CareFirst BlueChoice HSA Plans

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1 CareFirst BlueChoice HSA Plans W a s h i n g to n, D.C. Your money Your health Your choice

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3 Why you should choose a HSA Plan from CareFirst BlueChoice. Your money Your health Your choice No one can predict life s ups and downs. Emergencies, illnesses and health issues can happen at any time. That s why it s a smart strategy to cover yourself with a health plan that can protect your savings against high medical bills. And now, you can do that with a BlueChoice HSA plan from CareFirst BlueChoice, Inc. (CareFirst BlueChoice). Consider the advantages of your membership: n Lower-cost health coverage and tax-free investment options, in one easy plan n The most recognized card in health care n Nationwide coverage in case of an emergency n Broad network of providers and hospitals n Preventive services covered at 100% n No claims to file n Dedicated, local customer service representatives n Exclusive discounts on health & wellness services Make sure you re covered by an organization you can trust. A company that has been there for your neighbors, coworkers and friends. And one that will be there for you -- CareFirst BlueChoice. We re the company you trust.

4 BlueChoice Health Savings Account Plans BlueChoice HSA Advantages... 2 Opening a Health Savings Account...3 How the Plan Works...4 Benefits Summary...5 HSA Individual Example...6 HSA Family Example...7 What You Should Know About BlueChoice HSA...8 More Ways to Save...9 When You Need Care Apply Today...11 CareFirst BlueChoice s Privacy Practices CareFirst BlueChoice s Confidentiality Statement Additional Coverage Options... 15

5 BlueChoice HSA Advantages Your Money. Your Health. Your Choice. BlueChoice HSA is for people like you: people who don t like the high cost of health coverage and want control of their financial future. It s your money. You should be able to choose how to spend it. Now, you can. You can get great health coverage and still have money to invest in a tax-free savings plan. All for about the same price as a traditional insurance plan. What could be better? Until recently, you could pay a high price each month for a health plan even if you were never sick. Or, you could go without insurance, paying more than necessary for occasional doctor visits and prescriptions. But you know that a catastrophic health situation could leave you financially stranded. Why take that risk? A sudden illness or emergency could cost tens, even hundreds of thousands of dollars, threatening your financial security. Now, you have protection against the high cost of medical care. CareFirst BlueChoice introduces BlueChoice HSA. These plans leave your money choices up to you. Just look at the built-in cost savings you ll get as a BlueChoice HSA member: n Lower monthly premiums. BlueChoice HSA plans have high deductibles, giving you a lower monthly premium cost and allowing you to spend or save that money elsewhere. n Lower doctor s office costs. Because of CareFirst BlueChoice s negotiating power, you ll usually pay substantially less for doctors and hospitals than you would pay without insurance coverage. n Prescription drugs. Again, you ll pay CareFirst BlueChoice s negotiated rates for prescription drugs, saving you money over the high cost of retail drugs. And once you meet your deductible, you ll only pay a copayment for prescriptions. n Preventive care benefits. You ll pay nothing for most preventive benefits. These work to keep you healthy, and can help you spend less money on health care in the long run. You can see that enrolling in a BlueChoice HSA plan is a great option for health coverage one which can protect you against catastrophic health expenses, without costing a lot of money up front. A BlueChoice HSA plan also allows you to invest the money you save, tax-free. BlueChoice HSA Plans 2

6 Your money Your health Multiply your savings with a Health Savings Account BlueChoice HSA plans are designed to work along with a health savings account. An HSA Your choice is almost like an individual retirement account (IRA) for health expenses. And CareFirst BlueChoice has made it easy for you to open a health savings account by partnering with The Bancorp Bank, offering a wide range of personal and business financial services. Just consider how it can work for you. You ll have money to invest. n Instead of paying for traditional, high-cost health insurance, enroll in a low-cost CareFirst BlueChoice HSA plan. n Take the money you save on monthly premiums, and invest it in a tax free health savings account. Under current IRS rules, the maximum contribution is $2,850 for self-only coverage and $5,650 for family coverage. (Each year these amounts may be adjusted upward for inflation.) n The Bancorp Bank offers BlueChoice HSA account holders a range of financial investment options once the account balance reaches $2,500, increasing your potential earning power. n From the moment you open your account, you ll earn a competitive interest rate. Your money stays in your control. n You can use the money in your health savings account to pay for smaller medical expenses, including your deductible and copayments, knowing your BlueChoice HSA plan will handle any larger medical expenses you may incur. n Or, you can leave the money in your account earning interest, or growing through other investments the bank provides. n Bottom line: you decide when to spend your money on medical costs for you or your dependents. You never lose your investment. n Unlike flexible spending accounts with reimbursements for medical expenses, there is no use-it-or-lose-it policy. You are not obligated to use the money you contribute by the end of each year. n Your money can remain in your account and keep earning interest indefinitely. You can take it with you. n Because the health savings account is owned by you, it is completely portable. That means you can take it with you when you change jobs, change your medical coverage, become unemployed, or move out of state. n At age 65, you can use the money as retirement savings, or continue to use it for medical expenses. You get three levels of tax savings. n All money you contribute is tax-deductible, even if you don t itemize your deductions. n All earnings on your money in the HSA are tax free. n All deductions for qualified medical expenses are tax free. n For additional information, you can visit the IRS website at or call It s easy to use. n Use your Bancorp-issued CareFirst BlueChoice Visa check card to access money in your account to pay for eligible expenses. No filling out claim forms or waiting for reimbursements. n The Bancorp Bank provides full on-line services*. Easily view your account, investments and expenditures, any time of the day or night at and toll-free at *Individual charges may apply 3 BlueChoice HSA Plans

7 BlueChoice HSA: How the Plan Works A BlueChoice HSA plan provides substantial coverage at a low monthly rate. When you open your HSA bank account, you ll be able to invest your savings, tax free. It s your hard-earned money. If you don t need medical attention, you ll save. But in the event of a medical emergency, let CareFirst BlueChoice cover you. With a BlueChoice HSA plan, you will know what your maximum out-of-pocket expenses will be in any given year. And, you can rest easy knowing that your CareFirst BlueChoice coverage has an unlimited lifetime benefit maximum for covered medical services so you ll never run out of coverage. Choose from two deductible levels. The higher your deductible, the lower your monthly premium. Option 1: $1,200 Individual Deductible 1. You pay all costs you incur for health care and prescriptions, until you meet the annual DEDUCTIBLE. 2. After you meet your deductible, CareFirst BlueChoice pays medical costs, and you pay a set COPAY for some services. Many services are covered in full. 3. Your payments for covered expenses in any year will not exceed your OUT-OF-POCKET MAXIMUM. 4. Once you meet your out-of-pocket maximum, CareFirst BlueChoice pays all remaining charges for the rest of the benefit period. You Pay Individual: $1,200 Family: $2,400 Copay, if any, varies by service Individual: $2,400 Family: $4,800 0% Option 2: $2,700 Individual Deductible 1. You pay all costs you incur for health care and prescriptions, until you meet the annual DEDUCTIBLE. 2. After you meet your deductible, CareFirst BlueChoice pays medical costs, and you pay a set COPAY for some services. Many services are covered in full. 3. Your payments for covered expenses in any year will not exceed your OUT-OF-POCKET MAXIMUM. 4. Once you meet your out-of-pocket maximum, CareFirst BlueChoice pays all remaining charges for the rest of the benefit period. You Pay Individual: $2,700 Family: $5,400 Copay, if any, varies by service Individual: $5,250 Family: $10,500 0% CareFirst BlueChoice s regional provider network gives you access to more than 18,000 providers and 42 hospitals throughout Maryland, DC and Northern Virginia. You and your family members must choose a Primary Care Physician (PCP) from this network. Women have direct access to participating GYNs for covered services no referrals are needed. *Copayment or portion of deductible may be required at the point of sale during the deductible period. Member will never be required to pay more than CareFirst BlueChoice s Allowed Benefit for service rendered. BlueChoice HSA Plans 4

8 BlueChoice HSA Benefits Summary- D.C. Selected Benefits at a Glance Preventive Services MEDICAL BENEFITS Adult Physicals (including routine GYN visits) Well-Child Care (including exams and immunizations) Mammograms, PAP Tests and Prostate Screening & Colorectal Screening Office Visits, Labs and Testing Office Visit for Illness X-ray and Lab Tests Allergy Testing and Treatment Outpatient Surgery Emergency Care Emergency Room Urgent Care Center (participating) Ambulance (when medically necessary) Hospitalization Inpatient Facility Services Inpatient Physician Services Outpatient Facility Services Outpatient Physician Services Home Health Care, Hospice, Skilled Nursing Facility Prescription Drug Benefits* Deductible Generic Copay Preferred Brand Copay Non-Preferred Brand Copay No Charge No Charge No Charge YOU PAY Per visit: $30 PCP/$40 Specialist (after deductible) No Charge (after deductible) Per visit: $30 PCP/$40 Specialist (after deductible) Per visit: $30 PCP/$40 Specialist (after deductible) Per visit: $100 (after deductible); waived if admitted Per visit: $60 (after deductible) No Charge (after deductible) Per day: $600 (after deductible), up to out-ofpocket maximum, then covered in full No Charge (after deductible) No Charge (after deductible) No Charge (after deductible) No Charge (after deductible) Combined with medical deductible $5 (after deductible) $25 (after deductible) $45 (after deductible) n CareFirst BlueChoice has made it even easier to manage your costs by combining the medical and prescription deductibles. Money you spend toward covered prescriptions and medical care will go toward meeting the same annual deductible. In addition, all money you pay for medical and prescription costs will go toward meeting the out-ofpocket maximum. n Your annual deductible can be met by a combination of family members receiving care, or just one family member receiving care. Once you meet the deductible each benefit period, CareFirst BlueChoice begins paying benefits at the level shown on page 4. n Optional Vision, Dental and/ or Maternity benefits may be added to make your coverage even more valuable. Optional Maternity Services (may be added for a fee) Office Visits (Prenatal and Postnatal) Delivery Facility Services Per visit: $30 PCP/$40 specialist (after deductible) No Charge (after deductible) Per admission: $500 (after deductible) *Self-administered injectable drugs are subject to 50% coinsurance with a $75 per fill cap. **Optional Coverage. You may also choose to add maternity coverage to your policy (for yourself or your covered spouse). For an additional $126 a month, you will receive coverage for pre and postnatal care as well as covered services associated with the delivery. Maternity may only be added at the time of the initial enrollment of a female applicant. Applicants will not be able to add maternity coverage at any time subsequent to the initial enrollment in BlueChoice HSA. Please note: Copayment or portion of deductible may be required at the point of sale during the deductible period. Member will never be required to pay more than CareFirst BlueChoice s Allowed Benefit for service rendered. 5 BlueChoice HSA Plans Your money Your health Your choice

9 HSA Individual: Maria Maria is 30 years old and an avid cyclist. She carries her own health insurance since her husband s company doesn t provide her with coverage. Maria had been enrolled in a traditional health plan, but switched to a BlueChoice HSA plan when she learned about the low rates and tax-free investment options. In fact, Maria was able to invest the money she saved in monthly premiums in her new health savings account. Maria saved almost $1,000 a year in health insurance premiums when she switched to a BlueChoice HSA plan. She has chosen to invest the maximum amount in her HSA bank account, $1,200 per year to take full advantage of the tax benefits. Year One Maria recently injured her knee. Thankfully, a short rehabilitation with a doctor specializing in sports medicine has her cycling once again. Maria Year Two Deductible $ 1,200 Deductible $ 1,200 **HSA Contribution for Year 1 $ 1,200 **HSA Balance from Year 1 $ 400 HSA Contribution for Year 2 $ 1,200 HSA Balance at Beginning of Year 2 $ 1,600 Health Expenses: Preventive Care: Covered in full Health Expenses: $ 0 Preventive Care: Covered in full $ 0 Specialist Office Visits $ 450 Specialist Office Visits $ 200 Lab Tests $ 100 Lab Tests $ 100 Prescription Drugs $ 250 Rehabilitation $ 2,000 Prescription Drugs $ 300 X-Rays $ 200 Total Health Expenses $ 800 Total Health Expenses $ 2,800 Amount Paid with HSA Dollars $ 800 Amount Paid with HSA Dollars (full deductible) $ 1,200 Additional Amount Paid by Maria $ 0 Additional Amount Paid by Maria $ 0 Amount Paid by CareFirst BlueChoice $ 1,600 Amount in HSA at end of Year 1* $ 400 Amount in HSA at end of Year 2* $ 400 *Does not include interest accrued in Maria s HSA. **Assume benefit period starts January 1. BlueChoice HSA Plans 6

10 HSA Family: The Johnsons Anna and Jeff Johnson are an active and energetic couple with two children. They left their jobs to start their dream business in catering, and enrolled in a BlueChoice HSA plan with a $5,400 annual family deductible. Recently, Jeff made an unexpected trip to an urgent care facility after twisting his ankle in a roller blading accident. He made several trips to the doctor s office and received prescription drugs. The Johnsons saved about $2,000 a year in premiums when they switched to BlueChoice HSA with an annual family deductible of $5,400. Anna and Jeff contributed the maximum amount to their HSA, $5,400, which is all tax-deductible. Year One The Johnsons Year Two Family Deductible $ 5,400 Family Deductible $ 5,400 HSA Contribution for Year 1 $ 5,400 HSA Balance from Year 1 $ 4,040 HSA Contribution for Year 2 $ 5,400 HSA Balance at Beginning of Year 2 $ 9,440 Health Expenses: Health Expenses: Preventive Care: Covered in full $ 0 Preventive Care: Covered in full $ 0 Office Visits for sickness (pay in full until you meet the deductible) $ 160 Hospitalization $ 7,000 Lab Tests $ 200 Lab Tests $ 100 X-Rays $ 400 Prescription Drugs $ 200 Urgent Care $ 400 Prescription Drugs $ 200 Total Health Expenses $ 1,360 Total Health Expenses $ 7,300 Amount Paid with HSA Dollars $ 1,360 Amount Paid with HSA Dollars (full deductible) Additional Amount Paid by the Johnsons $ 0 Additional Amount Paid by the Johnsons Amount Paid by CareFirst BlueChoice $ 5,400 $ 0 $ 1,900 Amount in HSA at end of Year 1* $ 4,040 Amount in HSA at end of Year 2* $ 4,040 *Does not include interest accrued in the Johnson s HSA. **Assume benefit period starts January 1. 7 BlueChoice HSA Plans

11 What Else Should I Know About BlueChoice HSA and Bancorp Bank? You can open a health savings account if you: n Have coverage under an HSA-qualified plan such as the BlueChoice HSA plan n Have no other first-dollar medical coverage n Are not enrolled in Medicare n Cannot be claimed as a dependent on someone else s tax return. Eligible Medical Expenses You can use the money in your health savings account to pay for a wide range of medical services incurred by you, your spouse, or your dependent children even if they aren t covered by your health plan. These services include medical care, dental and vision care, prescription drugs, and over-the counter medications. Your health savings account can also be used to pay for qualified long-term care insurance as well as Medicare premiums. You generally cannot use the money to pay your health insurance premiums, unless you are covered under COBRA or you are receiving unemployment benefits. Choosing a bank for your HSA Many banks or other financial institutions have a health savings account program available. You are free to evaluate the programs offered by each institution, and choose whichever best suits your needs. However, for your convenience, CareFirst BlueChoice has researched many banks and has chosen to partner with The Bancorp Bank. A nationally recognized commercial bank, The Bancorp Bank provides many benefits to people who want the advantages of an health savings account. Some key advantages of a health savings account, administered by The Bancorp Bank, include: n No application or account set-up fees. n No monthly maintenance fee if the account balance is greater than $2,500; otherwise, a low monthly maintenance fee is deducted directly from your account. n Earn interest on your account from day one. n Gain access to investment vehicles once your balance reaches $2,500. n Access to a wide range of deposit locations and electronic deposit options, including an exclusive electronic money mover service, wire and electronic bank transfers, direct deposit, credit card, ATM, personal check or money order. n Free Bancorp-issued CareFirst BlueChoice Visa check card for easy payment of medical expenses. n Full on-line access to monitor your account. n All Bancorp Bank account depositors are FDIC insured up to $100,000. Plus, applying for a BlueChoice HSA bank account couldn t be easier. When you apply for a BlueChoice HSA plan, The Bancorp Bank will automatically send you an Enrollment Packet and application, unless you indicate you do not want to receive one. Your money Your health Your choice BlueChoice HSA Plans 8

12 BlueChoice HSA: More Ways to Save Dental As a BlueChoice HSA member, you have the option of adding dental coverage to your medical plan, making your medical plan even more valuable. Dental HMO services are administered by The Dental Network (TDN) Inc. When you select dental, you get coverage for: n Preventive Care n Orthodontics n Cleanings n X-rays n Fillings n and much more Dental savings are guaranteed as long as you select one of the providers within the regional TDN network. There is very little paperwork to fill out and no claim forms to file with this benefit. You simply present your BlueChoice HSA card at the time of service and receive pre-negotiated discounted fees for dental services. If requested, a dental information kit will be sent to you seperately. You cannot be turned down for this product. Service You Pay If you have questions regarding the dental coverage or wish to inquire about participating providers, please contact the TDN Client Services department at Basic Dental Services Includes all exams, cleaning, x-rays, simple extraction, etc. Soft Tissue Management Includes all periodontal scaling and root planing, etc. $20 Copay per visit $70 Copay per visit Orthodontics Comprehensive Adult $2,500 Comprehensive Child $2,700 Vision Vision coverage can also be added to your medical plan. Vision services are offered by CareFirst BlueCross BlueShield* through our network administrator, Davis Vision, Inc. When you use a provider in the Davis Vision network which includes both independent and retail providers you are guaranteed a routine annual eye exam including dilation, for only $10. Additionally, through Davis Vision, Inc., you also receive discounts on frames and lenses or contact lenses. Your vision benefits are not available until you are approved for medical coverage. Once you have been approved for coverage, you will be provided with more specific information about your vision program. To qualify for benefits, you must select the same type of coverage as the medical portion of your CareFirst BlueChoice HSA medical product. Simply select Vision on the application for BlueChoice HSA. To locate a vision provider, contact Davis Vision, Inc. at or visit Type of Coverage Vision Individual $2.00 Individual & Child(ren) $4.00 Individual & Adult $4.00 Family $5.00 * CareFirst BlueCross BlueShield is the business name of Group Hospitalization and Medical Services, Inc., CareFirst BlueCross BlueShield and The Dental Network are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc. 9 BlueChoice HSA Plans

13 When You Need Care Options Discount Program The advantages of carrying the CareFirst BlueChoice card go beyond the benefits listed in the enclosed benefits chart. The CareFirst BlueChoice card entitles you to discounts on alternative therapies and health and wellness programs such as chiropractic, acupuncture, massage, yoga, Pilates, tai chi, qi gong, guided imagery, nutritional counseling, and fitness centers. Additionally, the program offers discounts on Weight Watchers Online, mail order contacts, laser vision correction, hearing aids, and eldercare referral services. Since this program is offered in addition to your medical plan, rather than a benefit, there are no claim forms, referrals or paperwork to complete. We see this as a way for our members to tap into health and wellness practitioners at discounted rates. To find out more, visit our web site at BlueCard Program Taking Your Benefits With You When You Travel With CareFirst BlueChoice, getting access to emergency or urgent care while out of town is as easy as presenting your CareFirst BlueChoice identification card. Providers, hospitals and urgent-care facilities who participate with the local Blue Cross and Blue Shield Plan wherever you are in the United States will recognize and honor your card. Need help finding a provider? Just call the BlueCard phone number listed on your CareFirst BlueChoice ID card for personal assistance. In addition, Away From Home Care membership is available in an affiliated Blue Cross and Blue Shield HMO for members and dependents away from home for at least 90 days. This special plan provides coverage for nonemergency services and is perfect for extended out-of-town business or travel, semesters at school or families living apart. FirstHelp Nurse Line Members of BlueChoice HSA who are sick, injured, or have medical questions can get quick help with just a toll-free phone call. The FirstHelp Nurse Line is staffed by registered nurses and is available 24-hours a day, 7 days a week. FirstHelp nurses will discuss your symptoms and concerns, then help you to decide whether to contact your doctor, seek urgent care, or go to the emergency room. BlueChoice HSA Plans 10

14 Apply Today for BlueChoice HSA Applying for a BlueChoice HSA plan and a health savings account administered by The Bancorp Bank is easy. To be eligible, each family member applying must be a resident of the District of Columbia and must complete a medical questionnaire. Follow these simple steps: 1. Choose a coverage type. You can select: n Individual (includes child-only; however, a child is not eligible for the tax-savings benefits of the HSA) n Individual and Child(ren)* n Individual and Adult** n Family (2 adults and eligible dependents)* 2. Choose the plan that best fits your needs. The enclosed rate charts for each plan, coverage type, and age will tell you what your monthly premium will be. 3. Locate the application form in this packet. Be sure to answer all questions honestly and completely, and don t forget to sign your application. Make sure you check yes in the Vision and/or Maternity benefits selection areas if you would like them added to your policy, for an additional charge. 4. Choose a Primary Care Physician (PCP) from the enclosed directory for each member on the application. You can also locate a PCP in our on-line directory at 5. Clearly indicate whether you wish to participate with The Bancorp Bank, on page 4 of the application, under Conditions of Enrollment. 6. Mail your application in the enclosed envelope. Send no money at this time. We ll begin processing your application right away! The review process takes about 4-6 weeks. Once you have submitted your application, you can call the Application Status Hotline at with questions. Your coverage will become effective the first of the month following the month in which we approve your application. Once effective, you ll receive your ID cards and everything else you need to get started saving. Of course, if you have any questions at all, please don t hesitate to contact our Product Specialists at They ll be happy to help with any questions you have regarding a BlueChoice HSA plan. Enrolling in a Health Savings Account is easy, too! Once you are enrolled in a BlueChoice HSA plan you will automatically receive an Enrollment Packet from our preferred bank, The Bancorp Bank, unless you request otherwise on your application. As soon as your health savings account is set up, you can start saving and earning tax free! It s that easy. *A Child means your unmarried, eligible child up to age 23. Eligibility requirements are defined in the CareFirst BlueChoice contract. **An Adult means the spouse of the Subscriber or the Domestic Partner of the Subscriber who resides with the Subscriber and satisfies the eligibility requirements defined in the CareFirst BlueChoice contract. The Subscriber and Domestic Partner may not share a blood or familial relationship, and must have shared a common legal residence continuously for at least six (6) months prior to applying for coverage. Your money Your health Your choice 11 BlueChoice HSA Plans

15 CareFirst BlueChoice s Privacy Practices Our Commitment to Our Members When you apply for any type of insurance, you disclose information about yourself and/or members of your family. The collection, use and disclosure of this information are regulated by law. Safeguarding your personal information is something that we take very seriously at CareFirst BlueChoice. CareFirst BlueChoice is providing this notice to inform you of what we do with the information you provide to us. Categories of Personal Information We May Collect We may collect personal, financial and medical information about you from various sources, including: n Information you provide on applications or other forms, such as your name, address, social security number, salary, age and gender. n Information pertaining to your relationship with CareFirst BlueChoice, its affiliates or others, such as your policy coverage, premiums and claims payment history. n Information (as described in preceding paragraphs) that we obtain from any of our affiliates. n Information we receive about you from other sources, such as your employer, your provider and other third parties. How Your Information Is Used We use the information we collect about you in connection with underwriting or administration of an insurance policy or claim or for other purposes allowed by law. At no time do we disclose your personal, financial and medical information to anyone outside of CareFirst BlueChoice unless we have proper authorization from you or we are permitted or required to do so by law. We maintain physical, electronic and procedural safeguards in accordance with federal and state standards that protect your information. In addition, we limit access to your personal, financial and medical information to those CareFirst BlueChoice employees, brokers, benefit plan administrators, consultants, business partners, providers and agents who need to know this information to conduct CareFirst BlueChoice business or to provide products or services to you. Disclosure of Your Information In order to protect your privacy, affiliated and nonaffiliated third parties of CareFirst BlueChoice are subject to strict confidentiality laws. Affiliated entities are companies that are a part of the CareFirst BlueChoice corporate family and include health maintenance organizations, third party administrators, health insurers, long-term care insurers and insurance agencies. In certain situations, related to our insurance transactions involving you, we disclose your personal, financial and medical information to a nonaffiliated third party that assists us in providing services to you. When we disclose information to these critical business partners, we require these business partners to agree to safeguard your personal, financial and medical information and to use the information only for the intended purpose, and to abide by the applicable law. The information CareFirst BlueChoice provides to these business partners can only be used to provide services we have asked them to perform for us or for you and/or your benefit plan. Changes in Our Privacy Policy CareFirst BlueChoice periodically reviews its policies and reserves the right to change them. If we change the substance of our privacy policy, we will continue our commitment to keep your personal, financial and medical information secure it is our highest priority. Even if you are no longer a CareFirst customer, our privacy policy will continue to apply to your records. You can always review our current privacy policy online at For questions, please contact us by calling the Member Services telephone number listed on your membership card. BlueChoice HSA Plans 12

16 CareFirst BlueChoice s Confidentiality Statement Here at CareFirst BlueChoice we have a number of policies and procedures to protect the confidentiality of our member information. The following brief summary is included to explain to you how we use and protect that information. Your money Your health Your choice General Policy All records that have confidential medical and insurance information must be handled and discarded in a way that ensures the privacy and security of the records. n All records that have information about a subscriber (person who signs the policy with CareFirst BlueChoice) or member are confidential and protected by law from unauthorized disclosure and access. n The release or re-release of confidential information to unauthorized persons is strictly prohibited. n CareFirst BlueChoice limits access to subscriber and member personal information to people who need to know, such as our medical directors. n The disposal of subscriber and member information must be done in a way that protects the information from unauthorized disclosure. Routine Consent for Release of Information By enrolling in a CareFirst BlueChoice health plan, the subscriber provides routine consent for the release of information. Note that this routine consent applies whether the subscriber enrolls electronically, by telephone, or by completing and signing an enrollment form. Member information under this routine consent may be used for many purposes, including: n Delivery of health care n Measurement and improvement of care and service n Investigation of complaints and appeals n Preventive health and disease management programs n Payment of doctors and other providers n Member surveys n Other purposes needed to administer benefits The routine consent for release of information is in effect for as long as the subscriber or member has health coverage under CareFirst BlueChoice. The routine consent can be extended past the last day of coverage to allow CareFirst BlueChoice to pay claims or resolve complaints or appeals. The routine consent from the subscriber applies to all covered adults and dependents. Dependents are other members of the family who are also enrolled. 13 BlueChoice HSA Plans

17 Consent for Release of Information for Other Purposes (Special) The following uses of member information require a special consent from the member: n Data requested for a worker s compensation or auto insurance claim n Release of information to a lawyer n Release of information that could result in the member being contacted by another company for marketing purposes n Release of information from behavioral health care practitioners (mental health and substance abuse providers) to the member s primary care physician or specialist. Subscriber/Member Access to Medical Records Subscribers and members may access their medical records by contacting the doctor s office or the provider of care (such as a hospital). The subscriber and member must follow the doctor s or provider s procedures for accessing medical information. Members covered under contracts issued under the Company s Maryland Certificate of Authority may access records directly from the Company. Family members or other authorized representatives may have access to a member s medical information only when the member gives written permission. Disclosure of Information to Employers Disclosure of information to employers is limited to the information the employer needs to administer the health plan. The employer must agree to protect information from being used for any decisions affecting the employee. The employer must identify persons or positions that may have access to the information and must ensure there are measures in place to prevent unauthorized access. Treatment Setting Practitioners and providers are expected to implement confidentiality policies that address the disclosure of medical information, patient access to medical information, and the storage/protection of medical information. The Plan reviews practitioner confidentiality processes during pre-contractual site visits for primary care physicians. Quality Improvement Measurement Data for quality improvement measures are collected from administrative sources (such as claims and pharmacy data) and/or from member medical records. The Plan protects member information by ensuring that medical records are reviewed in non-public areas, and that reports do not include member-identifiable information. Your money Your health Your choice BlueChoice HSA Plans 14

18 Coverage Available from CareFirst BlueCross BlueShield* BluePreferred & BluePreferred-Saver** A Preferred Provider Organization (PPO) Plan providing freedom of provider choice with a variety of options including three high-deductible options to lower your premiums. Your money Your health Your choice Supplement-65 Traditional coverage to supplement your Medicare policy. For more information about this plan, please call our Product Specialists toll free at Other Coverage Available CareFirst BlueChoice & BlueChoice-Saver** Flexible HMO coverage offering four plans including a low-premium option (offered by an affiliated HMO). * CareFirst BlueCross BlueShield is an independent licensee of the Blue Cross and Blue Shield Association. ** Medical questionnaire must be completed. 15 BlueChoice HSA Plans

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20 BlueChoice HSA: Giving you opportunities to save while keeping you covered. All from the company you ve come to trust. Apply today using the enclosed application. Policy Form Numbers DC/CFBC/DB/HSA (11/06) DC/CFBC/DBHSA RX (11/06) DC/CC/UW EOC (3/01) And any amendments 840 First Street, NE Washington, DC BRC6567-4S (12/06) CareFirst BlueChoice, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association Registered trademark of CareFirst of Maryland, Inc.

21 BlueChoice Health Savings Account Underwritten - District of Columbia $30/$40 Copay $1,200 Individual Deductible $2,400 Individual Out-of-Pocket $2,400 Family Deductible $4,800 Family Out-of-Pocket Rx $5 Generic Copay, $25 Preferred Brand Copay, $45 Non-Preferred Brand Copay Monthly Premium Rates Effective: November 1, 2006 AGE AT EFFECTIVE DATE INDIVIDUAL INDIVIDUAL & CHILD(REN) INDIVIDUAL & ADULT FAMILY 1-5 $ $41 $77 $81 $ $57 $109 $115 $ $58 $111 $117 $ $59 $113 $119 $ $60 $115 $121 $ $61 $117 $123 $ $62 $119 $125 $ $63 $121 $127 $ $64 $123 $129 $ $65 $124 $131 $ $66 $126 $133 $ $68 $130 $137 $ $70 $134 $140 $ $72 $138 $144 $ $74 $141 $148 $ $76 $144 $152 $ $78 $148 $156 $ $80 $152 $160 $ $82 $156 $164 $ $84 $160 $168 $ $86 $163 $172 $ $88 $167 $176 $ $92 $175 $184 $ $97 $184 $194 $ $101 $192 $202 $ $106 $201 $212 $ $111 $211 $222 $ $116 $220 $231 $ $121 $230 $241 $ $127 $240 $253 $ $133 $252 $265 $ $139 $263 $277 $ $144 $274 $289 $ $151 $288 $303 $ $158 $301 $317 $ $165 $314 $330 $ $173 $329 $346 $ $181 $344 $362 $ $190 $361 $380 $ $198 $376 $396 $ $208 $395 $416 $ $217 $412 $433 $ $227 $430 $453 $ $237 $451 $475 $ $248 $472 $497 $ $259 $493 $518 $699 65* $271 $515 $542 $732 *If you are age 65 or older, you can only apply for BlueChoice HSA if you are NOT eligible for Medicare. The actual premium rate may be either 25% or 50% higher than above premium rates based on the Medical Underwriting results. CUT7018-1N (7/06) CareFirst BlueChoice, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc.

22 BlueChoice Health Savings Account Underwritten - District of Columbia $30/$40 Copay $2,700 Individual Deductible $5,250 Individual Out-of-Pocket $5,400 Family Deductible $10,500 Family Out-of-Pocket Rx $5 Generic Copay, $25 Preferred Brand Copay, $45 Non-Preferred Brand Copay Monthly Premium Rates Effective: November 1, 2006 AGE AT EFFECTIVE DATE INDIVIDUAL INDIVIDUAL & CHILD(REN) INDIVIDUAL & ADULT FAMILY 1-5 $ $32 $62 $65 $ $46 $87 $92 $ $47 $89 $93 $ $47 $90 $95 $ $48 $92 $96 $ $49 $93 $98 $ $50 $95 $100 $ $51 $96 $101 $ $51 $98 $103 $ $52 $99 $104 $ $53 $100 $106 $ $55 $104 $109 $ $56 $107 $112 $ $58 $110 $115 $ $59 $113 $119 $ $61 $115 $122 $ $62 $119 $125 $ $64 $122 $128 $ $66 $125 $131 $ $67 $128 $134 $ $69 $130 $137 $ $70 $134 $141 $ $73 $140 $147 $ $77 $147 $155 $ $81 $153 $161 $ $85 $160 $169 $ $89 $168 $177 $ $92 $175 $185 $ $96 $183 $193 $ $101 $192 $202 $ $106 $202 $212 $ $111 $210 $221 $ $115 $219 $231 $ $121 $230 $242 $ $126 $240 $253 $ $132 $250 $264 $ $138 $263 $277 $ $145 $275 $289 $ $152 $288 $303 $ $158 $300 $316 $ $166 $315 $332 $ $173 $329 $346 $ $181 $344 $362 $ $190 $360 $379 $ $198 $377 $397 $ $207 $394 $414 $559 65* $217 $412 $433 $585 *If you are age 65 or older, you can only apply for BlueChoice HSA if you are NOT eligible for Medicare. The actual premium rate may be either 25% or 50% higher than above premium rates based on the Medical Underwriting results. Policy Form Numbers: DC/CC/UW EOC (3/01) DC/CFBC/DB HSA SOB (11/06) DC/CFBC/DB HSA RX (11/06)

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24 3. ENROLLING FAMILY MEMBER(S) Complete only if you select Individual & Child(ren), Individual & Adult or Family Coverage Last Name Spouse/Partner Dependent 1 Dependent 2 Dependent 3 Dependent 4 Dependent 5 First Name 4. OTHER INSURANCE INFORMATION IF YOU HAVE OTHER INSURANCE, FAILURE TO COMPLETE THIS SECTION WILL CAUSE SIGNIFICANT DELAYS IN PROCESSING ANY CLAIMS SUBMITTED. 1. Is anyone listed on this application eligible for Medicare? If yes, please provide the following: M. I. Relationship Social Security # Date of Birth (Mo/Day/Yr) Name of family member(s) Medicare No. Effective Date SEX M F M F M F M F M F M F HT (in.) WT (lbs.) YES NO 2. Is anyone listed on this application covered by other health insurance, including other Blue Cross and Blue Shield coverage? If yes, please provide the following: Name of family member(s) Insurance Company Policy Number and Type Effective Date If you are accepted, will your new CareFirst BlueCross BlueShield coverage replace your existing policy? Has anyone listed on this application been without health insurance for the past 12 months or longer? If yes, please list name(s): 5. HEALTH EVALUATION PLEASE COMPLETE SECTIONS A, B, AND C. CHECK EACH ITEM YES OR NO. Answering yes will not necessarily result in the rejection of your application. YES NO Have you or any family member named in this application had a physical examination within the past five years? SECTION 5A To the best of your knowledge or belief, has any person named in this application had within the last five years, or does such person now have, any of the following: YES NO 1. Cancer, tumor or other growth (malignant or benign) Acquired Immune Deficiency Syndrome (AIDS) or Human Immunodeficiency Virus Seropositivity (Positive HIV test) Kidney stones, kidney or bladder condition, urinary frequency or burning

25 5. HEALTH EVALUATION (Continued) YES NO 4. Goiter, thyroid condition, diabetes Seizure disorder, central nervous system disorder, multiple sclerosis Substance abuse (drug or alcohol dependency, abuse or addiction) Use of illicit drugs Gall bladder condition, hernia, stomach or intestinal condition, ulcers, hemorrhoids, liver condition Cataract or other eye condition Tuberculosis, lung condition, asthma, bronchitis Arthritis, rheumatism, external deformity, amputation(s), back or spinal trouble, limb condition Heart condition, abnormal blood pressure (hypertension or hypotension), rheumatic fever, cerebrovascular accident (stroke) (Female) Irregular or excessive menstrual bleeding, reproductive system disorders, infertility, breast condition (Female) Is currently pregnant; expected date of delivery: / / (Male) Prostate condition, reproductive system disorders, infertility Outpatient counseling, any psychiatric or psychological counseling, or any nervous or mental disorder Sexually transmitted diseases Anemia, blood disorders Excluding physical examinations, consulted a physician, health care provider, or other individual or facility for medical or surgical treatment, advice, screening for any condition, or prescription medication for a medical condition NOT listed above in items 1-18? Had any known departure from good health not previously mentioned in this questionnaire for which treatment or advice may or may not have been sought? NOTE: ALL QUESTIONS MUST BE CHECKED YES OR NO Or your application will be returned. SECTION 5B If you have checked YES to any part of SECTION 5A, for each box checked, please provide complete information regarding diagnosis or condition, treatment (including all medications, hospitalizations, surgeries and diagnostic testing results) and dates. If more space is needed, attach a separate sheet of paper. Patient s Question Diagnosis Duration Explain treatment including all medications, Recovery First Name Number or Condition Dates hospitalizations, surgery and diagnostic test (Check only results and physician s/hospital s name. one box.) FROM: TO: FROM: TO: FROM: TO: FROM: TO: FULL PARTIAL FULL PARTIAL FULL PARTIAL FULL PARTIAL NOTE: FAILURE TO DISCLOSE CONDITIONS MAY RESULT IN VOIDING OF MEMBERSHIP AND DENIAL OF BENEFITS. 1F (11/98) 3 (over, please)

26 5. HEALTH EVALUATION (Continued) SECTION 5C If any person included in this application is presently using medication or prescription drugs, please provide the following information. Illness or Date of Operation Attending Physician Name of Family Member Condition Medication Last Treatment (Yes or No) Name and Address 6. CONDITIONS OF ENROLLMENT Please Read This Section Carefully IT IS UNDERSTOOD AND AGREED THAT: A copy of this application is available to the Subscriber (or to a person authorized to act on his/her behalf) upon request, from Group Hospitalization and Medical Services, Inc. doing business as CareFirst BlueCross BlueShield (CareFirst). This information is subject to verification. Failure to complete any section may delay the processing of your application and/or claims payment. If we determine that additional information is needed, you will receive an authorization to release that information. Failure to execute an authorization may result in the denial of your application for coverage. To the best of my knowledge and belief, all statements made on this application are complete, true and correctly recorded. They are representations that are made to induce the issuance of, and form part of the consideration for a CareFirst policy. I understand that a medically underwritten policy is only issued under the conditions that the health of all persons named on the application remains as stated above. I also understand that failure to enter accurate, complete and updated medical information may result in the denial of all benefits, cancellation or voiding of my policy. I will update CareFirst if there have been any changes in health concerning any person listed in this application that occur prior to acceptance of this application by CareFirst. By signing this Application, I hereby authorize CareFirst BlueCross BlueShield to disseminate and share non-health questionnaire information contained on this Application with the Health Savings Account (HSA) preferred bank(s) affiliated with CareFirst BlueCross BlueShield. I understand that dissemination of information to any such bank is at my direction and with my full understanding. Further that dissemination of information on this Application, excluding health questionnaire information, is necessary in order to effectuate the establishment of a Health Savings Account in my name with the HSA bank. The authorization shall continue until my enrollment with CareFirst BlueCross BlueShield terminates or at any time that I provide a written instruction to CareFirst BlueCross BlueShield revoking this authorization or if this authorization terminates by operation of law. If you do not want information on this Application shared with the HSA preferred bank(s) please check here. IF YOU HAVE ANY QUESTIONS CONCERNING THE BENEFITS AND SERVICES THAT ARE PROVIDED BY OR EXCLUDED UNDER THIS AGREEMENT, PLEASE CONTACT A MEMBERSHIP SERVICES REPRESENTATIVE BEFORE SIGNING THIS APPLICATION. WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, CareFirst may deny insurance benefits if false information materially related to a claim was provided by the applicant. Signature of Applicant 1:* X Date: Signature of Applicant 2: X Date: *Rates are based on the age of the Subscriber. NOTE: Applications submitted solely on behalf of applicants under the age of 18, where payment of premium is made by the parent or legal guardian, must be signed by the parent or legal guardian. Parent or Legal Guardian s Signature: X Date: For Office Use Only: Re-sign and re-date below only if box is checked. Signature of Applicant 1: X Date: Signature of Applicant 2: X Date: 4