FOURTH QUARTER 2017 SMALL GROUP PRODUCT PORTFOLIO

FOURTH QUARTER 2017 SMALL GROUP PRODUCT PORTFOLIO

THE CARD THAT OPENS DOORS IN 50 STATES. Benefits of Blue Plan options NEW tiered benefit plans Tiered benefit plans offered at every metal level (align and focus plans) Lower premium, same benefits, full network employees choose preferred providers/facilities A comprehensive online benefits solution Premium Savings * Expanded (EX) network plans Enhanced network access with locally, PPO for out-of-area Available for employees who work and/or live in Western New York Preventive services NEW $0 preventive drugs available on non-standard HSA plans More than 50 free check-ups and preventive services Health and wellness Health assessment rewards $25 for taking assessment in the first 6 months of plan year An additional $25 when a covered spouse takes the health assessment $250 wellness debit card offered with every plan We ve got you covered Vision coverage included with all medical plans Pediatric and adult dental plans available BlueConnect is an online health management platform that helps employers manage their costs while delivering benefits to their employees in a more efficient manner. Streamlined new group registration Easy enrollment and management Online bill pay Real-time reporting Better for the employee, easier for the employer, affordable for everyone. Visit bcbswny.com/blueconnect today.

Platinum * Fourth Quarter Premium Savings * Plan/market name Platinum Standard Platinum Platinum align align* Platinum Platinum focus focus* Platinum HMO 110 Plus Platinum PPO 843 Network 200 200 100 PPO Optimum Preferred Flexible $0 $0 $1,500/$3,000 $0 $500/$1,000 Coinsurance N/A N/A 4 N/A 2 Out-of-pocket maximum (single/family) Out-of-network $2,000/$4,000 $5,000/$10,000 $4,000/$8,000 $1,500/$3,000 $4,000/$8,000 $1,500/$3,000 $1,000/$2,000 $500/$1,000 Coinsurance 5 4 4 4 Out-of-pocket maximum (single/family) Medical services PCP/specialist $15/$35 $20/$30 $4,000/$8,000 $20/4 $4,000/$8,000 $5,000/$10,000 $20/$30 2 Laboratory services $35 $0 4 $0 2 Diagnostic X-rays $35 $30 4 $30 2 Hospital services Inpatient hospital (per admission) $500 $500 4 $500 2 Outpatient facility $100 $150 4 $150 2 Emergency room visit $100 $100 $100 $100 2 Urgent care $55 $40 $40 $40 2 Prescription drugs Generic/formulary/non-formulary $10/$30/$60 $5/$30/5 $5/$30/5 Preventive drug list $10/$30/5 HSA-eligible Creditable coverage 4 4 4 4 Product name Platinum Standard Platinum align Platinum focus Platinum HMO 110 Plus Platinum PPO 843 Rates Single $591.28 $537.81 $571.87 $674.07 Employee and child $1,005.17 $914.28 $972.18 $1,145.92 Employee and spouse/domestic partner $1,182.56 $1,075.62 $1,143.74 $1,348.14 Family $1,685.15 $1,532.76 $1,629.83 $1,921.10 Available in Erie and Niagara counties only *Minimum of 6% savings compared to our other plans; savings may vary based on plan design

* Fourth Quarter Plan/market name Standard align align* focus focus* Aqua Complete 7100 NQ 7100 7100EX Network 200 200 100 200 100 100 100 PPO $600/$1,200 Optimum Preferred Premium Savings * Flexible First Dollar $500/$1,000 $1,000/$2,000 $2,500/$5,000 PPO 7100 Coinsurance N/A N/A 4 2 after first dollar and N/A N/A Out-of-pocket maximum (single/family) Out-of-network $4,000/$8,000 $5,000/$10,000 $4,000/$8,000 $6,000/$12,000 $1,000/$2,000 $2,500/$5,000 $2,500/$5,000 $4,000/$8,000 $4,000/$8,000 Coinsurance Out-of-pocket maximum (single/family) Medical services 5 4 5 $2,500/$5,000 4 after $10,000/ $20,000 4 PCP/specialist $25/$40 $20/$40 $20/4 2 after first dollar and $20/$40 $20/$40 Laboratory services $40 $40 4 2 after first dollar and $40 $40 Diagnostic X-rays $40 $40 4 2 after first dollar and $40 $40 Hospital care Inpatient hospital (per admission) Outpatient facility Emergency room Urgent care Prescription drugs $1,000 after $100 after $150 after $60 $500 $150 4 4 $150 $75 2 after first dollar 2 after first dollar and 2 after first dollar and 2 after first dollar and $500 $150 $150 $75 $500 $150 $150 $75 Generic/formulary/ non-formulary $10/$35/$70 $5/$30/$50 $15/$50/5 $5/$30/$50 $5/$30/$50 Preventive drug list 4 4 4 HSA-eligible 4 4 4 Creditable coverage 4 4 4 4 4 4 Product name Rates Standard align focus Aqua Complete 7100 NQ 7100 7100EX Single $515.95 $467.55 $459.73 $485.31 $469.72 $497.96 $493.05 $518.42 $584.09 Employee and child $877.12 $794.83 $781.54 $825.03 $798.53 $846.53 $838.19 $881.31 $992.95 Employee and spouse/ domestic partner $1,031.90 $935.10 $919.46 $970.62 $939.44 $995.92 $986.10 $1,036.84 $1,168.18 Family $1,470.46 $1,332.52 $1,310.23 $1,383.14 $1,338.70 $1,419.18 $1,405.19 $1,477.50 $1,664.66 PPO 7100 *Minimum of 6% savings compared to our other plans; savings may vary based on plan design

* Fourth Quarter Plan/market name Standard 7100 8100 8100EX Network 200 200 100 100 PPO 200 Coinsurance Out-of-pocket maximum (single/family) Out-of-network Coinsurance Out-of-pocket maximum (single/family) Medical services PCP/specialist Laboratory services $2,000/$4,000 N/A $6,750/$13,500 $5,000/$10,000 5 $30/$50 $50 Optimum Preferred 3 Flexible $3,500/$7,000 5 $6,550/$13,100 $3,500/$7,000 5 $30/$50 3 after Premium Savings * align focus $30/5 after 5 after $2,000/$4,000 N/A $6,500/$13,000 $2,000/$4,000 4 $25/$50 $50 PPO 8100 $2,000/$4,000 2 $5,500/$11,000 $2,000/$4,000 4 2 2 Blended $3,000/$6,000 2 $6,550/$13,100 $3,000/$6,000 4 $25/$50 $0 for first three adult PCP visits $50 Diagnostic X-rays Hospital care Inpatient hospital (per admission) Outpatient facility Emergency room Urgent care Prescription drugs $50 $1,500 $100 $250 $70 3 after 3 after 3 after 5 after 5 after 5 after 3 3 Generic/formulary/non-formulary $10/$35/$70 $5/$30/5 $50 $750 $150 $250 $75 $5/$30/5 2 $750 2 2 2 2 2 2 2 2 $5/$30/5 $15/$50/5 Preventive drug list 4 4 4 HSA-eligible 4 4 4 Creditable coverage 4 4 4 4 4 Product name Rates Standard align focus 7100 8100 8100EX PPO 8100 Blended Single $452.86 $412.40 $412.50 $436.15 $436.77 $458.82 $515.85 $420.44 Employee and child $769.87 $689.35 $701.08 $741.46 $742.51 $780.00 $876.95 $714.75 Employee and spouse/domestic partner $905.72 $824.80 $811.00 $872.30 $873.54 $917.64 $1,031.70 $840.88 Family $1,290.65 $1,155.68 $1,175.35 $1,243.02 $1,244.80 $1,307.63 $1,470.17 $1,198.26 Available in Erie and Niagara counties only *Minimum of 6% savings compared to our other plans; savings may vary based on plan design

Fourth Quarter Bronze Plan/market name Bronze Standard Bronze 8100EX Bronze PPO 8100 Premium Savings * Bronze align Bronze focus * Network 200 100 PPO 200 $4,000/$8,000 $5,500/$11,000 Optimum Preferred $7,000/$14,000 Flexible $7,150/$14,300 Coinsurance 5 2 5 Out-of-pocket maximum (single/family) Out-of-network $7,150/$14,300 $5,000/$10,000 $6,550/$13,100 $5,500/$11,000 $7,150/$14,300 $7,150/$14,300 Coinsurance 5 4 5 Out-of-pocket maximum (single/family) Medical services Pcp/specialist 5 2 5 5 / Laboratory services 5 2 5 Diagnostic X-rays 5 2 5 Hospital care Inpatient hospital (per admission) 5 2 Outpatient facility 5 2 Emergency room 5 2 Urgent care 5 2 5 5 5 5 5 Prescription drugs Generic/formulary/non-formulary $10/$35/$70 $15/$50/5 $10/5/5 Preventive drug list 4 HSA-eligible 4 Creditable coverage 4 Product name Bronze Standard Bronze 8100EX Bronze PPO 8100 Rates Single $382.88 $421.89 $473.91 Employee and child $650.90 $717.21 $805.64 Employee and spouse/domestic partner $765.76 $843.78 $947.82 Family $1,091.21 $1,202.39 $1,350.65 Bronze align Bronze focus $367.53 $624.81 $735.06 $1,047.46 *Minimum of 6% savings compared to our other plans; savings may vary based on plan design

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 you can add to your medical plan or purchase one separately. New for 2017 Blue Value Dental 3, a richer plan with coverage for cosmetic orthodontics (routine braces) for children and adults. Pediatric Dental is an essential health benefit as outlined in the Affordable Care Act. 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) Monthly Premium Benefits Deductible () $19.14 (per child) Children to age 19 years N/A $18.03 (one adult) $36.06 (two adults) $46.99 (subscriber and child(ren)) $75.09 (family) $24.18 (one adult) $48.36 (two adults) $56.54 (subscriber and child(ren)) $91.81 (family) $27.85 (one adult) $55.70 (two adults) $63.83 (subscriber and child(ren)) $103.96 (family) Adult/Family** Adult/Family** Adult/Family** $50 per member/ $150 family maximum $50 per member/ $150 family maximum $50 per member/ $150 family maximum Annual benefit maximum N/A $750 per member per plan year $1,250 per member per plan year $1,500 per member per plan year Out-of-pocket maximum $350 - one child $700 - two or more children (per plan year) N/A N/A N/A Orthodontic lifetime maximum (pediatric and adult cosmetic, routine braces) N/A N/A N/A $1,000 per member per lifetime Preventive/diagnostic (exams, cleaning, X-rays) Basic restorative (fillings, extractions, periodontics, endodontics) Major dental (bridges, crowns, dentures) $20 copay $0 copay $0 copay $0 copay Orthodontics (medically necessary only; routine braces not covered), subject to out-of-pocket max Not covered Not covered (adult and pediatric cosmetic orthodontics), subject to lifetime max 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. *** 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.

Pediatric Vision Benefit Platinum Standard Platinum align Platinum focus Platinum HMO 110 Plus Platinum PPO 843 Optimum Preferred* Flexible Pediatric exam (routine and well) $15 copayment $30 copayment 4 coinsurance $30 copayment Pediatric eyewear, incl. frames, lenses, contact lenses 1 coinsurance 1 coinsurance 4 coinsurance 1 coinsurance 1 coinsurance Standard Aqua Complete 7100 NQ Optimum Preferred* align focus Flexible 7100 7100EX PPO 7100 Pediatric exam (routine and well) $25 copayment after first dollar coinsurance $40 copayment $40 copayment 4 coinsurance $40 copayment Pediatric eyewear, incl. frames, lenses, contact lenses after first dollar and coinsurance 4 coinsurance Standard Optimum Preferred* align focus Flexible 7100 8100 8100EX PPO 8100 Blended Pediatric exam (routine and well) $30 copayment $50 copayment $50 copayment $50 copayment Pediatric eyewear, incl. frames, lenses, contact lenses 3 coinsurance 3 coinsurance 3 coinsurance 3 coinsurance 3 coinsurance Bronze Standard Bronze 8100EX Bronze PPO 8100 Optimum Preferred* Bronze align Bronze focus Flexible Pediatric exam (routine and well) coinsurance Pediatric eyewear, incl. frames, lenses, contact lenses Pediatric routine eye exams and eyewear are covered only in-network. Pediatric routine eye exams covered in full every other year for non-standard plans. Off year follows specialist cost-share. Standard plans covered in full every year (cost-share reflects multiple visits). * EyeMed providers covered under Optimum Preferred cost-share.

Annual benefit limits Habilitation (PT/OT/ST)1 60 combined visits, per plan year Rehab, outpatient (PT/OT/ST)1 60 combined visits, per plan year Hospice 210 days per plan year, 5 visits per plan year for family bereavement Rehab, inpatient (PT/OT/ST) 60 combined visits, per plan year Substance abuse, outpatient Unlimited, 20 visits per plan year for family counseling Home health care 40 visits per plan year Skilled nursing facility 2 Unlimited 1 Hearing aids Single purchase every 3 years For standard plans: 1 60 combined visits per condition, per lifetime 2 200 days per year

THE NAME TRUSTED FOR OVER 80 YEARS.

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