Regence Innova Plan Highlights For Groups of 51+ 1/1/2019

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1 Regence Innova Highlights Features Coinsurance levels are lowest for providers. If a member chooses a Category 3 provider, the member may be required to pay costs above the Category 3 allowed amount. Upfront outpatient radiology and laboratory services benefits: The first $400 per calendar year is not subject to the deductible. Any additional services above $400 and benefits for all other professional services are subject to member deductible and coinsurance levels as specified below. There is a select group of In-Network Providers referred to as Blue Distinction Total Care (BDTC) Providers. If a member chooses a BDTC Provider, they will have a lower out-of-pocket expense for most office visits. Ambulatory Surgical Center: While many surgical procedures are best performed in a hospital setting, many can be safely and effectively performed in an Ambulatory Surgery Center (ASC) at a lower cost. A member may pay less out-of-pocket if a surgical procedure is performed at a ASC. For more information, or a list of services that can be performed at an ASC, contact Regence customer service. Telehealth visits (conducted via phone, secure online video, mobile app or web) for primary care services are available from and Category 2 providers, usually with less out-of-pocket expense. Retail clinic office visits are available with and Category 2 providers, usually with lower out-of-pocket expense. Calendar Year Deductible Applies to all covered expenses except where noted Family deductible is three times the individual amount (additional choice of two times the individual amount is available), with one exception: $5,000 deductible option is two times the individual amount Individual deductible options per calendar year: $250, $500, $750, $1,000, $1,500, $2,000, $3,000, $4,000, or $5,000 Calendar Year Out-of-Pocket Maximums Out-of-pocket maximum amount per calendar year, including deductible and copays, applies to all covered expenses, including prescription medications, except where noted. When the out-of-pocket maximum is reached, this plan provides benefits at 100% of the allowed amount for the remainder of the calendar year. Individual out-of-pocket maximum options per calendar year: $250 deductible option: $2,500, $3,500, $4,500, $7,150 $500 and $750 deductible option: $3,000, $4,000, $5,000, $7,150 $1,000 deductible option: $3,500, $4,500, $5,500, $7,150 $1,500 deductible option: $4,000, $5,000, $6,000, $7,150 $2,000 deductible option: $4,500, $5,500, $7,150 $3,000 deductible option: $5,500, $7,150 $4,000 and $5,000 deductible options: $7,150 Family out-of-pocket maximum is two times the individual amount Regence BlueCross BlueShield of Oregon 1 Highlights - Group 51+ Regence Innova - RBCBSO

2 Regence Innova Highlights MEMBER RESPONSIBILITY Covered Services Office Visits and 2 not subject to deductible Options $20 / $35 Category 2 $30 / $45 Category 2 $40 / $55 Category 2 BDTC Providers not subject to deductible Options $10 $15 $20 Preventive Care and Immunizations and 2 not subject to deductible Upfront Outpatient Radiology and Laboratory First $400 per calendar year not subject to deductible (Preferred) Category 2 (Participating) Category 3 (Non-contracted) Category 2 Category 2 Category 2 0% 0% 0% 0% 0% 0% 30% 40% 50% N/A N/A N/A N/A N/A N/A Category 3 Benefits Apply Category 3 Benefits Apply Category 3 Benefits Apply 0% 0% 0% 0% 0% 0% 0% 0% 0% Member may be responsible for any provider costs above the Category 3 allowed amount. Regence BlueCross BlueShield of Oregon 2 Highlights - Group 51+ Regence Innova - RBCBSO

3 Regence Innova Highlights MEMBER RESPONSIBILITY Covered Services Professional Services/ Outpatient Radiology and Laboratory Office and inpatient services and supplies Ambulatory Surgical Center Hospital Services Inpatient and outpatient services and supplies Home Health 130 visits per calendar year Hospice Respite care limited to 14 days inpatient/outpatient per lifetime (Preferred) Category 2 (Participating) Category 3 (Non-contracted) 5% 10% 20% 30% 40% 50% 30% 40% 50% Maternity Rehabilitation Services Inpatient:30 days per calendar year Outpatient: 25 visits per calendar year Skilled Nursing Facility 60 inpatient days per calendar year Regence BlueCross BlueShield of Oregon 3 Highlights - Group 51+ Regence Innova - RBCBSO

4 Regence Innova Highlights Covered Services MEMBER RESPONSIBILITY (Preferred) Category 2 (Participating) Category 3 (Non-contracted) Mental Health / Substance Use Disorder Services No benefit maximum Inpatient 10% 20% 30% 10% 20% 30% 30% 40% 50% Outpatient Outpatient office / psychotherapy visits Options $20 $30 $40 (Deductible 30% (Deductible 40% (Deductible 50% BDTC outpatient office / psychotherapy visits Options $10 $15 $20 N/A N/A N/A N/A N/A N/A Other outpatient services 10% 20% 30% 10% 20% 30% 30% 40% 50% Emergency Room Services $100 copay per ER visit (waived if directly admitted) 10% 20% 30% 10% 20% 30% 10% 20% 30% Regence BlueCross BlueShield of Oregon 4 Highlights - Group 51+ Regence Innova - RBCBSO

5 Regence Innova Highlights Prescription Medication Coverage Prescription medication deductible options per calendar year: $0, $250, $500 Retail or Mail Order: Up to 90-day supply (one copay per 30-day supply) Specialty medications covered at participating retail pharmacies for first fill only. After first fill members use specialty pharmacies. Up to 30-day supply per fill. Deductible, copays and coinsurance apply to the out-of-pocket maximum. Member may be balance billed when a nonparticipating pharmacy is used. If an equivalent generic medication is available and a brand-name medication is chosen, the member is responsible for paying the applicable brand-name copay/coinsurance plus the difference in price between the equivalent generic medication and the brand-name medication not to exceed total retail cost. Three Tier Option - Retail Generics: not subject to deductible $5 generic $25 preferred brand $50 brand $10 generic $35 preferred brand $75 brand $7 generic 25% preferred brand 50% brand $10 generic 35% preferred brand 50% brand Six Tier Option - Retail Preferred Generics: not subject to deductible $5 preferred generic / 25% generic $25 preferred brand / $50 brand $150 preferred specialty / 50% specialty $10 preferred generic / 25% generic $35 preferred brand / $75 brand $150 preferred specialty / 50% specialty $7 preferred generic / 25% generic 25% preferred brand / 50% brand 25% preferred specialty / 50% specialty $10 preferred generic / 25% generic 35% preferred brand / 50% brand 40% preferred specialty / 50% specialty Regence BlueCross BlueShield of Oregon 5 Highlights - Group 51+ Regence Innova - RBCBSO

6 Regence Innova Highlights Optional Benefits Available Complementary Care Acupuncture and chiropractic spinal manipulations. Deductible waived for all Categories. Limited to $500 or $1,500 per calendar year. Emergency Room Services Deductible Waiver Deductible waived for all Categories $100 copay per ER visit (waived if directly admitted) Upfront Outpatient Radiology and Laboratory First $800 per calendar year. Not subject to deductible. (Preferred) Category 2 (Participating) Category 3 (Non-contracted) $25 copay $25 copay $25 copay $25 copay $25 copay $25 copay $25 copay $25 copay $25 copay 10% 20% 30% 10% 20% 30% 10% 20% 30% 0% 0% 0% 0% 0% 0% 0% 0% 0% Regence BlueCross BlueShield of Oregon 6 Highlights - Group 51+ Regence Innova - RBCBSO

7 Regence Innova Highlights Vision VSP Choice Doctor Out-of-Network VSP Choice Doctor Out-of-Network VSP Choice Doctor Out-of-Network Not subject to deductible. One routine eye exam per calendar year. Hardware: Maximum benefit per calendar year - $150 for VSP provider; $80 for VPSapproved wholesale vendor 0% Various Limits Apply 0% Various Limits Apply 0% Various Limits Apply Optional Program Available With All s Employee Assistance Program (EAP) No cost to the member for: Up to four face-to-face sessions per incident to manage stress or work-life balance situations Legal and financial assistance 24/7 crisis line Additional Information Outside the Service Area Members have the security of knowing they can access Blue Cross and/or Blue Shield (Blue ) providers across the country through the BlueCard Program and worldwide through BlueCross BlueShield Global Core Program. benefits apply as described within this document, and members may receive discounts on their services Regence BlueCross BlueShield of Oregon 7 Highlights - Group 51+ Regence Innova - RBCBSO

8 Regence Innova Highlights General Medical Exclusions Coverage is not provided for any of the following, including direct complications or consequences that arise from: Complementary Care: Acupuncture and chiropractic spinal manipulations except when covered under the Complementary Care benefit Cosmetic/Reconstructive Services and Supplies except for reconstruction for functional injury and disease, to treat a congenital anomaly for Members up to age 26, and for breast reconstruction following a medically necessary mastectomy to the extent required by law Counseling in the absence of illness is excluded unless required by law Custodial Care: Non-skilled care and helping with activities of daily living unless member is eligible for Palliative Care benefits Dental Examinations and Treatments except as required by law Fees, Taxes, Interest: Charges for shipping and handling, postage, interest, or finance charges that a provider might bill Government Programs: Benefits that are covered, or would be covered in the absence of this plan, by any federal, state or governmental program Infertility except to the extent covered services are required to diagnose such condition, treatment of infertility, including, but not limited to surgery and fertility drugs and medications is excluded Investigational Services: Treatment or procedures (health interventions) and services, supplies and accommodations provided in connection with investigational treatments or procedures Military Service Related Conditions: The treatment of any condition caused by or arising out of a member's active participation in a war or insurrection or conditions incurred in or aggravated during performance in the Uniformed Services Motor Vehicle Coverage and Other Available Insurance Non-Direct Patient Care including appointments scheduled and not kept, charges for preparing medical reports, itemized bills or claim forms, and visits or consultations that are not in person (except as specifically allowed under the telemedicine and telehealth medical benefits) Non-Duplication of Medicare: Services and supplies to the extent payable under Medicare, when by law, the plan would not be primary to Medicare Part B had the member properly enrolled in Medicare Part B when first eligible regardless of whether or not the member actually enrolled Obesity or Weight Reduction/Control: Medical treatment, medications, surgical treatment (including revisions, reversals and treatment of complications), programs, or supplies that are intended to result in or relate to weight reduction, regardless of diagnosis, unless required by law Orthognathic Surgery except when due to a temporomandibular joint disorder, injury, sleep apnea, congenital anomaly, and craniofacial anomalies Personal Comfort Items: Appliances or equipment primarily for comfort, convenience, cosmetics, environmental control, education or general physical fitness (e.g. televisions, telephones, air conditioners, air filters, humidifiers, whirlpools, heat lamps, weight lifting equipment, physical fitness programs, and therapy or service animals, including the cost of training and maintenance.) Physical Exercise Programs and Equipment including hot tubs or membership fees at spas, health clubs, or other facilities; applies even if the program, equipment, or membership is recommended by the member s provider Private Duty Nursing including ongoing shift care in the home Riot, Rebellion and Illegal Acts: Services and supplies for treatment of an illness, injury, or condition caused by a member s voluntary participation in a riot, armed invasion, or aggression, insurrection, or rebellion or sustained by a member while committing an illegal act Routine Foot Care Regence BlueCross BlueShield of Oregon 8 Highlights - Group 51+ Regence Innova - RBCBSO

9 Regence Innova Highlights Routine Hearing Exams Self-Help, Self-Care, Training, or Instructional Programs including childbirth-related classes including infant care; and instruction programs including those that teach a person how to use durable medical equipment or how to care for a family member Services and Supplies Provided by a Member of Member s Family Services and Supplies That Are Not Medically Necessary Services for Administrative or Qualification Purposes: Physical or mental examinations and associated services (such as laboratory or similar tests) primarily for administrative or qualification purposes. Services to Alter Refractive Character of the Eye Sexual Dysfunction: Services and supplies for or in connection with sexual dysfunction, except for Medically Necessary mental health services and supplies for a diagnosis of sexual dysfunction Third-Party Liability: Services and supplies for treatment of illness or injury for which a third party is or may be responsible Travel and Transportation Expenses other than covered ambulance services Work-Related Conditions except for subscribers and their dependents who are owners, partners, or corporate officers and are exempt from state or federal workers' compensation law This is a brief summary of benefits; it is not a certificate of coverage. All benefits must be medically necessary. For full coverage provisions, refer to the contract. Regence BlueCross BlueShield of Oregon 9 Highlights - Group 51+ Regence Innova - RBCBSO