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—HERITAGESELECT | |

|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 |

| | | | |

| |Helpful Hint: The Deductible and Coinsurance options you select below (sections 2A-2C) 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. |

| |

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

| | | |

| |In-Network |Out-of-Network (Hospitals) |

| | | |

| | $100 (DVI-H) | $1,500 (DVI-G) | $200 (DVO-D) | $2,000 (DVO-L) | $20,550 (DVO-CW) |

| | $250 (DVI-J) | $2,000 (DVI-I) | $500 (DVO-G) | $2,250 (DVO-DF) | $23,700 (DVO-DQ) |

| | $300 (DVI-C) | $2,500 (DVI-K) | $600 (DVO-H) | $3,000 (DVO-M) | Shared with In-Network Deductible (DVO-A)|

| | $500 (DVI-D) | $3,000* (DVI-X) | $750 (DVO-I) | $4,000 (DVO-O) | |

| | $750 (DVI-E) | $4,000* (DVI-AE) | $900 (DVO-DG) | $4,500 (DVO-AV) | |

| | $1,000 (DVI-F) | $5,000 (DVI-L) | $1,000 (DVO-J) | $5,000 (DVO-Q) | |

| | | $6,000 (DVI-BD) | $1,500 (DVO-K) | $6,000 (DVO-X) | |

| | | $6,350 (DVI-BY) | | $7,500 (DVO-AW) | |

| | | $6,850 (DVI-CN) | | $8,000 (DVO-AE) | |

| | | $7,900 (DVI-DM) | | $9,000 (DVO-AH) | |

| | | $8,150 (DVI-DP) | | $10,000 (DVO-P) | |

| | | $8,550 (DVI-ED) | | $12,000 (DVO-AL) | |

| | | | | $12,700 (DVO-CB) | |

| | | | | $13,700 (DVO-CV) | |

| | | | | $15,000 (DVO-U) | |

| | | | | $15,800 (DVO-DO | |

| | | | | $16,300 (DVO-DR) | |

| | | | | $17,100 (DVO-EC) | |

| | | | | $19,050 (DVO-CC) |

| |*Only available to coinsurance plans |

| | | |

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

| | | Excluded (QTR-B) |

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

| |

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

| | 2 times the individual deductible (DFR-B) |

| | No family deductible (DFR-C) |

| | |

| |

|C. |Coinsurance | |

| |

| |In-Network |Out-of-Network (Hospitals) | | |

| | |Physicians |Participating | | | | | |

| | | |Hospitals | | | | | |

| | | 0% (COI-A) |40% |60% (COO-T) | | | | |

| | |10%(COI-B) |40% |60% (COO-T) | | | | |

| | |20%(COI-C) |40% |60% (COO-T) | | | | |

| | |30%(COI-E) |40% |60% (COO-T) | | | | |

| |

| |

|D. |Individual Out-of-Pocket Maximum (per calendar year) *The out-of-pocket maximum includes any deductible |

| |

| |In-Network (Preferred / Participating) |Out-of-Network (Hospitals) |

| |

| | $500 (OMI-A) | $4,500 (OMI-Y) | | $45,000 (OMO-EA) | | |

| | $700 (OMI-AD) | $5,000 (OMI-O) | | Unlimited (OMO-A) | | |

| | $750 (OMI-B) | $6,000 (OMI-AA) | | | | |

| | $1,000 (OMI-C) | $6,350 (OMI-EJ) | | | | |

| | $1,100 (OMI-U) | $6,600 (OMI-EU) | | | | |

| | $1,200 (OMI-D) | $6,850 (OMI-CX) | | | | |

| | $1,250 (OMI-V) | $7,150 (OMI-FP) | | | | |

| | $1,300 (OMI-E) | $7,350 (OMI-GF) | | | | |

| | $1,500 (OMI-F) | $7,900 (OMI-GQ) | | | | |

| | $1,750 (OMI-G) | $8,150 (OMI-GX) | | | | |

| | $2,000 (OMI-H) | $8,200 (OMI-GY) | | | | |

| | $2,100 (OMI-Q) | $8,550 (OMI-HN) | | | | |

| | $2,250 (OMI-R) | | | | | |

| | $2,300 (OMI-J) | | | | | |

| | $2,500 (OMI-K) | | | | | |

| | $3,000 (OMI-M) | | | | | |

| | $3,500 (OMI-W) | | | | | |

| | $4,000 (OMI-N) | | | | | |

| | $4,500 (OMI-Y) | | | | | |

| | $5,000 (OMI-O) | | | | | |

| |

|E. |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. |

| |

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

| | 2 times the individual out-of-pocket maximum (OFR-B) |

| | |

|F. |Office Visit Cost-Share | | |

| | | | | | |

| | Deductible & Coinsurance* (OVI-A) | |Same as in-network (OVO-K) |

| |*Only available to coinsurance plans | | |

| | | | |

| | Copay of: | | | |

| | $20 (OVI-CE) | |Same as in-network (OVO-K) |

| | $25 (OVI-BW) | | |

|3. |FACILITY CARE OPTIONS |

| |

|A. |Inpatient Facility Care |

| |

| |In-Network (Preferred / Participating) |Out-of-Network (Hospitals) |

| |

| | Deductible & Coinsurance (IPI-AK, IPI-AL, IPI-AM, IPI-AN) |Deductible & Coinsurance (IPO-A) |

| | Copay of $100 Per Admit / Deductible & Coinsurance (IPI-AY) | |

| | | |

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

| | 60 days (SNF-A) | 100 days (SNF-F) | 120 days (SNF-C) | | |

|4. |EMERGENCY CARE OPTIONS |

| |

|A. |Emergency Room and Ambulance |

| |

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

| | | |

| |In-Network/Out-of-Network (Preferred Coinsurance Only) |

| | | |

| | Deductible & Coinsurance (ERV-AD, ERV-AE, ERV-AF, ERV-AG) & (AMB-- O) |

| |

| | 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) |

|5. DIAGNOSTIC AND MAMMOGRAPHY SERVICES OPTIONS |

| |Note: Out-of-Network Hospitals are subject to the out-of-network deductible and coinsurance. |

| | |

| |Preventive |Diagnostic (Basic/Major) | |

| | Covered in Full* |Deductible & Coinsurance (DXL-BF) (MMO-AC) |

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

| | Covered in Full* |Covered in Full* (DXL-I) (MMO-H) |

| | |

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

| | |

|6. |OTHER SERVICE OPTIONS | |

|A. |Acupuncture |

| | |

| | 12 visits PCY (ACL-A) |

| | Unlimited visits (ACL-C) |

| | Not covered (ACL-D) |

| | |

|B. |Spinal and Other Manipulations |

| | 12 visits PCY (MPL-A) |

| | 24 visits PCY (MPL-B) |

| | Unlimited visits (MPL-C) |

| | Not covered (MPL-D) |

| | |

| |

|C. |Foot Orthotics and Orthopedic Shoes (per calendar year) |

| | |

| |Note: Limits shared both in- and out-of-network. |

| | |

| | $300 (SUP-AM) | | | |

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

| |

| | |

|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) | |

| | Unlimited visits (HOH-C) | |

| | | |

| | |

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

| | |

| | 10 days (HPC-A) |240 hours |6 months |

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

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

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

| | | | |

| | |

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

| | |

| | Deductible & Coinsurance (INJ-L) | |

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

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

| | | | |

| |*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 (RNT-A) |30 days |45 visits |30 days |

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

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

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

| | | | | |

| | Not Covered (TMJ-A) | $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) | $5,000 lifetime (OGS-B) | |

| | |

|I. |Assisted Reproductive Services (optional for 100+ groups only) | | |

| | |

| Not covered (INF-B) |

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

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

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

|Unlimited* (INF-J) |

| |*Requires underwriting approval |

| | |

|J. |Elective Sterilization - Men | | |

| Covered in Full (CMI-J) |

|Deductible & Coinsurance (CMI-K) |

| |

|K. |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 |

| | | | |

|L. |Elective Procedure Travel | | |

| Not Covered (MTS-B) |

| Covered (MTS-A) |

| | | |

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

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

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

| | | Covered in full (TGM-C) |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 |

| | | | |

|N. |Colon Health | | |

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

| | Covered in full with frequency limits (COL-D) |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, and 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 Generic |

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

| | |

| |*Uses Select Drug List |

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

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

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

| | | |Brand |Preferred | |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 |$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 |$10 |$25% |50% |$25 |20% |45% |RDV-A/RR3-J/RM3-Q |

| | 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. |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 (DAW-A) | No (optional for 200+ groups only) |

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

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

| | |DAW-D (mbr pays appropriate 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) |

| | |

|8. |SUPPLEMENTAL BENEFIT OPTIONS |

| | |

|A. |Vision Benefits |

| |

|1. |Adult Vision Exam (per calendar year) | |

| | | |

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

| | Not covered (VSL-J & VSC-I) |

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

| | 1 Exam PCY; Waive Deductible, subject to 10% coinsurance** (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 & VSC-AC) |

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

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

| |

|2. |Adult Vision Hardware Note: Only available if routine vision exam selected in section A1above. |

| | | |

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

| | | |

| | Not covered (VSL-A or VSL-J & VHC-A) |

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

| | $150 per calendar year (VSL-G & VHC-B) |

| | $200 per calendar year (VSL-H & VHC-B) |

| | $300 per 2 calendar years (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 (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) |

| | 1 Exam per calendar year; subject to office visit copay **(PEDV-E or PEDV-V) |

| | 1 Exam per calendar year; Waive Deductible, subject to coinsurance * (PEDV-AJ or PEDV-U) |

| |*Only available to coinsurance plans |

| |**Only available to copay plans |

|4. |Pediatric Vision Hardware (for members under age 19 ) |

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

| | |

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

| | Not covered (PEDV-N, PEDV-U, PEDV-V) |

| | 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-AJ* or PEDV-E**) |

| |*Only available to coinsurance plans |

| |**Only available to copay plans |

| | |

|B. |Hearing Benefits |

| | |

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

| | |

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

| | Not covered (HEC-A) |

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

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

| | 1 visit per 2 calendar years; subject to deductible and coinsurance (HEC- K & HEA-C or HEA-E) |

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

| | 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) |

| | Waive deductible, covered in full* up to $3000 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 $3000 every 3 |

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

| | |

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

| | |

| | |

|9. |COMMENTS |

| | |

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