2550 Denali Street - 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—ENVOY | |

|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 |      |

| | | |(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 5 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 |

|2. |Subclass: | | |

|2. |MEDICAL PLAN OPTIONS — CHOOSE ONE BENEFIT PLAN |

| | |

|A. |Renewal Groups Only |

| | Renew H3T HeritagePlus Envoy as is — no benefit changes; form complete; stop here. |

|B. |Renew with changes – complete sections below |

| | |

| |HeritageSelect Envoy |

| | |

| |Note: Coinsurance shown is for physicians and preferred hospitals. Coinsurance for participating hospitals is 40%. Out-of-network hospital coinsurance is|

| |60%. |

| |

| Individual $1,000 / 20% / 40% / $3,500 / $25 (DVI-F, COI-C, OMI-W, OVI-CW) |

| | |Family |$2,000 / 20% / 40% / $7,000 / $25 | |

| | | | | | |

| Individual $1,500 / 20% / 40% / $4,000 / $25 (DVI-G, COI-C, OMI-N, OVI-CW) |

| | |Family |$3,000 / 20% / 40% / $8,000 / $25 | |

| | | | | | |

| Individual $2,000 / 20% / 40% / $4,500 / $25 (DVI-I, COI-C, OMI-Y, OVI-CW) |

| | |Family |$4,000 / 20% / 40% / $9,000 / $25 | |

| | | | | | |

| Individual $2,500 / 20% / 40% / $5,500 / $25 (DVI-K, COI-C, OMI-AL, OVI-CW) |

| | |Family |$5,000 / 20% / 40% / $11,000 / $25 | |

| | | | | | |

| Individual $3,000 / 20% / 40% / $6,000 / $30 (DVI-X, COI-C, OMI-AA, OVI-CV) |

| | |Family |$6,000 / 20% / 40% / $12,000/ $30 | |

| | | | | | |

| Individual $4,000 / 30% / 40% / $6,350 / $40 (DVI-AE, COI-E, OMI-EJ, OVI-CU) |

| | |Family |$8,000 / 30% / 40% / $12,700 / $40 | |

| | | | | | |

| Individual $5,000 / 30% / 40% / $6,350 / $45 (DVI-L, COI-E, OMI-EJ, OVI-CT) |

| | |Family |$10,000 / 30% / 40% / $12,700 / $45 | |

| |Note: Fourth Quarter Carry Over is excluded. (QTR-B) |

|C. |HeritagePlus Envoy (F3T) |

| | |

| |Note: The first coinsurance listed is for preferred physicians and preferred hospitals. The second coinsurance listed is for participating physicians and |

| |participating hospitals. Out-of-network physician and hospital coinsurance is 60%. |

| |

| Individual $1,000 / 20% / 40% / $3,500 / $25 (DVI-F, COI-J, OMI-W, OVI-CQ) |

| | |Family |$2,000 / 20% / 40% / $7,000 / $25 | |

| | | | | | |

| Individual $1,500 / 20% / 40% / $4,000 / $25 (DVI-G, COI-J, OMI-N, OVI-CQ) |

| | |Family |$3,000 / 20% / 40% / $8,000 / $25 | |

| | | | | | |

| | | | | | |

| Individual $2,000 / 20% / 40% / $4,500 / $25 (DVI-I, COI-J, OMI-Y, OVI-CQ) |

| | |Family |$4,000 / 20% / 40% / $9,000 / $25 | |

| | | | | | |

| Individual $2,500 / 20% / 40% / $5,500 / $25 (DVI-K, COI-J,OMI-AL, OVI-CQ) |

| | |Family |$5,000 / 20% / 40% / $11,000 / $25 | |

| | | | | | |

| Individual $3,000 / 20% / 40% / $6,000 / $30 (DVI-X, COI-J, OMI-AA, OVI-CP) |

| | |Family |$6,000 / 20% / 40% / $12,000/ $30 | |

| | | | | | |

| Individual $4,000 / 30% / 40% / $6,350 / $40 (DVI-AE COI-M, OMI-EJ, OVI-CR) |

| | |Family |$8,000 / 30% / 40% / $12,700 / $40 | |

| | | | | | |

| Individual $5,000 / 30% / 40% / $6,350 / $45 (DVI-L, COI-M, OMI-EJ, OVI-CS) |

| | |Family |$10,000 / 30% / 40% / $12,700 / $45 | |

| |Note: Fourth Quarter Carry Over is excluded. (QTR-B) |

|3. |PHARMACY 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, and then continue to optional benefits F, G & H within this section. |

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

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

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

| | |

| | |

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

| | |Generic |

| | |

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

| | |

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

| | | | | | | | | |

| | |Generic |Preferred Brand |Non-Preferred Brand |Generic |Preferred Brand|Non-Preferred Brand | |

| | | | | | | | | |

| | None |$10 |$20 |$40 |$25 |$50 |$100 |RDV-A/RR3-AC/RM3-AV |

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

| | $150 |$10 |$25 |$40 |$25 |$62 |$100 |RDV-H/RR3-E/RM3-I |

| | $300 |$10 |$25 |$45 |$25 |$62 |$112 |RDV-A/RR3-M/RM3-U |

| | None |$10 |$30 |$50 |$25 |$75 |$125 |RDV-A/RR3-J/RM3-Q |

| | None |$10 |25% |50% |$25 |20% |45% |RDV-A/RR3-G/RM3-L |

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

| | $150 |$15 |$25 |$50 |$37 |$62 |$125 |RDV-A/RR3-AB/RM3-AT |

| | None |$20 |$50 |50% |$50 |$125 |45% |RDV-A/RR3-AC/RM3-AV |

| | |

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

|D. | |

| | |

| |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. |Generic-Only Program |

| | |

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

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

| | |

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

| | |

| | No (RFR-C) | Yes (RFR-A = 3X; RFR-B = 2X) |

| | |

| | |

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

| | |

| | Yes | No (optional for 200+ groups only) |

| |(DAW-A) |DAW-B (mbr pays diff when dr allows sub) |

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

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

|H. |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) |

| | |

|4. |OTHER MEDICAL OPTIONS |

| | |

|A. |Spinal and Other Manipulations |

| | 12 visits per calendar year (MPL-A) | Unlimited visits (MPL-C) |

| | | |

|B. |Vision Benefit Options |

| | |

| |Adult Vision (for members age 19 and over) |

| | Not Covered (VSL-J) |

| | 1 exam per calendar year, subject to $25 copay; hardware benefit not covered (VSL-A, VSC-AN, VSL-J & VHC-A) |

| | 1 exam per calendar year, subject to $25 copay; hardware benefit $200 per calendar year (VSC-AN & VSL-H) |

| | 1 exam per calendar year, subject to $25 copay; hardware benefit $150 per calendar year (VSC-AN & VSL-G) |

| | 1 exam per calendar year, subject to $25 copay; hardware benefit $300 per 2 consecutive calendar years (VSC-AN & VSL-F) |

| | 1 exam per calendar year, waive deductible, subject to 10% coinsurance; 1 set of lenses per calendar year; 1 frame to $90 retail maximum |

| |per 2 calendar years; contacts to $170 per calendar year; with a combined benefit (vision exam and hardware) max to $350 per calendar |

| |year (mandated offering) VSC-AV, VSL-AE, VHC-B) or (VSL-BQ, VSL-BA, VHC-B) |

| |Pediatric Vision (for members under age 19) |

| | Not Covered (PEDV-N) |

| | 1 exam per calendar year, subject to office visit copay; hardware benefit not covered |

| |(Note: only available with Adult Vision exam but hardware benefit not covered option) (PEDV-AC, PEDV-AE, PEDV-AF, PEDV-AG) |

| | 1 exam per calendar year, subject to office visit copay; 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-O, PEDV-P, PEDV-R, PEDV-S) |

| |(Note: only available with Adult Vision exam and hardware benefit covered option) |

| | |

|C. |Hearing Benefit Options |

| |Note: Hearing exam subject to the medical office visit cost share unless mandated hearing offer is selected below. |

| | |

| | Not Covered (HEC-A, HHC-A) |

| | Waive deductible, 20% coinsurance for hearing exams, tests and hardware. Hearing exams and tests are limited to once every 2 calendar years and hearing |

| |hardware is limited to $3,000 every 3 calendar years ( (mandated offering) (HEC-L, HHC-C, HEA-E) |

| | |

|D. |Rehabilitation and Habilitation Therapy (Note: limits shared both in-out of network) |

| | |

| |Outpatient 45 visits PCY/Inpatient Rehabilitation 30 days PCY |

| | $25 Subject to office visit cost share (applies to OOP Max) (HP Envoy: RNC-AB/HS Envoy: RNC-AH) |

| | $30 Subject to office visit cost share (applies to OOP Max) (HP Envoy: RNC-AC/HS Envoy: RNC-AI) |

| | $40 Subject to office visit cost share (applies to OOP Max) (HP Envoy: RNC-AD/HS Envoy: RNC-AJ) |

| | $45 Subject to office visit cost share (applies to OOP Max) (HP Envoy: RNC-AE/HS Envoy: RNC-AK) |

| | Subject to Deductible & Coinsurance (HP Envoy: RNC- B/HS Envoy: RNC-AL) |

| | |

| |Outpatient 45 visits PCY/Inpatient Habilitation Therapy 30 days PCY |

| | $25 Subject to office visit cost share (applies to OOP Max) (NDC-R) |

| | $30 Subject to office visit cost share (applies to OOP Max) (NDC-S) |

| | $40 Subject to office visit cost share (applies to OOP Max) (NDC-T) |

| | $45 Subject to office visit cost share (applies to OOP Max) (NDC-U) |

| | Subject to Deductible & Coinsurance (NDC-B) |

| | |

| |Note: Inpatient rehab/habilitative therapy always subject to the inpatient cost share |

| |Note: 45 outpatient visits PCY combined for outpatient rehab/habilitative therapy |

| |Note: 30 inpatient days PCY combined for outpatient rehab/habilitative therapy |

| | |

|E. |Elective Sterilization - Men | | |

| Covered in Full (HP Envoy: CMI-E) (HS Envoy: CMI-J) |

|Deductible & Coinsurance (HP Envoy: CMI-I) (HS Envoy: CMI-K) |

| | |

|F. |Virtual Care (Choose options in Either 1 or 2, but not both.) |

| |1. HeritagePlus Envoy Plans: (Self-funded Opt in options only) |

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

| | Medical/Dermatology | $25 Copay (TGM-K) |Not applicable |

| | | $30 Copay (TGM-L) |Not applicable |

| | | $40 Copay (TGM-M) |Not applicable |

| | | $45 Copay (TGM-P) |Not applicable |

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

| | | | |

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

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

| | | | |

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

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

| | | | |

| | Opt-in Physical Therapy | Subject to In-network OP Rehab cost share (TRH-A) |Not applicable |

| |2. HeritageSelect Envoy Plans (Self-funded Opt in options only) |

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

| | Medical/Dermatology | $25 Copay (TGM-K) |Not applicable |

| | | $30 Copay (TGM-L) |Not applicable |

| | | $40 Copay (TGM-M) |Not applicable |

| | | $45 Copay (TGM-P) |Not applicable |

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

| | | | |

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

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

| | | | |

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

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

| | | | |

| | | | |

|G. |Premera Designated Centers of Excellence |

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

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

| |COE-A) | | |

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

| | | | |

|5. |COMMENTS |

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| |      |

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