Medical Plans Benefit Guide

Medical Plans Benefit Guide Employers with 1-50 employees 1.1.01

Provider network built for value and quality... Wellness rewards...3 Medical Travel Support and Air or Surface Transportation... Support for smart healthcare decisions... Easy-to-use online and mobile tools...5 Customer service experience...5 Premera health plans... The 10 essential benefits your plan covers... Choose from a range of plans... Plan summaries... Optional benefits...1 Definitions... General exclusions and limitations...5 b

Welcome to 01 Premera Blue Cross Blue Shield of Alaska Along with the great service and rich network access you have come to expect from Premera, we are pleased to offer benefits tailored for the needs of groups based in Alaska. Robust provider network* Did you know that Premera boasts the largest provider network in Alaska? Remember that, depending on the Premera medical plan you purchase, your employees have access to over 3,000 providers and 0 hospitals all across Alaska. Together with the Blue Cross Blue Shield system, our extended network includes more than,00 hospitals and 1,01,000 physicians across the country the largest contracted nationwide network available in the United States delivering the broadest access and lowest total cost of care available in all markets. (See page.) Wellness rewards We spend most of our time at work. What better place to encourage people to make healthy lifestyle choices? By offering robust rewards to employers and employees for participating in wellness programs, we aim to help employers inspire employees to engage in a wellness program based on the latest research to make the greatest impact to their health and well-being Ask your Premera representative for more information about the embedded wellness rewards program. (See page 3.) Medical Travel Support Also known as medical tourism, our Medical Travel Support is a voluntary program that gives members broader access to quality care at lower cost for certain approved procedures outside of Alaska within the Blues national network. The benefit covers travel costs for the member and a companion, up to the IRS guidelines. Talk to your producer or your Premera sales professional for more information. (See page.) Cost transparency tools As soon as they choose a plan, your employees receive instant access to free, easy-to-use online and mobile tools that help them understand and track their medical spending and prescriptions, estimate costs, and review claim status. (See page 5.) Thank you for considering Premera for your employer-sponsored benefits. * Consortium Health Plans, Inc. Network Compare Key Findings as of June 5, 015. Available at www.chpmarketquest.com. 1

Robust provider network Provider network built for value and quality The Premera network of doctors, hospitals, and other healthcare providers is designed to offer ready access to safe, effective, high-quality care at affordable prices. Our strong relationships with our provider partners help maximize healthcare dollars by: Focusing on quality and cost-effective care Helping control rising medical costs Providing resources for improved healthcare Premera also offers an excellent national network of preferred providers for members to access when outside Alaska. Members can use the Find a Doctor tool at premera.com to see if their favorite provider is in our network, or to find a new one. Members choose from two network options Balance Plus plans offer employees savings on health plan costs and give the highest benefit level to employees when they use preferred providers and hospitals. Nonpreferred and nonparticipating or out-of-network facilities and providers are also covered, but at a lower benefit level.* Balance Select plans give employees the same benefit whether their doctor is in the Premera network or not: Employees have the flexibility to see the doctor of their choice and receive the highest benefit levels.* When an employee needs care in a hospital setting, they will get the highest benefit levels at preferred facilities. Non-preferred and nonparticipating or out-ofnetwork facilities are also covered, but at a lower benefit level.* Healthcare coverage wherever you go National PPO access When outside of Alaska, employees can access doctors and hospitals in the BlueCard network around the world. In the U.S., the BlueCard Program gives them peace of mind that they ll be able to find the healthcare provider they need anywhere in the lower. Outside of the U.S., the BlueCard Worldwide Program gives them access to hospitals in nearly 00 countries and territories around the world. Blue Distinction Total Care A comprehensive solution for multistate employers, this program integrates local value-based care programs from Blue Plans across the country. Programs are custom designed to meet local market needs while also meeting national standards in four impact-driven categories: Value-based reimbursement Accountability across the care continuum Patient-centered quality care Provider empowerment Members who reside in geographic areas served by Blue Distinction Total Care are automatically assigned to these patient-centered, value-based programs. * Balance billing may still apply if a provider is not contracted with Premera Blue Cross Blue Shield of Alaska. For more information about providers, visit premera.com and use the Find a Doctor tool.

Built-in rewards for wellness activities The built-in wellness rewards program is a simple way to encourage your workforce to engage in wellness activities. Your employees get access to tools designed to help them maintain and improve their health. Our wellness rewards program rewards both employers and employees. All program participation data sharing and reports are HIPAA-compliant. Wellness tools The wellness reward program offers: Biometric screenings by using physician fax forms, home test kits, retail options, or at employer-sponsored on-site events Health assessments when members log in to use the Premera online wellness tools Rewards for employers Employers can earn a premium discount based on employee participation. Ask your Premera representative how to get your group involved in a wellness rewards program. Rewards for employees Employees earn a generous reward card if they participate in a biometric screening and take a health assessment within a designated time frame. 3

Support for smart network decisions Medical Travel Support Premera s Medical Travel Support benefit reimburses members for approved travel expenses when they travel for qualified medical procedures at pre-approved medical facilities in and outside of Alaska. Approved travel expenses are covered up to IRS guidelines for both the member and a travel companion. Because the price of medical care may be lower outside Alaska, the member s share of the medical costs may also be lower. Customer Service can also assist in medical records transfers if needed. Air or Surface Transportation Beginning in 01, all group plans will include a standard Air or Surface Transportation benefit of three round trips. Transportation to the nearest in-network location equipped to provide treatment is available for: A life-endangering illness or injury A required surgery that cannot be performed locally An existing condition that cannot be treated locally When transportation is for a child under the age of 1, the benefit also covers a parent or guardian to accompany the child. Premera health support programs help your employees maintain good health and change unhealthy behavior. Health support programs included in all plans: Virtual care gives covered members immediate and convenient access to care from a physician via phone call, online video, or other online media to treat certain ailments such as cold and flu symptoms, ear infections, and bronchitis. -Hour NurseLine offers free, confidential health advice from a registered nurse by phone any time day or night. CareCompass30 is a whole-person approach to health support that meets members needs wherever they land on the care continuum whether they re healthy or navigating complex conditions. Members receive easily accessible, appropriate health support services tailored to their health needs. Maternity and newborn support program promotes healthier mothers and babies and reduces costs associated with high-risk pregnancies and newborns that end up in neonatal intensive care units. Exclusive member discounts on fitness club memberships, weight loss programs, and many other health products and services not covered by their health plan.

Easy-to-use online and mobile tools These tools make it simple for administrators and your employees to manage money, care, and wellness. Tools for plan administrators We streamlined the experience of administering group plans with easy-to-use online tools. You can view helpful information such as: Administrator s Quick Reference Guide Employer contract and member benefit booklet Medical and dental invoices You can add and make changes to employee enrollment information, including ordering identification cards. You can also contribute and monitor allocations to health reimbursement accounts (HRAs) and health savings accounts (HSAs). Online tools for members Members register and log in at premera.com to use tools securely: Find and compare providers, including qualifications and user reviews with Find a Doctor. Enter different coverage options to see how choices affect costs before deciding on a health plan with the Treatment Cost Estimator. Review status of medical, prescription drug, and dental claims. Manage and monitor consumer-driven health plans (HSA and HRA) spending and saving amounts, including reviewing account balances. Access pharmacy information and order prescriptions Award-winning mobile apps Premera app Find nearby doctors and clinics, look up benefits, and check claims. ExpressScripts pharmacy app Track medications, order prescriptions, and find a pharmacy. ConnectYourCare app Check spending and account balances on health savings accounts (HSA). Wellness apps Track activities, participate in fun fitness challenges, and get healthier. Customer service experience All Premera customer service representatives are fully trained to provide excellent service to members. Our representatives are especially knowledgeable about the unique needs of Alaska, such as: Alaska s logistical challenges Alaskan culture Our customer service standard is first call resolution. 5

Premera health plans Premera offers a wide range of Bronze, Silver, and Gold plans. Each plan covers the 10 essential benefits as required by the Affordable Care Act (ACA) These essential benefits focus on prevention and primary care to help people stay healthy. They also aim to manage chronic medical conditions before these conditions become more complex. INSURANCE PLANS MONTHLY PREMIUM IN-NETWORK DEDUCTIBLE INSURANCE PAYS Bronze Plans $ $$$ $ Silver Plans $$ $$ $$ Gold Plans $$$ $ $$$ The 10 essential benefits your plan covers: 1 1 Ambulatory patient services such as office visits to your in-network primary care doctor or specialists. Emergency services for issues that could lead to death or disability if you do not treat them. 3 3 Hospitalization covers room and board, tests, drugs, and care from doctors and nurses while admitted; includes organ and tissue transplants, and hospice and respite care. Maternity and newborn care covers prenatal and postnatal care, delivery and inpatient maternity services, plus newborn child care. 5 5 Mental health and substance use disorder services, including behavioral health treatment covers inpatient hospital and outpatient mental and behavioral health. Prescription drugs covers retail, mail order, and specialty drugs. Rehabilitative and habilitative services and devices to help gain or regain mental and physical skills in case of injury, disability, or chronic condition. Includes inpatient rehabilitation; physical, speech, and occupational therapy; durable medical equipment; or skilled nursing. Laboratory services covers lab tests, X-ray services, and pathology, and imaging and diagnostics such as MRI, CT scan, and PET scan. Preventive/Wellness services and chronic disease management includes mammograms, colonoscopies, vaccines, and more. if you use in-network providers for care such as routine physicals, screening, and immunizations. Care management programs and services seek to coordinate care for a variety of chronic conditions, 10 such as diabetes and asthma. 10 Pediatric services Kids are covered for vision care (eye exam, lenses, and eyewear).

Choose from a range of plans Help your employees find the right balance between their budget and their healthcare needs. Balance PCP These innovative plans offer a combination of upfront, first-dollar benefits, and standard coverage for other services. The difference is that a lower copay applies when a member designates and gets care from a primary care provider (PCP). Balance PPO Our preferred provider plans offer a combination of upfront, first-dollar benefits, and standard coverage for other services. Balance HSA The Balance HSA plans offer valuable benefits for covered services and are qualified to work in combination with an employee-owned, tax-advantaged health savings account (HSA). Balance HRA The Balance HRA plan offers valuable benefits for covered services and works in combination with an employer-owned, health reimbursement arrangement (HRA). The employer contributes half of the pre-defined deductible amount in the HRA, and employees are reimbursed from the HRA after they meet the first half of the plans deductible.

Balance Plus Bronze PCP Alaska plans for group 1-50 Beginning January 1, 01 The deductible applies whenever there is a coinsurance listed, unless otherwise noted. Individual Deductible Coinsurance Out-of-Pocket Office Visits Network 10 Essential Benefits Covered Services Per Calendar Year = PCY Family = x individual deductible (in-network only) Amount you pay after your deductible is met Includes deductible, coinsurance, and copays Family = x Ind. out-of-pocket-max (in-network only) Designated PCP office visit Non-designated PCP or specialist office visit In-network Non-participating 30% 0% 0% $,50 First visits PCY $30/deductible waived, otherwise deductible, then coinsurance Heritage Plus BALANCE PLUS BRONZE PCP Non-preferred $5,500 / $,350 x individual deductible Unlimited Out-of-network 1 Ambulatory Patient Services Office visits Spinal manipulation (1 visits PCY); $30 Acupuncture (1 visits PCY) Emergency Services Emergency care Copay waived if directly admitted to inpatient facility Ambulance transportation (air & ground) $5 copay, then deductible & in-network coinsurance $00 Copay, then in-network deductible & coinsurance Emergent: Same as in-network Non-emergent: Air Ded, then 0% / Ded, then 0%; Ground Same as in-network 3 Hospitalization Inpatient Hospice: 10 days inpatient Respite care: 0 hours lifetime Organ and tissue transplants, inpatient unlimited, except $5,000 donor coverage limit and $,500 travel and lodging per transplant Maternity & Newborn Care Prenatal, delivery, postnatal care 5 Mental Health & Substance Use Office visit Disorder Services, including Inpatient hospital: mental/behavioral health Behavioral Health Treatment Rehabilitative & Habilitative Services & Devices Inpatient rehabilitation: 30 days PCY Inpatient habilitation: 30 days PCY Therapy Physical, speech, occupational, massage therapy: 5 visits PCY Rehabilitative and habiltative benefits have the same number of visits, but are counted separately Durable medical equipment Skilled nursing facility: 0 days PCY Laboratory Services Includes X-ray, pathology, imaging/diagnostic, MRI, CT, PET (Prior Authorization required for certain services) Preventive/Wellness Services & Chronic Disease Management Screenings Exams and immunizations Deductible, then 0% Pediatric Services, including Vision Care Under 1 years of age Eye exam: 1 PCY Eyewear: One pair of glasses PCY (frames & lenses); or 1-month supply of contacts PCY, in lieu of glasses (frames & lenses) Deductible waived, then 10% Dental: preventive/basic/major Orthodontia (medically necessary only) 10 Prescription Drugs Retail up to 0-day supply (3x 30 day supply cost) -Tier: Generic/Brand/ Mail Order 0-day supply; 3x retail supply cost Non-Preferred Brand/Specialty Specialty Rx 30-day supply Drug Formulary X $35 / Deductible, then 50% / Deductible, then 50% / Retail: Same as in-network Mail order & specialty: not covered Additional benefits embedded within the medical plan Hearing Hearing exam: 1 per calendar years Deductible waived, then 0% Hearing aids and hardware: $1,000/3 calendar years A full list of services is available on premera.com/ak/member

Balance Plus Silver PCP Alaska plans for group 1-50 Beginning January 1, 01 The deductible applies whenever there is a coinsurance listed, unless otherwise noted. Individual Deductible Per Calendar Year = PCY Family = x individual deductible (in-network only) BALANCE PLUS SILVER PCP In-network Non-preferred Non-participating $,000 x individual deductible Coinsurance Out-of-Pocket Maximum Amount you pay after your deductible is met Includes deductible, coinsurance, and copays Family = x Ind. out-of-pocket-max (in-network only) 30% 0% 0% $,50 Unlimited Office Visits Designated PCP office visit $5 copay First PCP visits covered in full Non-designated PCP or specialist office visit $5 Network Heritage Plus Out-of-network 10 Essential Benefits Covered Services 1 Ambulatory Patient Services Office visits Spinal manipulation (1 visits PCY); $5 Acupuncture (1 visits PCY) Deductible, then 0% Emergency Services 3 Hospitalization Emergency care Copay waived if directly admitted to inpatient facility Ambulance transportation (air & ground) Inpatient Hospice: 10 days inpatient Respite care: 0 hours lifetime Organ and tissue transplants, inpatient unlimited, except $5,000 donor coverage limit and $,500 travel and lodging per transplant $5 copay, then deductible & in-network coinsurance $00 Copay, then in-network deductible & coinsurance Emergent: Same as in-network Non-emergent: Air Ded, then 0% / Ded, then 0%; Ground Same as in-network Maternity & Newborn Care Prenatal, delivery, postnatal care 5 Mental Health & Substance Use Office visit $5 Disorder Services, including Behavioral Health Treatment Inpatient hospital: mental/behavioral health Rehabilitative & Habilitative Services & Devices Inpatient rehabilitation: 30 days PCY Inpatient habilitation: 30 days PCY Therapy Physical, speech, occupational, massage therapy: 5 visits PCY Deductible, then $5 Rehabilitative and habiltative benefits have the same number of visits, but are counted separately Durable medical equipment Skilled nursing facility: 0 days PCY Laboratory Services Includes X-ray, pathology, imaging/diagnostic, MRI, CT, PET (Prior Authorization required for certain services) Preventive/Wellness Services & Chronic Disease Management Screenings Exams and immunizations Deductible, then 0% Pediatric Services, including Vision Care Under 1 years of age Eye exam: 1 PCY Eyewear: One pair of glasses PCY (frames & lenses); or 1- month supply of contacts PCY, in lieu of glasses (frames & lenses) $5 Dental: preventive/basic/major Orthodontia (medically necessary only) 10 Prescription Drugs Retail up to 0-day supply (3x 30 day supply cost) -Tier: Generic/Brand/ Mail Order 0-day supply; 3x retail supply cost Non-Preferred Brand/Specialty Specialty Rx 30-day supply Drug Formulary X $15 / $50 / $150 / Retail: Same as in-network Mail order & specialty: not covered Additional benefits embedded within the medical plan Hearing Hearing exam: 1 per calendar years $5 Hearing aids and hardware: $1,000/3 calendar years A full list of services is available on premera.com/ak/member

Balance Plus Gold PCP Alaska plans for group 1-50 Beginning January 1, 01 The deductible applies whenever there is a coinsurance listed, unless otherwise noted. Individual Deductible Coinsurance Out-of-Pocket Maximum Office Visits Per Calendar Year = PCY Family = x individual deductible (in-network only) Amount you pay after your deductible is met Includes deductible, coinsurance, and copays Family = x Ind. out-of-pocket-max (in-network only) Designated PCP office visit Non-designated PCP or specialist office visit In-network Non-participating 0% 0% 0% $5,000 $10 copay First PCP visits covered in full $30 / $0 BALANCE PLUS GOLD PCP Non-preferred $500 / $1,000 x individual deductible Unlimited Network 10 Essential Benefits Covered Services Heritage Plus Out-of-network 1 Ambulatory Patient Services Office visits Spinal manipulation (1 visits PCY); $10 Acupuncture (1 visits PCY) Deductible, then 0% Emergency Services Emergency care Copay waived if direct admitted to inpatient facility Ambulance transportation (air & ground) $5 copay, then deductible & in-network coinsurance $00 Copay, then in-network deductible & coinsurance Emergent: Same as in-network Non-emergent: Air Ded, then 0% / Ded, then 0%; Ground Same as in-network 3 Hospitalization Inpatient Hospice: 10 days inpatient Respite care: 0 hours lifetime Organ and tissue transplants, inpatient unlimited, except $5,000 donor coverage limit and $,500 travel and lodging per transplant Maternity & Newborn Care Prenatal, delivery, postnatal care 5 Mental Health & Substance Use Office visit $30 / $0 Disorder Services, including Behavioral Health Treatment Inpatient hospital: mental/behavioral health Rehabilitative & Habilitative Services & Devices Inpatient rehabilitation: 30 days PCY Inpatient habilitation: 30 days PCY Therapy Physical, speech, occupational, massage therapy: 5 visits PCY 500 - Deductible, then $30 1000 - Deductible, then $0 Rehabilitative and habiltative benefits have the same number of visits, but are counted separately Durable medical equipment Skilled nursing facility: 0 days PCY Laboratory Services Includes X-ray, pathology, imaging/diagnostic, MRI, CT, PET (Prior Authorization required for certain services) Preventive/Wellness Services & Chronic Disease Management Screenings Exams and immunizations Deductible, then 0% Pediatric Services, including Vision Care Under 1 years of age Eye exam: 1 PCY Eyewear: One pair of glasses PCY (frames & lenses); or 1-month supply of contacts PCY, in lieu of glasses (frames & lenses) Dental: preventive/basic/major $30 / $0 Orthodontia (medically necessary only) 10 Prescription Drugs Retail up to 0-day supply (3x 30 day supply cost) -Tier: Generic/Brand/ Mail Order 0-day supply; 3x retail Non-Preferred Brand/Specialty Specialty Rx 30-day supply Drug Formulary X 500 - $0 / $0 / Deductible waived, then 50% / 1000 - $10 / $0 / Deductible waived, then 50% / Deductible waived, then 0% Additional benefits embedded within the medical plan Hearing Hearing exam: 1 per calendar years $30 / $0 Retail: Same as in-network Mail order & specialty: not covered Hearing aids and hardware: $1,000/3 calendar years A full list of services is available on premera.com/ak/member 10

Balance Plus Bronze HSA Alaska plans for group 1-50 Beginning January 1, 01 The deductible applies whenever there is a coinsurance listed, unless otherwise noted. Individual Deductible Coinsurance Per Calendar Year = PCY Family = x individual (embedded) Amount you pay after your deductible is met BALANCE PLUS BRONZE HSA In-network Non-preferred Non-participating Individual: $,500 / $5,50 Family: $,000 /$10,500 30% 0% x individual deductible 0% Out-of-Pocket Maximum Includes deductible, coinsurance, and copays Family = x individual (embedded) Individual: $,50 Family: $1,00 Unlimited Office Visits Cost share Network 10 Essential Benefits Covered Services Heritage Plus Out-of-network 1 Ambulatory Patient Services Office visits Spinal manipulation (1 visits PCY); Acupuncture (1 visits PCY) Emergency Services Emergency care Ambulance transportation (air & ground) Emergent: Same as in-network Non-emergent: Air Ded, then 0% / Ded, then 0%; Ground Same as in-network 3 Hospitalization Inpatient Hospice: 10 days inpatient Respite care: 0 hours lifetime Organ and tissue transplants, inpatient unlimited, except $5,000 donor coverage limit and $,500 travel and lodging per transplant Deductible, then 0% Maternity & Newborn Care Prenatal, delivery, postnatal care 5 Mental Health & Substance Use Disorder Services, including Office visit Behavioral Health Treatment Inpatient hospital: mental/behavioral health Deductible, then 0% Rehabilitative & Habilitative Services & Devices Inpatient rehabilitation: 30 days PCY Inpatient habilitation: 30 days PCY Therapy Physical, speech, occupational, massage therapy: 5 visits PCY Rehabilitative and habiltative benefits have the same number of visits, but are counted separately Durable medical equipment Skilled nursing facility: 0 days PCY Laboratory Services Includes X-ray, pathology, imaging/diagnostic, MRI, CT, PET (Prior Authorization required for certain services) Preventive/Wellness Services & Chronic Disease Management Screenings Exams and immunizations Deductible, then 0% Pediatric Services, including Vision Care Under 1 years of age Eye exam: 1 PCY Eyewear: One pair of glasses PCY (frames & lenses); or 1-month supply of contacts PCY, in lieu of glasses (frames & lenses) Deductible waived, then 10% Dental: preventive/basic/major Orthodontia (medically necessary only) 10 Prescription Drugs Retail up to 0-day supply Mail Order 0-day supply Specialty Rx 30-day supply Drug Formulary X1 Additional benefits embedded within the medical plan Hearing Hearing exam: 1 per calendar years Hearing aids and hardware: $1,000/3 calendar years Retail: Same as in-network Mail order & specialty: not covered A full list of services is available on premera.com/ak/member 11

Balance Plus Silver HSA Alaska plans for group 1-50 Beginning January 1, 01 The deductible applies whenever there is a coinsurance listed, unless otherwise noted. Individual Deductible Coinsurance Out-of-Pocket Maximum Per Calendar Year = PCY Family = x individual (embedded) Amount you pay after your deductible is met Includes deductible, coinsurance, and copays Family = x individual (embedded) BALANCE PLUS SILVER HSA In-network Non-preferred Non-participating Individual: $3,000 Family: $,000 30% 0% x individual deductible 0% Individual: $,00 Unlimited Family: $,00 Office Visits Cost share Network 10 Essential Benefits Covered Services Heritage Plus Out-of-network 1 Ambulatory Patient Services Office visits Spinal manipulation (1 visits PCY); Acupuncture (1 visits PCY) Emergency Services Emergency Care Ambulance transportation (air & ground) Emergent: Same as in-network Non-emergent: Air Ded, then 0% / Ded, then 0%; Ground Same as in-network 3 Hospitalization Inpatient Hospice: 10 days inpatient Respite care: 0 hours lifetime Organ and tissue transplants, inpatient unlimited, except $5,000 donor coverage limit and $,500 travel and lodging per transplant Maternity & Newborn Care Prenatal, delivery, postnatal care 5 Mental Health & Substance Use Disorder Services, including Office visit Behavioral Health Treatment Inpatient hospital: mental/behavioral health Rehabilitative & Habilitative Services & Devices Inpatient rehabilitation: 30 days PCY Inpatient habilitation: 30 days PCY Therapy Physical, speech, occupational, massage therapy: 5 visits PCY Deductible, then 0% Rehabilitative and habiltative benefits have the same number of visits, but are counted separately Durable medical equipment Skilled nursing facility: 0 days PCY Laboratory Services Includes X-ray, pathology, imaging/diagnostic, MRI, CT, PET (Prior Authorization required for certain services) Deductible, then 0% Preventive/Wellness Services & Chronic Disease Management Screenings Exams and immunizations Deductible, then 0% Pediatric Services, including Vision Care Under 1 years of age Eye exam: 1 PCY Eyewear: One pair of glasses PCY (frames & lenses); or 1-month supply of contacts PCY, in lieu of glasses (frames & lenses) Dental: preventive/basic/major Deductible waived, then 10% Orthodontia (medically necessary only) 10 Prescription Drugs Retail up to 0-day supply Mail Order 0-day supply Specialty Rx 30-day supply Drug Formulary X1 Additional benefits embedded within the medical plan Hearing Hearing exam: 1 per calendar years Hearing aids and hardware: $1,000/3 calendar years Retail: Same as in-network Mail order & specialty: not covered A full list of services is available on premera.com/ak/member 1

Balance Plus Gold HRA Alaska plans for group 1-50 Beginning January 1, 01 The deductible applies whenever there is a coinsurance listed, unless otherwise noted. Individual Deductible In-network Non-participating Required Employer Contribution Family = x employer contribution $1,500 x individual Coinsurance Amount you pay after your deductible is met 0% 0% 0% Out-of-Pocket Maximum Office Visits Per Calendar Year = PCY Family = x individual deductible (in-network only) Includes deductible, coinsurance, and copays Family = x Ind. out-of-pocket-max (in-network only) Designated PCP office visit Non-designated PCP or specialist office visit $,50 $15 copay First PCP visits covered in full $5 BALANCE PLUS GOLD PCP Non-preferred $3,000 x individual deductible Unlimited Network 10 Essential Benefits Covered Services Heritage Plus Out-of-network 1 Ambulatory Patient Services Office visits Spinal manipulation (1 visits PCY); $15 Acupuncture (1 visits PCY) Deductible, then 0% Emergency Services Emergency care Copay waived if directly admitted to inpatient facility Ambulance transportation (air & ground) $5 copay, then deductible & in-network coinsurance $00 Copay, then in-network deductible & coinsurance Emergent: Same as in-network Non-emergent: Air Ded, then 0% / Ded, then 0%; Ground Same as in-network 3 Hospitalization Inpatient Hospice: 10 days inpatient Respite care: 0 hours lifetime Organ and tissue transplants, inpatient unlimited, except $5,000 donor coverage limit and $,500 travel and lodging per transplant Maternity & Newborn Care Prenatal, delivery, postnatal care 5 Mental Health & Substance Use Office visit $5 Disorder Services, including Behavioral Health Treatment Inpatient hospital: mental/behavioral health Rehabilitative & Habilitative Services & Devices Inpatient rehabilitation: 30 days PCY Inpatient habilitation: 30 days PCY Therapy Physical, speech, occupational, massage therapy: 5 visits PCY Deductible, then $5 Rehabilitative and habiltative benefits have the same number of visits, but are counted separately Durable medical equipment Skilled nursing facility: 0 days PCY Laboratory Services Includes X-ray, pathology, imaging/diagnostic, MRI, CT, PET (Prior Authorization required for certain services) Preventive/Wellness Services & Chronic Disease Management Screenings Exams and immunizations Deductible, then 0% Pediatric Services, including Vision Care Under 1 years of age Eye exam: 1 PCY Eyewear: One pair of glasses PCY (frames & lenses); or 1-month supply of contacts PCY, in lieu of glasses (frames & lenses) Dental: preventive/basic/major $5 Orthodontia (medically necessary only) 10 Prescription Drugs Retail up to 0-day supply (3x 30 day supply cost) -Tier: Generic/Brand/ Mail Order 0-day supply; 3x retail Non-Preferred Brand/Specialty Specialty Rx 30-day supply Drug Formulary X $15 / $50 / Deductible waived, then 50% / Retail: Same as in-network Mail order & specialty: not covered Additional benefits embedded within the medical plan Hearing Hearing exam: 1 per calendar years $5 A full list of services is available on premera.com/ak/member Hearing aids and hardware: $1,000/3 calendar years 13

Balance Plus Bronze PCP 5000/100 Rx Alaska plans for group 1-50 Beginning January 1, 01 The deductible applies whenever there is a coinsurance listed, unless otherwise noted. Individual Deductible Per Calendar Year = PCY Family = x individual deductible (in-network only) In-network Pharmacy Deductible Family = x individual pharmacy deductible $1,00 Coinsurance Amount you pay after your deductible is met 30% Out-of-Pocket Includes deductible, coinsurance, and copays Family = x Ind. out-of-pocket-max (in-network only) $,50 First visits PCY $35/deductible Office Visits Designated PCP office visit waived, otherwise deductible, then coinsurance Non-designated PCP or specialist office visit Network Heritage Plus 10 Essential Benefits Covered Services BALANCE PLUS BRONZE PCP Non-preferred $5,000 x individual deductible Non-participating Shared with in-network pharmacy deductible 0% 0% Unlimited Out-of-network 1 Ambulatory Patient Services Office visits Spinal manipulation (1 visits PCY); $35 Acupuncture (1 visits PCY) Emergency Services Emergency care Copay waived if direct admitted to inpatient facility Ambulance transportation (air & ground) $5 copay, then deductible & in-network coinsurance $00 Copay, then in-network deductible & coinsurance Emergent: Same as in-network Non-emergent: Air Ded, then 0% / Ded, then 0%; Ground Same as in-network 3 Hospitalization Inpatient Hospice: 10 days inpatient Respite care: 0 hours lifetime Organ and tissue transplants, inpatient unlimited, except $5,000 donor coverage limit and $,500 travel and lodging per transplant Maternity & Newborn Care Prenatal, delivery, postnatal care 5 Mental Health & Substance Use Office visit Disorder Services, including Inpatient hospital: mental/behavioral health Behavioral Health Treatment Rehabilitative & Habilitative Services & Devices Inpatient rehabilitation: 30 days PCY Inpatient habilitation: 30 days PCY Therapy Physical, speech, occupational, massage therapy: 5 visits PCY Rehabilitative and habiltative benefits have the same number of visits, but are counted separately Durable medical equipment Skilled nursing facility: 0 days PCY Laboratory Services Includes X-ray, pathology, imaging/diagnostic, MRI, CT, PET (Prior Authorization required for certain services) Preventive/Wellness Services & Chronic Disease Management Screenings Exams and immunizations Deductible, then 0% Pediatric Services, including Vision Care Under 1 years of age Eye exam: 1 PCY Eyewear: One pair of glasses PCY (frames & lenses); or 1-month supply of contacts PCY, in lieu of glasses (frames & lenses) Deductible waived, then 10% Dental: preventive/basic/major Orthodontia (medically necessary only) 10 Prescription Drugs Retail up to 0-day supply (3x 30 day supply cost) -Tier: Generic/Brand/ Mail Order 0-day supply; 3x retail supply cost Non-Preferred Brand/Specialty Specialty Rx 30-day supply Drug Formulary X $5 / Rx Deductible, then 50% / Rx Deductible, then 50% / Rx Deductible, then 50% Retail: Same as in-network Mail order & specialty: not covered Additional benefits embedded within the medical plan Hearing Hearing exam: 1 per calendar years Deductible waived, then 0% Hearing aids and hardware: $1,000/3 calendar years A full list of services is available on premera.com/ak/member 1

Balance Plus Silver PCP 3000/1500 Rx Alaska plans for group 1-50 Beginning January 1, 01 The deductible applies whenever there is a coinsurance listed, unless otherwise noted. Individual Deductible In-network Non-participating Pharmacy Deductible Family = x individual pharmacy deductible $1,500 Shared with in-network pharmacy deductible Coinsurance Amount you pay after your deductible is met 30% 0% 0% Out-of-Pocket Maximum Includes deductible, coinsurance, and copays $,50 Unlimited Family = x Ind. out-of-pocket-max (in-network only) Office Visits Network 10 Essential Benefits Covered Services Per Calendar Year = PCY Family = x individual deductible (in-network only) Designated PCP office visit Non-designated PCP or specialist office visit $0 copay First PCP visits covered in full $0 Heritage Plus BALANCE PLUS SILVER PCP Non-preferred $3,000 x individual deductible 0% 0% Out-of-network 1 Ambulatory Patient Services Office visits Spinal manipulation (1 visits PCY); $0 Acupuncture (1 visits PCY) Deductible, then 0% Emergency Services 3 Hospitalization Emergency care Copay waived if directly admitted to inpatient facility Ambulance transportation (air & ground) Inpatient Hospice: 10 days inpatient Respite care: 0 hours lifetime Organ and tissue transplants, inpatient unlimited, except $5,000 donor coverage limit and $,500 travel and lodging per transplant $5 copay, then deductible & in-network coinsurance $00 Copay, then in-network deductible & coinsurance Emergent: Same as in-network Non-emergent: Air Ded, then 0% / Ded, then 0%; Ground Same as in-network Maternity & Newborn Care Prenatal, delivery, postnatal care 5 Mental Health & Substance Use Office visit $0 Disorder Services, including Behavioral Health Treatment Inpatient hospital: mental/behavioral health Rehabilitative & Habilitative Services & Devices Inpatient rehabilitation: 30 days PCY Inpatient habilitation: 30 days PCY Therapy Physical, speech, occupational, massage therapy: 5 visits PCY Deductible, then $0 Deductible, then 0% Rehabilitative and habiltative benefits have the same number of visits, but are counted separately Durable medical equipment Skilled nursing facility: 0 days PCY Laboratory Services Includes X-ray, pathology, imaging/diagnostic, MRI, CT, PET (Prior Authorization required for certain services) Deductible, then 0% Preventive/Wellness Services & Chronic Disease Management Screenings Exams and immunizations Deductible, then 0% Pediatric Services, including Vision Care Under 1 years of age Eye exam: 1 PCY Eyewear: One pair of glasses PCY (frames & lenses); or 1-month supply of contacts PCY, in lieu of glasses (frames & lenses) $0 Dental: preventive/basic/major Orthodontia (medically necessary only) 10 Prescription Drugs Retail up to 0-day supply (3x 30 day supply cost) -Tier: Generic/Brand/ Mail Order 0-day supply; 3x retail supply cost Non-Preferred Brand/Specialty Specialty Rx 30-day supply Drug Formulary X $15 / Rx / Rx / Rx Retail: Same as in-network Mail order & specialty: not covered Additional benefits embedded within the medical plan Hearing Hearing exam: 1 per calendar years $0 Hearing aids and hardware: $1,000/3 calendar years A full list of services is available on premera.com/ak/member 15

Balance Plus Gold PCP 1500/500 Rx Alaska plans for group 1-50 Beginning January 1, 01 The deductible applies whenever there is a coinsurance listed, unless otherwise noted. Individual Deductible In-network Non-participating Pharmacy Deductible Family = x individual pharmacy deductible $500 Shared with in-network pharmacy deductible Coinsurance Amount you pay after your deductible is met 0% 0% 0% Out-of-Pocket Maximum Office Visits Per Calendar Year = PCY Family = x individual deductible (in-network only) Includes deductible, coinsurance, and copays Family = x Ind. out-of-pocket-max (in-network only) Designated PCP office visit Non-designated PCP or specialist office visit $,000 $10 copay First PCP visits covered in full $35 BALANCE PLUS GOLD PCP Non-preferred $1,500 x individual deductible Unlimited Network 10 Essential Benefits Covered Services Heritage Plus Out-of-network 1 Ambulatory Patient Services Office visits Spinal manipulation (1 visits PCY); $10 Acupuncture (1 visits PCY) Deductible, then 0% Emergency Services Emergency care Copay waived if directly admitted to inpatient facility Ambulance transportation (air & ground) $5 copay, then deductible & in-network coinsurance $00 Copay, then in-network deductible & coinsurance Emergent: Same as in-network Non-emergent: Air Ded, then 0% / Ded, then 0%; Ground Same as in-network 3 Hospitalization Inpatient Hospice: 10 days inpatient Respite care: 0 hours lifetime Organ and tissue transplants, inpatient unlimited, except $5,000 donor coverage limit and $,500 travel and lodging per transplant Maternity & Newborn Care Prenatal, delivery, postnatal care 5 Mental Health & Substance Use Office visit $35 Disorder Services, including Behavioral Health Treatment Inpatient hospital: mental/behavioral health Rehabilitative & Habilitative Services & Devices Inpatient rehabilitation: 30 days PCY Inpatient habilitation: 30 days PCY Therapy Physical, speech, occupational, massage therapy: 5 visits PCY Deductible, then $35 Rehabilitative and habiltative benefits have the same number of visits, but are counted separately Durable medical equipment Skilled nursing facility: 0 days PCY Laboratory Services Includes X-ray, pathology, imaging/diagnostic, MRI, CT, PET (Prior Authorization required for certain services) Preventive/Wellness Services & Chronic Disease Management Screenings Exams and immunizations Deductible, then 0% Pediatric Services, including Vision Care Under 1 years of age Eye exam: 1 PCY Eyewear: One pair of glasses PCY (frames & lenses); or 1-month supply of contacts PCY, in lieu of glasses (frames & lenses) Dental: preventive/basic/major $35 Orthodontia (medically necessary only) 10 Prescription Drugs Retail up to 0-day supply (3x 30 day supply cost) -Tier: Generic/Brand/ Mail Order 0-day supply; 3x retail Non-Preferred Brand/Specialty Specialty Rx 30-day supply Drug Formulary X $10 / Rx / Rx / Rx Retail: Same as in-network Mail order & specialty: not covered Additional benefits embedded within the medical plan Hearing Hearing exam: 1 per calendar years $35 A full list of services is available on premera.com/ak/member Hearing aids and hardware: $1,000/3 calendar years 1

Balance Select Silver PPO Alaska plans for group 1-50 Beginning January 1, 01 The deductible applies whenever there is a coinsurance listed, unless otherwise noted. Individual Deductible Coinsurance Out-of-Pocket Maximum Per Calendar Year = PCY Family = x individual deductible (in-network only) Amount you pay after your deductible is met Includes deductible, coinsurance, and copays Family = x Ind. Out-of-pocket-max (in-network only) In-network 30% $,50 BALANCE SELECT SILVER PPO Non-preferred $,000 / $3,000 x individual deductible Non-participating Hospital: 0% Hospital: 0% Unlimited Office Visits Cost share $35 Same as in-network Network 10 Essential Benefits Covered Services Heritage Select Out-of-network 1 Ambulatory Patient Services Office visits Spinal manipulation (1 visits PCY); Office visit cost share Acupuncture (1 visits PCY) Emergency Services Emergency care Copay waived if directly admitted to inpatient facility Ambulance transportation (air & ground) $5 copay, then deductible & in-network coinsurance $00 Copay, then in-network deductible & coinsurance Emergent: Same as in-network Non-emergent: Air Ded, then 0% / Ded, then 0%; Ground Same as in-network 3 Hospitalization Inpatient Hospice: 10 days inpatient Respite care: 0 hours lifetime Organ and tissue transplants, inpatient unlimited, except $5,000 donor coverage limit and $,500 travel and lodging per transplant Maternity & Newborn Care Prenatal, delivery, postnatal care 5 Mental Health & Substance Use Office visit Office visit cost share Disorder Services, including Behavioral Health Treatment Inpatient hospital: mental/behavioral health Rehabilitative & Habilitative Services & Devices Inpatient rehabilitation: 30 days PCY Inpatient habilitation: 30 days PCY Therapy Rehabilitative and habiltative benefits have the same number of visits, but are counted separately Physical, speech, occupational, massage therapy: 5 visits PCY Durable medical equipment Skilled nursing facility: 0 days PCY Deductible, then $35 Laboratory Services Includes X-ray, pathology, imaging/diagnostic, MRI, CT, PET (Prior Authorization required for certain services) Preventive/Wellness Services & Chronic Disease Management Screenings Exams and immunizations Pediatric Services, including Vision Care Under 1 years of age Eye exam: 1 PCY Eyewear: One pair of glasses PCY (frames & lenses); or 1-month supply of contacts PCY, in lieu of glasses (frames & lenses) Dental: preventive/basic/major Office visit cost share Orthodontia (medically necessary only) 10 Prescription Drugs Retail up to 0-day supply (3x 30 day supply cost) -Tier: Generic/Brand/ Mail Order 0-day supply; 3x retail supply cost Non-Preferred Brand/Specialty Specialty Rx 30-day supply Drug Formulary X Additional benefits embedded within the medical plan Hearing Hearing exam: 1 per calendar years Hearing aids and hardware: $1,000/3 calendar years $5 $50 $100 Office visit cost share Retail: Same as in-network Mail order & specialty: not covered A full list of services is available on premera.com/ak/member 1

Balance Select Gold PPO Alaska plans for group 1-50 Beginning January 1, 01 The deductible applies whenever there is a coinsurance listed, unless otherwise noted. Individual Deductible Coinsurance Out-of-Pocket Maximum Per Calendar Year = PCY Family = x individual deductible (in-network only) Amount you pay after your deductible is met Includes deductible, coinsurance, and copays Family = x Ind. out-of-pocket-max (in-network only) In-network 0% $5,000 / $5,000 / $,500 BALANCE SELECT GOLD PPO Non-preferred $500 / $1,000 / $1,500 x individual deductible Non-participating Hospital: 0% Hospital: 0% Unlimited Office Visits Cost share $5 / $30 / $30 Same as in-network Network 10 Essential Benefits Covered Services Heritage Select Out-of-network 1 Ambulatory Patient Services Office visits Spinal manipulation (1 visits PCY); Office visit cost share Acupuncture (1 visits PCY) Emergency Services Emergency care Copay waived if directly admitted to inpatient facility Ambulance transportation (air & ground) $5 copay, then deductible & in-network coinsurance $00 Copay, then in-network deductible & coinsurance Emergent: Same as in-network Non-emergent: Air Ded, then 0% /Ded, then 0%; Ground Same as in-network 3 Hospitalization Inpatient Hospice: 10 days inpatient Respite care: 0 hours lifetime Organ and tissue transplants, inpatient unlimited, except $5,000 donor coverage limit and $,500 travel and lodging per transplant Maternity & Newborn Care Prenatal, delivery, postnatal care 5 Mental Health & Substance Use Office visit Office visit cost share Disorder Services, including Behavioral Health Treatment Inpatient hospital: mental/behavioral health Rehabilitative & Habilitative Services & Devices Inpatient rehabilitation: 30 days PCY Inpatient habilitation: 30 days PCY Therapy Rehabilitative and habiltative benefits have the same number of visits, but are counted separately Physical, speech, occupational, massage therapy: 5 visits PCY Durable medical equipment Skilled nursing facility: 0 days PCY 500 - Deductible, then $5 1000/1500 - Deductible, then $30 Laboratory Services Includes X-ray, pathology, imaging/diagnostic, MRI, CT, PET (Prior Authorization required for certain services) Preventive/Wellness Services & Chronic Disease Management Screenings Exams and immunizations Pediatric Services, including Vision Care Under 1 years of age Eye exam: 1 PCY Eyewear: One pair of glasses PCY (frames & lenses); or 1-month supply of contacts PCY, in lieu of glasses (frames & lenses) Dental: preventive/basic/major Office visit cost share Orthodontia (medically necessary only) 10 Prescription Drugs Retail up to 0-day supply (3x 30 day supply cost) -Tier: Generic/Brand/ Mail Order 0-day supply; 3x retail supply cost Non-Preferred Brand/Specialty Specialty Rx 30-day supply Drug Formulary X Additional benefits embedded within the medical plan Hearing Hearing exam: 1 per calendar years Hearing aids and hardware: $1,000/3 calendar years 500 - $10 / $0 / $0 / 1000, 1500 - $10 / $5 / $5 / Office visit cost share Retail: Same as in-network Mail order & specialty: not covered A full list of services is available on premera.com/ak/member 1

Balance Select Bronze HSA Alaska plans for group 1-50 Beginning January 1, 01 The deductible applies whenever there is a coinsurance listed, unless otherwise noted. Individual Deductible Per Calendar Year = PCY Family = x individual (embedded) In-network Individual: $,500 / $5,50 Family: $,000 / $10,500 BALANCE SELECT BRONZE HSA Non-preferred x individual deductible Non-participating Coinsurance Amount you pay after your deductible is met 30% Hospital: 0% Hospital: 0% Out-of-Pocket Maximum Includes deductible, coinsurance, and copays Family = x individual (embedded) Individual: $,50 Family: $1,00 Unlimited Office Visits Cost share Same as in-network Network 10 Essential Benefits Covered Services Heritage Select Out-of-network 1 Ambulatory Patient Services Office visits Spinal manipulation (1 visits PCY); Acupuncture (1 visits PCY) Emergency Services Emergency Care Ambulance transportation (air & ground) Emergent: Same as in-network Non-emergent: Air Ded, then 0% / Ded, then 0%; Ground Same as in-network 3 Hospitalization Inpatient Hospice: 10 days inpatient Respite care: 0 hours lifetime Organ and tissue transplants, inpatient unlimited, except $5,000 donor coverage limit and $,500 travel and lodging per transplant Maternity & Newborn Care Prenatal, delivery, postnatal care 5 Mental Health & Substance Use Disorder Services, including Office visit Behavioral Health Treatment Inpatient hospital: mental/behavioral health Rehabilitative & Habilitative Services & Devices Therapy Inpatient rehabilitation: 30 days PCY Inpatient habilitation: 30 days PCY Physical, speech, occupational, massage therapy: 5 visits PCY Rehabilitative and habiltative benefits Durable medical equipment have the same number of visits, but are counted separately Skilled nursing facility: 0 days PCY Laboratory Services Includes X-ray, pathology, imaging/diagnostic, MRI, CT, PET (Prior Authorization required for certain services) Preventive/Wellness Services & Chronic Disease Management Screenings Exams and immunizations Pediatric Services, including Vision Care Under 1 years of age Dental: preventive/basic/major Orthodontia (medically necessary only) 10 Prescription Drugs Retail up to 0-day supply Mail Order 0-day supply Specialty Rx 30-day supply Drug Formulary X1 Additional benefits embedded within the medical plan Hearing Hearing exam: 1 per calendar years Hearing aids and hardware: $1,000/3 calendar years A full list of services is available on premera.com/ak/member Eye exam: 1 PCY Eyewear: One pair of glasses PCY (frames & lenses); or 1-month supply of contacts PCY, in lieu of glasses (frames & lenses) Deductible waived, then 10% Retail: Same as in-network Mail order & specialty: not covered 1

Balance Select Silver HSA Alaska plans for groups 1-50 Beginning January 1, 01 The deductible applies whenever there is a coinsurance listed, unless otherwise noted. BALANCE SELECT SILVER HSA PCY = per calendar year In-network Non-preferred Non-participating Individual Deductible PCY Family = x individual (embedded) Individual: $3,000 Family: $,000 x individual deductible Coinsurance Amount you pay after your deductible is met 30% Hospital: 0% Hospital: 0% Out-of-Pocket Maximum Includes deductible, coinsurance, and copays Family = x individual (embedded) Individual: $,00 Family: $,00 Unlimited 1 Office Visits Cost share Network 10 Essential Benefits Covered Services Ambulatory Patient Services Office visits Spinal Manipulation (1 visits PCY); Acupuncture (1 visits PCY) Heritage Select Same as in-network Out-of-network Emergency Services Emergency Care Ambulance transportation (air & ground) Emergent: Same as in-network Non-emergent: Air Ded, then 0% / Ded, then 0%; Ground Same as in-network 3 Hospitalization Inpatient Hospice 10 days inpatient Respite care: 0 hours lifetime Organ and tissue transplants, inpatient unlimited, except $5,000 donor and $,500 travel and lodging per transplant Maternity & Newborn Care Prenatal, delivery, postnatal care 5 Mental Health & Substance Use Disorder Services, including Behavioral Health Treatment Rehabilitative & Habilitative Services & Devices Therapy Rehabilitative and habilitative benefits have the same number of visits, but are counted separately Laboratory Services Office visit Inpatient hospital: mental/behavioral health Inpatient rehabilitation: 30 days PCY Physical, speech, occupational, massage therapy: 5 visits PCY Durable medical equipment Skilled nursing facility: 0 days PCY Includes x-ray, pathology, imaging/diagnostic, CT, PET, MRI (Prior Authorization required for certain services ) Preventive/Wellness Services & Chronic Disease Management Screenings Exams and immunizations Pediatric Services, including Vision & Oral Care Under 1 years of age Eye exam: 1 PCY Eyewear: One pair of glasses PCY (frames & lenses); or 1-month supply of contacts PCY, in lieu of glasses (frames & lenses) Dental: preventative/basic/major Deductible waived, then 10% Orthodontia (medically necessary only) 10 Prescription Drugs Retail up to 0-day supply Mail Order 0-day supply Specialty Rx 30-day supply Retail: Same as in-network; Mail order & specialty: not covered Drug Formulary X1 Additional benefits embedded within the medical plan Hearing Hearing exam: 1 per calendar years Hearing aids and hardware: $1,000/3 calendar years A full list of services is available on premera.com/ak/member 0

Optional benefits Premera Adult Vision Plan These optional vision benefits include exams and eyewear. Vision exam and eyewear are covered up to a maximum benefit of $350 per calendar year per member. Exam One per calendar year with $5 copayment Eyewear One pair of lenses for eyeglasses per calendar year per member One pair of frames up to $0 every two calendar years per member Contact lenses up to $10 per calendar year per member Life and disability Employers can offer an integrated benefits program to help reduce disability and healthcare costs, improve health, and increase workforce productivity. Through our partner, USAble Life, groups will find flexible products, high-quality customer service, and fast, reliable claims service. Several package options are available for employers with 1 50 employees. Employers with 10 or more enrolled employees can choose from the following products: Group life insurance Group term life Provides benefits to a beneficiary in the event of an employee s death Accidental death and dismemberment (AD&D) Provides benefits in the event that a death or dismemberment is caused by an accident Dependent life Provides benefits to the employee in the event of a dependent s death Supplemental life and AD&D Provides additional coverage options for your employees Disability coverage Short-term disability coverage: Protects a portion of employees income in the event of a disability Long-term disability coverage: Provides employees and their families the income needed to help meet financial commitments and give them financial stability Dental coverage It s no secret good dental health affects your employees overall health. Premera s dental plans help both kids and adults maintain healthy teeth. Plus, they have access to a nationwide network of more than 10,000 dentists for dental care. See our DentalBlue benefit guide for information about our full line of dental plans. NOTE: The Balance Kids Dental plan meets the federal requirements for providing pediatric dental plans. 1

This is only a summary of the major benefits provided by our plans. This is not a contract. Please and Glossary. On our website, you can also find a Supplemental Guide with information about pri procedures, and pharmaceutical management procedures. Definitions Allowed amount* Coinsurance Copay Deductible Embedded deductible The negotiated amount for which a contracted provider agrees to provide services or supplies. Your employee s share of the cost for a service. If the plan s coinsurance is 0%, the employee pays 0% of the allowed amount and the plan benefit pays the other 0% of the allowed amount. A flat fee your employee pays for a specific service, such as an office visit, at the time they receive service. Services the plan pays for in full. Benefits provided at 100 percent of the allowed amount; not subject to deductible or coinsurance. The amount of money your employee pays every year before the plan pays for certain services. There are two deductibles one for the family and one for each member of the family. When an individual family member reaches his or her deductible, the member starts to receive benefit coverage. For other family members to receive benefit coverage, they must either reach their own deductible or the family deductible must be met. The family out-of-pocket maximum is also embedded. * Note that if they see a non-contracted provider, your employee will be responsible for the difference between the allowed amount and the provider s billed charges, in addition to the coinsurance and any applicable copay. The allowed amount for a non-contracted provider is determined by Premera as described in your forthcoming benefit book.

see premera.com for the Summary of Benefits and Coverage vacy policies, provider organization, key utilization management Formulary In-network Out-of-pocket maximum Primary care provider (PCP) A list of drugs the plan covers for specific uses. Not all generic, name-brand, and specialty drugs are included in the formulary. To find the formulary for your employee s plan, go to premera.com and select Pharmacy. A group of doctors, dentists, hospitals, and other healthcare providers that contract with Premera to provide services and supplies at negotiated amounts called allowed amounts. A preset limit after which the plan pays 100 percent of the allowed amount for services received in-network. All in-network essential benefits apply to the out-of-pocket maximum. The provider who helps coordinate your employee s care. They can choose a different primary care provider for each family member from: physicians and internists, physician assistants, and nurse practitioners; ob/gyns and women s health specialists, pediatricians, and geriatric specialists; or naturopaths. To get a reduced office visit copay with the PCP plans, your employee must choose a provider contracted as part of the Premera network and inform us this is your designated PCP. This is not a contract. Please see premera.com/sbc for the Summary of Benefits and Coverage and Glossary. On our website, you can also find a Supplemental Guide with information about privacy policies, provider organization, key utilization management procedures, and pharmaceutical management procedures. 3

General exclusions Benefits are not provided for treatment, surgery, services, drugs, or supplies for any of the following: Cosmetic surgery Experimental or investigative services Infertility Obesity/morbid obesity, related surgery, drugs, and supplements obesity surgery, drugs, and supplements for weight loss or weight control Orthognathic surgery Services in excess of specified benefit maximums Services payable by other types of insurance coverage Services received when you are not covered by this program Sexual dysfunction Sterilization reversal This is only a summary of the major benefits provided by our plans. This is not a contract. Please see premera.com/sbc for the Summary of Benefits and Coverage and Glossary. On our website, you can also find a Supplemental Guide with information about privacy policies, provider organization, key utilization management procedures, and pharmaceutical management procedures. For a complete list of exclusions and limitations, visit premera.com and click the Member Services tab, then click Benefit Exclusions. Prior authorization Certain medical services and prescriptions require prior authorization (approval from the health plan). See your Premera representative for more information. 5

Contact information Premera Blue Cross Blue Shield of Alaska 550 Denali St., Suite 10 Anchorage, AK 503..53 Premera Blue Cross Blue Shield of Alaska is an Independent Licensee of the Blue Cross Blue Shield Association 0 (0-01)