bcbswny.com. Benefit Summary: Effective on or after 1/1/2019. Platinum Standard (2019) In-Network Out-of-Network Additional Information

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1 bcbswny.com Benefit Summary: Effective on or after 1/1/2019 General Information Provider Network 200 Network Deductible N/A $5,000 single / $10,000 family Deductible Administration Type Coinsurance N/A N/A Embedded - once any individual has met the individual, even if the family has not been satisfied Out of Pocket Maximum $2,000 single / $4,000 family $10,000 single / $20,000 family Out of Pocket Administration Type Benefit Administration Date Dependent Coverage Embedded OOP Max - once any individual has met the individual OOP Max, even if the family OOP Max has not been satisfied Embedded OOP Max - once any individual has met the individual OOP Max, even if the family OOP Max has not been satisfied Plan Year Dependent Age 26/26 Dependent Coverage Ends Domestic Partner and Children Prescription Drug Coverage End of birth month Covered Prescription Drugs $10/$30/$60 Not Covered Mail Order 2.5 copays per 90 day supply Not Covered Is Rx subject to Medical Deductible? No Page 1 of 5

2 Physician and Other Services Primary Office Visit Specialist Office Visit Allergy Injections Allergy Testing Outpatient Surgical Procedures (in physician's office) Emergency and Urgent Care Services / / / Emergency Room $100 copayment Covered as in-network Cost-share waived if admitted Ambulance $100 copayment Covered as in-network Urgent Care Center $55 copayment $55 copayment Preventive Services Bone mineral density measurement or test Cholesterol Test (lipid panel) Immunizations Prostate Test (Prostate Specific Antigen "PSA") $ 15 copayment/$ 35 copayment Routine Physical Exam Not covered Well Child Visits Page 2 of 5

3 Hospital Services Inpatient Hospital Outpatient Surgical Procedure (Facility) Skilled Nursing Facility Diagnostic Testing Services Laboratory Tests Radiology Maternity Services Physician Services: Prenatal and Postnatal Care (initial visit) Inpatient Maternity Mental Health and Substance Abuse Inpatient Mental Health Outpatient Mental Health Inpatient Substance Abuse - Rehab Inpatient Substance Abuse - Detox Outpatient Substance Abuse Diabetic Supplies and Services Diabetic Equipment Insulin and Other Oral Agents Diabetic Medical Supplies (Test strips, Syringes, etc) $100 copayment 200 days per year Up to 20 visits a year may be used for family counseling Diabetic drugs and supplies rendered at pharmacy will be covered as a medical benefit. Diabetic drugs rendered at pharmacy are only covered innetwork. Page 3 of 5

4 Rehabilitation Services Chiropractic Care Physical - Occupational - Speech Therapies Pulmonary Rehabilitation Additional Services Durable Medical Equipment Prosthetics and Appliances Home Health Care Hospice Chemotherapy - Outpatient Facility Dialysis Wellness Card Pediatric Vision Services Routine Exam Medical Eye Exam Adult Vision Services $25 copayment 10% coinsurance 10% coinsurance $250 per contract N/A Not covered Routine Exam Not covered Not covered Medical Eye Exam 60 combined PT/OT/ST visits per condition per plan year One prosthetic device, per limb, per lifetime (standard equipment only); For children, the cost of replacements is also covered but only if the previous device has been outgrown. Shoe orthotics not 40 aggregate visits per year; Home Infusion counts toward home health care visit limit. 210 days per year Benefit allowance accessible through use of debit card at participating providers for gym membership, massage, acupuncture, health food stores, chiropractic visits, etc One routine exam every year, coverage up to Age 19 Page 4 of 5

5 *For a list of Medicare Part D creditable coverage prescription drug plans, please refer to our website. **This is a summary of covered benefits and exclusions and is not intended as an actual contract or group plan. It does not detail all benefits, limitations and exclusions that may apply A division of HealthNow New York Inc. An independent licensee of the BlueCross BlueShield Association. Page 5 of 5