2018 BCBSM Large Group Medical Product Menu

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1 2018 Medical Products for Fully Insured Groups with 51+ FTEs & ASC Groups with 50+ Enrolled Note: For RX Options with all plans except Achieve, which are included below, please refer to the 2017 RX Menu for 101+FTE and 50+ Enrolled ASC Groups Red/bold indicates new plan PPO ECM ECM Out of Out of OV In SB 250 /$500 $500/$ %/40% $2,500/$5000 (0/00) $5000/$10,000 (00/$6000) $20 SB 500 $500/$1000 $1000/$ %/40% 0/$5000 $5000/$10,000 $20 SB 750 $750/0 0/00 20%/40% 0/$5000 $5000/$10,000 $6850/$13,700 $13,700/$27,400 $20 SB 1000 (0%) $1000/$2000 $2000/$4000 0%/20% N/A N/A PPO SB 1000 $1000/$2000 $2000/$ %/40% 0/$5000 $5000/$10,000 SB /00 00/$ %/40% 0/$5000 $5000/$10,000 SB 1500 (0%) 0/00 00/$6000 0%/20% N/A N/A SB 1500 MVP NO RX 0/00 00/$ %/40% N/A N/A $4000/$8000 $8000/$16,000 SB 2000 $2000/$4000 $4000/$8,000 20%/40% 0/$5000 $5000/$10,000 $6850/$13,700 $13,700/$27,400 SB /$5000 $5000/$10,000 20%/40% N/A N/A SB /$6000 $6000/$12,000 20%/40% 0/$5000 $5000/$10,000 $6850/$13,700 $13,700/$27,400 SB 4000 $4000/$8000 $8000/$16,000 30%/60% N/A N/A for all plans - Tiered Copay riders are available that include higher copays

2 Red/bold indicates new plan PPO, continued ECM ECM Out of Out of OV Routine Care PPO* SB Routine care 2500 SB Routine Care /$5000 $5000/$10,000 20%/40% 0/$5000 $5000/$10,000 $6600/$13,200 $13,200/$26,400 PCP* $4000/$8000 $8000/$16,000 20%/40% N/A N/A $6600/$13,200 $13,200/$26,400 PCP* Subject to and SBHRA 1000 $1000/$2000 $2000/$ %/40% 0/$5000 $5000/$10,000 SBHRA /00 00/$ %/40% 0/$5000 $5000/$10,000 for all plans - Tiered Copay riders are available that include higher copays HRA SBHRA /$5000 $5000/$10,000 20%/40% N/A N/A SBHRA 4000 $4000/$8000 $8000/$16,000 20%/40% N/A N/A SBHRA 5000 $5000/$10,000 $10,000/$20,000 20%/40% N/A N/A $6600/$13,200 $13,200/$26,400 * Routine Care s apply flat Copay for PCP OV and Generic Rx copays only - all other OV (Specialist, Chiro/MT, UC) and Rx tiers apply deductible and coinsurance

3 Red/bold indicates new plan PPO, continued ECM ECM Out of Out of OV SB HSA %** $1300/$2600 $2600/$5200 0%/20% N/A N/A $2250/$4500 $4500/$9000 SBHSA %** $1300/$2600 $2600/$ %/40% N/A N/A $2250/$4500 $4500/$9000 SB HSA % $2000/$4000 $4000/$8000 0%/20% N/A N/A 00/$6000 $6000/$12,000 SB HSA % $2000/$4000 $4000/$ %/40% N/A N/A 00/$6000 $6000/$12,000 HSA** SB HSA % SB HSA % 00/$6000 $6000/$12,700 0%/20% N/A N/A $4000/$8000 $8000/$16,000 00/$6000 $8000/$16,000 20%/40% N/A N/A $4000/$8000 $8000/$16,000 Subject to and SB HSA % $3500/$7000 $7000/$14,000 0%/20% N/A N/A $4500/$9000 $9000/$18,000 SB HSA % $3500/$7000 $7000/$14,000 20%/40% N/A N/A $4500/$9000 $9000/$18,000 SB HSA % MVP $4000/$8000 $8000/$16,000 50% N/A N/A $6350 / $12700 $12,700/$25,400 SB HSA % MVP 0%/20% N/A N/A $6350 / $12700 $12,700/$25,400 ** HSA 1250 plans have an indexed deductible that adjusts to the annual IRS minimum guidelines for compliance as a Qualified High Health. HSA 1250 and 2000 plans have aggregate deductible and out-of-pocket maximum. All Other HSA s have an embedded deductible and out of pocket maximum for a single member covered under a family contract in order to meet ACA compliancy related to Maximum Out Of Pocket Regulations for one person on a family contract.

4 Community PPO ECM ECM Out of Out of Office Visit (options) Emergency Room (options) CB1 $0/ $0/$500 0%/20% N/A N/A $10 ($20, ) $50 () CB3 /$500 $500/$ %/40% $1000/$2000 $2000/$4000 $20 () CB 4 $500/$1000 $1000/$ %/40% 0/00 00/$6000 $20 (, $40) CB 12-0% $1000/$2000 $2000/$4000 0%/20% N/A N/A CB 12-20% $1000/$2000 $2000/$ %/40% 0/$5000 $5000/$10,000 Community PPO CB 14-20% 0/00 00/$ %/40% 0/$5000 $5000/$10,000 CB 15-0% 0/$5000 $5000/$10,000 0%/20% N/A N/A CB 15-20% 0 0/$5000 $5000/$10,000 20%/40% 0/$5000 $5000/$10,000 CB 15-0% $5000 $5000/$10,000 $10,000/ $20,000 0%/20% N/A N/A CB 15-20% $5000 $5000/$10,000 $5000/$20,000 20%/40% N/A N/A CB 15-30% $5000 $5000/$10,000 $5000/$20,000 30%/40% N/A N/A

5 Achieve PPO ECM ECM Out of Out of OV/SP/UC/ Rx Options Achieve Each plan comes with both the Enhanced and Standard level of benefits Achieve PPO Achieve PPO $500 Achieve PPO $1000 Achieve PPO 0 E /$500 $500/$ %/40% 0/00 00/$6000 S $1000/$2000 $2000/$ %/40% 0/$5000 $5000/$10,000 E $500/$1000 $1000/$ %/40% 0/00 00/$6000 S 0/00 00/$ %/40% 0/$5000 $5000/$10,000 E $1000/$2000 $2000/$ %/40% 0/$5000 $5000/$10,000 S 0/$5000 $5000/$10,000 30%/40% 0/$5000 $5000/$10,000 E 0/00 00/$ %/40% 0/$5000 $5000/$10,000 S $4000/$8000 $8000/$16,000 30%/40% $2350/$4700 $4700/$9400 $20/$40/$60/ $20/$40/$60/ /$50/$60/ /$50/$60/ May select from 2 Paired RX Options ONLY Option 1 - E=$10/$40/$80 RXCM with S=$15/$50/50% RXCM OR Option 2 - E=$15/$50/50% RXCM with S=$20/$60/50%/$80/ $100 RXCM Achieve PPO $2000 E $2000/$4000 $4000/$ %/40% 0/$5000 $5000/$10,000 S $4000/$8000 $8000/$16,000 30%/40% $2350/$4700 $4700/$9400 /$50/$60/

6 PPO Level Ded. Ded. Coins. % ECM ECM OOPM OOPM (OV/SPEC/UC/) PPO PPO PPO $500 PPO $1000 PPO 0 Level 1 $500 20% 0 00 $20/$40/$60/ Level 2 $ % 0 $5000 OON 0 $ % N/A N/A $13,200 $26,400 Ded + Coins/ Level 1 $500 $ % 0 00 $20/$40/$60/ Level % 0 $5000 OON 00 $ % N/A N/A $13,200 $26,400 Ded + Coins/ Level 1 $1000 $ % 0 $5000 /$50/$60/ Level 2 0 $ % N/A N/A OON $5000 $10,000 50% N/A N/A $13,200 $26,400 Ded + Coins/ Level % 0 $5000 /$50/$60/ Level 2 $4000 $ % N/A N/A OON $8000 $16,000 50% N/A N/A $13,200 $26,400 Ded + Coins/