Blue Essential Open Access POS Large Group Benefit Summary Plan OAP12 2.5K/30

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Blue Essential Open Access POS Large Group Benefit Summary Plan OAP12 2.5K/30 All benefits are subject to the calendar year deductible, except those with in-network copayments, unless otherwise noted. All calendar year benefit visit maximums are combined between in-network and out-of-network. In addition to copayments, members are responsible for deductibles and any applicable coinsurance. Members are also responsible for all costs over the plan maximums. Some services may require pre-certification before services are covered by the Plan. When using out-of-network providers, members are responsible for any difference between the Maximum Allowed Amount and the amount the provider actually charges, as well as any copayments, deductibles and/or applicable coinsurance. Deductibles, Coinsurance and Maximums In-Network Benefit Level Out-of-Network Benefit Level Calendar Year Deductible* Individual Family $2,500 $7,500 Coinsurance Member pays 30% Plan pays 70% Calendar Year Out-of-Pocket Maximum* (includes calendar year deductible) Individual Family $7,150 $14,300 $7,500 $22,500 Member pays 50% Plan pays 50% $21,450 $42,900 *Deductibles and out-of-pocket maximums are added separately for in-network and out-of-network services. One family member may reach his or her Individual deductible and be eligible for coverage on health care expenses before other family members. Each family member s deductible amount also applies to the Family deductible and out-of-pocket maximum. Not everyone has to meet his or her deductible and out-of-pocket maximum for the family to meet theirs. When the Family deductible is met, all family members can access coverage for health care expenses. The medical and pharmacy copayments, deductible(s), and coinsurance on this plan will apply toward the out-of-pocket maximums. The following do not apply to out-of-pocket maximums: noncovered items, plan premiums, any balance billing due to Out-of-Network services or any fourth quarter deductible amounts carried over from the previous benefit period. Covered Services In-Network Benefit Level Out-of-Network Benefit Level Preventive Care Services for Children and Adults (preventive care services that meet the requirements of federal and state law, including certain screenings, immunizations and physician visits) Well-child care, immunizations Periodic health examinations Annual gynecology examinations Prostate screenings Physician Office Visits for Illness and Injury (PCP and Specialist) Primary Care Physician (PCP) Specialist Physician Retail Health Clinic -(located in some pharmacies: search for innetwork providers through Find a Doctor search tool on bcbsga.com) Immunizations Periodic health examinations Maternity Physician Services Global obstetrical care (prenatal, delivery and postpartum services) Online Medical Visit (https://livehealthonline.com) Online Behavioral Health Visit (https://livehealthonline.com) Diagnostic Services (office and/or outpatient facility) Labs, x-rays, and diagnostic procedures Office Surgery (surgery and administration of general anesthesia) Member pays 0% (not subject to deductible) $30 copayment $60 copayment (deductible waived through age 5) $30 copayment $30 copayment $30 copayment

Covered Services In-Network Benefit Level Out-of-Network Benefit Level Other Therapy Services Chemotherapy, radiation therapy, cardiac rehabilitation (there is no cardiac rehabilitation visit max on this plan; authorization required) and respiratory/pulmonary therapy. Advanced Diagnostic Imaging (MRI, MRA, CT Scans and PET Scans) Urgent Care Services $60 copayment Emergency Room Services Life-threatening illness or serious accidental injury only The ER copayment will be waived if admitted to the hospital Outpatient Surgery at Free Standing Surgical Center Facility surgery charges $150 copayment; then member pays 30% $150 copayment, then member pays 30% $150 copayment; then member pays 30% Diagnostic x-ray and lab services Physician services (anesthesiologist, radiologist, pathologist) Outpatient Surgery at Hospital Facility surgery charges Diagnostic x-ray and lab services Physician services (anesthesiologist, radiologist, pathologist Inpatient Facility Services Daily room, board and general nursing care at semi-private room rate, ICU/CCU charges; other medically necessary hospital charges such as diagnostic x-ray and lab services; newborn nursery care Physician services (anesthesiologist, radiologist, pathologist) Skilled Nursing Facility 60-day benefit period maximum Mental Health/Substance Abuse Services (*services must be authorized by calling 1-800-292-2879) Inpatient mental health and substance abuse services* (facility fee) Inpatient mental health and substance abuse services* (physician fee) Partial Hospitalization Program (PHP) and Intensive Outpatient Program (IOP)* (facility and physician fee) Office mental health and substance abuse services (physician fee) Member pays 30% Member pays 30% $500 copayment per admission; then member pays 30% after deductible $500 copayment per admission; then member pays 30% after deductible $500 copayment per admission; then member pays 30% after deductible $30 copayment Outpatient mental health and substance abuse services (physician fee) Home Health Care Services 120-visits benefit period maximum Hospice Care Services Inpatient and outpatient services covered under the hospice treatment program Durable Medical Equipment (DME) Only DME required for the treatment of diabetes and prosthetics are covered; all other DME is excluded Ambulance Services Covered only when medically necessary

Prescription Drugs (Option C) Current benefit period cost share for pharmacy benefits will apply to the plan Out-Of-Pocket Maximums. Members must file a claim form for reimbursement when using an out-of-network pharmacy. Refer to last page for Tier definitions Retail Drugs - Tier 1 (includes Tier 2 diabetic drugs/supplies) (30 day supply) Retail Drugs - Tier 2 (30 day supply) Retail Drugs - Tier 3 (30 day supply) Retail Drugs - Tier 4 (Specialty Drugs) (30 day supply) Mail Order Maintenance Drugs - Tier 1 (includes Tier 2 diabetic drugs/supplies) (90 day supply) Mail Order Maintenance Drugs - Tier 2 (90 day supply) Mail Order Maintenance Drugs - Tier 3 (90 day supply) Mail Order Maintenance Drugs - Tier 4 (Specialty Drugs) (30 day supply) * Member pays negotiated network rate at in-network pharmacy $15 copayment $40 copayment For a full disclosure of all benefits, exclusions and limitations please refer to your Certificate Booklet. Prescription Drug Tier Definitions Tier 1 These drugs have the lowest copayment. This tier will contain low cost or preferred medications. This tier may include generic, single source brand drugs, or multi-source brand drugs. Tier 2 These drugs will have a higher copayment than tier 1 drugs. This tier will contain preferred medications that generally are moderate in cost. This tier may include generic, single source, or multi-source brand drugs. Tier 3 These drugs will have a higher copayment than tier 2 drugs. This tier will contain non-preferred or high cost medications. This tier may include generic, single source brand drugs, or multi-source brands drugs. Tier 4 Tier 4 Prescription Drugs will have a higher Coinsurance or Copayment than those in Tier 3. This tier will contain Specialty Drugs. Plan Wellness Incentives Tools and resources to help you and your family stay healthy. Incentives apply to eligible employees and spouses. Future Moms Program 866-664-5404 Online Wellness Tool Kit To access the Online Wellness Tool Kit online, go to bcbsga.com, register or log in. Select the Health & Wellness tab then select the Wellness Tool Kit tab. 24/7 NurseLine 888-724-2583 Mothers-to-be can earn up to $200 toward gift cards to national retailers for participating and get personalized support and guidance. You can call to speak to a nurse coach at 866-664-5404 for answers to your pregnancy questions any time, any day. Earn up to $150 towards gift cards to national retailers when you participate in the Online Wellness Tool Kit. The Wellness Took Kit is an online personalized well-being improvement program that focuses on physical, social and emotional behaviors that affect your total well-being. You start by completing a Health Assessment to help identify health goals and to develop a well-being plan. Your wellbeing plan uses the personal goals you set to keep you motivated, and it changes over time as you make progress toward them. Access to Registered nurses any time of the day or night. Call 24/7 NurseLine at 888-724-2583.

Summary of Limitations and Exclusions Your Certificate Booklet will provide you with complete benefit coverage information. Some key limitations and exclusions, however, are listed below: Routine physical examinations necessitated by employment, foreign travel or participation in school athletic programs Outpatient therapy services physical therapy, occupational therapy, speech therapy, chiropractic care, and athletic training services All allergy services including, but not limited to testing, treatment, extracts and injections Durable medical equipment (DME) (except prosthetics and DME required for the treatment of diabetes) Non-emergency use of the emergency room Removal/extraction of impacted teeth Private duty nursing Care or treatment that is not medically necessary Cosmetic surgery, except to restore function altered by disease or trauma Dental care and oral surgery; except for accidental injury to natural teeth and treatment of TMJ Occupational related illness or injury Treatment, drugs or supplies considered experimental or investigational See Certificate Booklet for Complete Details It is important to keep in mind that this material is a brief outline of benefits and covered services and is not a contract. Please refer to your Certificate Booklet Form# POS-LG, 01012017 (the contract) for a complete explanation of covered services, limitations and exclusions. 3350 Peachtree Road, NE Atlanta, Georgia 30326 1-855-397-9267 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc., is an independent licensee of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 02609GAMENBGA eff 1/1/17

Language Access Services: Get help in your language Curious to know what all this says? We would be too. Here s the English version: If you have any questions about this document, you have the right to get help and information in your language at no cost. To talk to an interpreter, call (855) 333-5731. Separate from our language assistance program, we make documents available in alternate formats for members with visual impairments. If you need a copy of this document in an alternate format, please call the customer service telephone number on the back of your ID card. (TTY/TDD: 711) )Arabic( )العربية(: إذا كان لديك أي استفسارات بشأن هذا المستند فيحق لك الحصول على المساعدة والمعلومات بلغتك دون مقابل. للتحدث إلى مترجم اتصل على (855) 333-5731 Armenian (հայերեն). Եթե այս փաստաթղթի հետ կապված հարցեր ունեք, դուք իրավունք ունեք անվճար ստանալ օգնություն և տեղեկատվություն ձեր լեզվով: Թարգմանչի հետ խոսելու համար զանգահարեք հետևյալ հեռախոսահամարով (855) 333-5731 Chinese ( 中文 ): 如果您對本文件有任何疑問, 您有權使用您的語言免費獲得協助和資訊 如需與譯員通話, 請致電 (855) 333-5731 )Farsi( )فارسي(: در صورتی که سؤالی پیرامون این سند دارید این حق را دارید که اطالعات و کمک را بدون هیچ هزینهای به زبان مادریتان دریافت کنید. برای گفتگو با یک مترجم شفاهی با شماره (855) 333-5731 تماس بگیرید. French (Français): Si vous avez des questions sur ce document, vous avez la possibilité d accéder gratuitement à ces informations et à une aide dans votre langue. Pour parler à un interprète, appelez le (855) 333-5731. Haitian Creole (Kreyòl Ayisyen): Si ou gen nenpòt kesyon sou dokiman sa a, ou gen dwa pou jwenn èd ak enfòmasyon nan lang ou gratis. Pou pale ak yon entèprèt, rele (855) 333-5731. Italian (Italiano): In caso di eventuali domande sul presente documento, ha il diritto di ricevere assistenza e informazioni nella sua lingua senza alcun costo aggiuntivo. Per parlare con un interprete, chiami il numero (855) 333-5731 (Japanese) ( 日本語 ): この文書についてなにかご不明な点があれば あなたにはあなたの言語で無料で支援を受け情報を得る権利があります 通訳と話すには (855) 333-5731 にお電話ください

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