Health Insurance Marketplace in Illinois Plan Comparison Charts

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1 2015 Independent Authorized Agent for An Independent Licensee of the Blue Cross Blue Shield Association Health Insurance Marketplace in Illinois Plan Comparison Charts preventive services and maternity care. Please see your Summary of Benefits or visit bcbsil.com for more specific information

2 Bronze 2 Deductible and coinsurance still apply. 3 As a reminder, Health Savings Accounts (HSA) have tax and legal ramifications. Blue Cross and Blue Shield of Illinois does not provide legal or tax advice and nothing herein should be construed as legal or tax advice. These materials, and any tax-related statements in them, are not intended or written to be used, and cannot be used consequences of specific health insurance plans or products. 4 Preferred Generics / Non Preferred Generics / Preferred Formulary / Non Preferred Formulary / Specialty 5 Prescription benefit coverage starts after annual medical deductible has been met. 6 Mail order is not available for Specialty tier drugs. Specialty tier is limited to a 30 day supply. 7 Coverage limitations may apply to certain medications. Blue PPO Bronze SM Blue Choice Bronze PPO SM Blue Precision Bronze HMO SM Individual Deductible $5,000 $6,000 $5,000 $6,000 $6,000 Coinsurance 80% 100% 80% 100% 70% Out of Pocket Maximum (includes deductible) $6,600 $6,000 $6,600 $6,000 $6,250 Office Visit Copay (PCP/Specialist) 1st 3 Office Visits are $30 PCP/$60 Specialist copay, then 80% 2 N/A 2 1st 3 Office Visits are $30 PCP/$60 Specialist N/A 2 $25 / $100 copay, then 80% 2 Emergency Room/Outpatient Emergency Care N/A 2 N/A 2 N/A 2 N/A 2 $600 Urgent Care $75 N/A 2 $75 N/A 2 N/A Deductible for Physician Medical/Surgical Services, Hospital Services and Hospital Diagnostic Testing N/A 2 N/A 2 N/A 2 N/A 2 $300 / $250 N/A 2 N/A 2 N/A 2 N/A 2 $300 / $250 HSA Eligible 3 No Yes No Yes No Outpatient Prescription Drugs 4 80% 5 100% 5 90% / 90% / 80% / 70% 60% 5 100% 5 70% / 70% / 60% / 50% 50% 5 Mail-Order Program / 90 Day Retail Benefit 6 Yes Yes Yes Yes Yes Prior Authorization/Step Therapy Requirements: Before receiving coverage for some medications, your doctor will need to receive

3 Silver 2 The standard deductible for this plan is shown. Based on your income and family status you may qualify for one of three lower deductible levels. You will be able to see if you qualify and what your premium, deductible and out-of-pocket costs will be before you make a decision to enroll. 3 The standard out-of-pocket maximum for this plan is shown. Based on your income and family status you may qualify for one of three lower deductible levels. You will be able to see if you qualify and what your premium, deductible and out-of-pocket costs will be before you make a decision to enroll. 4 As a reminder, Health Savings Accounts (HSA) have tax and legal ramifications. Blue Cross and Blue Shield of Illinois does not provide legal or tax advice and nothing herein should be construed as legal or tax advice. These materials, and any tax-related statements in them, are not intended or written to be used, and cannot be used consequences of specific health insurance plans or products. 5 Preferred Generics / Non Preferred Generics / Preferred Formulary / Non Preferred Formulary / Specialty 6 Mail order is not available for Specialty tier drugs. Specialty tier is limited to a 30 day supply. 7 Coverage limitations may apply to certain medications. Blue Precision Silver Blue PPO Silver SM Blue Choice Silver PPO SM HMO SM Individual Deductible $6,000 2 $3,000 2 $6,000 2 $3,000 2 $5,000 2 Coinsurance 100% 80% 100% 80% 80% Out of Pocket Maximum (includes deductible) $6,000 3 $6,350 3 $6,000 3 $6,350 3 $6,350 3 Office Visit Copay (PCP/Specialist) $30 / $50 $30 / $50 $30 / $50 $30 / $50 $30 / $50 Emergency Room/Outpatient Emergency Care $500 $500 $500 $500 $500 Urgent Care $75 $75 $75 $75 N/A Deductible for Physician Medical/Surgical Services, Hospital Services and Hospital Diagnostic $250 / $200 $250 / $200 $250 / $200 $250 / $200 $250 / $200 Testing $250 / $200 $250 / $200 $250 / $200 $250 / $200 $250 / $200 HSA Eligible 4 No No No No No Outpatient Prescription Drugs 5 $0 / $10 / $50 / $100 / $150 $0 / $10 / $50 / $100 / $150 $0 / $10 / $50 / $100 / $150 $0 / $10 / $50 / $100 / $150 $0 / $10 / $50 / $100 / $150 Mail-Order Program / 90 Day Retail Benefit 6 Yes Yes Yes Yes Yes Prior Authorization / Step Therapy Requirements: Before receiving coverage for some medications, your doctor will need to receive

4 Gold Blue PPO Gold SM Blue Choice Gold PPO SM Blue Precision Gold HMO SM Individual Deductible $3,250 $1,500 $3,250 $1,500 $2,000 Coinsurance 100% 80% 100% 80% 80% Out of Pocket Maximum (includes deductible) $3,250 $3,500 $3,250 $3,500 $5,000 Office Visit Copay (PCP / Specialist) $30 / $50 $10 / $60 $30 / $50 $10 / $60 $30 / $50 Emergency Room / Outpatient Emergency Care $400 $400 $400 $400 $400 Urgent Care $75 $75 $75 $75 N/A Deductible for Physician Medical / Surgical Services, Hospital Services and Hospital Diagnostic Testing $200 / $150 $200 / $150 $200 / $150 $200 / $150 $200 / $150 (Inpatient/ Outpatient Surgery) $200 / $150 $200 / $150 $200 / $150 $200 / $150 $200 / $150 HSA Eligible 2 No No No No No Outpatient Prescription Drugs 3 $0 / $10 / $50 $100 / $150 Mail-Order Program/90 Day Retail Benefit 4 Yes Yes Yes Yes Yes Specialty Pharmacy Program: To be eligible for maximum benefits, specialty medications must be obtained through the preferred Specialty Pharmacy provider. Management Programs 5 Member Pay the Difference: When choosing a brand name drug over an available generic equivalent, you pay your usual share plus the difference in cost. Prior Authorization/Step Therapy Requirements: Before receiving coverage for some medications, your doctor will need to receive 2 As a reminder, Health Savings Accounts (HSA) have tax and legal ramifications. Blue Cross and Blue Shield of Illinois does not provide legal or tax advice and nothing herein should be construed as legal or tax advice. These materials, and any tax-related statements in them, are not intended or written to be used, and cannot beused or relied on for the purpose of avoiding tax penalties. Tax related statements, if any, may have been written in connection with the promotion or marketing of the transaction(s) or matter(s) addressed by these materials. You should seek advice based on your particular circumstances from an independent tax advisor regarding tax consequences of specific health insurance plans or products. 3 Preferred Generics / Non Preferred Generics / Preferred Formulary / Non Preferred Formulary / Specialty 4 Mail order is not available for Specialty tier drugs. Specialty tier is limited to a 30 day supply. 5 Coverage limitations may apply to certain medications. 6 Prescription benefit coverage starts after annual medical deductible has been met.

5 in Illinois Plan Comparison Chart Blue Cross Blue Shield Blue Cross Blue Shield Blue Cross Blue Shield Blue Cross Blue Shield Blue Cross Blue Shield Premier 1, Premier 2, Solution 3, Solution 4, Basic 5, Multi-State Plans a Multi-State Plan SM a Multi-State Plan SM a Multi-State Plan SM a Multi-State Plan SM a Multi-State Plan SM Gold Gold Silver Silver Bronze Individual Deductible $1,000 $500 $4,500 $6,250 $3,750 Coinsurance 80% 80% 80% 100% 70% Out of Pocket Maximum (includes deductible) $2,750 $4,000 $6,350 $6,250 $6,250 Office Visit Copay (PCP / Specialist) $25 / $50 $30 / $60 $30 / $50 $40 / $70 N/A 2 Emergency Room / Outpatient Emergency Care $400 $400 $500 $500 $600 Urgent Care $75 $75 $75 $75 $75 Deductible for Physician Medical / Surgical Services, Hospital Services and Hospital Diagnostic $200 / $150 $200 / $150 $250 / $200 $250 / $200 $300 / $250 Testing (Inpatient / Outpatient Surgery) $200 / $150 $200 / $150 $250 / $200 $250 / $200 $300 / $250 (Inpatient / Outpatient Surgery) Network PPO PPO PPO PPO PPO HSA Eligible 3 No No No No No Outpatient Prescription Drugs 4 $0 / $10 / $50 / $100 / $150 $0 / $10 / $50 / $100 / $150 / $0 / $10 / $50 / $100 / $150 70% 5 Prescription Drug Formulary Standard Standard Standard Standard Standard Mail-Order Program / 90-Day Retail Benefit 6 Yes Yes Yes Yes Yes Prior Authorization/Step Therapy Requirements: Before receiving coverage for some medications, your doctor will need to receive 1 Benefits reduced when non-participating providers are used. This is a summary of benefit highlights only 2 Deductible and coinsurance still apply 3 As a reminder, Health Savings Accounts (HSA) have tax and legal ramifications. Blue Cross and Blue Shield of Illinois does not provide legal or tax advice and nothing herein should be construed as legal or tax advice. These materials, and any tax-related statements in them, are not intended or written to be used, and cannot be used consequences of specific health insurance plans or products 4 Preferred Generics / Non-Preferred Generics / Preferred Formulary / Non-Preferred Formulary / Specialty 5 Prescription benefit coverage starts after annual medical deductible has been met. 6 Mail order is not available for Specialty tier drugs. Specialty tier is limited to a 30-day supply 7 Coverage limitations may apply to certain medications

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