Plans and Rates Health Insurance. Available directly through Highmark for Individuals and Families

Transcription

1 2016 Health Insurance Plans and Rates Available directly through Highmark for Individuals and Families BENEFIT PERIOD: JANUARY 1, 2016 TO DECEMBER 31, B

2 GET COVERED DIRECTLY THROUGH HIGHMARK At Highmark Blue Cross Blue Shield, we believe that change is a good thing. Because health care can, and should, be a better experience. With plans and services that put you first. And easy access to health and wellness tools and services that help you make more informed health care decisions. If you don t have health insurance through your employer, Highmark can help you find an affordable 2016 qualified health plan option that is right for you. Listed in this brochure are Highmark plans that are available directly through Highmark. For more than 75 years, Highmark has been helping people like you in our area find the right health insurance plan that fits their needs and budget. This dedication has helped make Highmark the most preferred health insurance company in the areas we serve. 1 Highmark also offers plans with financial help through the Health Insurance Marketplace. Financial help is only available with plans purchased through the Health Insurance Marketplace. To see if you qualify for financial help please contact the Health Insurance Marketplace at or The Highmark Difference Highmark is dedicated to making health insurance easier for you when and where you need it. Our goal is to transform health care, because you deserve a better health care experience: Lower Costs Get the most out of your health care dollars with the best quality care at the most competitive price Higher Quality Standards Hospitals and doctors close to where you live and work for the best access to care Better Health Outcomes Get better access to doctors and specialists who meet the highest benchmarks for delivering quality, cost-effective care And when you become a Highmark member, you have access to exclusive health and wellness tools and services for when you need care, to check health care costs before a procedure is done and most importantly, to help you make good decisions to keep you healthy. If you are already a Highmark member, visit HighmarkBCBS.com and Log In to your secure member website to see more. My Care Navigator SM A built-in guide for navigating the health care system. Whether it s help with a care claim or assistance with provider billing, My Care Navigator helps members understand and manage their care costs. BlueCard Wherever you go nationwide as a Highmark member, you re in a Blue network. Just show your BlueCard to the thousands of participating physicians and hospitals across the country, and you ll receive in-network access away from home. Find a Doctor or RX Now Highmark gives you more ways than ever to find a health care provider that s right for you. Our easy-to-use online directory can help you find doctors, dentists, pharmacies, and even search for covered medications. To Find a Doctor, visit HighmarkBCBS.com. Blues On Call SM Your medical questions don t just come up during offce hours. That s why Blues On Call gives you a 24/7 hotline to a team of registered nurses to help you with personal health questions. Health & Wellness Tools Members get access to today s leading-edge, online health and wellness tools. With Highmark you get what you need to launch your journey toward better health and wellness. It s convenient, easy to use, and best of all, it s free. Care Cost Estimator When you re planning a medical treatment, Highmark s Care Cost Estimator online tool lets you find and compare costs just like you do for other big purchases for more than 1,600 kinds of care visits. 1 Highmark Brand Perception Study Conducted by Lynx Research Consulting. 1 Call (TTY/TDD 711) to enroll or learn more.

3 QUALITY, AFFORDABLE COVERAGE FROM HIGHMARK Highmark offers a variety of affordable plan options. All of our plans: Let you see a specialist without needing a referral from your primary care doctor, so you can get the care that you need when you need it Offer covered emergency care at in-network rates at any emergency room Cover these Essential Health Benefits: Ambulatory services, such as primary care and specialist visits Maternity and newborn care Emergency services Prescription drugs, including retail and mail order Pediatric services, including oral and vision care Mental health and substance abuse services Rehabilitative services and devices Hospitalization Laboratory services No-cost preventive and wellness services, and chronic disease management Cover preventive services like annual physicals, immunizations and screenings at no cost to you, when delivered by a doctor in the Highmark network Include coverage for dependents up to age 26 Cover you even if you have a pre-existing health or medical condition Things You Need to Know Choosing a health plan can be complicated. There are a lot of things to take into account. It s important that you have all the information you need to make the best possible health insurance decision. To help you get a better understanding of the basics of health insurance, here are some of the most common health insurance terms that are important to know: Premium The amount you pay each month for your health insurance. Deductible The dollar amount you must pay each benefit period (usually a year) for your health care expenses before your plan begins to pay. Out-of-Pocket Maximum The highest amount you will need to pay each benefit period (usually a year) for covered in- network care before your insurance company pays 100% of covered in-network services. Coinsurance The part of a medical bill that you pay after reaching your deductible. Copayment (Copay) Fixed, upfront dollar amounts that you pay each time you receive certain health care services; can be before or after deductible. Formulary A formulary is a list of prescription drugs that are covered by your health insurance plan; out-of-pocket costs may apply. Call (TTY/TDD 711) to enroll or learn more. 2

4 IMPORTANT 2016 OPEN ENROLLMENT DATES The Open Enrollment Period for 2016 health insurance coverage starts November 1, Coverage may begin as soon as January 1, 2016 depending on when you enroll. Enroll in a 2016 plan any time between November 1, 2015 and January 31, NOVEMBER 1, 2015 Open Enrollment Begins If you don t enroll before Open Enrollment ends on January 31, 2016 you may pay a fee on your federal income tax return for To learn more about fee exceptions visit HealthCare.gov. DECEMBER 15, 2015 Enroll by this date for coverage to begin January 1, 2016 There is a Special Enrollment Period if you have a qualifying life event.* Examples include, but are not limited to, certain permanent moves, certain changes in your income, and changes in your family size (such as marriage, childbirth or adoption). JANUARY 15, 2016 Documentation that shows you are eligible for the Special Enrollment Period must be submitted to Highmark if you do not enroll in a 2016 plan during the Open Enrollment Period. Enroll by this date for coverage to begin February 1, 2016 *A special enrollment period may occur during or outside of Open Enrollment. JANUARY 31, 2016 Open Enrollment Ends Enroll by this date for coverage to begin March 1, 2016 HOW TO ENROLL THROUGH HIGHMARK Highmark is here to be your health insurance partner, every step of the way. Together, we ll help you find the coverage you need. 1 Review your 2016 Highmark plan options in this booklet on pages 4-7. Please note that some plans are only available in certain counties. The Catastrophic (Major Events) plan is only for individuals and their families under age 30 or those who meet financial hardship requirements. 3 Calculate your rate by first finding the county you live in for your rate on pages * Then find your age, tobacco use and the plan you wish to purchase directly from Highmark.** The base rate listed is the maximum amount you will pay every month. 2 Gather the documents you ll need to complete the enrollment application for yourself and every family member you want to enroll in your 2016 plan, including: Social Security Numbers (or documents for legal immigrants) Birth dates Policy numbers for any current health insurance Information about any health insurance you or your family could get from your jobs 4 5 You may save on monthly premiums if you qualify for financial help and purchase a plan through the Health Insurance Marketplace. Highmark offers plans on the Marketplace. To see if you qualify for financial help please contact the Health Insurance Marketplace at HealthCare.gov or Complete the Highmark paper Application for New 2016 Individual/Family Plan Health Insurance and return it to Highmark with payment. (See rates on pages to calculate payment amount.) Contact Highmark for questions or to enroll in a Highmark plan by calling or by visiting your local Highmark Direct store or Highmark insurance agent. * If you are over 21 years of age, find the county where you reside. If you are under 21 years of age, either find the county where you reside, or the county where you reside with your parent or guardian. ** For two-parent families with more than three children under age 21: Only include rates for you, your spouse/domestic partner, children between ages 21-26, and/ or three oldest children under age 21. Your policy automatically covers your remaining children. Please include them on your application as eligible dependents, but without a rate listed with their names. 3 Call (TTY/TDD 711) to enroll or learn more.

5 2016 HIGHMARK PLANS Plans are available in these counties: Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Centre, Clarion, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Huntingdon, Indiana, Jefferson, Lawrence, McKean, Mercer, Potter, Somerset, Venango, Warren, Washington and Westmoreland Plan Name Shared Cost Blue PPO 6000 Health Savings Blue PPO Embedded 4500 Health Savings Blue PPO Embedded 2700 Health Savings Blue PPO 1400 Network KEYSTONE HEALTH PLAN WEST NETWORK Metal Level BRONZE BRONZE SILVER GOLD Deductible (Individual) $6,000 $4,500 $2,700 $1,400 Deductible (Family) 1,2 $12,000 $9,000 $5,400 $2,800 Out-of-Pocket Maximum (Individual) 3 $6,850 $6,450 $5,400 $2,800 Out-of-Pocket Maximum (Family) $13,700 $12,900 $10,800 $5,600 Coinsurance (Play Pays) 60% after deductible 70% after deductible 90% after deductible 90% after deductible Shared Cost plans have copays with coverage for some services right from the start. For other services, you first need to meet your deductible. Health Savings plans offer the tax and savings advantages of a Health Savings Account (HSA). You pay all costs until your deductible is met. Then you pay a percentage of costs until you meet your out-ofpocket maximum. Specialty pharmacy drugs treat complex, chronic conditions like multiple sclerosis or cancer. They often are more expensive and may require special handling, administering and monitoring, and are distributed by an approved specialty pharmacy. HCR Comprehensive Formulary a list of prescription drugs that your health insurance plan covers. A generic drug will be dispensed unless the prescription order specifies that a brand drug is required. Primary Care Visit 100% after $80 copay, no deductible 70% after deductible 90% after deductible 90% after deductible Specialist Visit 100% after $125 copay, no deductible 70% after deductible 90% after deductible 90% after deductible Urgent Care Visit 100% after $125 copay, no deductible 70% after deductible 90% after deductible 90% after deductible Emergency Room Visit 60% after deductible 70% after deductible 90% after deductible 90% after deductible Inpatient Hospital Services Diagnostic Lab 7 60% after deductible 70% after deductible 90% after deductible 90% after deductible 100% after $75 copay, no deductible 70% after deductible 90% after deductible 90% after deductible Prescription Formulary HCR Comprehensive 6 HCR Comprehensive 6 HCR Comprehensive 6 HCR Comprehensive 6 Prescription Drug Coverage Retail Generic/Brand/Non- Formulary (Member Pays) Specialty Pharmacy Retail Brand/ Non-Formulary (Member Pays) Pediatric Vision Services 5 Pediatric Dental Services (Diagnostic & Preventive) 40% after deductible 30% after deductible 10% after deductible 10% after deductible 40% after deductible 30% after deductible 10% after deductible 10% after deductible no deductible or copay no deductible or copay no deductible or copay no deductible or copay no deductible or copay no deductible or copay no deductible or copay no deductible or copay Do you need adult dental insurance? Highmark Blue Edge Dental offers a level of coverage that will fit your budget. Visit HighmarkBlueEdgeDental.com to find out more. Call (TTY/TDD 711) to enroll or learn more. 4

6 2016 HIGHMARK PLANS Plans are available in these counties: Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Centre, Clarion, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Huntingdon, Indiana, Jefferson, Lawrence, McKean, Mercer, Potter, Somerset, Venango, Warren, Washington and Westmoreland Plan Name Comprehensive Care Blue PPO 1500 Comprehensive Care Flex Blue PPO 500 Care Guide Blue HMO 500 Comprehensive Care plans feature a lower yearly deductible and a lower out-ofpocket maximum. You pay for all medical services until your deductible is met. Then you pay a percentage of your care costs until your out-of-pocket maximum is met. Specialty pharmacy drugs treat complex, chronic conditions like multiple sclerosis or cancer. They often are more expensive and may require special handling, administering and monitoring, and are distributed by an approved specialty pharmacy. HCR Progressive Formulary a list of prescription drugs that your health insurance plan covers. A generic drug will be dispensed regardless of whether or not the prescription order specifies a brand drug. Members who cannot or will not accept a generic substitution will be required to pay more for the brand drug. HCR Comprehensive Formulary a list of prescription drugs that your health insurance plan covers. A generic drug will be dispensed unless the prescription order specifies that a brand drug is required. Network KEYSTONE HEALTH PLAN WEST NETWORK Metal Level SILVER PLATINUM GOLD Deductible (Individual) $1,500 Deductible (Family) 1,2 $3,000 Out-of-Pocket Maximum (Individual) 3 $6,850 Out-of-Pocket Maximum (Family) Coinsurance (Plan Pays) Primary Care Visit Specialist Visit Urgent Care Visit $13,700 Deductible then 100% after $35 copay Deductible then 100% after $70 copay Deductible then 100% after $70 copay *HCR Progressive Formulary offers $3 low-cost generic drugs. $500 (enhanced); $1,500 (standard) $1000 (enhanced); $3,000 (standard) $1,650 Enhanced and Standard Combined $3,300 Enhanced and Standard Combined 90% after deductible (enhanced); 60% after 90% after deductible (enhanced); 60% after 90% after deductible (enhanced); 60% after 90% after deductible (enhanced); 60% after $500 $1,000 $5,000 $10, % after $15 copay, no deductible 100% after $40 copay, no deductible 100% after $40 copay, no deductible Emergency Room Visit 90% after deductible $100 copay Inpatient Hospital Services Diagnostic Lab 7 Deductible then 100% after $40 copay 90% after deductible (enhanced); 60% after 90% after deductible (enhanced); 60% after 100% after $15 copay, no deductible Prescription Formulary HCR Progressive* 4 HCR Comprehensive 6 HCR Progressive* 4 Prescription Drug Coverage Retail Generic/Brand/Non- Formulary (Member Pays) Specialty Pharmacy Retail Brand/ Non-Formulary (Member Pays) $10 copay; $50 copay; $100 copay 50% with $600 max per prescription; 50% up to $1,000 max per prescription Pediatric Vision Services 5 Pediatric Dental Services (Diagnostic & Preventive) $5 copay; $20 copay; $45 copay, no deductible 50% with $500 max per prescription; 50% up to $750 max per prescription $10 copay; $50 copay; $100 copay 50% with $600 max per prescription; 50% up to $1,000 max per prescription 5 Call (TTY/TDD 711) to enroll or learn more.

7 2016 HIGHMARK PLANS Shared Cost & Major Events plans are available in these counties: Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Centre, Clarion, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Huntingdon, Indiana, Jefferson, Lawrence, McKean, Mercer, Potter, Somerset, Venango, Warren, Washington and Westmoreland +Health Savings plan is only available in these counties: Allegheny, Armstrong, Beaver, Butler, Crawford, Erie, Fayette, Greene, Indiana, Lawrence, McKean, Mercer, Warren, Washington and Westmoreland ++PA Mountains plan is only available in these counties: Armstrong, Blair, Cameron, Clarion, Crawford, Forest, Indiana, Jefferson, Lawrence, McKean and Potter +++Penn Highlands plan is only available in these counties: Elk, Centre, Clearfield and Jefferson Plan Name Shared Cost Blue PPO 6000 a Community Blue Flex Plan Major Events PPO Blue 6850 a Community Blue Plan Health Savings Blue PPO Embedded 2700 a Community Blue Flex Plan + Flex Blue PPO 1200 PA Mountains Healthcare Region a Community Blue Plan ++ Flex Blue PPO 1200 Penn Highlands Region a Community Blue Plan +++ Network COMMUNITY BLUE NETWORK Metal Level BRONZE CATASTROPHIC SILVER GOLD GOLD Deductible (Individual) Deductible (Family) 1,2 Out-of-Pocket Maximum (Individual) 3 Out-of-Pocket Maximum (Family) Coinsurance (Plan Pays) Primary Care Visit Specialist Visit Urgent Care Visit $6,000 Enhanced and Standard Combined $12,000 Enhanced and Standard Combined $6,850 Enhanced and Standard Combined $13,700 Enhanced and Standard Combined 60% after deductible (enhanced); 40% after 100% after $75 copay, no deductible (enhanced); 100% after $110 copay, no 100% after $125 copay, no deductible (enhanced); 100% after $160 copay, no 100% after $125 copay, no deductible (enhanced); 100% after $160 copay, no $6,850 $13,700 $6,850 $13, % after deductible 100% after deductible, Eligible for 3 visits prior to deductible at no cost 100% after deductible 100% after deductible $2,700 Enhanced and Standard Combined $5,400 Enhanced and Standard Combined $5,250 Enhanced and Standard Combined $10,500 Enhanced and Standard Combined (enhanced); 60% after (enhanced); 60% after (enhanced); 60% after (enhanced); 60% after $1,200 (enhanced); $2,400 (standard); Deductibles Cross Accumulate $2,400 (enhanced); $4,800 (standard); Deductibles Cross Accumulate $3,850 Enhanced and Standard Combined $7,700 Enhanced and Standard Combined (enhanced); 60% after 100% after $20 copay, no deductible (enhanced); 100% after $50 copay, no deductible (standard) 100% after $30 copay, no deductible (enhanced); 100% after $60 copay, no deductible (standard) 100% after $30 copay, no deductible (enhanced and standard) $1,200 (enhanced); $2,400 (standard); Deductibles Cross Accumulate $2,400 (enhanced); $4,800 (standard); Deductibles Cross Accumulate $3,950 Enhanced and Standard Combined $7,900 Enhanced and Standard Combined (enhanced); 60% after 100% after $20 copay, no deductible (enhanced); 100% after $50 copay, no deductible (standard) 100% after $30 copay, no deductible (enhanced); 100% after $60 copay, no deductible (standard) 100% after $30 copay, no deductible (enhanced and standard) Emergency Room Visit 60% after deductible 100% after deductible 80% after enhanced deductible 80% after enhanced deductible 80% after enhanced deductible Inpatient Hospital Services Diagnostic Lab 7 60% after deductible (enhanced); 40% after 100% after $75 copay, no deductible (enhanced); 100% after $110 copay, no 100% after deductible 100% after deductible (enhanced); 60% after (enhanced); 60% after (enhanced); 60% after 100% after $20 copay, no deductible (enhanced); 100% after $50 copay, no deductible (standard) (enhanced); 60% after 100% after $20 copay, no deductible (enhanced); 100% after $50 copay, no deductible (standard) Prescription Formulary HCR Comprehensive 6 HCR Comprehensive 6 HCR Comprehensive 6 HCR Progressive* 4 HCR Progressive* 4 Prescription Drug Coverage $10 copay; $50 copay; $10 copay; $50 copay; Retail Generic/Brand/Non- 40% after deductible 0% after deductible 20% after deductible $100 copay $100 copay Formulary (Member Pays) Specialty Pharmacy Retail Brand/Non-Formulary (Member Pays) Pediatric Vision Services 5 Pediatric Dental Services (Diagnostic & Preventive) 40% after deductible 0% after deductible 20% after deductible *HCR Progressive Formulary offers $3 low-cost generic drugs. 100% after deductible 50% with $600 max per prescription; 50% up to $1,000 max per prescription 50% with $600 max per prescription; 50% up to $1,000 max per prescription Call (TTY/TDD 711) to enroll or learn more. 6

8 2016 CONNECT BLUE PLANS Connect Blue is only available in these 6 Western Pennsylvania counties: Allegheny, Beaver, Butler, Washington, Westmoreland and Erie Connect Blue is an innovative, lower-cost Exclusive Provider Organization, or EPO, that covers services from participating in-network health providers at three different levels of benefits: 1 Preferred Value Level of Benefits When you choose health care providers participating at this level, you pay the least in out of-pocket costs 2 Enhanced Value Level of Benefits You pay slightly more out-ofpocket at this level 3 Standard Value Level of Benefits You pay the most out-of-pocket at this level Your out-of-pocket savings on your deductible, coinsurance or copayment will depend on the provider s level of participation. You save the most by using providers participating at the Preferred Value Level of Benefits. (See partial provider list on the next page.) Emergency care services are covered at Preferred Value Level of Benefits no matter where care is provided. From the full network of providers, at all levels of benefits, you will receive high quality care and easy access to every kind of service. Plan Name Connect Blue EPO 5500 a Community Blue Flex Plan Connect Blue EPO 2500 a Community Blue Flex Plan Connect Blue EPO 750 a Community Blue Flex Plan Connect Blue EPO 250 a Community Blue Flex Plan Network COMMUNITY BLUE NETWORK Metal Level BRONZE SILVER SILVER GOLD Deductible (Individual) $5,500 (Preferred); $6,500 (Enhanced); $6,850 (Standard) Deductible (Family) 1,2 $11,000 (Preferred); $13,000 (Enhanced); $13,700 (Standard) $2,500 (Preferred); $4,000 (Enhanced); $6,000 (Standard) $5,000 (Preferred); $8,000 (Enhanced); $12,000 (Standard) $750 (Preferred); $4,000 (Enhanced); $6,000 (Standard) $1,500 (Preferred); $8,000 (Enhanced); $12,000 (Standard) $250 (Preferred); $750 (Enhanced); $2,250 (Standard) $500 (Preferred); $1,500 (Enhanced); $4,500 (Standard) Out-of-Pocket Maximum (Individual) 3 $6,850 Combined All Tiers $6,850 Combined All Tiers $6,850 Combined All Tiers $6,850 Combined All Tiers Out-of-Pocket Maximum (Family) $13,700 Combined All Tiers $13,700 Combined All Tiers $13,700 Combined All Tiers $13,700 Combined All Tiers Coinsurance (Plan Pays) Primary Care Visit Specialist Visit Urgent Care Visit Emergency Room Visit Inpatient Hospital Services Diagnostic Lab 7 70% after deductible (Preferred); 50% after deductible (Enhanced); 40% after 100% after $65 copay, no deductible (Preferred); 100% after $110 copay, no deductible (Enhanced); 40% after 100% after $100 copay, no deductible (Preferred); 100% after $160 copay, no deductible (Enhanced); 40% after 100% after $100 copay, no deductible (Preferred); 100% after $100 copay, no deductible (Enhanced); 40% after 70% after Preferred deductible, waived if admitted $1,500 copay, per admission, then 100% (Preferred); 50% after deductible (Enhanced); 40% after 100% after $60 copay, no deductible (Preferred); 100% after $110 copay, no deductible (Enhanced); 40% after 90% after deductible (Preferred); 70% after deductible (Enhanced); 50% after 100% after $30 copay, no deductible (Preferred); 100% after $50 copay, no deductible (Enhanced); 50% after 100% after $45 copay, no deductible (Preferred); 100% after $90 copay, no deductible (Enhanced); 50% after 100% after $45 copay, no deductible (Preferred); 100% after $45 copay, no deductible (Enhanced); 50% after 100% after $500 Copay, waived if admitted $500 copay per day, 3 day max then 100% (Preferred); $1,000 copay per day, 3 day max then 100% (Enhanced); 50% after 100% after $45 copay, no deductible (Preferred); 100% after $90 copay, no deductible (Enhanced); 50% after 70% after deductible (Preferred); 50% after deductible (Enhanced); 40% after 100% after $25 copay, no deductible (Preferred); 100% after $70 copay, no deductible (Enhanced); 40% after 100% after $80 copay, no deductible (Preferred); 100% after $100 copay, no deductible (Enhanced); 40% after 100% after $80 copay, no deductible (Preferred); 100% after $80 copay, no deductible (Enhanced); 40% after 100% after $500 Copay, waived if admitted $1,000 copay per day, 3 day max then 100% (Preferred); $1,500 copay per day, 3 day max then 100% (Enhanced); 40% after 100% after $80 copay, no deductible (Preferred); 100% after $120 copay, no deductible (Enhanced); 40% after 90% after deductible (Preferred); 70% after deductible (Enhanced); 50% after 100% after $10 copay, no deductible (Preferred); 100% after $40 copay, no deductible (Enhanced); 50% after 100% after $40 copay, no deductible (Preferred); 100% after $65 copay, no deductible (Enhanced); 50% after 100% after $40 copay, no deductible (Preferred); 100% after $40 copay, no deductible (Enhanced); 50% after 100% after $600 Copay, waived if admitted $500 copay per day, 3 day max then 100% (Preferred); $1,000 copay per day, 3 day max then 100% (Enhanced); 50% after 100% after $40 copay, no deductible (Preferred); 100% after $65 copay, no deductible (Enhanced); 50% after Prescription Formulary HCR Comprehensive 6 HCR Progressive* 4 HCR Progressive* 4 HCR Progressive* 4 Prescription Drug Coverage $10 Copay; $50 Copay; $10 Copay; $50 Copay; $10 Copay; $50 Copay; Retail Generic/Brand/Non- 30% after deductible $100 copay $100 copay $100 copay Formulary (Member Pays) Specialty Pharmacy Retail Brand/Non-Formulary (Member Pays) 30% after deductible 50% coinsurance with $500 max per prescription; 50% up to $750 max per prescription 50% coinsurance with $500 max per prescription; 50% up to $750 max per prescription 50% coinsurance with $500 max per prescription; 50% up to $750 max per prescription Pediatric Vision Services 5 Services performed by out-of-network providers are generally not covered. Pediatric Dental Services (Diagnostic & Preventive) *HCR Progressive Formulary offers $3 low-cost generic drugs. 7 Call (TTY/TDD 711) to enroll or learn more.

9 CONNECT BLUE You decide how much to save on your out-of-pocket costs because you decide which provider to use with our Connect Blue EPO health plan options. Connect Blue EPO covers services from participating in-network health providers at three different levels of benefits: Preferred Value Level of Benefits, Enhanced Value Level of Benefits or Standard Value Level of Benefits. Connect Blue uses the Community Blue network of providers a network of high-performing, patient-focused care providers, specialists and hospitals that you and your neighbors have relied on for generations. Specialists in the Community Blue network represent medical specialties, including cancer, cardiology, gastroenterology, neurology, neurosurgery, obstetrics, gynecology and many more. Connect Blue is only available in six Western Pennsylvania counties, Allegheny, Beaver, Butler, Washington, Westmoreland and Erie. You can choose from nearly 60 community, specialty and tertiary hospitals and more than 10,300 physicians and health care providers who participate in the Community Blue network in 29 counties in Western Pennsylvania. Outside Western Pennsylvania, providers participating in a local Blue plan offer quality care and are covered at the Enhanced Value. More than 97 percent of all U.S. hospitals and more than 92 percent of all U.S. physicians nearly 720,000 providers across the country participate in their local Blue Cross and/or Blue Shield PPO network, or BlueCard program. CONNECT BLUE is only available to individuals that reside in these counties Allegheny, Beaver, Butler, Washington, Westmoreland and Erie. Members have access to any of these hospitals and affliated physicians at the in-network levels of benefits.* Plus, access to over 10,300 physicians and health care providers in the Community Blue network in Western PA and nearly 720,000 providers across the country with the BlueCard program. PREFERRED Value Level of Benefits ALLEGHENY COUNTY Allegheny General Hospital Allegheny Valley Hospital Children s Hospital of Pittsburgh of UPMC Forbes Hospital Jefferson Hospital St. Clair Hospital West Penn Hospital Western Psychiatric Institute and Clinic BUTLER COUNTY Butler Memorial Hospital ERIE COUNTY Saint Vincent Hospital WASHINGTON COUNTY Canonsburg Hospital Washington Hospital ENHANCED Value Level of Benefits ALLEGHENY COUNTY Heritage Valley Sewickley Ohio Valley General Hospital BEAVER COUNTY Heritage Valley Beaver ERIE COUNTY Corry Memorial Hospital Millcreek Community Hospital WASHINGTON COUNTY Advanced Surgical Hospital Monongahela Valley Hospital WESTMORELAND COUNTY Excela Frick Hospital Excela Latrobe Area Hospital Excela Westmoreland Hospital STANDARD Value Level of Benefits ALLEGHENY COUNTY UPMC Hospitals under Consent Decree ERIE COUNTY UPMC Hamot *Provider designation within Levels of Benefits and participating hospitals/doctors is subject to change. List current as of 10/15. To Find a Doctor and check that provider s level of participation visit HighmarkBCBS.com. The Level of Benefits will be listed under the provider s name. Call (TTY/TDD 711) to enroll or learn more. 8

10 DISCLOSURE Important Benefit Details 1 Flex, Shared Cost, Health Savings Embedded and Comprehensive Care Family Deductible: For an Agreement covering more than one (1) family member, as each Member satisfies their individual Deductible, the Plan will begin to pay benefits for Covered Services for that Member for the remainder of the Benefit Period (January 1, 2016 December 31, 2016), whether or not the entire family Deductible has been satisfied. When the family Deductible has been satisfied, the family Deductible will be considered to have been satisfied for all remaining covered family members. No individual Member may satisfy the entire family Deductible. 2 Health Savings and Major Events Family Deductible: For an Agreement covering more than one (1) family member, the ENTIRE family deductible must be met [within a benefit period (January 1, 2016 December 31, 2016)] before Highmark will pay for covered services for ANY family member. The family deductible can be satisfied by an individual family member or a combination of one or more family members. 3 You are responsible for out-of-pocket costs each Benefit Period up to a maximum amount shown. Thereafter, the Plan pays 100% of the Provider s Allowable Charge during the remainder of the Benefit Period. This amount does not include amounts in excess of the Provider s Allowable Charge. 4 HCR Progressive Formulary prescription drug copays for a 31-day supply (Retail): $3 low-cost generic; $10 generic; $50 brand; $100 non-formulary brand and nonformulary generic; specialty drug copays vary. The plan has a six-tier structure and utilizes the HCR Progressive Formulary on the National network. Mail order available. If a generic substitution is available but not accepted by the Member they are responsible for paying the difference between the price for a Brand Drug and any available generic equivalent, for each separate Prescription Order or refill plus the drug copay. 5 Vision benefits utilize the Davis National Network. Pediatric Dental benefits utilize United Concordia s Advantage Network 6 The plan utilizes the HCR Comprehensive Formulary on the National network. Specialty drug copays may vary. Mail order available. 7 Basic Diagnostic Services include four types of service: Standard Imaging Services, Laboratory and Pathology, Diagnostic Medical and Allergy Testing. Basic Diagnostic Services require one copay per date of service and type of service. Additional Basic Diagnostic Services are subject to deductible and coinsurance. Advanced Diagnostic Services include but are not limited to CAT Scan, CTA, MRI, MRA, PET Scan and PET/CT Scan. Health Savings Plans are Qualified High Deductible Health Plans that may be coupled with a Health Savings Account (HSA). However, certain Cost-Sharing Reductions (CSR) or plan variations of this plan that are offered through the Health Insurance Marketplace are not intended to be used with an HSA. If you have questions, please check with your financial advisor. Multi-State Plans are only available for enrollment through the Health Insurance Marketplace. Insurance may be provided by Highmark Blue Cross Blue Shield, Highmark Health Insurance Company or Highmark Choice Company. Highmark Blue Cross Blue Shield, Highmark Health Insurance Company and Highmark Choice Company are independent licensee of the Blue Cross and Blue Shield Association. Blue Cross, Blue Shield and the Cross and Shield symbols are registered service marks of the Blue Cross and Blue Shield Association. Highmark is a registered mark of Highmark Inc. Information regarding the Patient Protection and Affordable Care Act of 2010 (a.k.a. PPACA, Affordable Care Act, ACA, and/or Health Care Reform ), as amended, and/or any other law, does not constitute legal or tax advice and is subject to change based upon the issuance of new guidance and/or change in laws. State laws may be applicable. Any review of materials, request for information, or application does not obligate you to enroll for coverage. Please request the Outline of Coverage for details on benefits, conditions and exclusions. Federal and state laws and regulations govern health insurance and health plans may vary from state to state. Highmark does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations. We are committed to providing outstanding services for our applicants and members. If you require special assistance, including accommodations for disabilities or limited English proficiency, please call us at to request these free services (TTY/TDD users may call 711). To find more information about Highmark s benefits and operating procedures, such as accessing the drug formulary or using network providers, please go to DiscoverHighmark. com/qualityassurance; or for a paper copy, call Highmark Blue Cross Blue Shield and Highmark Health Insurance Company are Qualified Health Plan issuers in the Health Insurance Marketplace. Blues On Call and My Care Navigator are service marks and BlueCard is a registered mark of the Blue Cross and Blue Shield Association. Access to UPMC Providers for 2016: As of November 2015, Highmark members who are in the midst of a course of treatment for a chronic/persistent condition in 2013, 2014 or 2015 with a UPMC provider will continue to have in-network access to that provider for Additionally, members who have been treated by a UPMC physician for pregnancy in 2015, are eligible to deliver at Magee-Womens Hospital in To learn more visit DiscoverHighmark.com/ConsentWP. You should confirm the network status of a provider prior to receiving services. You can call My Care Navigator at BLUE-428 to confirm if a doctor or facility will be in network in If you are looking for additional plan details, each plan s Summary of Benefits and Coverage is available online at Shop.Highmark.com/sales/#/sbcs. With this information, you ll be able to shop and compare with confidence. If you do not have online access, you can get a paper copy of any Summary of Benefits free of charge by calling toll-free Call (TTY/TDD 711) to enroll or learn more.

11 RATES FOR YOUR COUNTY Allegheny, Beaver, Butler, Erie, Washington, Westmoreland Age PPO Bronze Bronze Silver Gold Silver Shared Cost Blue PPO 6000 Health Savings Blue PPO Embedded 4500 Health Savings Blue PPO Embedded 2700 Health Savings Blue PPO 1400 Comprehensive Care Blue PPO 1500 Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco 0-20 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ Call (TTY/TDD 711) to enroll or learn more. 10

12 RATES FOR YOUR COUNTY Allegheny, Beaver, Butler, Erie, Washington, Westmoreland Age PPO HMO PPO Platinum Gold Bronze Catastrophic Silver Comprehensive Care Flex Blue PPO 500 Care Guide Blue HMO 500 Shared Cost Blue PPO 6000 a Community Blue Flex Plan Major Events Blue PPO 6850 a Community Blue Plan Health Savings Embedded Blue PPO 2700 a Community Blue Flex Plan Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco 0-20 $ $ $ $ $95.10 $95.10 $83.44 $83.44 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $1, $1, $ $ $ $ $ $ $ $ $1, $1, $ $ $ $ $ $ $ $ $1, $1, $ $1, $ $ $ $ $ $ $1, $1, $ $1, $ $ $ $ $ $ $1, $1, $ $1, $ $ $ $ $ $ $1, $1, $ $1, $ $ $ $ $ $ $1, $1, $ $1, $ $ $ $ $ $ $1, $1, $ $1, $ $ $ $ $ $ Call (TTY/TDD 711) to enroll or learn more.

13 RATES FOR YOUR COUNTY Allegheny, Beaver, Butler, Erie, Washington, Westmoreland Age EPO Bronze Silver Silver Gold Connect Blue EPO 5500 a Community Blue Flex Plan Connect Blue EPO 2500 a Community Blue Flex Plan Connect Blue EPO 750 a Community Blue Flex Plan Connect Blue EPO 250 a Community Blue Flex Plan Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco 0-20 $83.70 $83.70 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Call (TTY/TDD 711) to enroll or learn more. 12

14 RATES FOR YOUR COUNTY Armstrong, Crawford, Fayette, Greene, Indiana, Lawrence, McKean, Mercer, Warren Age PPO Bronze Bronze Silver Gold Silver Platinum Shared Cost Blue PPO 6000 Health Savings Blue PPO Embedded 4500 Health Savings Blue PPO Embedded 2700 Health Savings Blue PPO 1400 Comprehensive Care Blue PPO 1500 Comprehensive Care Flex Blue PPO 500 Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco 0-20 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $1, $ $ $1, $1, $ $ $ $ $ $ $ $1, $ $ $1, $1, $ $ $ $ $ $ $ $1, $ $ $1, $1, $ $ $ $ $ $ $ $1, $ $ $1, $1, $ $ $ $ $ $ $ $1, $ $ $1, $1, $ $ $ $ $ $ $ $1, $ $ $1, $1, $ $ $ $ $ $ $ $1, $ $ $1, $1, $ $ $ $ $ $ $ $1, $ $ $1, $1, Call (TTY/TDD 711) to enroll or learn more.

15 RATES FOR YOUR COUNTY Armstrong, Crawford, Fayette, Greene, Indiana, Lawrence, McKean, Mercer, Warren *Plan Only Available for Counties: Armstrong, Crawford, Indiana, Lawrence, McKean Age HMO Gold Bronze Catastrophic Silver Gold Care Guide Blue HMO 500 Shared Cost Blue PPO 6000 a Community Blue Flex Plan Major Events Blue PPO 6850 a Community Blue Plan PPO Health Savings Embedded Blue PPO 2700 a Community Blue Flex Plan Flex Blue PPO 1200 PA Mountains Healthcare Region a Community Blue Plan* Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco 0-20 $ $ $95.10 $95.10 $83.44 $83.44 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ Call (TTY/TDD 711) to enroll or learn more. 14

16 RATES FOR YOUR COUNTY Bedford, Blair, Cambria, Cameron, Clarion, Forest, Huntingdon, Jefferson, Potter, Somerset, Venango Age PPO Bronze Bronze Silver Gold Silver Shared Cost Blue PPO 6000 Health Savings Blue PPO Embedded 4500 Health Savings Blue PPO Embedded 2700 Health Savings Blue PPO 1400 Comprehensive Care Blue PPO 1500 Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco 0-20 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ Call (TTY/TDD 711) to enroll or learn more.

17 RATES FOR YOUR COUNTY Bedford, Blair, Cambria, Cameron, Clarion, Forest, Huntingdon, Jefferson, Potter, Somerset, Venango *Plan Only Available for Counties: Blair, Cameron, Clarion, Forest, Jefferson, Potter Age PPO HMO PPO Platinum Gold Bronze Catastrophic Gold Comprehensive Care Flex Blue PPO 500 Care Guide Blue HMO 500 Shared Cost Blue PPO 6000 a Community Blue Flex Plan Major Events Blue PPO 6850 a Community Blue Plan Flex Blue PPO 1200 PA Mountains Healthcare Region a Community Blue Plan* Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco 0-20 $ $ $ $ $ $ $89.25 $89.25 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $1, $1, $ $ $ $ $ $ $ $ $1, $1, $ $ $ $ $ $ $ $ $1, $1, $ $1, $ $ $ $ $ $ $1, $1, $ $1, $ $ $ $ $ $ $1, $1, $ $1, $ $ $ $ $ $ $1, $1, $ $1, $ $ $ $ $ $ $1, $1, $ $1, $ $ $ $ $ $ $1, $1, $ $1, $ $ $ $ $ $ Call (TTY/TDD 711) to enroll or learn more. 16

18 RATES FOR YOUR COUNTY Clearfield, Jefferson, Elk Age PPO Bronze Bronze Silver Gold Silver Shared Cost Blue PPO 6000 Health Savings Blue PPO Embedded 4500 Health Savings Blue PPO Embedded 2700 Health Savings Blue PPO 1400 Comprehensive Care Blue PPO 1500 Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco 0-20 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ Call (TTY/TDD 711) to enroll or learn more.

19 RATES FOR YOUR COUNTY Clearfield, Jefferson, Elk Age PPO HMO PPO Platinum Gold Bronze Catastrophic Gold Comprehensive Care Flex Blue PPO 500 Care Guide Blue HMO 500 Shared Cost Blue PPO 6000 a Community Blue Flex Plan Major Events Blue PPO 6850 a Community Blue Plan Flex Blue PPO 1200 Penn Highlands Region, a Community Blue Plan Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco 0-20 $ $ $ $ $ $ $89.25 $89.25 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $1, $1, $ $ $ $ $ $ $ $ $1, $1, $ $ $ $ $ $ $ $ $1, $1, $ $1, $ $ $ $ $ $ $1, $1, $ $1, $ $ $ $ $ $ $1, $1, $ $1, $ $ $ $ $ $ $1, $1, $ $1, $ $ $ $ $ $ $1, $1, $ $1, $ $ $ $ $ $ $1, $1, $ $1, $ $ $ $ $ $ Call (TTY/TDD 711) to enroll or learn more. 18

20 RATES FOR YOUR COUNTY Centre Age PPO Bronze Bronze Silver Gold Silver Shared Cost Blue PPO 6000 Health Savings Blue PPO Embedded 4500 Health Savings Blue PPO Embedded 2700 Health Savings Blue PPO 1400 Comprehensive Care Blue PPO 1500 Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco 0-20 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $1, $1, $ $1, $ $ $ $ $ $1, $1, $1, $ $1, $ $ $ $ $ $1, $1, $1, $ $1, $ $ $ $ $ $1, $1, $1, $ $1, Call (TTY/TDD 711) to enroll or learn more.

21 RATES FOR YOUR COUNTY Centre Age PPO HMO PPO Platinum Gold Bronze Catastrophic Gold Comprehensive Care Flex Blue PPO 500 Care Guide Blue HMO 500 Shared Cost Blue PPO 6000 a Community Blue Flex Plan Major Events Blue PPO 6850 a Community Blue Plan Flex Blue PPO 1200 Penn Highlands Region a Community Blue Plan Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco 0-20 $ $ $ $ $ $ $95.69 $95.69 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $1, $1, $ $ $ $ $ $ $ $ $1, $1, $ $1, $ $ $ $ $ $ $1, $1, $ $1, $ $ $ $ $ $ $1, $1, $ $1, $ $ $ $ $ $ $1, $1, $ $1, $ $ $ $ $ $ $1, $1, $ $1, $ $ $ $ $ $ $1, $1, $ $1, $ $ $ $ $ $ $1, $1, $ $1, $ $ $ $ $ $ $1, $1, $ $1, $ $ $ $ $ $ Call (TTY/TDD 711) to enroll or learn more. 20

22 ا COMMITTED TO PROVIDING OUTSTANDING SERVICE We are committed to providing outstanding services for our applicants and members. If you require special assistance, including accommodations for disabilities or limited English proficiency, please call us at to request these free services. (TTY/TDD: 711) Estamos comprometidos a ofrecer servicios excepcionales a nuestros solicitantes y miembros. Si usted necesita ayuda especial, incluyendo acomodaciones para discapacidades o dominio limitado del inglés, por favor llámenos al para solicitar estos servicios gratuitos. (TTY/TDD: 711) Wir haben uns verpflichtet, unseren Bewerbern und Mitgliedern außerordentliche Dienstleistungen anzubieten. Falls Sie beispielsweise Unterkünfte für Menschen mit Behinderungen oder aufgrund eingeschränkter Englischkenntnisse besondere Unterstützung benötigen, kontaktieren Sie uns unter der Rufnummer , um unsere kostenlosen Dienstleistungen in Anspruch zu nehmen. (TTY/TDD: 711) Ci impegniamo a fornire sempre servizi all avanguardia per i nostri candidati e membri. In caso necessitiate di assistenza speciale, compresi alloggi per disabili o supporto per la scarsa padronanza della lingua inglese, contattateci allo per richiedere gratuitamente tali servizi. (TTY/TDD: 711) 我們致力於為我們的申請人和會員們提供卓越的服務 如果您需要特殊協助, 包括殘障或英語能力有限, 請致電 來要求這些免費服務 (TTY/TDD: 711) Nous nous engageons à fournir des services exceptionnels pour nos candidats et membres. Si vous avez besoin d'une assistance particulière, y compris pour handicapés ou compétences limitées en anglais, s'il vous plaît appelez-nous au pour demander ces services gratuits. (TTY/TDD: 711) Мы стремимся оказывать первоклассные услуги для наших кандидатов и членов. Если вы нуждаетесь в специальной помощи, включая принятие мер в связи с инвалидностью или ограниченным владением английским языком, пожалуйста, позвоните нам по телефону и попросите об оказании этих бесплатных услуг. (TTY/TDD: 711) Chúng tôi quyết tâm cung cấp dịch vụ xuất sắc cho các đương đơn và hội viên của mình. Nếu quý vị cần được trợ giúp đặc biệt, bao gồm các thích nghi cho người bị khuyết tật hoặc có khả năng Anh Ngữ hạn hẹp, xin gọi chúng tôi tại số để yêu cầu các dịch vụ miễn phí này. (TTY/TDD: 711) Zależy nam, aby usługi, które świadczymy dla naszych kandydatów i członków charakteryzowały się zawsze najwyższą jakością. Jeżeli potrzebna jest specjalna pomoc, np. w przypadku osób niepełnosprawnych lub osób z ograniczoną znajomością języka angielskiego, oferujemy bezpłatne usługi w tym zakresie prosimy o telefon pod numer (TTY/TDD: 711) 저희들은신청자들과회원들에게탁월한서비스를제공하고자노력하고있습니다. 신체장애인들이나비영어권참석자들을위해특별한도움이필요하시면전화 로알려주시기바랍니다. 이러한서비스는무료입니다. (TTY/TDD: 711) نلتزم بتوفير خدمة متميزة للمتقدمين واألعضاء. إذا كنت تتطلب مساعدة خاصة شام ل التجهيزات ال لزمة ل لحتياجات الخاصة أو إجادة محدودة لإلنجليزية برجاء االتصال ع ىل لط بل هذه الخدمات المجانية. (711 (TTY/TDD: हम अपन आव दक और सदस य क ल ए उत क ष ट स व ए प द न करन क प त वचनबद ह यदद आपक ववश ष सह य च दहए ह, ज सम अक म अथव स लम अ ग तनपण ह सम य न भ श लम ह, क पय इन तनश ल क स व ओ ह अन र ध क ल ए हम पर क कर (TTY/TDD: 711) 21 Call (TTY/TDD 711) to enroll or learn more.

23 COMMITTED TO PROVIDING OUTSTANDING SERVICE અમ અમ ર અરજ કર ઓ અન સભ ય મ ટ ઉમદ સ વ ઓ પર પ ડવ કટટબદ છ એ. જ ર મન વવકલ ગર ક અ ગ જ મ મય ટદર વનપણર ધર વન ર ઓ મ ટ સગવડભર ગ ઠવણ સટ ર ન વવશષ સ યર જ ઈર ય, ર આ મફર સવ ઓન વવનર કરવ ક પ કર અમન ન બર પર ફ ન કર. (TTY/TDD: 711) May pananagutan kaming magbigay ng bukod-tanging mga serbisyo para sa aming mga aplikante at mga miyembro. Kung kailangan mo ng espesyal na tulong, kabilang ang mga akomodasyon para sa mga kapansanan o limitadong kahusayan sa wikang Ingles, mangyaring tawagan kami sa para hilingin ang mga libreng serbisyong ito. (TTY/TDD: 711) Είμαστε δεσμευμένοι να παρέχουμε εξαιρετικές υπηρεσίες για τους αιτούντες και τα μέλη μας. Εάν χρειάζεστε ειδική βοήθεια, συμπεριλαμβανομένων διευκολύνσεων για ειδικές ανάγκες ή περιορισμένη ευχέρεια στα Αγγλικά, παρακαλούμε επικοινωνήστε μαζί μας στο να ζητήσετε τις δωρεάν αυτές παροχές. (TTY/TDD: 711) 私たちは入会志願者とメンバーのために卓越したサービスを提供することに全力を注いでいます あなたが 障害者のための便宜または制限英語能力を含む特別な支援が必要な場合は これらの無料サービスを受けるために までお電話ください (TTY/TDD: 711) ہم اپنے درخواست دہندگان اور ممبران کے لیے عمدہ خدمات فراہم کرنے کے لیے عہد بستہ ہیں اگر آپ کو خصوصی اعانت کی ضرورت ہے جس میں معذوریوں یا انگریزی کی محدود لیاقت کے لیے سہولیات شامل ہیں ان مفت خدمات کی درخواست کرنے کے لیے براہ کرم ہمیں پر کال کریں (711 (TTY/TDD: Estamos empenhados em fornecer serviços especiais para os nossos candidatos e membros. Caso necessite de assistência especial, incluindo alojamento por motivos de deficiência ou conhecimentos limitados de língua inglesa, ligue para o n.º para solicitar estes serviços gratuitos. (TTY/TDD: 711) Ebe fun awon alaabo ara tabi oore ofe lati le so ede geesi to se gbo seti. Ejowo e pe wa fun eyikeyi ohun ti e ba nfe ki a se fun yin lofe. (TTY/TDD: 711) Sisi ni nia ya kutoa huduma bora kwa waombaji wetu na wanachama. Kama unahitaji msaada maalum, ikiwa ni pamoja na malazi kwa ulemavu au mdogo Kiingereza duni, tafadhali wito wetu katika idadi ya kuomba huduma hizi bure. (TTY/TDD: 711) Nihinaanish niizhóni go bee nihiká adiilwołi gi i binahji ts i dá ye ego bidiilkaal, nihi naaltsoos nidahoni łi gi i dóó Bee Atah i dli ni gi i nihił hada di t e hi gi i nihá. Hait e ego da anáhóót i go, bilagáana bizaad t áá nił nanitł ago, áká a ayeed holo, koji be e sh beehane e bee hodi i lnih ,, e i t áá ji i k eh áká a ayeed biniiye. (TTY/TDD: 711) เราม งม นท จะมอบบร การท โดดเด นให แก ผ สม ครและสมาช กของเรา หากค ณต องการความช วยเหล อเป นพ เศษ รวมถ งการอานวยความสะดวกให แก บ คคลท พพลภาพหร อผ ท ม ความสามารถทางภาษาอ งกฤษในระด บอ อน โปรดต ดต อเราได ท เพ อร องขอบร การด งกล าวได โดยไม ม ค าใช จ าย (TTY/TDD: 711) Call (TTY/TDD 711) to enroll or learn more. 22

24 There are many ways for you to enroll. Call (TTY/TDD 711) and talk directly to a Highmark representative who can answer your questions. Visit a local Highmark Direct store. Talk to your local Highmark insurance agent (11/15)