In Network: $1,000 Out of Network: $3,000. In Network: $1,500 Out of Network: $3,500. In Network: $4,000 Out of Network: $5,000

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1 Platinum+, Platinum, Gold+, Gold,, HSA, HSA+, HSA,, Plan Features Groups can choose from one of the following three networks for In Network benefits: Oregon Select Adventist, Oregon Select Tuality and. Member coinsurance levels are lowest for In Network providers. If a member chooses an Network provider, the member may be required to pay costs above the allowed amount. Provider choice: Members have direct access to their choice of providers. Member coinsurance levels are lowest for In Network providers. If a member chooses an Outof Network provider, the member may be required to pay costs above the allowed amount. In Network office visits are not subject to the deductible on, Gold, Gold+, Platinum, Platinum+ and Plans. The first $400 of outpatient radiology and laboratory services combined In and Network per calendar year are not subject to the deductible on Gold, Gold+, Platinum and Platinum+ Plans. Members get access to Value Based generics and certain medications for chronic conditions, before satisfying a deductible for HSA, HSA+ and HSA Plans. Members pay lower prices for a 90 day supply of prescription medications, when using the Pharmacy Network. Calendar Year Platinum+ Platinum Gold+ Gold HSA HSA+ HSA Separate deductible amounts per calendar year for In Network / Network providers. Family deductible and out of pocket maximum is two times the individual amounts shown Applies to all covered expenses except where noted $250 $500 $2,500 $1,000 $3,000 $1,500 $3,500 $2,500 $6,000 $6,000 Calendar Year Pocket Maximums Platinum+ Platinum Gold+ Gold HSA HSA+ HSA Separate Pocket maximum amounts for In Network / Network providers. Applies to all covered expenses 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. $1,500 $3,500 $5,000 $5,000 $5,250 $7,500 $7,500 $6,250 $6,250 $2,500 $6,350 $12,500 $5,000 $6,350 $12,500 1

2 Platinum+, Platinum, Gold+, Gold,, HSA, HSA+, HSA,, MEMBER RESPONSIBILITY Covered Services Platinum+ Platinum Gold+ Gold HSA HSA+ HSA Preventive Care and Immunizations In Network not subject to deductible Office Visits, Gold, Gold+, Platinum, Platinum+ and Plans: In Network office visits are not subject to the deductible. Outpatient Radiology and Laboratory Gold, Gold+, Platinum and Platinum+ Plans: First $400 of outpatient radiology and laboratory services combined In and Network per calendar year are covered at 0% coinsurance and not subject to the deductible. Biofeedback 10 visits per lifetime for migraine headaches and urinary incontinence combined. Cardiac Rehabilitation Inpatient and outpatient services. 36 visits per lifetime for Phase II (outpatient) services. Chemical Dependency/Mental Health (Outpatient) Gold, Gold+, Platinum, Platinum+ and Plans: In Network services are not subject to the deductible. 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% Care: $20 Care: $30 Care: $20 Care: $30 care: $30 Care: $45 care: $30 Care: $45 care: $30 Care: $45 30% 50% 50% Care: $35 Care: $70 Urgent Care Facility: $90 Care: $60 Care: $100 Urgent Care Facility: $120 $20 $20 $30 $30 30% 30% 50% 50% $35 $60 Member responsibility for In Network services is indicated above, after In Network deductible is met and until out of pocket maximum is met, except where noted. Network services are covered 50% on all plans after Network deductible is met and until out of pocket maximum is met, except where noted. 2

3 Platinum+, Platinum, Gold+, Gold,, HSA, HSA+, HSA,, Chemical Dependency/Mental Health (Inpatient) Emergency Room Services In Network deductible, coinsurance and In Network out of pocket maximum apply regardless of provider network. Habilitative Services (Inpatient) 30 days per calendar year Habilitative Services (Outpatient) 30 visits per calendar year. Plan: In Network services are not subject to the deductible. Hospital Services/Ambulatory Surgical Center Inpatient and outpatient services and supplies. $150 Copay 10% $150 Copay 10% $250 Copay 20% $250 Copay 20% $250 Copay 30% 30% 50% 50% 30% 50% 10% 10% 20% 20% 30% 30% 50% 50% $35 $60 Copay Home Health Hospice Respite care limited to a maximum of five consecutive days and 30 days inpatient/outpatient per lifetime. Maternity Rehabilitation Services (Inpatient) 30 days per calendar year Rehabilitation Services (Outpatient) 30 visits per calendar year. Plan: In Network services are not subject to the deductible. Skilled Nursing Facility 60 inpatient days per calendar year 10% 10% 20% 20% 30% 30% 50% 50% $35 $60 3

4 Platinum+, Platinum, Gold+, Gold,, HSA, HSA+, HSA,, Prescription Medications All out of pocket expenses go towards In Network Medical Pocket Maximum. Essential Formulary to all plans except the and plans which use the Oregon Formulary. Nonparticipating pharmacies not covered. 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. Self Administrable: Up to 30 day supply per fill. Calendar Year In Network medical deductible unless otherwise specified Platinum+ Platinum Gold+ Gold HSA HSA+ HSA waived Tier 1: Generics (Category 1) $10 Retail / $20 Mail 25% Retail / 20% Mail $15 Retail / $30 Mail $20 Retail / $40 Mail Generics Generics : Generics (Category 2) and Name (Category 1) $25 Retail / $50 Mail $25 Retail / $50 Mail $30 Retail / $60 Mail $30 Retail / $60 Mail $40 Retail / $80 Mail 35% Retail / 25% Mail $50 Retail / $100 Mail $80 Retail / $160 Mail Tier 3: Name (Category 2) Non Non Tier 4: Specialty Medications 50% 50% 50% 50% 50% 50% 50% 50% 50% Specialty 50% Specialty 4

5 Platinum+, Platinum, Gold+, Gold,, HSA, HSA+, HSA,, Pediatric Dental Services Platinum+ Platinum Gold+ Gold HSA HSA+ HSA Various limits apply. Covered for members up to age 19 Member responsibility for both In Network/ Network Preventive: 0% / Basic: 20% / Major: 50% waived on all services. Applies to In Network out of pocket maximum Pediatric Vision Services Platinum+ Platinum Gold+ Gold HSA HSA+ HSA Covered for members up to age 19 One routine eye exam per calendar year. One pair (two lenses) and one standard frame per calendar year. Contacts in lieu of glasses. Member responsibility for both In Network / Network Eye exam: 0% / Vision Hardware: 50% waived on all services. Applies to In Network out of pocket maximum Eye exam: 0% Vision Hardware: 50% waived on all services No Coverage Eye exam: 0% Vision Hardware: 50% waived on all services Optional Benefits Available With All Plans Complementary Care In Network and Network deductibles waived. Not subject to out of pocket maximum. Member responsibility for both In Network/Network shown. $500 or $1,500 limits per calendar year. Adult Vision Platinum+ Platinum Gold+ Gold HSA HSA+ HSA $25 $25 $25 $25 $25 Not available Not available Not available $25 $25 Covered for members age 19 and older. No member responsibility for: One routine eye exam per calendar year. Hardware limited to $150 per calendar year. Not subject to deductible. 5

6 Platinum+, Platinum, Gold+, Gold,, HSA, HSA+, HSA,, Optional Program Available With All Plans Employee Assistance Program (EAP) No member responsibility 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 Waiting Periods Outside the Service Area No benefits are provided for treatment relating to a transplant until the member has been covered under this or a prior plan for 24 consecutive months or since birth (corneal transplants are not subject to the waiting period). No benefits are provided for surgical procedures for inner/middle ear infections, elective surgeries and procedures (those that are unlikely to have an adverse affect on your health if delayed six months), removal of tonsils/adenoids, and vasectomies until the member has been covered under this or a prior plan for 6 months. Members may receive credit from prior medical coverage. Members have the security of knowing they can access Blue Cross and/or Blue Shield (Blue Plan) providers across the country and worldwide through the BlueCard Program. When groups elect the network, plan benefits apply as described above, and members may receive discounts on their services. General Medical Exclusions Coverage is not provided for any of the following, including direct complications or consequences that arise from: Cosmetic/Reconstructive Services and Supplies except as necessary to correct a congenital anomaly for Members up to age 26; to correct a craniofacial anomaly; to restore a physical bodily function lost as a result of Injury or Illness; for one attempt to correct a scar or defect that resulted from an accidental Injury or treatment for an accidental Injury, provided the attempt is made within 18 months of the accidental Injury or treatment causing the scar or defect; or for one attempt to correct a scar or defect on the head or neck that resulted from a surgery, provided the attempt is made within 18 months of the surgery causing the scar or defect. Counseling in the absence of illness. Custodial Care: Non skilled care and helping with activities of daily living. Dental Examinations and Treatments except when covered under the Pediatric Dental benefit or the Injury to Teeth benefit. 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. Investigational Services: Treatment or procedures (health interventions) and services, supplies, and accommodations provided in connection with investigational treatments or procedures. Medications without a Prescription Order 6

7 Platinum+, Platinum, Gold+, Gold,, HSA, HSA+, HSA,, 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 Insurance Liability 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, including telephone consultations and exchanges. Non Duplication of Medicare: Services and supplies to the extent payable under Medicare, when by law, the plan would not be primary to Medicare had the member properly enrolled in Medicare when first eligible regardless of whether or not the member actually enrolled. Obesity or Weight Reduction/Control: Medical treatment, medication, surgical treatment (including reversals), programs, or supplies that are intended to result in or relate to weight reduction, regardless of diagnosis. Orthognathic Surgery except for congenital anomalies, injury, and illness. Personal Comfort Items: Items that are primarily for comfort, convenience, cosmetics, environmental control, or education. Physical Exercise Programs and Equipment including hot tubs or membership fees at spas, health clubs, or other such facilities; 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 or felony. Routine Foot Care including treatment of corns and calluses and trimming of nails. Routine Hearing Exams Self Help, Self Care, Training, or Instructional Programs including, but not limited to control weight, or provide general fitness (childbirth classes); Programs 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 Your Family Services and Supplies That Are Not Medically Necessary Services to Alter Refractive Character of the Eye Sexual Dysfunction: Regardless of cause, except for counseling provided by covered, licensed mental health practitioners. Temporomandibular Joint Disorders (TMJ) Third Party Liability: Services and supplies for treatment of illness or injury for which a third party is responsible. Travel and Transportation Expenses other than covered ambulance services and for transplant services for the patient and caregiver. Work Related Conditions except for subscribers only who are owners, partners, or corporate officers and are exempt from L&I coverage. 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. 7