Small Business Plan Portfolio

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2018 Small Business Plan Portfolio

2018 Small Business Plan Pairing Options Most Small Group plans can be combined, please see restrictions below. This allows you to offer your employees up to three plans to choose from. BlueCHiP Advance plans can be paired with one other plan as noted. However, they cannot be combined with a health reimbursement account (HRA). BlueCHiP Advance $0/$1,500 can be paired with: VantageBlue 100/80 $2,000/$4,000 BlueSolutions 100/60 $1,500/$3,000 BlueSolutions 100/60 $1,500/$3,000 +co-pay BlueSolutions 100/60 $1,900/$3,800 BasicBlue 100/Not Covered $2,750/$5,500 Blue Choice New England 100/80 $2,000/$4,000 Blue Choice New England 100/80 $3,000/$6,000 Network Blue New England 100/Not Covered $2,000/$4,000 Network Blue New England 100/Not Covered $3,000/$6,000 BlueCHiP Advance $500/$2,000 and BlueCHiP Advance $1,000/$2,000 can be paired with: VantageBlue 100/80 $3,000/$6,000 VantageBlue 80/60 $3,000/$6,000 VantageBlue 70/50 $2,000/$4,000 Blue Choice New England 100/80 $3,000/$6,000 Network Blue New England 100/ Not Covered $3,000/$6,000 BasicBlue 100/Not Covered $2,750/$5,500 BlueSolutions 100/60 $1,500/$3,000 BlueSolutions 100/60 $1,900/$3,800 These plans can be paired together but not with any other plans: BlueSolutions 100/60 $5,000/$10,000 BlueSolutions 100/60 $6,000/$12,000 BlueSolutions 100/60 $6,550/$13,100 BasicBlue 100/Not Covered $7,150/ $14,300 2 3

BlueCHiP Product Family Network Blue New England Network Blue New England Network Blue New England Blue Choice Blue Choice Blue Choice BlueCHiP Advance * BlueCHiP Advance * BlueCHiP Advance * Coinsurance 100/Not Covered 100/Not Covered 100/Not Covered 100/80 100/80 100/80 Copay Plan Copay Plan Copay Plan In-Network Deductible $1,000/$2,000 $2,000/$4,000 $3,000/$6,000 $1,000/$2,000 $2,000/$4,000 $3,000/$6,000 Tier 1: $0/$0 Tier 2: $1,500/$3,000 Tier 1: $500/$1,000 Tier 2: $2,000/$4,000 Tier 1: $1,000/$2,000 Tier 2: $2,000/$4,000 In-Network Out-of-Pocket Max Out-of-Network Deductible Out-of-Network Out-of-Pocket $3,000/$6,000 $6,000/$12,000 $6,500/$13,000 $3,000/$6,000 $6,000/$12,000 $7,150/$14,300 $4,750/$9,500 $6,800/$13,600 $6,800/$13,600 Not Covered Not Covered Not Covered $2,000/$4,000 $4,000/$8,000 $6,000/$12,000 $6,600/$13,200 $6,600/$13,200 $6,600/$13,200 Not Covered Not Covered Not Covered $6,000/$12,000 $12,000/$24,000 $14,300/$28,600 $14,250/$28,500 $20,400/$40,800 $20,400/$40,800 PCMH / Non PCMH $20/$20 $25/$25 $25/$25 $20/$20 $25/$25 $25/$25 T2: $40 Specialist $30 $40 $40 $30 $40 $40 Retail Clinic $20 $25 $25 $20 $25 $25 T2: $40 Urgent Care / Emergency Room $75/$150 $100/$200 $100/$200 $75/$150 $100/$200 $100/$200 $50/$150 $75/$150 $75/$150 Inpatient 0% 0% 0% 0% 0% 0% T2: $800 T1: $500 High End Radiology 0% 0% 0% 0% 0% 0% T1:$0 T2: $200 T1: $0 T2: $250 0 0 PT / OT / ST 20% 20% 20% 20% 20% 20% Lab / X-ray $20/$50 $25/$75 $25/$75 $20/$50 $25/$75 $25/$75 T1:$30 T1: $0/$0 T1: $0/$0 T1: $0/$0 T2: $0/$0 T2: $25/$75 T2: $25/$75 Outpatient Surgery 0% 0% 0% 0% 0% 0% T2: $800 Pharmacy $10/25/35/60/100 $10/30/50/75/125 $10/30/50/75/125 $10/25/35/60/100 $10/30/50/75/125 $10/30/50/75/125 $10/30/50/75/125 $10/30/50/75/125 $10/30/50/75/125 This is a summary of benefits. It is not a contract. For details about each plan including any limitations or exclusions not noted here, please refer to the subscriber agreement. * These plans have pairing requirements and restrictions. Please contact your broker or Blue Cross account executive for details. 4 5

BlueSolutions Product Family BlueSolutions BlueSolutions BlueSolutions BlueSolutions BlueSolutions BlueSolutions BlueSolutions BlueSolutions BlueSolutions Coinsurance 100/60 100/60 + Copay 100/60 100/60 100/60 100/60 100/60 100/60 100/60 In-Network Deductible In-Network Out-of-Pocket Max Out-of-Network Deductible Out-of-Network Out-of-Pocket $1,500/$3,000 $1,500/$3,000 $1,900/$3,800 $2,650/$5,300 $3,000/$6,000 $4,000/$8,000 $5,000/$10,000 $6,000/$12,000 $6,550/$13,100 $4,500/$9,000 $3,000/$6,000 $2,600/$5,200 $6,550/$13,100 $6,350/$12,700 $5,550/$11,100 $6,550/$13,100 $6,550/$13,100 $6,550/$13,100 $3,000/$6,000 $3,000/$6,000 $3,800/$7,600 $5,300/$10,600 $6,000/$12,000 $8,000/$16,000 $10,000/$20,000 $12,000/$24,000 $13,100/$26,200 $13,500/$27,000 $9,000/$18,000 $7,800/$15,600 $19,650/$39,300 $19,050/$38,100 $16,650/$33,300 $19,650/$39,300 $19,650/$39,300 $19,650/$39,300 PCMH / Non PCMH 0% $5/$15 0% 0% 0% 0% 0% 0% 0% Specialist 0% $20 0% 0% 0% 0% 0% 0% 0% Retail Clinic 0% $20 0% 0% 0% 0% 0% 0% 0% Urgent Care / Emergency Room 0% $100/$200 0% 0% 0% 0% 0% 0% 0% Inpatient 0% 0% 0% 0% 0% 0% 0% 0% 0% High End Radiology 0% 0% 0% 0% 0% 0% 0% 0% 0% PT / OT / ST 0% $20 0% 0% 0% 0% 0% 0% 0% Lab / X-ray 0% 0% 0% 0% 0% 0% 0% 0% 0% Outpatient Surgery 0% 0% 0% 0% 0% 0% 0% 0% 0% Pharmacy $10/30/50/75/125 $10/30/50/75/125 $10/30/50/75/125 $10/40/70/90/125 $10/40/70/90/125 $10/40/70/90/125 $10/50/75/95/150 $10/50/75/95/150 $0/0/0/0/0 This is a summary of benefits. It is not a contract. For details about each plan including any limitations or exclusions not noted here, please refer to the subscriber agreement. * These plans have pairing requirements and restrictions. Please contact your broker or Blue Cross account executive for details. 6 7

VantageBlue Product Family VantageBlue VantageBlue VantageBlue VantageBlue VantageBlue VantageBlue VantageBlue VantageBlue VantageBlue VantageBlue VantageBlue VantageBlue Coinsurance 100/80 100/80 100/80 100/80 100/80 100/80 100/80 100/60 80/60 80/60 80/60 70/50 In-Network Deductible In-Network Out-of-Pocket Max Out-of-Network Deductible Out-of-Network Out-of-Pocket $500/$1,000 $750/$1,500 $1,000/$2,000 $2,000/$4,000 $2,500/$5,000 $3,000/$6,000 $4,000/$8,000 $1,500/$3,000 $1,000/$2,000 $2,000/$4,000 $3,000/$6,000 $2,000/$4,000 $1,500/$3,000 $1,700/$3,400 $4,000/$8,000 $3,600/$7,200 $6,000/$12,000 $6,500/$13,000 $6,350/$12,700 $4,500/$9,000 $4,000/$8,000 $5,000/$10,000 $5,800/$11,600 $6,150/$12,300 $2,000/$4,000 $3,000/$6,000 $2,000/$4,000 $4,000/$8,000 $5,000/$10,000 $6,000/$12,000 $8,000/$16,000 $3,000/$6,000 $2,000/$4,000 $4,000/$8,000 $6,000/$12,000 $4,000/$8,000 $6,000/$12,000 $6,800/$13,600 $12,000/$24,000 $10,800/$21,600 $18,000/$36,0000 $19,500/$39,000 $19,050/$38,100 $13,500/$27,000 $12,000/$24,000 $15,000/$30,000 $17,400/$34,800 $18,450/$36,900 PCMH / Non PCMH (1st sick visit free) Specialist $30 $30 $30 $40 $40 $40 $40 $30 $50 $50 $50 $50 Retail Clinic $20 $20 $20 $30 $30 $30 $30 $20 $40 $40 $40 $40 Urgent Care / Emergency Room $50/$100 $50/$100 $50/$100 $100/$200 $100/$200 $100/$200 $100/$200 $50/$100 $125/$250 $125/$250 $125/$250 $125/$250 Inpatient 0% 0% 0% 0% 0% 0% 0% 0% 20% 20% 20% 30% High End Radiology 0% 0% 0% 0% 0% 0% 0% 0% 20% 20% 20% 30% PT / OT / ST 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 30% Lab / X-ray $0/$0 $0/$0 $0/$0 $25/$75 $25/$75 $25/$75 $25/$75 $0/$0 $25/$75 $25/$75 $25/$75 $25/$75 Outpatient Surgery 0% 0% 0% 0% 0% 0% 0% 0% 20% 20% 20% 30% Pharmacy $10/25/35/60/100 $10/25/35/60/100 $10/25/35/60/100 $10/40/70/90/125 $10/40/70/90/125 $10/40/70/90/125 $10/40/70/90/125 $10/25/35/60/100 $10/40/70/90/125 $10/40/70/90/125 $10/40/70/90/125 $10/40/70/90/125 This is a summary of benefits. It is not a contract. For details about each plan including any limitations or exclusions not noted here, please refer to the subscriber agreement. 8 9

BasicBlue Product Family BasicBlue BasicBlue BasicBlue Coinsurance 100/Not Covered 100/Not Covered 100/Not Covered In-Network Deductible In-Network Out-of-Pocket Max Out-of-Network Deductible Out-of-Network Out-of-Pocket $2,750/$5,500 $5,000/$10,000 $7,150/$14,300 $2,750/$5,500 $5,000/$10,000 $7,150/$14,300 Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered PCMH / Non PCMH $15/$25 $50/$70 Specialist $30 $45 $85 Retail Clinic $30 $45 $50 Urgent Care / Emergency Room 0% 0% 0% Inpatient 0% 0% 0% High End Radiology 0% 0% 0% PT / OT / ST 0% 0% 0% Lab / X-ray 0% 0% 0% Outpatient Surgery 0% 0% 0% Pharmacy $10/30/ 0/0/0 $10/40/ 0/0/0 $10/50/ 0/0/0 This is a summary of benefits. It is not a contract. For details about each plan including any limitations or exclusions not noted here, please refer to the subscriber agreement.

500 Exchange Street Providence, RI 02903-2699 Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. 08/17 PER-174800 5938

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