When you care more, you do more. SM. PersonalBlue PPO SM. Medically Underwritten Products. Affordable, comprehensive, individual health insurance

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1 PersonalBlue PPO SM Medically Underwritten Products Affordable, comprehensive, individual health insurance

2 Rely on Capital BlueCross At different times in your life, your health coverage needs may vary significantly. When deciding on a medically underwritten individual plan for you or your family, rely on Capital BlueCross as your trusted advisor. With over 70 years of experience and a broad-reaching physician network, we provide the knowledge and breadth of options to help you choose the plan that best fits your needs. Your individual plan opens the door to informational resources, health and wellness programs, and personal advice to help you to live a healthier life.

3 PersonalBlue PPO Plan Benefits Plan Options PersonalBlue PPO: $500 Deductible Medically Underwritten PersonalBlue PPO: $1,100 Deductible Medically Underwritten In-Network Out-of-Network In-Network Out-of-Network Deductible Member $500 $500 $1,100 $1,100 Deductible Family $1,500 $1,500 $2,200 $2,200 Out-of-Pocket Maximum Member (excludes deductible and copayments) coinsurance only Out-of-Pocket Maximum Family (excludes deductible and copayments) coinsurance only Coinsurance (only applied after any applicable deductibles have been met) $1,500 for in- and out-of-network covered $2,250 for in- and out-of-network covered $4,500 for in- and out-of-network covered $4,500 for in- and out-of-network covered Lifetime Policy Maximum Unlimited Unlimited Benefit Period Maximum Unlimited Unlimited Hospital Facility Expense Inpatient Hospital Facility Expense Outpatient Emergency Room Care Urgent Care ; Rehab: 10-day maximum in- and out-of-network combined; SNF: 45-day maximum $100 copayment (waived if admitted). $50 copayment. ; benefit period, long-term care not covered Rehab: 10-day maximum in- and out-of-network combined; SNF: 45-day maximum $100 copayment (waived if admitted). $50 copayment. Office/Home Visits Exempt from deductible, $30 copayment for PCP, $40 for specialist Exempt from deductible, $30 copayment for PCP, $40 for specialist Medical-Surgical Expenses Preventive Care in full covered in full covered Spinal Manipulations Mental Health Services covered covered Substance Abuse Rehabilitation covered covered Substance Abuse Detoxification covered covered

4 PersonalBlue PPO Plan Benefits (continued) Plan Options PersonalBlue PPO: $1,500 Deductible Medically Underwritten PersonalBlue PPO: $2,500 Deductible Medically Underwritten In-Network Out-of-Network In-Network Out-of-Network Deductible Member $1,500 $1,500 $2,500 $2,500 Deductible Family $3,000 $3,000 $5,000 $5,000 Out-of-Pocket Maximum Member (excludes deductible and copayments) coinsurance only Out-of-Pocket Maximum Family (excludes deductible and copayments) coinsurance only Coinsurance (only applied after any applicable deductibles have been met) $2,250 for in- and out-of-network covered $2,500 for in- and out-of-network covered $4,500 for in- and out-of-network covered $5,000 for in- and out-of-network covered Lifetime Policy Maximum Unlimited Unlimited Benefit Period Maximum Unlimited Unlimited Hospital Facility Expense Inpatient Hospital Facility Expense Outpatient ; Rehab: 10-day maximum in- and out-ofnetwork combined; SNF: 45-day maximum ; Rehab: 10-day maximum in- and out-of-network combined; SNF: 45-day maximum in- and outof-network combined Emergency Room Care $100 copayment (waived if admitted). $100 copayment (waived if admitted). Urgent Care $50 copayment. $50 copayment. Office/Home Visits Medical-Surgical Expenses Exempt from deductible, $30 copayment for PCP, $40 for specialist Exempt from deductible, $30 copayment for PCP, $40 for specialist Preventive Care in full covered in full covered Spinal Manipulations Mental Health Services covered covered Substance Abuse Rehabilitation covered covered Substance Abuse Detoxification covered covered

5 PersonalBlue PPO Plan Benefits (continued) Plan Options PersonalBlue PPO: $5,000 Deductible Medically Underwritten In-Network Out-of-Network Deductible Member $5,000 $5,000 Deductible Family $10,000 $10,000 Out-of-Pocket Maximum Member (excludes deductible and copayments) coinsurance only Out-of-Pocket Maximum Family (excludes deductible and copayments) coinsurance only Coinsurance (only applied after any applicable deductibles have been met) Lifetime Policy Maximum Benefit Period Maximum Hospital Facility Expense Inpatient Hospital Facility Expense Outpatient $5,000 for in- and out-of-network covered $10,000 for in- and out-of-network covered Unlimited Unlimited ; benefit period, long-term Rehab: 10-day maximum SNF: 45-day maximum Emergency Room Care Urgent Care Office/Home Visits $100 copayment (waived if admitted). $50 copayment Exempt from deductible, $30 copayment for PCP, $40 for specialist $100 copayment (waived if admitted). $50 copayment Medical-Surgical Expenses Preventive Care in full covered Spinal Manipulations Mental Health Services Substance Abuse Rehabilitation Substance Abuse Detoxification covered covered covered

6 PersonalBlue PPO Pharmacy Benefits The below pharmacy benefit is optional with the following PersonalBlue PPO plans: $500 Deductible; $1,100 Deductible; $1,500 Deductible; $2,500 Deductible; and $5,000 Deductible. Optional Pharmacy Benefits Copayments Retail Mail Service (up to 90-day supply) Specialty Pharmacy Generic Prescription Drugs $15 $40 $50 Preferred Brand Prescription Drugs $40 $100 $100 Non-preferred Brand Prescription Drugs Deductible $60 $150 $200 $100/Member; $300/family Benefit Period Maximum Retail Mail Service (up to 90-day supply) Specialty Pharmacy Generic Prescription Drugs Unlimited Unlimited Unlimited Preferred and Non-preferred Brand Prescription Drugs 12 prescription limit, including refills (combined with Mail Service and Specialty Pharmacy) 12 prescription limit, including refills (combined with Retail Service and Specialty Pharmacy) 12 prescription limit, including refills (combined with Mail Service and Retail Pharmacy) (If a Member reaches his/her Benefit Maximum per Benefit Period, benefits for diabetic supplies mandated by law will still be available.)

7 Qualified High Deductible Health Plan (Qhdhp) Benefits Plan Options PersonalBlue PPO: $1,500 Deductible Medically Underwritten QHDHP 100/50 PersonalBlue PPO: $2,500 Deductible Medically Underwritten QHDHP 100/50 In-Network Out-of-Network In-Network Out-of-Network Deductible Member $1,500 $3,000 $2,500 $5,000 Deductible Family (The entire family deductible must be met prior to receiving nonpreventive benefits) Out-of-Pocket Maximum Member (includes deductible, coinsurance, and copayments) Out-of-Pocket Maximum Family (includes deductible, coinsurance, and copayments) Coinsurance (only applied after any applicable deductibles have been met) $3,000 $6,000 $5,000 $10,000 $2,500 $7,000 $3,500 $11,000 Separate in- and out-of network OOP s Separate in- and out-of network OOP s $4,000 $13,000 $6,000 $17,000 Separate in- and out-of network OOP s Separate in- and out-of network OOP s in full in full Lifetime Policy Maximum Unlimited Unlimited Benefit Period Maximum Unlimited Unlimited Hospital Facility Expense Inpatient Hospital Facility Expense Outpatient in full ; Rehab: 10-day maximum in- and out-of-network combined; SNF: 45-day maximum in full in full ; Rehab: 10-day maximum in- and out-of-network combined; SNF: 45-day maximum in full Emergency Room Care $100 copayment $100 copayment Urgent Care $50 copayment $50 copayment Office/Home Visits $30 PCP/$40 SCP $30 PCP/$40 SCP Medical-Surgical Expenses in full in full Preventive Care in full coinsurance and $400 benefit period maximum in full coinsurance and $400 benefit period maximum Spinal Manipulations in full in full Mental Health Services covered covered Substance Abuse Rehabilitation covered covered Substance Abuse Detoxification covered covered

8 Qualified High Deductible Health Plan (Qhdhp) Benefits (continued) Plan Options PersonalBlue PPO: $3,500 Deductible Medically Underwritten QHDHP 100/50 PersonalBlue PPO: $5,000 Deductible Medically Underwritten QHDHP 100/50 In-Network Out-of-Network In-Network Out-of-Network Deductible Member $3,500 $7,000 $5,000 $10,000 Deductible Family (The entire family deductible must be met prior to receiving nonpreventive benefits) Out-of-Pocket Maximum Member (includes deductible, coinsurance, and copayments) Out-of-Pocket Maximum Family (includes deductible, coinsurance, and copayments) Coinsurance (only applied after any applicable deductibles have been met) $7,000 $14,000 $10,000 $20,000 $4,500 $15,000 $6,000 $17,000 Separate in- and out-of network OOP s Separate in- and out-of network OOP s $8,000 $21,000 $11,000 $26,000 Separate in- and out-of network OOP s Separate in- and out-of network OOP s in full in full Lifetime Policy Maximum Unlimited Unlimited Benefit Period Maximum Unlimited Unlimited Hospital Facility Expense Inpatient Hospital Facility Expense Outpatient in full ; Rehab: 10-day maximum in- and out-of-network combined; SNF: 45-day maximum in full ; Rehab: 10-day maximum in- and out-of-network combined; SNF: 45-day maximum in full in full Emergency Room Care $100 copayment $100 copayment Urgent Care $50 copayment $50 copayment Office/Home Visits $30 PCP/$40 SCP $30 PCP/$40 SCP Medical-Surgical Expenses in full in full Preventive Care in full coinsurance and $400 benefit period maximum in full coinsurance and $400 benefit period maximum Spinal Manipulations in full in full Mental Health Services covered covered Substance Abuse Rehabilitation covered covered Substance Abuse Detoxification covered covered

9 Pharmacy Benefits Included With QHDHP The below pharmacy benefits are included with the following QHDHP plans: $1,500 Deductible QHDHP 100/50; $2,500 Deductible QHDHP 100/50; $3,500 QHDHP 100/50; and $5,000 Deductible QHDHP 100/50. Embedded Qhdhp Pharmacy Benefits Copayments Retail Mail Service (up to 90-day supply) Specialty Pharmacy Generic Prescription Drugs Preferred Brand Prescription Drugs Non-preferred Brand Prescription Drugs Deductible Integrated Medical/Rx deductible Benefit Period Maximum Retail Mail Service (up to 90-day supply) Specialty Pharmacy Generic Prescription Drugs Unlimited Unlimited Unlimited Preferred and Non-preferred Brand Prescription Drugs 12 prescription limit, including refills (combined with Mail Service and Specialty Pharmacy) 12 prescription limit, including refills (combined with Retail Service and Specialty Pharmacy) 12 prescription limit, including refills (combined with Mail Service and Retail Pharmacy) (If a Member reaches his/her Benefit Maximum per Benefit Period, benefits for diabetic supplies mandated by law will still be available.) Out-of-Pocket Maximum (includes deductible and coinsurance) Medical plan out-of-pocket maximum applies

10 PersonalBlue Saver PPO SM Plan Benefits Plan Options PersonalBlue Saver PPO $750 PersonalBlue Saver PPO $1,500 PersonalBlue Saver PPO $2,500 PersonalBlue Saver PPO $5,000 In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network Deductible Member $750 $1,500 $2,500 $5,000 Deductible Family $1,500 $3,000 $5,000 $10,000 Out-of-Pocket Maximum Member (includes deductible and coinsurance) $2,250 $3,000 $5,000 $10,000 Out-of-Pocket Maximum Family (includes deductible and $4,500 $6,000 $10,000 $20,000 coinsurance) Coinsurance (only applied after any applicable deductibles have been met) Lifetime Policy Maximum Unlimited Unlimited Unlimited Unlimited Benefit Period Maximum Unlimited Unlimited Unlimited Unlimited Hospital Facility Expense Inpatient (excludes maternity, except for * ; limited to 90 days/benefit period ; limited to 90 days/benefit period ; limited to 90 days/benefit period ; limited to 90 days/benefit period Hospital Facility Expense Outpatient (excludes maternity, except for Emergency Room Care $300 $300 $300 $300 $300 $300 $300 $300 Urgent Care $100 $100 $100 $100 $100 $100 $100 $100 Office/Home Visits $40 PCP/ $40 PCP/ $40 PCP/ $40 PCP/ (up to six visits per member/benefit covered covered covered covered $50 SCP $50 SCP $50 SCP $50 SCP period) Medical Surgical Expenses Preventive Care Spinal Manipulation (six visits per member/benefit period) Mental Health Services Substance Abuse Rehabilitation Substance Abuse Detoxification in full *Subject to coinsurance after a $500 copayment per admission in full in full in full

11 PersonalBlue Saver PPO Pharmacy Benefits Embedded PersonalBlue Saver PPO Pharmacy Benefits Copayments Participating Retail Participating Mail Service Specialty Pharmacy Generic Prescription Drugs (includes diabetic prescription drugs and/or supplies such as but not limited to insulin, needles, and syringes, with no generic equivalent) $15 $30 $45 Preferred Brand Prescription Drugs covered covered covered Non-preferred Brand Prescription Drugs Deductible covered covered covered applicable Benefit Period Maximum applicable Summary of Restrictions Applicable to Prescription Drug Benefits Participating Retail Participating Mail Service Specialty Pharmacy Days Supply Up to 30 days Up to 90 days Up to 30 days Ample Day Supply Limit (percent of the previous supply dispensed that must be used by the Member before a refill will be dispensed) Drug Quantity Management Preauthorization Specialty Medication Preferred Network 75% 60% 75% Applicable Applicable Applicable

12 PersonalBlue PPO Serves the following counties in Pennsylvania: * *The Capital BlueCross service area extends to just one half of Centre County. Thank you for considering Capital BlueCross If you have any questions, visit us online at capitalblue4u.com, or call us at Do you have a smart phone? Scan this barcode to automatically visit our Web site. Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company, Capital Advantage Assurance Company and Keystone Health Plan Central. All are independent licensees of the BlueCross BlueShield Association, serving 21 counties in Central Pennsylvania and the Lehigh Valley. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. NF-837 (1/2013)

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