2550 Denali Street, Suite 1404 - Premera Blue Cross



|3800 Centerpoint Dr. |tel 907-258-5065 | |

|Suite 940 | 888-669-2583 toll-free | |

|Anchorage, AK 99503 |fax 907-258-1619 | |

| | |

|GROUP MASTER APPLICATION BENEFIT SELECTIONS—HERITAGEPLUS (F3T) |

|LARGE GROUP 51+ |

|This form is part of the Group Master Application. | |

| |GROUP NAME |      |

|Note: |No customizations will be allowed without prior approval. | | |

| |No customization required (only standard options taken) | | |

| |Yes, approved Product Customization Request form attached | | |

| | | | |

| |Cost-share amounts represent members’ costs. | | |

| | |GROUP ID |      |

| | |ALPHA PLAN PREFIX |      |

| |Default values are shown as bold-faced options. | |(Completed by Premera Blue Cross Blue Shield of Alaska) |

| | |

|1. |BENEFIT COVERAGE SELECTION | | |

|A. |How many benefit plans will the group offer?       |

| |Note: If this plan is for dental only, complete only section 9 of this form. |

| |

|B. |Class Selection | |

| |If you are differentiating your benefit coverage selection by class of employee, you will need to complete a benefit coverage selection worksheet for each |

| |separate class of employee you wish to cover. Select both a class and subclass from B1 and B2 below. |

| |

|1. |Class: | Active | Retiree* | Early Retiree* | Other, please specify |      |

| |* Requires Underwriting Approval |

|2. |Subclass: | | | | |

| | All employees | Management | Salaried | Hourly | Part-time | Full-time |

| | Union | Non-Union | Other, please specify |      |

| |

|2. |MEDICAL COST-SHARE OPTIONS |

| | | | |

|A. |Renewal Groups Only |

| | |

| |Renew as is – no benefit changes; form complete: stop here |

| |Renew with changes – complete sections below |

| | |

| |Helpful Hint: The Deductible and Coinsurance options you select below (sections 2B-2D) will not apply to the Prescription Drug benefits in Section 8 and |

| |the Dental benefits in Section 10. Subsequent sections of this form will allow you to further customize your cost-share options by applying |

| |Deductible/Coinsurance or Copays to specific benefits. Please note that references to “Deductible and Coinsurance” as a benefit choice in this worksheet |

| |will select whatever deductible and coinsurance options were chosen in this Section 2. |

| |

|B. |Individual Deductible (per calendar year) | |

| |

|1. |In-Network | |Out-of-Network |

| | |Note: If separate out-of-network deductible is taken, it must be at least 2 times the in-network |

| | |deductible. |

| |For 51+ groups | |

| | $100 (DVI-H | $3,000 (DVI-X) | $200 (DVO-D) | $7,500 (DVO-AW) |

| | $250 (DVI-J) | $4,000 (DVI-AE) | $500 (DVO-G) | $8,000 (DVO-AE) |

| | $300 (DVI-C) | $5,000 (DVI-L) | $600 (DVO-H) | $9,000 (DVO-AH) |

| | $500 (DVI-D) | $6,350 (DVI-BY) | $750 (DVO-I) | $10,000 (DVO-P) |

| | $750 (DVI-E) | $6,850 (DVI-CN) | $900 (DVO-DG) | $12,000 (DVO-AL) |

| | $1,000 (DVI-F) | $7,550 (DVI-EF) | $1,000 (DVO-J) | $12,700 (DVO-CB) |

| | $1,500 (DVI-G) | $7,900 (DVI-DM) | $1,500 (DVO-K) | $13,700 (DVO-CV) |

| | $2,000 (DVI-I) | $8,150 (DVI-DP) | $2,000 (DVO-L) | $15,000 (DVO-U) |

| | $2,500 (DVI-K) | $8,550 (DVI-ED) | $2,250 (DVO-DF) | $15,100 (DVO-EE) |

| | | | $3,000 (DVO-M) | $15,800 (DVO-DO) |

| | | | $4,000 (DVO-O) | $16,300 (DVO-DR) |

| | | | $4,500 (DVO-AV) | $17,100 (DVO-EC) |

| | | | $5,000 (DVO-Q) | $19,050 (DVO-CC) |

| | | | $6,000 (DVO-X) | $20,550 (DVO-CW) |

| | | | | $23,700 (DVO-DQ) |

| | | | | |

| | | | | Shared with In-Network Deductible |

| | |

| |Fourth-Quarter Deductible Carry Over? | Included (QTR-A) |

| | | Excluded (QTR-B) (only option for $7550/$8550) |

| | | |

| | |

|C. |Family Deductible (per calendar year) |

| |

| | 3 times the individual deductible (DFR-A) |

| | 2 times the individual deductible (DFR-B) (only option for $7550/$8550) |

| | No family deductible (DFR-C) |

|D. |Coinsurance |

| |In-Network |Out-of-Network |

| |Preferred Providers |Participating |

| | |Providers |

| | 0% | 40% (COI-K) | 60% (COO-W) |

| | 10% | 40% (COI-L) | 60% (COO-W) |

| | 20% | 40% (COI-J) | 60% (COO-W) |

| | 30% | 40% (COI-M) | 60% (COO-W) |(only option for $7550) |

| | 0% | 50% (COI-N) | 60% (COO-W) |

| | 10% | 50% (COI-O) | 60% (COO-W) |

| | 20% | 50% (COI-P) | 60% (COO-W) |

| | 30% | 50% (COI-Q) | 60% (COO-W) |

| | 0% | 0% (COI-A) | 60% (COO-W) |(only option for $8550) |

|E. |Individual Out-of-Pocket Maximum (per calendar year) |

| |Note: Out-of-pocket maximums include any deductibles and copays except for Hearing Exam copay, Adult Vision Exam copay and Prescription Drug copays. |

| |In-Network | |Out-of-Network |

| | $500 (OMI-A) | $2,000 (OMI-H) | $6,000 (OMI-AA) | $45,000 (OMO-EA) |

| | $700 (OMI-AD) | $2,100 (OMI-Q) | $6,350 (OMI-EJ) | No limit (OMO-A) (only option for $7550/$8550) |

| | $750 (OMI-B) | $2,250 (OMI-R) | $6,600 (OMI-EU) | |

| | $1,000 (OMI-C) | $2,300 (OMI-J) | $6,850 (OMI-CX) | |

| | $1,100 (OMI-U) | $2,500 (OMI-K) | $7,150 (OMI-FP) | |

| | $1,200 (OMI-D) | $3,000 (OMI-M) | $7,350 (OMI-GF) | |

| | $1,250 (OMI-V) | $3,500 (OMI-W) | $7,900 (OMI-GQ) | |

| | $1,300 (OMI-E) | $4,000 (OMI-N) | $8,150 (OMI-GY) | |

| | $1,500 (OMI-F) | $4,500 (OMI-Y) | $8,550 (OMI-HN) (only option for $7550/$8550) |

| | $1,750 (OMI-G) | $5,000 (OMI-O) | | |

| |

|F. |Family Out-of-Pocket Maximum |

| |Note: If both family deductible and family out-of-pocket maximum are selected, the family-to-individual ratio (3 times or 2 times) on both must be the |

| |same. |

| | |

| |In-Network/Out-of-Network |

| |

| | 3 times the individual out-of-pocket maximum (OFR-A) |

| | 2 times the individual out-of-pocket maximum (OFR-B) (only option for $7550/$8550) |

| | | | |

|G. |Office Visit Cost-Share |

| |In-Network |Out-of-Network |

| | Deductible & Coinsurance (OVI-A) |Deductible & Coinsurance (OVO-A) (only option for $7550/$8550) |

| | | |

| | |(Preferred / | |

| | |Participating) | |

| | | $20 / 40% (OVI-CK) | 60% (OVO- A) |

| |Copay| | |

| |of: | | |

| | | $20 / 50% (OVI-CL) | 60% (OVO- A) |

| | | $25 / 40% (OVI-CI ) | 60% (OVO- A) |

| | | $25 / 50% (OVI- CJ ) | 60% (OVO- A) |

|3. |FACILITY CARE OPTIONS |

| |

|A. |Inpatient Facility Care |

| |

| |In-Network |Out-of-Network |

| |

| | Deductible & Coinsurance (IPI-A) (only option for $7550/$8550) |Deductible & Coinsurance (IPO-A) |

| | Copay of $100 Per Admit (IPI- AY or IPI-BA) | |

| | |

|B. |Skilled Nursing Facility Care(per calendar year) |

| |

| | 60 days (SNF-A) (only option for $7550/$8550) | 100 days (SNF-F) | 120 days (SNF-C) |

|4. |EMERGENCY CARE OPTIONS |

| |

|A. |Emergency Room and Ambulance Transportation |

| | |

| |Note: If Copay option is selected, Emergency room copay waived if direct admit to an inpatient facility. There is a separate copay for emergency |

| |room and ambulance transportation benefits. |

| |

| | Deductible & Coinsurance (ERV-A, ERV-AD, ERV-AE, ERV-AF, or ERV-AG & AMB-O, AMB-S) (only option for $8550) |

| | Deductible & Coinsurance PLUS Copay of: | |

| | $50 (ERV-AY, ERV-BA, ERV-BB, ERV-BC & AMB-AC) |

| | $100 (ERV-AU, ERV-AV, ERV-AW, ERV-AX & AMB-AB) |

| | $150 (ERV-AR, ERV-AS, ERV-AT, ERV-BD & AMB-AD) |

| | $250 (ERV-BN, ERV-CB, ERV-CC, ERV-CD & AMB-AT) |

| | $450 (ERV-CE & AMB-AU) (only option for $7550) |

| | |

|B. |URGENT CARE CENTER |

| | |In-Network |Out-of-Network |

| | |(Preferred / Participating) | |

| | | $40 / 40% (UCC-AD) |Deductible & Coinsurance |

| | | $40 / 50% (UCC-AE) |Deductible & Coinsurance |

| | | Deductible & Coinsurance (UCC-F) |Deductible & Coinsurance (only option for $7550/$8550) |

| | | | |

|5. |DIAGNOSTIC SERVICES OPTIONS |

| |

| |Preventive |Diagnostic (Basic / Major) |

| | Covered in Full* |Deductible & Coinsurance (DXL- BM) (MMO- AE) (only option for $7550/$8550) |

| | Covered in Full* |Waive Deductible; Subject to Coinsurance (DXL- BL) (MMO- Y) |

| | Covered in Full* |Covered in Full* (DXL- C) (MMO- C) |

| | | |

| |*Benefits provided at 100% of allowable charge, not subject to deductible or coinsurance. |

| | |

|6. |OTHER SERVICE OPTIONS | |

| |

|A. |Acupuncture |

| | | | | | |

| | 12 visits PCY (ACL-A) |

| | 12 visits PCY (ACL-B) |

| | Unlimited visits(ACL-C) |

| | Not Covered (ACL-D & ACC-H) (only option for $7550/$8550) |

| | |

|B. |Spinal and Other Manipulations |

| | |

| | 12 visits PCY (MPL-A) |

| | 24 visits PCY (MPL-B) |

| | Unlimited visits (MPL-C) |

| | Not Covered (MPL-D & MPC-H) (only option for $7550/$8550) |

| | |

|C. |Foot Orthotics and Orthopedic Shoes (per calendar year) Note: Limits shared both in- and out-of-network. |

| | |

| | Unlimited (SUP-G) | | | |

| | $300 (SUP-AM) (only option for $7550/$8550) |

| | |

|D. |Home and Hospice Care Note: Limits shared both in- and out-of-network. |

| | |

|1. |Home Health Care (per calendar year) |

| | 130 visits (HOH-A) (only option for $7550/$8550) | Unlimited visits (HOH-C) |

|2. |Hospice Inpatient |Respite care |Overall Benefit Limit |

| | 10 days |240 hours + |6 months + (HPC-A) (only option for $7550/$8550) |

| | 30 days |240 hours |6 months (HPC-B) |

| | Unlimited |240 hours |6 months (HPC-H) |

| | Unlimited |Unlimited |Unlimited (HPC-D) |

|E. |Therapeutic Injections (includes allergy injections and allergy testing) |

| |In-Network |Out-of-Network |

| | Deductible & Coinsurance (INJ- A) (only option for $7550/$8550) |Deductible & Coinsurance (INJ- A, INJ- B, INJ- C) |

| | Waive Deductible; Subject to Coinsurance (INJ- B) | |

| | Covered in Full* (INJ- C) | | |

| | | | |

| |*Benefits provided at 100% of allowable charge, not subject to deductible or coinsurance. |

| | |

|F. |Rehabilitation and Habilitation Therapy (per calendar year) Note: Limits shared both in- and out-of-network. |

| |

| |Outpatient |Inpatient |Outpatient |Inpatient |

| |Rehabilitation |Rehabilitation |Habilitation Therapy |Habilitation Therapy |

| | | | | |

| | 45 visits |30 days |45 visits |30 days (RNT-A) (only option for $7550/$8550) |

| | 60 visits |60 days |60 visits |60 days (RNT-B) |

| | Unlimited |Unlimited |Unlimited |Unlimited (RNT-AD) |

|G. |Temporomandibular Joint Disorders (TMJ) Care |

| | Not Covered (TMJ-A) (only option for $7550/$8550) | $1,000 per calendar year; $5,000 lifetime maximum (TMJ-E) |

| | |

| |Note: For members covered under the medical plan, only medical TMJ services will be covered unless a dental plan is selected; in that case, dental TMJ |

| |services will also be covered. |

| | |

|H. |Orthognathic Surgery (Jaw Augmentation or Reduction) | |

| |

| | Not covered (OGS-A) (only option for $7550/$8550) | $5,000 lifetime (OGS-B) |

| | |

|I. |Assisted Reproduction Services (per calendar year) | | |

| | Not covered (INF-B) |(only option for $7550/$8550) | |

| | $5,000 (INF-G) | | | | |

| | $10,000 (INF-H) | | | | |

| | $20,000 (INF-I) |

| | Unlimited* (INF-J) |

| |*Requires underwriting approval |

| | |

|J. |Premera Designated Centers of Excellence |

| |Premera Designated COE |In-Network |Out-of-Network |

| | Waive Deductible, 0% (Covered in full) (COEP-C, COE-A) |Covered as any other service |Covered as any other service |

| |(only option for $7550/$8550) | | |

| | Covered as any other service (COEP-B, COE-D) |Covered as any other service |Covered as any other service |

| | | | |

|K. |Elective Procedure Travel |

| | Not covered (MTS-B) |

| | Covered (MTS-A) (only option for $7550/$8550) |

|L. |Virtual Care(Self-funded Opt-in options only): |

| | |In-Network |Out-of-Network |

| | Medical/Dermatology | $20 copay |Not applicable (TGM-O) |

| | | Covered in full (only option for $7550/$8550) |Not applicable (TGM-C) |

| | | Not covered |Not covered (TGM-E) |

| | | | |

| | | | |

| | Mental Health | Subject to In-network MH cost share |Not applicable (TMH-A) |

| | | Covered in full (only option for $7550/$8550) |Not applicable (TMH-C) |

| | | Not covered |Not covered (TMH-B) |

| | | | |

| | Substance Use Disorder | Subject to In-network SUD cost share ) |Not applicable (TCD-A) |

| | | Covered in full (only option for $7550/$8550) |Not applicable (TCD-C) |

| | | Not covered |Not covered (TCD-B) |

| | | | |

|M. |Colon Health | |

| |In-Network |Out-of-Network |

| | Covered in full with frequency limits (COL-D) (only option for $7550/$8550) |Deductible & Coinsurance |

| | Covered in full no frequency limits (COL-G) |Deductible & Coinsurance |

|7. |Prescription Drug Coverage Options (Mandatory for insured plans) |

| | | |

| |Dispensing limits |Retail: 90-day supply per prescription refill (1 copay per 30-day supply); 30-day supply for specialty drug refill |

| | |Mail: 90-day supply per prescription refill (1 copay per 90-day supply); 30-day supply for specialty drug refill |

| | |

| |Complete only one option A, B, C, D or E, then continue to optional benefit F, G & H within this section. |

| |(Prescription OOP applies to the medical OOP) | |

|A. |4-Tier Essentials (E4 Formulary) (Deductible waived for Preferred Generics) | |

|Deductible | Retail Pharmacy | Mail-Order Pharmacy Service | |

| |Preferred |Preferred |Preferred |Non-Pref |Pref |Preferred |Non-Preferred |Specialty | |

| |Generic |Brand |Specialty |Generic Brands|Generic |Brand |Brand | | |

| | | | |& Specialty | | | | | |

| None |$10 |$25 |$45 |30% |$25 |$62.50 |$45 |30% |RDV-A/RR4-H/RM4-AC |

| $150 |$10 |$25 |$45 |30% |$25 |$62.50 |$45 |30% |RDV-W/RR4-H/RM4-AC |

| $300 |$10 |$25 |$45 |30% |$25 |$62.50 |$45 |30% |RDV-U/RR4-H/RM4-AC |

| $500 |$10 |$25 |$45 |30% |$25 |$62.50 |$45 |30% |RDV-V/RR4-H/ RM4-AC |

| | | | | | | | | | |

| None |$10 |$30 |$30 |30% |$25 |$75 |$30 |30% |RDV-A/RR4-D/RM4-AD |

| $150 |$10 |$30 |$30 |30% |$25 |$75 |$30 |30% |RDV-W/RR4-D/RM4-AD |

| $300 |$10 |$30 |$30 |30% |$25 |$75 |$30 |30% |RDV-U/RR4-D/RM4-AD |

| $500 |$10 |$30 |$30 |30% |$25 |$75 |$30 |30% |RDV-V/RR4-D/RM4-AD |

| | | | | | | | | | |

| None |$10 |$30 |$50 |30% |$25 |$75 |$50 |30% |RDV-A/RR4-E/RM4-AE |

| $150 |$10 |$30 |$50 |30% |$25 |$75 |$50 |30% |RDV-W/RR4-E/RM4-AE |

| $300 |$10 |$30 |$50 |30% |$25 |$75 |$50 |30% |RDV-U/RR4-E/RM4-AE |

| $500* |$10 |$30 |$50 |30% |$25 |$75 |$50 |30% |RDV-V/RR4-E/RM4-AE |

| | | | | | | | | | |

| None |$15 |$30 |$50 |30% |$37.50 |$75 |$50 |30% |RDV-A/RR4-F/RM4-AF |

| $150 |$10 |$30 |$50 |30% |$37.50 |$75 |$50 |30% |RDV-W/RR4-F/RM4-AF |

| $300 |$10 |$30 |$50 |30% |$37.50 |$75 |$50 |30% |RDV-U/RR4-F/RM4-AF |

| $500* |$10 |$30 |$50 |30% |$37.50 |$75 |$50 |30% |RDV-V/RR4-F/RM4-AF |

| | | | | | | | | | |

| None |$15 |$60 |$100 |50% |$37.50 |$150 |$100 |50% |RDV-A/RR4-V/RM4-AG |

| $150 |$15 |$60 |$100 |50% |$37.50 |$150 |$100 |50% |RDV-W/RR4-V/RM4-AG |

| $300 |$15 |$60 |$100 |50% |$37.50 |$150 |$100 |50% |RDV-U/RR4-V/RM4-AG |

| $500* |$15 |$60 |$100 |50% |$37.50 |$150 |$100 |50% |RDV-V/RR4-V/RM4-AG |

| | | | | | | | | | |

| None |$20 |$50 |30% |50% |$50 |$125 |30% |50% |RDV-A/RR4-W/RM4-Y |

| $150 |$20 |$50 |30% |50% |$50 |$125 |30% |50% |RDV-W/RR4-W/RM4-Y |

| $300 |$20 |$50 |30% |50% |$50 |$125 |30% |50% |RDV-U/RR4-W/RM4-Y |

| $500* |$20 |$50 |30% |50% |$50 |$125 |30% |50% |RDV-V /RR4-W/RM4-Y |

| | |

| | | | | | | | | | |

| None |10% |20% |30% |40% |10% |20% |30% |40% |RDV-A/RR4-X/RM4-AH |

| $150 |10% |20% |30% |40% |10% |20% |30% |40% |RDV-W/RR4-X/RM4-AH |

| $300 |10% |20% |30% |40% |10% |20% |30% |40% |RDV-U/RR4-X/RM4-AH |

| $500* |10% |20% |30% |40% |10% |20% |30% |40% |RDV-V /RR4-X/RM4-AH |

| | | | | | | | | | |

| $7,550 |$30 |30% |30% |50% |$90 |30% |50% |50% |RMM-MQ ($7550 plan) |

|B. |4-Tier Program (Deductible waived for Generics) | |

| | | |

| |Deductible |Retail Pharmacy |Mail-Order Pharmacy Service | |

| | | | | |

| | |

|C. |3-Tier Program (Deductible waived for Generics) | |

| |Deductible |Retail Pharmacy |Mail-Order Pharmacy Service | |

| | | | | |

| | |Generic |Pref |Non-Pref Brand|Generic |Pref Brand |Non-Pref Brand | |

| | | |Brand | | | | | |

| | None |$10 |$25 |$40 |$25 |$62 |$100 |RDV-A/RR3-AC/RM3-AV |

| | $150 |$10 |$25 |$40 |$25 |$62 |$100 |RDV-K/RR3-AC/RM3-AV |

| | $300 |$10 |$25 |$45 |$25 |$62 |$112 |RDV-H/RR3-E/RM3-I |

| | None |$10 |$30 |$50 |$25 |$75 |$125 |RDV-A/RR3-M/RM3-U |

| | None |$10 |25% |50% |$25 |20% |45% |RDV-A/RR3-J/RM3-Q |

| | None |$15 |$25 |$50 |$37 |$62 |$125 |RDV-A/RR3-G/RM3-L |

| | $150 |$15 |$25 |$50 |$37 |$62 |$125 |RDV-K/RR3-G/RM3-L |

| | None |$20 |$50 |50% |$50 |$125 |45% |RDV-A/RR3-AB/RM3-AT |

|D. |2-Tier Program (Deductible waived for Generics) | |

| | |

| |Deductible |Retail Pharmacy | |Mail-Order Pharmacy Service | |

| | | | | |

| | |Generic |Brand | |Generic |Brand | |

| | None |$10 |$25 | |$25 |$62 |RDV-A/RR2-B/RM2-C |

| | $150 |$10 |$25 | |$25 |$62 |RDV-K/RR2-B/RM2-C |

| | None |$10 |$30 | |$25 |$75 |RDV-A/RR2-O/RM2-U |

|E. |1-Tier Essentials Program (E1 Formulary) (Plan deductible applies to all covered pharmacy tiers) |

| |Deductible |Retail Pharmacy |Mail-Order Pharmacy Service | |

| | $8,550 |0% (In-Network & OON) | |0% In-network/Not Covered OON |RMM-MY ($8550 plan) |

| | | | | | |

|F. |Generic-Only Program |

| | |

| |Deductible |Retail Pharmacy |Mail-Order Pharmacy Service | |

| | | | | |

| | None |$10 |$25 |RDV-A/RR1-H/RM1-H |

| | |

|G. |Rx Family Deductible* (only available if an individual Rx deductible taken) |

| | | | |

| | None (RFR-C) | Yes (RFR-A = 3x or RFR-B = 2x) |

| | | | |

|H. |Mandatory Generic Substitution – Dispensed As Written Waiver |

| | | |

| Yes (DAW-A) |

|No (optional for 200+ groups only) |

| |DAW-B (mbr pays when doctor allows sub) |

| |DAW-C (select/generic only program) |

| |DAW-D (member pays appropriate cost-share) |

|I. |Specialty Pharmacy |

| | Specialty RX (Optional – Dual) (RSP-A) |

| | Specialty RX (Mandatory-Dual) (RSP-B) | |

| | Specialty RX (Optional – Exclusive) (RSP-E) | |

| | Specialty RX (Mandatory Exclusive) (RSP-F) | |

|8. |SUPPLEMENTAL BENEFIT OPTIONS |

| | |

|A. |Vision Benefits |

| |

|1. |Adult Vision Exam |

| | |

| |In-Network |Out-Of-Network |

| | Not Covered (VSL-J & VSC-I) (only option for $7550/$8550) |Not Covered |

| | 1 Exam PCY; Covered in full* (VSL-A, VSL-BD, VSL-E, VSL-F, VSL-G, VSL-H, VSL-I & VSC-R) |Deductible and Coinsurance |

| | 1 Exam PCY; Waive Deductible, subject to 10% coinsurance to $350 per calendar |Waive Deductible, subject to 10% coinsurance (mandate |

| |year (packaged with hardware benefit in section A2 below, not available |offering) |

| |separately (mandated offering)** (VSL-AE, VSC-AV) or (VSL-BA, VHC-BQ) | |

| | 1 Exam PCY; Subject to a $25 copay (VSL-A, VSL-BD, VSL-E, VSL-F, VSL-G, VSL-H, VSL-I & |Deductible and Coinsurance |

| |VSC-AN) | |

| |

|*Benefits provided at 100% of allowable charge, not subject to deductible or coinsurance. |

|**Packaged with 10 % vision hardware benefit in section A2; not available separately. |

|2. |Adult Vision Hardware Note: Only available if routine vision exam selected in section A1 above. |

| | |

| | Not covered (VSL-A or VSL-J & VHC-A) (only option for $7550/$8550) |

| | 1 set of lenses per calendar year; 1 frame per 2 consecutive calendar years (VSL- BD & VHC-B) |

| | $150 per calendar year, waive deductible, covered in full (VSL-G & VHC-B) |

| | $200 per calendar year, waive deductible, covered in full (VSL-H & VHC-B) |

| | $300 per calendar year, waive deductible, covered in full (VSL-I & VHC-B) |

| | $200 per 2 consecutive calendar years, waive deductible, covered in full (VSL-E & VHC-B) |

| | $300 per 2 consecutive calendar years, waive deductible, covered in full (VSL-F & VHC-B) |

| | 1 set of lenses per calendar year; 1 frame to $90 retail maximum per 2 calendar years; contacts to $170 per calendar year; |

| |must be taken with 10% coinsurance exam benefit in section A1 with a combined benefit max to $350 per |

| |calendar year, not available separately) (mandated offering) (VSL- AE & VHC-B)or (VSL-BA & VHC-B) |

| | |

|3. |Pediatric Vision Exam (per calendar year & for members under age 19) |

| |Note: Only available if adult vision exam selected in section A1 above. |

| | |

| |In-Network |Out-Of-Network |

| | Not covered (PEDV-N) (only option for $7550/$8550) |Not covered |

| | 1 Exam, Subject to Office Visit Copay* (PEDV-AN or PEDV-AO) |Same as in-network |

| | 1 Exam, Waive Deductible, Subject to ( (PEDV-AP or PEDV-AQ) |Same as in-network |

| | * Copay plans only | |

| | ( Coinsurance plans only | |

| | | |

|4. |Pediatric Vision Hardware |

| |Note: Only available if adult vision hardware selected in section A2 above and if pediatric vision exam selected in section A3.. |

| | Not covered (PEDV-N, PEDV-AQ, PEDV-AO) (only option for $7550/$8550) |

| | 1 pair of frames and 1 pair of lenses for glasses; or 1 pair of hard contact lenses per calendar year; or 12-month supply of disposable |

| |contact lenses per calendar year (PEDV-AN, PEDV-AP) |

| | | |

|B. |Hearing Benefits |

| | |

|1. |Routine Hearing Exam (includes testing) |

| | Not covered (HEC-A) (only option for $7550/$8550) |

| | 1 visit per calendar year; subject to office visit cost-share (Copay – HEC-AN or HEC-AO** & HEA-A or HEA-G) (Coins – HEC-B & HEA-A or HEA-G) |

| | 1 visit per calendar year; covered in full* (HEC-R & HEA-A or HEA-G) |

| | 1 visit per 2 calendar years; subject to office visit cost-share (Copay – HEC-AN or HEC-AO & HEA-C or HEA-E) (Coins – HEC-B & HEA-C) |

| | 1 visit per 2 calendar years; covered in full* (HEC-R & HEA-C) |

| | |Waive deductible, 20% coinsurance (packaged with 20% coinsurance hardware benefit in section B2 below; not available separately) limited to once |

| | |every 2 calendar years (mandated offering) (HEC-L, HEA-E) |

| | |**Only available to copay plans |

| | |*Benefits provided at 100% of allowable charge, not subject to deductible or coinsurance. |

| | |

|2. |Hearing Hardware Note: Only available if Routine Hearing Exam selected in section B1 above |

| | Not covered (HHC-A) (only option for $7550/$8550) |

| | Waive deductible, covered in full up to $3,000 every 3 calendar years (HHC-B & HEA-E or HEA-G) |

| | |Waive deductible, 20% coinsurance (packaged with 20% coinsurance exam benefit above; not available separately) is limited to $3,000 every 3 calendar|

| | |years (mandated offering) (HHC-C & HEA-E) |

| | | |

| | |*Benefits provided at 100% of allowable charge, not subject to deductible or coinsurance. |

| | |

|9. |BLUECARD® PROGRAM OPTIONS |

| | |

| |Option |BlueCard Option |

| | | |

| | Default |In-Network & Out-of-Network – BlueCard PPO (ZKR) |

| | Buy-up |In-Network & Out-of-Network – BlueCard Traditional (ZKT) |

|10. |COMMENTS |

| | |

| |      |

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