FIRST QUARTER 2018 SMALL GROUP PRODUCT PORTFOLIO

FIRST QUARTER 2018 SMALL GROUP PRODUCT PORTFOLIO

Benefits of Blue Innovative plan designs Full-network tiered benefit plans at every metal level align and focus plans are designed to help keep your costs in line while offering choices for you and your employees, and can be an effective way to launch a defined contribution strategy align provides lower cost-share options for members who choose Kaleida Health providers focus provides lower cost-share options for employees who choose Catholic Health providers align and focus are available to employers in Erie and Niagara counties Expanded (EX) network plans Enhanced network access with POS locally and PPO for out-of-area Available for employees who work or live in Western New York Employees must select and receive their annual routine physical from a PCP located within the eight counties of Western New York National PPO plans offered at every metal level Health and wellness offerings Telemedicine hosted by Doctor On Demand Connect with a doctor face-to-face via phone, tablet, or computer $250 wellness debit card with every plan Health assessment $25 for subscriber taking the health assessment, and an additional $25 when a covered spouse/ domestic partner takes the health assessment Preventive services More than 50 free checkups and preventive services $0 preventive drugs available on nonstandard HSA plans We have you covered Blue Flex Services We offer integrated health reimbursement accounts (HRAs), flexible spending accounts (FSAs), and transit expense administration (TEA) Provides a single point of contact for you and an improved, more seamless experience for your employees Vision programs included with all medical plans Pediatric vision benefit Adult vision discount program Pediatric and adult dental plans available A comprehensive online benefits solution BlueConnect is an online health management platform that helps you manage costs while delivering benefits to your employees in a more efficient manner. Streamlined new group registration Easy enrollment and management Convenient auto-deductions through ebilling (never miss a payment) Real-time reporting Better for your employee, easier for you, affordable for everyone. Visit bcbswny.com/blueconnect today.

Platinum First Quarter 2018 Manage costs with our full network, tiered benefit plans Plan/market name Platinum Standard Platinum HMO 110 Plus Platinum PPO 843 Platinum align* or Platinum focus* Class ID 5701 1501 1601 2501 7501 Network 200 100 PPO 200 In-network Optimum Choice Flexible Choice Coinsurance Out-of-network $2,000/$4,000 $3,800/$7,600 $500/$1,000 2 $1,000/$2,000 $3,800/$7,600 $1,500/$3,000 Coinsurance Medical services PCP/specialist $15/$35 $20/$30 2 $20/$30 Laboratory services $35 $0 Diagnostic X-rays and radiology Hospital services Inpatient hospital (per admission) $35 $30 $500 $500 Outpatient facility $100 $150 Emergency room visit $100 $100 Urgent care $55 $40 Prescription drugs Generic/formulary/ non-formulary $10/$30/$60 $5/$30/ 2 2 2 2 2 2 $10/$30/ $0 $30 $500 $150 $100 $100 $40 $5/$30/ Preventive drug list No No No No Vision benefits Pediatric annual exam (routine) Adult vision discount program $15 Covered in full Covered in full Covered in full Standard Enhanced Enhanced Enhanced HSA-eligible No No No No Creditable coverage Yes Yes Yes Yes Product name Rates Platinum Standard Platinum HMO 110 Plus Platinum PPO 843 $40 Platinum align* or Platinum focus* Subscriber $613.55 $590.74 $700.97 $559.23 Subscriber and child(ren) $1,043.03 $1,004.26 $1,191.65 $950.69 Subscriber and spouse/ domestic partner $1,227.10 $1,181.48 $1,401.94 $1,118.46 Family $1,748.62 $1,683.61 $1,997.77 $1,593.81 *Available in Erie and Niagara counties only

Gold First Quarter 2018 Plan/market name Gold Standard Gold Aqua Gold Complete Gold POS 7100 Gold POS 7100EX Gold PPO 7100 Manage costs with our full network, tiered benefit plans Gold align* or Gold focus* Class ID 9101 4401 7401 4501 4601 4701 2601 7601 Network 200 100 200 100 100 PPO 200 In-network Coinsurance Out-of-network Coinsurance Medical services $600/$1,200 $4,000/$8,000 First Dollar $500/$1,000 $1,010/$2,020 $7,350/$14,700 $2,500/$5,000 $2,500/$5,000 $1,350/$2,700 Optimum Choice $1,350/$2,700 Flexible Choice $1,350/$2,700 $3,900/$7,800 $3,900/$7,800 PCP/specialist $25/$40 $20/$40 $20/$40 Laboratory services Diagnostic X-rays and radiology Hospital services Inpatient hospital (per admission) Outpatient facility Emergency room visit Urgent care Prescription drugs Generic/formulary/ non-formulary $40 $40 $1,000 $100 $150 $60 $10/$35/$70 $15/$50/ $40 $40 $500 $150 $150 $75 $40 $40 $500 $150 $150 $75 $150 $75 $5/$30/ $5/$30/ Preventive drug list No No Yes Yes Yes Vision benefits Pediatric annual exam (routine) Adult vision discount program $25 Covered in full Covered in full Covered in full Covered in full Standard Enhanced Enhanced Enhanced Enhanced HSA-eligible No No Yes Yes Yes Creditable coverage Yes Yes Yes Yes Yes Product name Gold Standard Gold Aqua Gold Complete Rates Gold POS 7100 Gold POS 7100EX Gold PPO 7100 Gold align* or Gold focus* Subscriber $539.14 $476.62 $500.87 $505.21 $526.25 $603.13 $480.56 Subscriber and child(ren) $916.53 $810.25 $851.48 $858.86 $894.63 $1,025.32 $816.96 Subscriber and spouse/ domestic partner $1,078.28 $953.24 $1,001.74 $1,010.42 $1,052.50 $1,206.26 $961.12 Family $1,536.55 $1,358.37 $1,427.48 $1,439.84 $1,499.81 $1,718.92 $1,369.59 *Available in Erie and Niagara counties only

First Quarter 2018 Plan/market name Standard POS 7100 POS 7100EX PPO 7100 POS 8100 POS 8100EX PPO 8100 Manage costs with our full network, tiered benefit plans align* or focus* Class ID 4801 5301 9601 9701 1901 2101 4901 5501 7701 Network 200 100 100 PPO 100 100 PPO 200 In-network Optimum Choice Flexible Choice $2,000/$4,000 $1,700/$3,400 $2,900/$5,800 Coinsurance 2 Out-of-network Coinsurance Medical services PCP/specialist Laboratory services Diagnostic X-rays and radiology Hospital services Inpatient hospital (per admission) Outpatient facility Emergency room visit Urgent care Prescription drugs Generic/formulary/ non-formulary $6,750/$13,500 $30/$50 $50 $50 $1,500 $100 $250 $70 $1,350/$2,700 3 $6,500/$13,000 $6,650/$13,300 $6,650/$13,300 $25/$50 2 $50 2 $50 2 $750 $1,000 $150 2 $250 2 $75 2 $30/$50 3 3 3 3 3 3 3 3 $10/$35/$70 $5/$30/ $5/$30/ $5/$30/ Preventive drug list No Yes Yes Yes Vision benefits Pediatric annual exam (routine) Adult vision discount program $30 Covered in full Covered in full Covered in full Standard Enhanced Enhanced Enhanced HSA-eligible No Yes Yes Yes Creditable coverage Yes Yes Yes Yes Product name Rates Standard POS 7100 POS 7100EX PPO 7100 POS 8100 POS 8100EX PPO 8100 align* or focus* Subscriber $476.82 $464.69 $483.88 $554.02 $438.99 $457.00 $522.85 $430.15 Subscriber and child(ren) $810.60 $789.97 $822.60 $941.84 $746.28 $776.90 $888.85 $731.26 Subscriber and spouse/ domestic partner $953.64 $929.38 $967.76 $1,108.04 $877.98 $914.00 $1,045.70 $860.30 Family $1,358.94 $1,324.37 $1,379.06 $1,578.95 $1,251.13 $1,302.45 $1,490.13 $1,225.93 *Available in Erie and Niagara counties only

Bronze First Quarter 2018 Plan/market name Bronze Standard Bronze POS 8100EX Bronze PPO 8100 Manage costs with our full network, tiered benefit plans Bronze align* or Bronze focus* Class ID 2401 5401 5101 2201 7801 Network 200 100 PPO 200 In-network Optimum Choice Flexible Choice Coinsurance Out-of-network Coinsurance Medical services PCP/specialist Laboratory services Diagnostic X-rays and radiology Hospital services Inpatient hospital (per admission) Outpatient facility Emergency room visit Urgent care Prescription drugs Generic/formulary/ non-formulary $4,000/$8,000 $7,150/$14,300 $10/$35/$70 $5,500/$11,000 2 $7,000/$14,000 $7,350/$14,700 $6,550/$13,100 $7,350/$14,700 $5,500/$11,000 $7,350/$14,700 2 2 2 2 2 2 2 $15/$50/ $10// Preventive drug list No Yes No Vision benefits Pediatric annual exam (routine) Adult vision discount program Covered in full Covered in full Standard Enhanced Enhanced HSA-eligible No Yes No Creditable coverage Yes Yes Yes Product name Bronze Standard Bronze POS 8100EX Bronze PPO 8100 Rates Bronze align* or Bronze focus* Subscriber $409.87 $449.45 $514.10 $393.27 Subscriber and child(ren) $696.78 $764.07 $873.97 $668.56 Subscriber and spouse/ domestic partner $819.74 $898.90 $1,028.20 $786.54 Family $1,168.13 $1,280.93 $1,465.18 $1,120.82 *Available in Erie and Niagara counties only

Pediatric and Adult Dental Plans Dental care is important to overall health. That s why our dental plans include essential benefits to ensure members receive complete oral health coverage through our own dental network. Blue Value dental plans have no participation requirements add to your medical plan or purchase one separately. Groups can choose one Blue Value dental plan to offer their employees in addition to Blue Pediatric dental. Blue Pediatric Dental* (PPO) Blue Value Dental 1* (PPO) Blue Value Dental 2 (PPO) Blue Value Dental 3*** (PPO) Benefits Children up to age 19 years Adult/family** Adult/family** Adult/family** () Annual benefit maximum Orthodontic lifetime maximum (pediatric and adult cosmetic, routine braces) Preventive/diagnostic (exams, cleaning, X-rays) Basic restorative (fillings, extractions, periodontics, endodontics) Major dental (bridges, crowns, dentures) Orthodontics $350 per one child $700 for two or more children (per plan year) $50 per member/ $150 family maximum $750 per member per plan year $50 per member/ $150 family maximum $1,250 per member per plan year $50 per member/ $150 family maximum $1,500 per member per plan year $1,000 per member per lifetime $20 copay $0 copay $0 copay $0 copay coinsurance coinsurance coinsurance (medically necessary only, routine braces not covered), subject to out-of-pocket max coinsurance coinsurance Not coveredno 2 coinsurance coinsurance Not covered 2 coinsurance coinsurance coinsurance (adult and pediatric cosmetic orthodontics); subject to lifetime max Product name Blue Pediatric Dental* (PPO) Blue Value Dental 1* (PPO) Blue Value Dental 2 (PPO) Blue Value Dental 3*** (PPO) Monthly premium Subscriber $18.68 $24.92 $28.80 Subscriber and child(ren) $49.58 $58.67 $66.43 $19.89 Subscriber and spouse/ (per child) $37.36 $49.84 $57.60 domestic partner Family $76.97 $93.84 $106.82 Note: Members can receive dental services from a provider who does not participate in the BlueCross BlueShield contracted network of providers. Out-of-network services are reimbursed at 10 of the in-network fee schedule and the non-participating provider may balance bill the member for the remainder. * Available on SHOP ** Blue Pediatric dental benefits and cost-sharing are included in all Blue Value dental plans. Adults and adult dependents, ages 19-26, are covered in Blue Value Dental plans. *** Blue Value Dental 3 includes coverage for children up to age 19 for medically necessary orthodontics subject to an out-of-pocket maximum (see Blue Pediatric Benefits) and cosmetic orthodontics (routine braces) subject to a lifetime maximum per member. Adults and adult dependents have coverage for cosmetic orthodontics (routine braces) subject to a lifetime maximum per member.

Adult Vision Discount Programs BlueCross BlueShield of Western New York plan benefits include eye care services for pediatric members (under age 19) and adult members. Pediatric members are covered for essential health benefits, including routine eye exams, frames, and lenses under their medical plan. Exam and eyewear discounts for adults vary depending on their medical plan. The chart below provides highlights of the adult vision discount programs. Adult Vision Discount Programs Vision Enhanced Discount Program* Vision Discount Program* Available Non-standard medical plans Standard medical plans Benefits Member cost Discounted member cost Eye exam $0 annual cost $5 off routine, $10 off contact lens exam Frames 4 off retail price 4 off retail price Standard plastic lenses (single vision, bifocal, trifocal, lenticular) Lens options (for example, tint, UV and anti-reflective coating) Contact lens materials Disposable Conventional Other add-ons and services First purchase covered in full, additional purchases 4 off total cost Member cost varies based on lens options $40 allowance toward first purchase, additional purchases discount $40 allowance toward first purchase, additional purchases 15% discount Discounted cost varies based on lenses Discounted cost varies based on lens options off retail 15% off retail Sunglasses, contact lens solutions, etc. 2 discount 2 discount Laser vision correction** (LASIK or PRK) Frequency Examination 15% off retail price or 5% off promotional price 15% off retail price or 5% off promotional price Annual Frames Lenses Contact lenses Unlimited Covered in full annually $40 allowance annually Unlimited * EyeMed, an independent company, administers vision programs on behalf of BlueCross BlueShield of Western New York. Members must receive services from an EyeMed provider, and services out-of-network are not covered. ** Since LASIK or PRK vision correction is an elective procedure, performed by specially trained providers, this discount may not always be available from a provider in your immediate location. For a location near you and the discount authorization, please call 1-877-5LASER6.

Annual Benefit Limits Habilitation (PT/OT/ST) 60 combined visits per condition, per plan year Rehabilitation, outpatient (PT/OT/ST) 60 combined visits per condition, per plan year Rehabilitation, inpatient (PT/OT/ST) 60 combined visits, per plan year Home health care 40 visits per plan year Hearing aids Single purchase every three years Hospice 210 days per plan year, five visits per plan year for family bereavement Substance abuse, outpatient Unlimited, 20 visits per plan year for family counseling Skilled nursing facility 1 Unlimited For standard plans: 1 200 days per year

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