enhanced Standard Enhanced Standard Enhanced Standard Specialty Formulary/ (2x Fam) (2x Fam) (2x Fam) (2x Fam) Standard Specialty Non-Formulary Member Pays Plan Pays Member Pays Premier Balance PPO $0 30% $3/$15/$55/$90/ $1250 A $1,250 $2,500 $7,500 100% 70% 50% $6,000 $18,000 $25 $65 $55 $90 $70 $100 $15 $225 $55 $90 $225 $325 after ded after ded 20%/30%* a Community Blue Flex Plan Premier Balance PPO $0 30% $90 30% $3/$15/$55/$90/ $1400 A $1,400 $5,000 $15,000 100% 70% 50% $7,350 $22,050 $40 $75 $70 $90 $85 $125 $15 $300 $70 $350 after ded after ded after ded after ded 20%/30%* a Community Blue Flex Plan Premier Balance PPO $0 30% $3/$15/$55/$90/ $1500 A $1,500 $3,000 $9,000 100% 70% 50% $7,350 $22,050 $25 $65 $55 $90 $70 $100 $15 $225 $55 $90 $225 $325 after ded after ded 20%/30%* a Community Blue Flex Plan Premier Balance PPO $0 30% $3/$15/$55/$90/ GOLD $2000 A $2,000 $3,000 $9,000 100% 70% 50% $7,350 $22,050 $25 $65 $55 $90 $70 $100 $15 $225 $55 $90 $225 $325 after ded after ded 20%/30%* a Community Blue Flex Plan Balance PPO $1000 $75 $75 $95 10% 30% $95 $350 30% $3/$15/$55/$90/ $1,000 $5,000 $12,000 90% 70% 50% $6,400 $19,200 $45 $100 $150 $15 $300 $75 a Community Blue Flex Plan after ded after ded after ded after ded after ded after ded after ded after ded 20%/30%* Balance PPO $1750 A 10% 30% $3/$15/$55/$90/ $1,750 $5,250 $15,700 90% 70% 50% $7,150 $21,450 $35 $65 $60 $90 $75 $100 $15 $250 $60 $90 $200 $400 a Community Blue Flex Plan after ded after ded 20%/30%* Balance PPO $2000 A 10% 30% $3/$15/$55/$90/ $2,000 $6,000 $18,000 90% 70% 50% $7,150 $21,450 $35 $65 $60 $90 $75 $100 $15 $250 $60 $90 $200 $400 a Community Blue Flex Plan after ded after ded 20%/30%* Health Savings PPO $1500 $15 $50 $25 $70 $40 $95 $0 $0 30% $200 $30 $70 $100 $200 $3/$10/$50/$85/ $1,500 $4,500 100% 70% 50% $3,300 $9,900 a Community Blue Flex Plan4,6 after ded after ded after ded after ded after ded after ded after ded after ded after ded after ded after ded after ded after ded after ded 20%/30% after ded* Continued on next page... *Member pays (at retail) a maximum of $350 for Specialty Formulary Rx / $500 for Specialty Non-Formulary Rx ERIE MCKEAN WARREN CRAWFORD POTTER

FOREST CAMERON VENANGO ELK MERCER CLARION JEFFERSON LAWRENCE CLEARFIELD CENTRE BUTLER ARMSTRONG

BEAVER INDIANA

BLAIR ALLEGHENY CAMBRIA

WESTMORELAND HUNTINGDON Zone A WASHINGTON

SOMERSET BEDFORD FAYETTE GREENE

21 22 2018 COMMUNITY BLUE FLEX Zone A: Allegheny, Armstrong, Beaver, Butler, Crawford, Erie, Fayette, Greene, Indiana, For Small Groups with 50 or fewer employees Lawrence, McKean, Mercer, Warren, Washington and Westmoreland Counties HIGHMARKBCBS.COM Primary Care Plan Payment Level Basic Diagnostic Services Advanced Out-of-Pocket Provider/ Inpatient Emergency (standard imaging, Imaging Rx Formulary Medical Deductible (Coinsurance) Retail Clinic Specialist2 Urgent Care Telemedicine Maximum1 Hospital Room diagnostic medical, (MRI, CAT, (Comprehensive)3 After Deductible (except where For Health Plans noted) lab/pathology, etc.) PET scan, etc.) with Effective Dates Low Cost Generic/Standard Beginning In-Network Out-of- In-Network Out-of- Out-of- In-Network In-Network In-Network In-Network In-Network In-Network In-Network In-Network Enhanced/ Generic/Brand Formulary/ January 1, 2018 Network Network Network Non-Formulary/ Enhanced Standard Enhanced Standard (2 x Fam) Enhanced/ Standard (2 x Fam) (2 x Fam) (2 x Fam) Enhanced Standard Enhanced Standard Enhanced Standard Enhanced Standard Enhanced Standard Enhanced Standard Specialty Formulary/ (2x Fam) (2x Fam) (2x Fam) (2x Fam) Standard Specialty Non-Formulary Member Pays Plan Pays Member Pays

Balance PPO $600 60% 60% 60% 50% 60% 60% 50% 60% $3/$30/$60/$90/ $600 $1,800 $5,400 50% 40% 40% $7,350 $22,050 $55 $80 $90 $15 $500 $80 a Community Blue Flex Plan after ded after ded after ded after ded after ded after ded after ded after ded 20%/30%*

Balance PPO $2600 50% 50% 50% 30% 50% $75 50% 30% 50% $3/$30/$60/$90/ $2,600 $5,200 $15,600 70% 50% 50% $7,350 $22,050 $40 $75 $85 $15 $500 a Community Blue Flex Plan after ded after ded after ded after ded after ded after ded after ded after ded after ded 20%/30%*

$5,000 $6,000 $18,000 $7,350 $22,050 Balance PPO $5000 1x 50% 50% 50% 30% 50% $75 50% 30% 50% $3/$30/$60/$90/ 1x per 1x per 1x per 70% 50% 50% 1x per 1x per $25 $50 $60 $15 $500 a Community Blue Flex Plan after ded after ded after ded after ded after ded after ded after ded after ded after ded 20%/30%* SILVER SILVER family family family family family Health Savings PPO $0 $30 $30 $60 $45 $100 $0 $0 30% $250 $30 $60 $50 $150 $3/$15/$55/$90/ Embedded $2600 $2,600 $7,800 100% 70% 50% $6,550 $19,650 after ded after ded after ded after ded after ded after ded after ded after ded after ded after ded after ded after ded after ded after ded 20%/30% after ded* a Community Blue Flex Plan4,5,6 Health Savings PPO $0 40% $0 40% $0 40% $0 $0 40% $0 $0 40% $0 40% $3/$30/$60/$90/ Embedded $3000 $3,000 $9,000 100% 60% 50% $6,550 $19,650 after ded after ded after ded after ded after ded after ded after ded after ded after ded after ded after ded after ded after ded after ded 20%/30% after ded* a Community Blue Flex Plan4,5,6 Health Savings PPO 20% 40% 20% 40% 20% 40% 20% 20% 40% 20% 20% 40% 20% 40% 20% Embedded $5500 $5,500 $11,000 80% 60% 50% $6,550 $19,650 after ded after ded after ded after ded after ded after ded after ded after ded after ded after ded after ded after ded after ded after ded after ded a Community Blue Flex Plan4,5,6 Health Savings PPO

BRONZE $0 30% $0 30% $0 30% $0 $0 30% $0 $0 30% $0 30% $3/$15/$55/$90/ Embedded $6000 $6,000 $12,000 100% 70% 50% $6,550 $19,650 after ded after ded after ded after ded after ded after ded after ded after ded after ded after ded after ded after ded after ded after ded 20%/30% after ded* a Community Blue Flex Plan4,5,6 *Member pays (at retail) a maximum of $350 for Specialty Formulary Rx / $500 for Specialty Non-Formulary Rx

ERIE MCKEAN WARREN CRAWFORD POTTER

FOREST CAMERON VENANGO ELK MERCER CLARION JEFFERSON LAWRENCE CLEARFIELD CENTRE BUTLER ARMSTRONG

BEAVER INDIANA

BLAIR ALLEGHENY CAMBRIA

WESTMORELAND HUNTINGDON Zone A WASHINGTON

SOMERSET BEDFORD FAYETTE GREENE

23 24 2018 COMMUNITY BLUE FLEX Zone B: Bedford, Blair, Cambria, Cameron, Centre, Clarion, Clearfield, Elk, Forest, For Small Groups with 50 or fewer employees Huntingdon, Jefferson, Potter, Somerset, and Venango Counties only HIGHMARKBCBS.COM Primary Care Plan Payment Level Basic Diagnostic Services Advanced Out-of-Pocket Provider/ Inpatient Emergency (standard imaging, Imaging Rx Formulary Medical Deductible (Coinsurance) Retail Clinic Specialist Urgent Care Telemedicine Maximum1 Hospital Room diagnostic medical, (MRI, CAT, (Comprehensive)3 After Deductible (except where For Health Plans noted) lab/pathology, etc.) PET scan, etc.) with Effective Dates Low Cost Generic/Standard Beginning In-Network Out-of- In-Network Out-of- Out-of- In-Network In-Network In-Network In-Network In-Network In-Network In-Network In-Network Enhanced/ Generic/Brand Formulary/ January 1, 2018 Network Network Network Non-Formulary/ Enhanced Standard Enhanced Standard (2 x Fam) Enhanced/ Standard (2 x Fam) (2 x Fam) (2 x Fam) Enhanced Standard Enhanced Standard Enhanced Standard Enhanced Standard Enhanced Standard Enhanced Standard Specialty Formulary/ (2x Fam) (2x Fam) (2x Fam) (2x Fam) Standard Specialty Non-Formulary Member Pays Plan Pays Member Pays Premier Balance PPO $500 30% $3/$15/$55/$90 $250 IP A $250 $750 $2,250 100% 70% 50% $7,350 $22,050 $25 $65 $60 $90 $75 $100 $15 $250 $60 $90 $225 $325 per admit after ded 20%/30%* a Community Blue Flex Plan

Premier Balance PPO $500 30% $3/$15/$55/$90/ $750 IP A $750 $1,500 $4,500 100% 70% 50% $7,350 $22,050 $35 $65 $55 $90 $70 $100 $15 $225 $55 $90 $225 $325 per admit after ded 20%/30%* GOLD a Community Blue Flex Plan

Premier Balance PPO $70 $1,000 30% $95 30% $3/$15/$55/$90/ $1500 IP A $1,500 $4,500 $13,500 100% 70% 50% $7,150 $21,450 $45 $70 $90 $85 $100 $15 $250 $70 $350 after ded per admit after ded after ded after ded 20%/30%* a Community Blue Flex Plan

Health Savings PPO 20% 40% 20% 40% 20% 40% 20% 20% 40% 20% 20% 40% 20% 40% 20% Embedded $5500 $5,500 $11,000 80% 60% 50% $6,550 $19,650 4,5,6 after ded after ded after ded after ded after ded after ded after ded after ded after ded after ded after ded after ded after ded after ded after ded

BRONZE a Community Blue Flex Plan

*Member pays (at retail) a maximum of $350 for Specialty Formulary Rx / $500 for Specialty Non-Formulary Rx

ERIE MCKEAN WARREN CRAWFORD POTTER

FOREST CAMERON VENANGO ELK MERCER CLARION JEFFERSON LAWRENCE CLEARFIELD CENTRE BUTLER ARMSTRONG

BEAVER INDIANA

BLAIR ALLEGHENY CAMBRIA

WESTMORELAND HUNTINGDON Zone B WASHINGTON

SOMERSET BEDFORD FAYETTE GREENE

25 26 2018 PA Mountains Healthcare Region Zone G: PA Mountains Healthcare Region available in Armstrong, Blair, Cameron, For Small Groups with 50 or fewer employees Clarion, Crawford, Forest, Huntingdon, Jefferson, Indiana, Lawrence, McKean, Potter, and Somerset Counties only HIGHMARKBCBS.COM Primary Care Plan Payment Level Basic Diagnostic Services Advanced Out-of-Pocket Provider/ Urgent Inpatient Emergency (standard imaging, Imaging Rx Formulary Medical Deductible (Coinsurance) Retail Clinic Specialist2 Telemedicine Maximum1 Care Hospital Room diagnostic medical, (MRI, CAT, (Comprehensive)3 After Deductible (except where For Health Plans noted) lab/pathology, etc.) PET scan, etc.) with Effective Dates Low Cost Generic/Standard Beginning In-Network Out-of- In-Network Out-of- Out-of- In-Network In-Network In-Network In-Network In-Network In-Network In-Network Enhanced/ Generic/Brand Formulary/ January 1, 2018 Network Network In-Network Network Non-Formulary/ Enhanced Standard Enhanced Standard Enhanced/ Enhanced/ Standard (2 x Fam) (2 x Fam) (2 x Fam) Enhanced Standard Enhanced Standard Enhanced Standard Enhanced Standard Enhanced Standard Specialty Formulary/ (2x Fam) (2x Fam) (2x Fam) (2x Fam) Standard Standard Specialty Non-Formulary Member Pays Plan Pays Member Pays

Flex PPO PA Mountains $20 $50 Healthcare Region $0 30% $0 30% $3/$10/$50/$85/ $500 $1,500 $4,500 100% 70% 50% $7,350 $22,050 (Retail Clinic (Retail $45 $75 $75 $15 $225 $45 $75 $500/$1500 after ded after ded after ded after ded 20%/30%* GOLD $30) Clinic $30) a Community Blue Plan

*Member pays (at retail) a maximum of $350 for Specialty Formulary Rx / $500 for Specialty Non-Formulary Rx

ERIE MCKEAN WARREN CRAWFORD POTTER

FOREST CAMERON VENANGO ELK MERCER CLARION JEFFERSON LAWRENCE CLEARFIELD CENTRE BUTLER ARMSTRONG

BEAVER INDIANA

BLAIR ALLEGHENY CAMBRIA

WESTMORELAND HUNTINGDON WASHINGTON Zone G — PA Mountains Healthcare Region SOMERSET BEDFORD FAYETTE GREENE

27 28 2018 Penn Highlands Region Zone H: Penn Highlands Region available in Centre, Clearfield, Elk and Jefferson Counties only For Small Groups with 50 or fewer employees HIGHMARKBCBS.COM Primary Care Plan Payment Level Basic Diagnostic Services Advanced Out-of-Pocket Provider/ Urgent Inpatient Emergency (standard imaging, Imaging Rx Formulary Medical Deductible (Coinsurance) Retail Clinic Specialist2 Telemedicine Maximum1 Care Hospital Room diagnostic medical, (MRI, CAT, (Comprehensive)3 After Deductible (except where For Health Plans noted) lab/pathology, etc.) PET scan, etc.) with Effective Dates Low Cost Generic/Standard Beginning In-Network Out-of- In-Network Out-of- Out-of- In-Network In-Network In-Network In-Network In-Network In-Network In-Network Enhanced/ Generic/Brand Formulary/ January 1, 2018 Network Network In-Network Network Non-Formulary/ Enhanced Standard Enhanced Standard Enhanced/ Enhanced/ Standard (2 x Fam) (2 x Fam) (2 x Fam) Enhanced Standard Enhanced Standard Enhanced Standard Enhanced Standard Enhanced Standard Specialty Formulary/ (2x Fam) (2x Fam) (2x Fam) (2x Fam) Standard Standard Specialty Non-Formulary Member Pays Plan Pays Member Pays

Flex PPO $500/$1500 $25 $55 $0 30% $0 30% $3/$10/$50/$85/ Penn Highlands Region $500 $1,500 $4,500 100% 70% 50% $7,350 $22,050 (Retail Clinic (Retail Clinic $45 $75 $75 $15 $250 $50 $75 after ded after ded after ded after ded 20%/30%* GOLD a Community Blue Plan $35) $35)

*Member pays (at retail) a maximum of $350 for Specialty Formulary Rx / $500 for Specialty Non-Formulary Rx

ELK

JEFFERSON

CLEARFIELD CENTRE Zone H — Penn Highlands Region

29 30 this page was left blank intentionally

31 WESTERN PENNSYLVANIA REGION CONNECT BLUE & CONEMAUGH REGION CONNECT BLUE

For Small Groups

Efective January 1, 2018

32 CONNECT BLUE

Connect Blue and Conemaugh Region Connect Blue are EPO (Exclusive Provider Organization) health plans that provides benefts when care is received from network providers. Out-of-network care is not covered (except in an emergency).

These plans use the Community Blue network of providers that participate at a specifc level of benefts. These plans have three value levels of benefts for in-network services: Preferred, Enhanced, and Standard. All levels ofer the same high-quality care — no matter which level they use.

With the Conemaugh Region Connect Blue EPO, Highmark and Conemaugh Health System have partnered to provide services at the Preferred Value Beneft Level in Blair, Cambria, and Somerset counties.

Outside of the counties where these plans are ofered, services received from providers participating in a local Blue plan, or BlueCard® program, are covered at the Enhanced value level of benefts.

Connect Blue plans ofer 3 tiers of in-network benefts & No out-of-network coverage Level of Benefits Your Cost

Preferred Value If members use providers participating at the Preferred Value Level of Benefts, their out-of-pocket costs are the lowest. $ If members use providers participating at the Enhanced Value Enhanced Value Level of Benefts, their out-of-pocket costs are often higher than Preferred. $$ In-Network In-Network Standard Value If members use providers participating at the Standard Value Level of Benefts, their out-of-pocket costs are the highest. $$$

SERVICESERVICE AREA AREA

Connect Blue Conemaugh Region

BLAIR BUTLER CAMBRIA

BEAVER

ALLEGHENY ERIE SOMERSET WESTMORELAND WASHINGTON Zone J Zone Y

33 PROVIDER NETWORK

CONNECT BLUE PREFERRED VALUE LEVEL ENHANCED VALUE LEVEL

ALLEGHENY BEAVER ALLEGHENY WESTMORELAND • Allegheny General Hospital • Heritage Valley Beaver • Ohio Valley Hospital • Excela Frick Hospital • Allegheny Valley Hospital BUTLER • Excela Latrobe Hospital ERIE • Children’s Hospital of Pittsburgh of UPMC • Butler Memorial Hospital • Excela Westmoreland Hospital • Forbes Hospital ERIE • Corry Memorial Hospital • Heritage Valley Sewickley • Saint Vincent Hospital • Millcreek Community Hospital • Jeferson Hospital WASHINGTON WASHINGTON • St. Clair Hospital • Canonsburg Hospital • Advanced Surgical Hospital • West Penn Hospital • Washington Hospital • Monongahela Valley Hospital • Western Psychiatric Institute and Clinic

STANDARD VALUE LEVEL

ERIE • UPMC Hamot

CONEMAUGH REGION CONNECT BLUE In-Network Region County Preferred Value Enhanced Value Standard Value WPA Blair • Nason Hospital • Tyrone Hospital • UPMC Altoona (Plan available Cambria • Conemaugh Memorial Medical Center for purchase in • Conemaugh Miners Medical Center these counties) Somerset • Conemough Meyersdale Medical Center • Somerset Hospital • Chan Soon-Shlong Medical Center (formerly Windber Medical Center) WPA Allegheny • Allegheny General Hospital • All remaining INN providers • UPMC Hamot • Allegheny Valley Hospital (with the exception of Standard • UPMC Consent Decree* (Members may Erie providers) also access Washingron • Canonsburg General Hospital facilities in • Forbes Regional Hospital these counties) • Jeferson Regional Medical Center • St. Vincent Health System • Western Pennsylvania Hospital • Children’s Hospital of UPMC • Western Psychiatric Institute & Clinic Remaining • All INN providers • UPMC Bedford Counties • UPMC Horizon • UPMC Jameson • UPMC Kane • UPMC Northwest CPA/NEPA All 29 Counties • All INN providers Blue Card Out-of-Area • All INN providers Network in WPA = Community Blue; Network in CPA/NEPA = Premier Blue Shield; Out-of-Area = Blue Card *Members enrolled in Connect Blue products access UPMC facilities in network for oncology/cancer services and continuation of care. Covered claims from UPMC may be processed at the lower level of benefts. Emergency room and any related inpatient care is covered at the Preferred Value Level of Benefts for Connect Blue. The specifc terms of coverage will be according to the member’s beneft plan. The BlueCard® Program - With the Blue Cross and Blue Shield BlueCard® network, your coverage travels with you. When you enroll in a Highmark plan, you have access to thousands of providers and hospitals nationwide at the Enhanced Value Benefit Level. Getting access to care is as easy as presenting your Highmark identification (ID) card. Providers who participate with the local Blue Cross and Blue Shield plan, wherever you are, will recognize and honor your card. So no matter where you go, your benefits go with you.

*Provider list as of September 2017. Please refer to the online Find a Doctor tool at highmarkbcbs.com for a listing of network hospitals. 34 2018 CONNECT BLUE EPO Zone J: Allegheny, Beaver, Butler, Erie, Washington, and Westmoreland Counties only For Small Groups with 50 or fewer employees HIGHMARKBCBS.COM

Basic Diagnostic Services Advanced Plan Payment Level Out- Primary Care Inpatient Emergency (standard imaging, Imaging Rx Formulary Medical Deductible (Coinsurance) of-Pocket Provider/ Specialist2 Urgent Care Telemedicine diagnostic medical, (MRI, CAT, Retail Clinic** Hospital Room (Comprehensive)3 After Deductible Maximum1 lab/pathology, etc.) PET scan, etc.) For Health Plans with Effective Dates Low Cost Generic/ In-Network In-Network In-Network In-Network In-Network In-Network In-Network In-Network In-Network Beginning Standard Generic/ Preferred/ Brand Formulary/ January 1, 2018 Preferred/ Enhanced/ Non-Formulary/

(2 x Fam) Preferred/ Specialty Formulary/ In-Network Enhanced/ Standard

Out-of-Network Out-of-Network Out-of-Network Enhanced Specialty (2x Fam) (2x Fam) (2x Fam) (2x Fam) (2x Fam) (2x Fam) Standard Standard Standard Standard Standard Standard Standard Standard Preferred Preferred Preferred Preferred Preferred Preferred Preferred Enhanced Enhanced Enhanced Enhanced Standard Enhanced Enhanced Enhanced Non-Formulary Member Pays Plan Pays Member Pays $250 $1,000 Connect Blue EPO $100 up to 3 50% 50% 50% 50% up to 3 50% $250 $35/$45 50% $125/$150 $3/$15/$55/$90/ $100 $1,000 $3,000 N/A 100% 70% 50% N/A $7,350 N/A $25 $50 $40 $70 $60 $15 after ded (SOS)7 $70 after ded (SOS)7 $350 after a Community Blue Plan after ded after ded after ded days-then days-then ded 20%/30%* $0 copay $0 copay $250 $1,000 50% Connect Blue EPO $250 50% 50% 50% up to 3 up to 3 50% $35/$50 50% $150/$175 $3/$15/$55/$90/ $250 7 7 $250 $1,000 $3,000 N/A 100% 70% 50% N/A $7,350 N/A $15 $40 after ded $35 $65 after ded $50 after ded $15 days-then after ded (SOS) $70 after ded (SOS) $350 after a Community Blue Plan days-then ded 20%/30%* $0 copay $0 copay Connect Blue EPO $500 50% 50% 50% $500 $1,500 50% $35/$50 50% $150/$175 50% $3/$15/$55/$90/ $500 $2,000 $4,000 N/A 100% 70% 50% N/A $7,350 N/A $15 $40 after ded $35 $65 after ded $55 after ded $15 per admit per admit after ded $225 (SOS)7 $70 7 $350 after a Community Blue Plan after ded (SOS) ded 20%/30%* Connect Blue EPO $750 50% 50% 50% $500 $1,500 50% $35/$50 50% $750 $3,000 $6,000 N/A 100% 70% 50% N/A $7,350 N/A $15 $40 $30 $65 $55 $15 $225 $70 50% $150/$175 $350 after $3/$15/$55/$90/ a Community Blue Plan after ded after ded after ded per admit per admit after ded (SOS)7 after ded (SOS)7 20%/30%*

GOLD ded Connect Blue EPO $900 50% 50% 50% $500 $1,500 50% $35/$50 50% $150/$175 50% $3/$15/$55/$90/ $900 $3,600 $4,600 N/A 100% 70% 50% N/A $7,350 N/A $15 $40 after ded $40 $65 after ded $65 after ded $15 per admit per admit after ded $225 (SOS)7 $70 7 $350 after a Community Blue Plan after ded (SOS) ded 20%/30%* Connect Blue EPO $1100 50% 50% 50% $500 $1,500 50% $35/$50 50% $150/$175 50% $3/$15/$55/$90/ $1,100 $3,300 $4,300 N/A 100% 70% 50% N/A $7,350 N/A $15 $40 after ded $40 $65 after ded $65 after ded $15 per admit per admit after ded $225 (SOS)7 $70 7 $350 after a Community Blue Plan after ded (SOS) ded 20%/30%* Connect Blue EPO $2500 50% 50% 50% $500 $1,500 50% $25/$50 50% $150/$200 50% $3/$10/$50/$85/ $2,500 $5,000 $6,000 N/A 100% 70% 50% N/A $7,350 N/A $25 $60 after ded $50 $85 after ded $65 after ded $15 per admit per admit after ded $250 (SOS)7 $85 after ded (SOS)7 $400 after a Community Blue Plan ded 20%/30%* Connect Blue EPO $3200 50% 50% 50% $500 $1,500 50% $25/$50 50% $150/$200 50% $3/$10/$50/$85/ $3,200 $4,400 $5,400 N/A 100% 70% 50% N/A $7,350 N/A $25 $60 after ded $50 $85 after ded $65 after ded $15 per admit per admit after ded $250 (SOS)7 $85 7 $400 after a Community Blue Plan after ded (SOS) ded 20%/30%* *Member pays (at retail) a maximum of $350 for Specialty Formulary Rx / $500 for Specialty Non-Formulary Rx **Retail Clinic: Preferred/Enhanced = member pays Preferred benefit level copay. Standard Retail Clinic = member pays Standard benefit level coinsurance.

BUTLER

BEAVER

ALLEGHENY ERIE Zone J – Connect Blue WESTMORELAND WASHINGTON

35 36 2018 CONEMAUGH REGIONAL CONNECT BLUE EPO Zone Y: Blair, Cambria and Somerset For Small Groups with 50 or fewer employees HIGHMARKBCBS.COM

Basic Diagnostic Services Advanced Plan Payment Level Out- Primary Care Inpatient Emergency (standard imaging, Imaging Rx Formulary Medical Deductible (Coinsurance) of-Pocket Provider/ Specialist2 Urgent Care Telemedicine diagnostic medical, (MRI, CAT, Retail Clinic** Hospital Room (Comprehensive)3 After Deductible Maximum1 lab/pathology, etc.) PET scan, etc.) For Health Plans with Effective Dates Low Cost Generic/ In-Network In-Network In-Network In-Network In-Network In-Network In-Network In-Network In-Network Beginning ork Standard Generic/ w Preferred/ Brand Formulary/ January 1, 2018 et -N Preferred/ Enhanced/ Non-Formulary/ of

(2 x Fam) Preferred\ Specialty Formulary/

In-Network Standard

ut- Enhanced/ Out-of-Network Out-of-Network O Enhanced Specialty (2x Fam) (2x Fam) (2x Fam) (2x Fam) (2x Fam) (2x Fam) Standard Standard Standard Standard Standard Standard Standard Standard Preferred Preferred Preferred Preferred Preferred Preferred Preferred Enhanced Enhanced Enhanced Enhanced Standard Enhanced Enhanced Enhanced Non-Formulary Member Pays Plan Pays Member Pays 50% 50% $0 30% 50% 50% 50% Conemaugh Region $0 $1,500 $3,000 N/A 100% 70% 50% N/A $7,350 N/A $25 $60 after $45 $70 50% $55 after $15 after after after $250 $45 $70 after $275 $375 after $3/$15/$55/$90/ Connect Blue EPO $0 ded after ded ded ded ded ded ded ded 20%/30%*

GOLD 50% 50% $0 30% 50% 50% 50% Conemaugh Region $1,000 $3,000 $4,000 N/A 100% 70% 50% N/A $7,350 N/A $15 $40 after $45 $70 50% $55 after $15 after after after $250 $45 $70 after $175 $350 after $3/$15/$55/$90/ Connect Blue EPO $1000 ded after ded ded ded ded ded ded ded 20%/30%*

30% 50% 30% 50% $0 30% 50% 50% 30% 50% Conemaugh Region 50% 30% $3/$20/$60/$90/ VER Connect Blue EPO $3800 $3,800 $5,000 $5,500 N/A 100% 70% 50% N/A $7,350 N/A $50 after after $75 after after ded $90 after $15 after after after $400 $75 after ded after $300 after after 20%/30%*

SIL ded ded ded ded ded ded ded ded ded ded

Conemaugh Region $0 30% 50% $35 30% 50% $0 $0 30% 50% $35 30% 50% $0 30% 50% $3/$15/$55/$90/ Connect Blue EPO $5,000 N/A 100% 70% 50% N/A $6,550 N/A after after after after after 50% $50 after after after after after $300 after after after after after after 20%/30%* Embedded $50004,5,6 ded ded ded ded ded after ded after ded ded ded ded ded ded after ded ded ded ded ded ded ded after ded BRONZE

*Member pays (at retail) a maximum of $350 for Specialty Formulary Rx / $500 for Specialty Non-Formulary Rx **Retail Clinic: Preferred/Enhanced = member pays Preferred benefit level copay. Standard Retail Clinic = member pays Standard benefit level coinsurance.

BLAIR CAMBRIA

Zone Y SOMERSET

37 38 this page was left blank intentionally

39 WESTERN PENNSYLVANIA REGION PEDIATRIC DENTAL & VISION COVERAGE BENEFIT SUMMARY

For Small Groups

Efective January 1, 2018

40 For Small Group Health Benefit Pediatric Dental Plans with Effective Dates Beginning Coverage Benefit Summary January 2018 Small Group – 50 or Fewer Employees These benefits apply to Qualified High Deductible Health Plans (QHDHP). This plan meets the minimum essential health benefit requirements for pediatric oral health as required under the Federal Affordable Care Act. These benefits are only available for children through the end of the contract year that they turn 19. This Policy will pay benefts for Covered Services shown below subject to the Schedule of Exclusions and Limitations and other Policy terms. Payment is based on the Maximum Allowable Charge (MAC) for the specifc Covered Service. Participating Dentists accept contracted MACs as payment in full for services. Contract Year Deductible per Insured Person: Combined with Medical Annual Maximum per Insured Person: Unlimited Out-of-Pocket (OOP) Year Maximum per Insured Person: Combined with Medical

POLICY PAYS WAITING AFTER SERVICE CATEGORY Non-Participating PERIOD Participating Dentists* DEDUCTIBLE Dentists Oral Evaluations (Exams) None 100% Not Covered No Radiographs (All X-rays) None 100% Not Covered No

Prophylaxis (Cleanings) None 100% Not Covered No

Fluoride Treatments None 100% Not Covered No

Palliative Treatment (Emergency) None Coinsurance matches medical coinsurance Not Covered Yes

Sealants None 100% Not Covered No

Space Maintainers None 100% Not Covered No

Basic Restoration Anterior Amalgam None Coinsurance matches medical coinsurance Not Covered Yes

Basic Restoration Anterior Composite None Coinsurance matches medical coinsurance Not Covered Yes

Basic Restoration Posterior Amalgam None Coinsurance matches medical coinsurance Not Covered Yes

Crowns, Inlays, Onlays None Coinsurance matches medical coinsurance Not Covered Yes

Crown Repair None Coinsurance matches medical coinsurance Not Covered Yes

Endodontic Therapy (Root canals, etc.) None Coinsurance matches medical coinsurance Not Covered Yes

Surgical Periodontics None Coinsurance matches medical coinsurance Not Covered Yes

Non-Surgical Periodontics None Coinsurance matches medical coinsurance Not Covered Yes

Periodontal Maintenance None Coinsurance matches medical coinsurance Not Covered Yes Prosthetics (Complete or Fixed Partial Dentures) None Coinsurance matches medical coinsurance Not Covered Yes Adjustments and Repairs of Prosthetics None Coinsurance matches medical coinsurance Not Covered Yes

Maxillofacial Prosthetics N/A Not Covered Not Covered N/A

Implant Services None Coinsurance matches medical coinsurance Not Covered Yes

Simple Extractions None Coinsurance matches medical coinsurance Not Covered Yes

Surgical Extractions None Coinsurance matches medical coinsurance Not Covered Yes

Oral Surgery None Coinsurance matches medical coinsurance Not Covered Yes General Anesthesia, Nitrous Oxide and/or IV Sedation None Coinsurance matches medical coinsurance Not Covered Yes Consultations None Coinsurance matches medical coinsurance Not Covered Yes

Medically Necessary Orthodontics None Coinsurance matches medical coinsurance Not Covered Yes

*Pediatric Dental benefts utilize the United Concordia Advantage Network. Members must use a United Concordia provider. There is no Out-of-Network coverage for this beneft. United Concordia Companies, Inc., is a separate company that does not provide Blue Cross and/or Blue Shield products or services. United Concordia is solely responsible for the products and services described here. 41 MEDICALLY NECESSARY ORTHODONTICS COVERAGE OF MEDICALLY NECESSARY COVERAGE ORTHODONTICS

In this section, “Medically Necessary” or “Medical Necessity” 1. Orthodontic treatment must be Medically Necessary and shall mean health care services that a physician or Dentist be the only method capable of: exercising prudent clinical judgment would provide to a a) Preventing irreversible damage to the Insured Person’s patient for the purpose of evaluating, diagnosing, or treating teeth or their supporting structures and, an illness, injury, disease, or its symptoms, and that are: b) Restoring the Insured Person’s oral structure to health 1. in accordance with the generally accepted standards of and function. medical/dental practice; 2. Insured Persons must have a fully erupted set of permanent 2. clinically appropriate, in terms of type, frequency, extent, teeth to be eligible for comprehensive, Medically Necessary site and duration, and considered efective for the patient’s orthodontic services. illness, injury, or disease; and 3. All Medically Necessary orthodontic services require prior 3. not primarily for the convenience of the patient or physician/ approval and a written plan of care. Dentist, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury, or disease. As used in subpart 1, above, “generally accepted standards of medical/dental practice” means: • standards that are based on credible scientifc evidence published in peer-reviewed, medical/dental literature generally recognized by the relevant professional community; • recognized Medical/Dental and Specialty Society recommendations; • the views of physicians/Dentists practicing in the relevant clinical area; and • any other relevant factors. A Medically Necessary orthodontic service is an orthodontic procedure that occurs as part of an approved orthodontic plan that is intended to treat a severe dentofacial abnormality.

42 For Small Group Health Benefit Pediatric Dental Plans with Effective Dates Beginning Coverage Benefit Summary January 2018 Small Group – 50 or Fewer Employees These benefits apply to Non-Qualified High Deductible Health Plans (Non-QHDHP). This plan meets the minimum essential health benefit requirements for pediatric oral health as required under the Federal Affordable Care Act. These benefits are only available for children through the end of the contract year that they turn 19. This Policy will pay benefts for Covered Services shown below subject to the Schedule of Exclusions and Limitations and other Policy terms. Payment is based on the Maximum Allowable Charge (MAC) for the specifc Covered Service. Participating Dentists accept contracted MACs as payment in full for services. Contract Year Deductible per Insured Person: $0 Out-of-Pocket (OOP) Year Maximum per Insured Person: Combined with Medical Annual Maximum per Insured Person: Unlimited

POLICY PAYS WAITING AFTER SERVICE CATEGORY PERIOD Participating Non-Participating DEDUCTIBLE Dentists* Dentists Oral Evaluations (Exams) None 100% Not Covered N/A Radiographs (All X-rays) None 100% Not Covered N/A Prophylaxis (Cleanings) None 100% Not Covered N/A Fluoride Treatments None 100% Not Covered N/A Palliative Treatment (Emergency) None 100% Not Covered N/A Sealants None 100% Not Covered N/A Space Maintainers None 100% Not Covered N/A Basic Restoration Anterior Amalgam None 50% Not Covered N/A Basic Restoration Anterior Composite None 50% Not Covered N/A Basic Restoration Posterior Amalgam None 50% Not Covered N/A Crowns, Inlays, Onlays None 50% Not Covered N/A Crown Repair None 50% Not Covered N/A Endodontic Therapy (Root canals, etc.) None 50% Not Covered N/A Surgical Periodontics None 50% Not Covered N/A Non-Surgical Periodontics None 50% Not Covered N/A Periodontal Maintenance None 50% Not Covered N/A Prosthetics (Complete or Fixed Partial Dentures) None 50% Not Covered N/A Adjustments and Repairs of Prosthetics None 50% Not Covered N/A Maxillofacial Prosthetics N/A Not Covered Not Covered N/A Implant Services None 50% Not Covered N/A Simple Extractions None 50% Not Covered N/A Surgical Extractions None 50% Not Covered N/A Oral Surgery None 50% Not Covered N/A General Anesthesia, Nitrous Oxide and/or IV Sedation None 50% Not Covered N/A Consultations None 100% Not Covered N/A Medically Necessary Orthodontics None 50% Not Covered N/A

*Pediatric Dental benefts utilize the United Concordia Advantage Network. Members must use a United Concordia provider. There is no Out-of-Network coverage for this beneft. United Concordia Companies, Inc., is a separate company that does not provide Blue Cross and/or Blue Shield products or services. United Concordia is solely responsible for the products and services described here. 43 MEDICALLY NECESSARY ORTHODONTICS COVERAGE OF MEDICALLY NECESSARY COVERAGE ORTHODONTICS

44 For Small Group Health Benefit PEDIATRIC VISION Plans with Effective Dates Beginning COVERAGE BENEFIT SUMMARY January 2018 SMALL GROUP - 50 OR FEWER EMPLOYEES

These benefits apply to Qualified High Deductible Health Plans (QHDHP).

NETWORK BENEFIT (Independents & Visionworks)* FREQUENCY ELIGIBLE PARTICIPANTS Members under 19 years of age(1) Eye Examination (including dilation, as professionally indicated) Once every 12 months Eyeglass Lenses** Once every 12 months Frames** Once every 12 months PLAN RESPONSIBILITY EYE EXAMINATION (including dilation, as professionally indicated) 100% FRAMES Pediatric Frame Selection 100% after deductible EYEGLASS LENSES(2) (Per Pair) Single vision 100% after deductible Bifocal 100% after deductible Trifocal 100% after deductible Lenticular 100% after deductible VALUE ADDED BENEFITS Lens Options purchased from a participating provider will be MEMBER RESPONSIBILITY provided to the member at the amounts listed below. LENS OPTIONS Standard progressive lenses (3) $50 Premium progressive lenses (3) $90 Polycarbonate lenses $0 Intermediate vision lenses $30 High-index (thinner and lighter) lenses $55 Polarized lenses $75 Fashion, sun or gradient tinted plastic lenses $11 Ultraviolet coating $12 Scratch-resistant coating $0 Scratch Protection Plan Single Vision $20 Scratch Protection Plan Multifocal $40 Standard ARC (anti-refective coating) $35 Premium ARC (anti-refective coating) $48 Ultra ARC (anti-refective coating) $60

These benefits apply to Non-Qualified High Deductible Health Plans (Non-QHDHP).

NETWORK BENEFIT (Independents & Visionworks)* FREQUENCY ELIGIBLE PARTICIPANTS Members under 19 years of age(1) Eye Examination (including dilation, as professionally indicated) Once every 12 months Eyeglass Lenses Once every 12 months Frames Once every 12 months PLAN RESPONSIBILITY EYE EXAMINATION (including dilation, as professionally indicated) 100% FRAMES Pediatric Frame Selection 100% EYEGLASS LENSES(2) (Per Pair) Single vision 100% Bifocal 100% Trifocal 100% Lenticular 100% VALUE ADDED BENEFITS Lens Options purchased from a participating provider will be MEMBER RESPONSIBILITY provided to the member at the amounts listed below. LENS OPTIONS Standard progressive lenses (3) $50 Premium progressive lenses (3) $90 Polycarbonate lenses $0 Intermediate vision lenses $30 High-index (thinner and lighter) lenses $55 Polarized lenses $75 Fashion, sun or gradient tinted plastic lenses $11 Ultraviolet coating $12 Scratch-resistant coating $0 Scratch Protection Plan Single Vision $20 Scratch Protection Plan Multifocal $40 Standard ARC (anti-refective coating) $35 Premium ARC (anti-refective coating) $48 Ultra ARC (anti-refective coating) $60

(1) Dependents will be terminated from the contract at the end of the month in which they turn 19. Termination rules for employer groups are determined by the client. (2) Includes glass, plastic or oversized lenses. (3) Progressive multifocals can be worn by most people. Conventional bifocals will be supplied at no additional charge for anyone who is unable to adapt to progressive lenses. However, the member’s payment towards the progressive upgrade will not be refunded. *Vision benefts utilize the Davis Vision Network. Members must use a Davis Vision provider who participates in the Health Care Reform Vision Network. There is no out-of-network coverage. Davis Vision is a separate company that administers Highmark vision benefts. Visionworks, also a separate company, is a provider within the Davis Vision Network. 46 Important Plan Details: 1 Out-of-pocket maximum calculation includes deductible, copayment and coinsurance. 2 Specialist copay applies to outpatient: mental health, behavior health, substance abuse, chiropractic, physical therapy and speech therapy office visits. 3 Rx information displayed: Retail 31-day supply. NOTE: Member’s maximum coinsurance payment for a retail Specialty Rx is $350 Formulary/$500 Non-Formulary. 4 Integrated Rx plans include all medical and prescription claims accumulating toward one overall deductible. 5 “Embedded” plans: In this approach, an individual family member can be eligible for payment of benefts upon meeting the Individual deductible amount (even if the rest of the family has not met the Family deductible amount). Additionally, an individual family member’s out-of-pocket (OOP) maximum will be the same as that of a member purchasing Individual Coverage for the specifed health plan. 6 A Health Savings Account (HSA) is available to employees. Employer contributions in amounts that exceed annual federally mandated maximum(s) may result in actuarial value changes that may impact compliance as a Qualifed Health Plan. 7 (SOS): Connect Blue plans have “Site of Service” at the Preferred Level for Labs/Basic Diagnostic Services and Advanced Imaging benefts. Non-Hospital locations have a lower copay and Hospital locations have a higher copay — similar to the Out-Patient Surgery beneft.

Disclosures: Insurance or beneft administration may be provided by Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Coverage Advantage or Highmark Health Insurance Company, all of which are independent licensees of the Blue Cross and Blue Shield Association. BlueCard program and Blue Cross Blue Shield Global Core is a registered mark of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. To fnd more information about Highmark’s benefts and operating procedures, such as accessing the drug formulary or using network providers, please go to DiscoverHighmark.com/QualityAssurance; or for a paper copy, call1-855-873-4106.

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