Plans effective 1/1/2013 affordable group health Insurance... only from the 01MK1418 R2/13

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1 Plans effective 1/1/ MK1418 R2/13 affordable group health Insurance... only from the Cross and Shield!

2 What s Inside Introducing trueblue 3 The trueblue Difference 4 trueblue Benefits 5 Solid PPO Provider Network 5 Deductibles and Coinsurance 5 Out-of-Pocket Maximums 6 Preventive Care 6 Prescription Drug Program 7 Special Options and Features 8 Owner 24-Hour Coverage 8 Accidental Injuries 8 Organ, Tissue and Bone Marrow Transplant Benefits 8 Mental and Nervous/Alcohol and Drug Abuse 9 Pregnancy Care 9 care Management Programs 9 Customer Service 9 Value-Added Services 10 Cafeteria Plans 11 General Conditions 12 Benefit Summary Chart 14 Small Employer Notice 16 This proposal is presented for general information only. It is not a Benefit Plan, nor intended to be construed as a Benefit Plan. If there is any discrepancy between this document and the Benefit Plan, the Benefit Plan will govern the benefits paid. For complete information, please refer to the Benefit Plan. Premium will vary with the amount of benefits chosen. trueblue refers to Benefit Plan #40HR1543. Cafeteria Plans refer to Flexible Spending/Cafeteria Section 125 contract #28XX1412. NOTICE: Healthcare services may be provided to you at a network healthcare facility by facility-based physicians who are not in your health plan. You may be responsible for payment of all or part of the fees for those out-of-network services, in addition to applicable amounts due for copayments, coinsurance, deductibles and non-covered services. Specific information about in-network and out-of-network facility-based physicians can be found at or by calling the customer service telephone number on the back of your ID card. 2

3 Affordable group health insurance? You better believe it! If you thought group health coverage was out of your reach, you ll be glad to know there s an innovative plan that gives your employees the protection they deserve at a price you can afford! As an employer, you benefit in a number of ways by providing health insurance to your employees. The most obvious benefit is employee retention. A study conducted by Randstad North America showed that 70 percent of employees ranked healthcare coverage as the most important benefit offered by a company. Insured employees also tend to seek the care of a doctor more often than uninsured employees, making them healthier and keeping production levels up. Additionally, tax benefits ensure that healthcare is a very cost-effective way to compensate employees employer contributions are 100 percent tax deductible. Introducing trueblue from Blue Cross and Blue Shield of Louisiana trueblue is a fully comprehensive health plan that offers substantial savings over other plans. trueblue covers a complete list of comprehensive services, including: Doctor visits Visits to other healthcare providers lab tests X-rays Prescription drugs Inpatient procedures outpatient procedures trueblue Information on the most current rating is available at or by calling Standard & Poor s at

4 This innovative coverage features comprehensive networks that are both affordable and predictable. The trueblue Difference THE trueblue Difference trueblue offers options to fit your needs and budget. trueblue s unique benefit design is divided into two benefit categories: (1) Inpatient/Outpatient services and (2) Prescription Drugs. Services and supplies rendered in an inpatient setting and services performed on an outpatient basis are included in the Inpatient/Outpatient benefit category (see example below). Brand-name and generic prescription drugs are included in the Prescription Drugs benefit category. (1) (2) Inpatient/Outpatient prescription Drugs physician & allied brand-name & generic provider charges prescription drugs X-rays lab tests hospital and allied facility charges emergency room services prescription drugs administered in an inpatient setting trueblue: The Affordable Alternative We found a way to make trueblue so affordable through a simple cost-sharing idea. Like other comprehensive plans, trueblue requires that a deductible first be met before benefits are paid. A deductible is an amount that the member must pay out-of-pocket in a benefit period (calendar year) before coverage begins. In such cases, the member pays the first dollars of his or her coverage. Once the deductible is met, the costs of healthcare are shared between Blue Cross and the member on a percentage basis. This shared percentage is called the coinsurance. Unlike other plans, a separate deductible applies to each of the two benefit categories above. 2 4

5 Solid PPO Provider Network Lifetime Maximum Deductibles & Coinsurance Out-of-Pocket Maximums Preventive Care Prescription Drug Program Solid PPO Provider Network Our roots in the Louisiana medical community date back to 1934, when the forerunner of today s company was founded. Because of our longstanding relationship with hospitals, physicians and other providers in the state, we are able to offer special features to our members and pass on the cost savings. The PPO network is a select group of hospitals, physicians and allied providers who have contracted with us and agreed to accept the lesser of billed charges or a negotiated amount as payment in full for covered services. This amount is called the PPO provider s allowable charge and is used to determine our payment for covered services. The PPO benefit option provides the highest level of coinsurance when members receive care from PPO network providers. When covered services are received from a non-participating hospital or provider, benefits will be reduced. See Benefit Plan for details. Provider information can be found on our website at trueblue Benefits Deductibles and Coinsurance trueblue PPO plans offer a variety of deductibles: $500 $750 $1,000 You choose one deductible amount for each of the two benefit categories. This deductible must be met for each benefit category before coinsurance begins for that category. Once the deductible is met for the Inpatient/Outpatient benefit category, trueblue pays 80 percent of the allowable charge for covered services received by a PPO provider and 60 percent of the allowable charge for covered services received by a non-ppo provider in the applicable benefit category. trueblue Benefits 5

6 Once the deductible is met in the Prescription Drugs benefit category, trueblue plans pay 50 percent for brand-name prescription drugs and 100 percent for generic prescription drugs. For example: (1) (2) Inpatient/Outpatient prescription Drugs $500 deductible $500 deductible once met, trueblue once met, trueblue PPO pays PPO pays 80% in-network 50% brand-name prescription drugs 60% out-of-network 100% generic prescription drugs The deductible applies to a January 1 through December 31 calendar-year benefit period. Each covered family member has an individual deductible; once three family members reach their deductibles, no other member has to satisfy a deductible within the same category for that benefit period. The family deductible applies separately to the Inpatient/ Outpatient and Prescription Drugs benefit categories. Out-of-Pocket Maximums trueblue also allows you to choose one out-of-pocket maximum for each benefit category: $1,000 or $2,000. Once this maximum is reached, trueblue pays 100 percent of the allowable charge for covered expenses. For example: (1) (2) Inpatient/Outpatient prescription Drugs $1,000 out-of- $1,000 out-ofpocket max pocket max once reached, trueblue pays 100% of allowable charges for covered services once reached, trueblue pays 100% for brandname prescription drugs 100% for generic prescription drugs For extra protection, there is a combined out-ofpocket maximum for family coverage for the Inpatient/ Outpatient benefit category. If the member s individual out-of-pocket maximum is $1,000, the family outof-pocket maximum is two-and-a-half times that amount. If the member s individual out-of-pocket maximum is $2,000 or more, the family out-of-pocket maximum is twice that amount. $1,000 X 2 ½ = $2,500 $2,000 X 2 = $4,000 There is no family out-of-pocket maximum for prescription drugs. Preventive Care Blue Cross and Blue Shield of Louisiana is committed to preventive care. Detecting illnesses in their early stages ensures better health for our members and reduces medical costs for everyone. To promote preventive care, trueblue covers a full array of wellness services. Blue Cross pays 100 percent of the allowable charge, with no deductible needed, on the following services when rendered by a preferred provider: routine physical exam digital rectal exam and prostate specific antigen (Psa) screening test (age 50 and older), if recommended by physician routine hemoccult (colon) test routine gynecological (pelvic) exam 6

7 network pharmacist and he or she will determine the discounted charge. The pharmacist will automatically file a claim on behalf of the member and advise the member when the deductible has been satisfied. Prescriptions filled at a retail pharmacy may be limited to a 30-day supply. well baby care immunizations as recommended by the member s physician routine Pap smear mammogram screening as recommended by the member s physician autism screening breast cancer screening cervical cancer screening depression (adults) screening HIV screening lipid disorders (adults) screening phenylketonuria (PKU) screening type 2 diabetes mellitus (adults) screening visual impairment in children younger than age 5 years screening Wellness services received from non-ppo providers are subject to out-of-network coinsurance levels. Prescription Drug Program Since prescription drugs can be a costly part of your healthcare, trueblue includes a prescription drug benefit that helps to defray these costs. Members may access prescription drugs through retail pharmacies or through our mail-order service. Broad Pharmacy Retail Network Blue Cross and Blue Shield of Louisiana s prescription drug program is administered by Express Scripts, Inc., which is an independent company. Most major retail pharmacies across the nation participate in our pharmacy network. To fill a prescription, members simply present their ID card to an Express Scripts Mail-Order Service For prescriptions used on an ongoing basis such as medication for blood pressure, asthma or diabetes mail service may be more cost-effective for the member. To use this service, members simply mail or fax their prescriptions to our mail-order pharmacy, Express Scripts, Inc., for up to a 90-day supply. Members have ongoing access to prescription drug information through the Express Scripts website at Step Therapy In some cases, you may be required to try a certain prescription drug to treat a condition in order to receive coverage. If this drug does not work for your condition, we will cover a second prescribed medication. Prior Authorization Certain prescription drugs and supplies require prior authorization. Please check your Schedule of Benefits, visit the website at or call the Customer Service number on the back of your ID card to see what drugs and supplies require prior authorization. Quantity Per Dispensing Limitations & Allowances Covered prescriptions have a quantity limit described in your benefit plan (typically up to a 30-day supply at a retail pharmacy and up to a 90-day supply for mail-order). These limits are based on the manufacturer s recommended dosage and duration of therapy; common usage for episodic or intermittent treatment; FDA-approved recommendations and/or clinical studies; and/or as determined by Blue Cross and Blue Shield of Louisiana. QPD limits/allowances are subject to quantity limits per day supply, per dispensing event, or any combination thereof. NOTE: Specialty drugs may be limited to a 30-day supply. trueblue Benefits 7

8 Owner 24-Hour Coverage Accidental Injuries Organ, Tissue and Bone Marrow Transplant Benefits Mental and Nervous / Substance Abuse Pregnancy Care Cafeteria Plans Care Management Programs Customer Service Value-Added Services Special Options and Features Owner 24-Hour Coverage For the protection of employers, Blue Cross offers coverage for occupational injuries and diseases for qualified company owners. Coverage for services that are required to be covered in whole or in part by Workers Compensation insurance is also available for owners, if the owner complies with La. R.S. 23:1035(A). Accidental Injuries Blue Cross and Blue Shield of Louisiana includes coverage for accidental injuries up to a maximum benefit of $350 per benefit period, not subject to benefit period deductible or coinsurance. The first $350 of covered medical expenses from an accidental injury will be covered at 100 percent of the allowable charge. Once this maximum is exhausted, comprehensive medical benefits will be paid, subject to benefit year deductibles and coinsurance, for the remainder of that benefit period. Organ, Tissue and Bone Marrow Transplant Benefits Eligible organ, tissue and bone marrow transplants are covered. Members have access to the Blue Quality Centers for Transplant, a network of major hospitals and research institutions located throughout the country. Patient care is coordinated with Blue Cross and Blue Shield of Louisiana case management, physicians and institutions. Eligible organ, tissue and bone marrow transplants will be covered, including a $50,000 acquisition expense maximum. See the organ, tissue and bone marrow transplant section of the benefit plan or contract for complete details and qualifications. 2 8

9 Mental and Nervous / substance Abuse Coverage for Mental and Nervous/Substance Abuse is paid the same as or better than any other illness. All benefits are subject to any applicable deductible and coinsurance and/or copayments (coinsurance applies to the out-of-pocket maximum). Please refer to the quote sheet for specific option(s) quoted and appropriate deductible, coinsurance and/ or copayment quoted for the group. Pregnancy Care Pregnancy care is automatically included for employees and covered spouses in all group plans with 15 or more employees. Groups with 14 or fewer employees on the payroll can exclude pregnancy benefits if desired. Miscarriages and ectopic pregnancies are covered under medical and surgical benefits regardless of whether the pregnancy option is chosen. Please refer to the quote sheet for options quoted. Care Management Programs trueblue is strengthened by our Care Management programs that ensure your care is appropriate. Our team of doctors, nurses and in-house pharmacists oversees our members care through the following functions: 1. Authorization of Elective Admissions If you need to be hospitalized for a condition other than an emergency, your admission to the hospital requires authorization. Patients, physicians, hospitals and our Care Management Department all participate in this process that is used to determine whether hospitalization is necessary and an appropriate length of stay. In the case of an emergency admission, written authorization must be requested within 48 hours of the admission by you or your provider. 2. Concurrent Review The process of determining whether continued hospital care is appropriate, also called concurrent review, will be conducted from time to time during a lengthy hospital stay. Our Care Management Department works directly with the patient, the hospital and the admitting physician to assess the continued necessity of hospitalization. If a patient chooses to stay in the hospital after it is determined to be unnecessary, he or she will be responsible for all expenses incurred during the remainder of the stay. 3. Case Management Case Management is a special service performed at the discretion of Blue Cross. Case Management oversees the treatment of unusually complex, difficult or lengthy illnesses. The case management staff, with the member s acceptance, can develop a long-term treatment plan to achieve the most efficient, effective use of medical resources. 4. Authorization of Covered Services Certain services and supplies require written authorization from Blue Cross before services can be performed. This allows our medical staff to review a procedure or service and determine whether it is in the best interest of the patient. Please see the Benefit Plan and schedule of benefits for a list of services and supplies that require prior authorization. 5. Retrospective Review A retrospective review may be performed to assess the medical need and correct billing level for services that have already been rendered. Customer Service Your Answer is Just a Click or a Call Away Have a question about your claim? Want to know if a service is covered under your plan? Get the answers to your healthcare coverage questions using our new, secure online Customer Inquiry Form. This form allows you to submit questions to our Customer Service Department securely and conveniently any time of day or night. Simply log on to the Blue Cross website at click on Customer, then choose Customer Inquiry Form. Follow the directions on the screen to get started! You can always call us between 8 a.m. and 5 p.m., Monday through Friday, at BLUE (2583). This number is also listed on your member ID card. Special Options and Features 9

10 Value-Added Services DISCOUNT FEATURES Dental Discount Network Members can take advantage of special discounts on dental services. Members simply present their ID card to one of the participating providers and immediately receive significant savings. To find a discount provider, visit and click on Find a Doctor or Hospital. Under the Online Louisiana Directory, click on Search Our Directory. From the drop-down menu, choose Discount Dental. Please note that these services are not eligible for benefits under the benefit plan. Blue 365 Living well means having healthy options every day. That s why we offer Blue365 to take our members beyond health insurance and give them access to trusted health and wellness resources 365 days a year and enjoy special member values on many services. Blue365 is a national program that s part of every trueblue plan, offering exclusive access to information, discounts and savings, making it easier and more affordable to make healthy choices. Health & Wellness Fitness discounts on local health club memberships and free access to online tools Diet/Weight Control savings on programs, products and consultations at Jenny Craig, ediets and NutriSystem. Vision Discounts With Blue365 our members can receive routine eye exams, frames, lenses, conventional contact lenses and laser vision correction at substantial savings when using Davis Vision network providers. Members have access to more than 30,000 providers nationwide, including optometrists, ophthalmologists and many retail centers. BCBSLA members can also save 40 to 50 percent off the overall national average price for Lasik surgery through QualSight lasik. Family Care Senior Care discounts on care advisory services Child Safety resources for child safety and consumer product information Long-Term Insurance free guidelines and information Managing Medicare resources to understand coverage options from Medicare Financial Well-Being Plan for Your Future understanding Medicare-related health insurance options and how they affect your financial future Financial Resources educational tools to prepare for long-term healthcare needs Travel Healthy Getaways special discounts on hotel programs and services Worldwide Health Coverage access to doctors and hospitals across the globe Travel Tips a wealth of online travel tips and resources Members can explore all the healthy choices through the Wellness Discount link in AccessBlue at My Health Commitment, our unique workplace wellness program It s easy to overlook the critical link between your employees health and your company s bottom line. Healthy employees can have a positive impact on: Healthcare costs Productivity Absenteeism Retention of quality personnel Employee quality of life My Health Commitment, our workplace wellness program offered at no cost, gives your employees the resources they need to live healthier every day. Built right into your Blue Cross health plan, My Health Commitment includes: Personal Health Assessments Healthy lifestyle resources Wellness trackers Regional wellness events Local resource listings Discount programs And more! For employers who want to expand their wellness offering, we offer upgrades to the core program listed above. For more information about My Health Commitment, talk to your producer or visit us at 10

11 Sometimes referred to as a Section 125 Cafeteria plan, a Flexible Spending Account lets employees set aside a certain amount of each paycheck into an account before paying income tax. The participant can use the account to pay for out-of-pocket expenses at the doctor or pharmacy, chiropractic, eyeglasses, contacts, Lasik, orthodontics and more. Advantages of an FSA for Employers Save on payroll taxes approximately 8 percent on every dollar employees set aside. Cushion health insurance increases to lessen the impact on employee s paycheck. Plan fees can be paid by employer or employee. Participants and employers can view and manage their flex accounts online at their convenience. The standard Flexible Spending Accounts include a Premium-Only Plan, Medical Reimbursement Account and Dependent Care Plan. Cafeteria Plan Premium-Only Plan The Section 125 Premium Only Plan saves you and your employees by reducing payroll taxes. It works by making one simple adjustment in your payroll process: Employees pay their portion of insurance premiums on a pre-tax basis. Qualifying premiums may include an employee s share of employersponsored health, dental, disability, accident and group term life insurance. Medical Reimbursement This account allows participants to set aside money from each paycheck for the reimbursement of medical expenses of a dependent child under age 13. Dependent Care Plan Employees set aside pre-tax payroll deductions to budget for the daycare expenses of a dependent child under age 13. You can review our entire Flexible Spending Account offerings plan online at Our online resource provides employers with plan options, advantages to employees and numerous administrative tools. Once enrolled in our Fsa, employers and employees can view and manage their flex accounts at their convenience. Cafeteria Plan 11

12 Eligible Groups Eligible Employees Eligible Dependents Group Rates Renewability Coordination of Benefits Health Questions Prior Group Coverage Special Enrollment Late Enrollee Benefit Plan Limitations and Exclusions General Conditions Eligible Groups All groups with two or more employees are eligible to apply for coverage. There are no industry restrictions. Firms that have been in business less than one year are subject to home-office rating and approval. Firms that do not have a current carrier or are seasonal also are subject to home-office rating and approval. In some cases, firms with a significant number of employees living outside of Louisiana may not be eligible. If a firm chooses a contributory plan, at least 75 percent of its full-time eligible employees must participate. For non-contributory plans, 100 percent participation is required. These percentage requirements are for the initial and ongoing enrollment. Other specific conditions that may apply are contained within the group master application. Eligible Employees All full-time employees working a minimum of 30 hours per week and their qualified dependents may apply. Individuals on retainer (examples: attorneys, accountants, business consultants and 1099 contract employees) and members of boards of directors are not eligible. Eligible employees, their eligible spouses and their eligible dependents cannot be individually denied coverage for any reason related to health status. If health question responses are requested by Blue Cross, they will be used for group rating purposes. The effective date of coverage or benefit change will not be delayed because an employee is not actively at work due to health status. Exclusions for pre-existing conditions may apply. 2 12

13 Eligible Dependents Insured employees may cover their spouses. They also may cover their children and grandchildren as long as they are under 26 years of age. For grandchildren to be eligible, they also must reside with, and be in legal custody of, the employee. Children (and grandchildren in legal custody of and residing with the employee) who are mentally or physically disabled also are eligible for coverage. They must be incapable of self-support and enrolled prior to reaching age 26. They must also continue to meet the disability criteria. See Benefit Plan for details on other dependents who may qualify. Group Rates Rates may increase after the first 12 months and every six months thereafter due to factors including, but not limited to: demographic changes of the group, including age changes claims experience of all groups in the class of business a group s claims experience, health status and duration of coverage an overall rise in medical costs regulatory considerations changes to benefit plan design However, rates may increase more frequently than stated above as described in the benefit plan. Renewability All benefit plans are renewable at the employer s option, except in the cases of: nonpayment of premium fraud or misrepresentation noncompliance with plan provisions, including not meeting minimum participation and eligibility requirements termination of all employer plans in that class of business (90 days advance notice will be given) The employer or Blue Cross may terminate the benefit plan with 60 days advance notice. Coordination of Benefits Coordination of benefits will be conducted when a participant has additional group coverage. This provision helps keep premiums low by preventing duplicate payments for the same services. Health Questions In groups with two to 19 employees, applicants and any eligible dependents must answer all health questions on the employee application form. In groups with 20 or more employees, employees who apply after the group s initial eligibility period can apply within 30 days prior to the group s anniversary date and must answer all health questions on the employee application form. These questions will not be used to reject the application. Prior Group Coverage When the employer is replacing another group insurer, Blue Cross adheres to all replacement requirements. Credit will be given for any time served toward a waiting period for pre-existing conditions. This applies to employees listed on the current invoice of the previous insurer. If an employee declines coverage for himself/ herself, spouse, or dependent child(ren) because of certain other health insurance coverage, he/she may in the future be able to enroll himself/herself or spouse, or dependent child(ren) in this health plan, provided that a complete request for enrollment is received within 30 days after the other coverage ends. General Conditions 13

14 benefit Summary chart Plan Option Deductible Options Family Deductible Max Out-of-Pocket Max Options Family Out-of- Pocket Max Wellness Benefits Prescription Benefits PPO 80/20 $250 $1,500 $1,000 $2,500 (60/40 $500 $2,250 $2,000 $4,000 out-of- $750 $3,000 network) $ 1,000 In addition, if an employee gains a new dependent as a result of marriage, birth, adoption, or placement for adoption, he/she may be able to enroll himself/herself, spouse, and dependent child(ren) in this plan, provided a complete request for enrollment is received within 30 days after marriage, or within 30 days after birth, adoption, or placement of adoption. Special Enrollee In certain circumstances, an employee may enroll himself/herself or spouse, or dependent child(ren) in this health plan. These circumstances include, but are not limited to, the following: Loss of certain types of other coverage Acquiring a dependent Please refer to the benefit plan for details on special enrollment rights. Late Enrollee A late enrollee is an eligible employee, spouse or dependent child(ren) who: does not enroll for group health insurance coverage when first eligible, and does not meet the qualifications of a special enrollee. An eligible employee must be covered in order to add a spouse or dependent(s). Late enrollees may apply for coverage during the group s open enrollment period within 30 days prior to the group s policy anniversary date, but will have an 18-month exclusion period for pre-existing conditions. 14

15 Drug Dental Insurance Option Owner 24-Hour Coverage Rehab Services Accidental Injury Option Organ, Tissue and Bone Marrow Transplants Mental Disorders & Substance Abuse Pregnancy Benefits (optional below 15) $350 deductible eligible per & employee benefit coinsurance & covered period apply spouse only Benefit Plan Limitations and Exclusions (See Benefit Plan for complete list.) Limitations and exclusions include, but are not limited to: charges exceeding the allowable charge investigational surgery or treatments sales tax (except on covered prescription drugs) interest infertility treatments fertility drugs cosmetic surgery or treatment weight reduction surgery and programs corrective eyeglasses or lenses contact lenses treatment of impotence custodial care services that are not medically necessary General Conditions 15

16 Small Employer Notice Change in Premium Amount Premiums for this Benefit Plan may increase after the Group s first twelve (12) months of coverage and every six (6) months thereafter, except when premiums may increase more frequently as described in the following paragraph. Except as provided in the following paragraph, We will give Group forty-five (45) days written notice of any change in premium rates (ninety (90) days written notice for employer groups with more than one-hundred (100) enrolled employees). We will send notice to the Group s latest address shown in Our records. Any increase in premium is effective on the date specified in the rate change notice. Continued payment of premium will constitute acceptance of the change. We reserve the right to increase the premiums more often than stated above due to a change in the extent or nature of the risk that was not previously considered in the rate determination process at any time during the life of the Benefit Plan. This risk includes, but is not limited to, the right to increase the premium amount because of: (1) the addition of a newly covered person; (2) the addition of a newly covered entity; (3) a change in age or geographic location of any individual insured or policyholder; (4) or a change in the policy Benefit level from that which was in force at the time of the last rate determination. An increase in premium will become effective on the next billing date following the effective date of the change to the risk. Continued payment of premium will constitute acceptance of the change. If the sole reason for termination is that Group s participation falls to less than two (2) employees (there is only one (1) employee covered (or owner, if covered), termination of Group coverage will be effective on the Group s next anniversary date. Otherwise, termination for a reason addressed in this paragraph will be effective after Group receives sixty (60) days written notice as described below: In the case of Network plans, there is no longer any enrollee under the Group benefit plan that lives, resides, or works in the service area of the Company or in the area for which the Company is authorized to do business. Group s coverage is provided through a bona fide association and the employer s membership in the association ends. Company ceases to offer this product or coverage in the market. Renewability of Coverage Company may terminate this Benefit Plan if any one of the following occurs: Group commits fraud or makes an intentional misrepresentation. Group fails to comply with a material plan provision, including, but not limited to provisions relating to eligibility, employer contributions or Group participation rules. 16

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20 Sales OFFICES Alexandria Coliseum Boulevard, Suite A Alexandria, Louisiana Baton Rouge Reitz Avenue Baton Rouge, Louisiana Houma St. Charles Street, Suite 135 Houma, Louisiana Lafayette Johnston Street Lafayette, Louisiana Lake Charles West Prien Lake Road Lake Charles, Louisiana Monroe Mercedes Drive Monroe, Louisiana New Orleans North Causeway Boulevard, Suite 600 Metairie, Louisiana Shreveport Ashley Ridge Boulevard Shreveport, Louisiana Customer Service Baton Rouge help@bcbsla.com 5525 Reitz Avenue Baton Rouge, Louisiana Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company