Capital BlueCross offers a variety of health care choices. Pick the one that s right for you!

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1 Traditional Our traditional product features comprehensive benefits and complete freedom to choose your physician, specialist or hospital. You minimize your out-of-pocket costs by receiving covered services from a participating health care provider. Tr a d i t i o n a l covers the following benefits when you see a participating provider. Hospital Services Physician Services Major Medical Services Annual deductible N o n e $250 per person; up to a maximum of 3 deductibles applied per family per benefit period Out-of-pocket maximum N o n e $500 per person; up to a maximum of 3 deductibles applied per family per benefit period Preventive care services Some services are covered Physician office visits Not covered Maternity care Covered in full Outpatient hospital services Covered in full Inpatient hospital services Covered in full Covered in full Covered in full, deductible waived Ambulance services Not covered Covered in full for emergency care Durable medical equipment Not covered Inpatient mental health care* Covered in full ; unlimited days (30 days per benefit period) Outpatient mental health care* Not covered 50% coinsurance; unlimited visits Substance abuse care* Covered in full Not covered Not covered Lifetime maximum bene f i t U n l i m i t e d $ 1, 0 0 0, long-term disability. *Standard products include Pennsylvania mandated benefits. Deductible, copayments and/or coinsurance may be waived for some products. Please contact Customer Service for more detailed information. Basic hospitalization issued by Capital BlueCross and medical surgical and major medical issued by its wholly owned subsidiary, Capital Advantage Insurance Company, Independent Licensees of the Blue Cross and Blue Shield Association. This information highlights our product offerings and is not intended to be a complete list or complete description of available services. All coverages are subject to contract terms, conditions, exclusions and limitations, including but not limited to, preauthorization requirements for certain treatments or procedures and exclusions for medical care that is experimental, not medically necessary and appropriate, and for injuries caused by the use or maintenance of a motor vehicle or covered under worker's compensation. Please contact your marketing representative for additional information on conditions, exclusions or limitations. Programs subject to change.

2 P re f e rred Provider Organization (PPO) A Preferred Provider Organization (PPO) plan with enhanced traditional coverage, including comprehensive benefits, preventive health care services and freedom to choose your physician, specialist or hospital. You minimize your out-of-pocket costs by receiving covered services from a network provider. Preferred Provider Organization (PPO) covers the following benefits. Network Provider N o n - N e t w o r kp r o v i d e r Annual deductible N o n e $250 per person $750 per family Out-of-pocket maximum N o n e $2,000 per person $6,000 per family Preventive care services $10 copayment per office visit Physician office visits $10 copayment per visit Maternity care Covered in full Outpatient hospital services Covered in full 20% professional coinsurance 50% facility coinsurance^ Inpatient hospital services Covered in full 20% professional coinsurance 50% facility coinsurance^ Covered in full; $35 emergency room copayment (waived if admitted); deductible waived Ambulance services Covered in full for emergency care Durable medical equipment Covered in full Inpatient mental health care* Covered in full 50% coinsurance (30 days per benefit period) Outpatient mental health care* $10 copayment per visit 50% coinsurance (60 visits per benefit period) Substance abuse care* Covered in full Not covered Lifetime maximum bene f i t U n l i m i t e d long-term disability. *Standard products include Pennsylvania mandated benefits. Deductible, copayments and/or coinsurance may be waived for some products. Please contact Customer Service for more detailed information. Issued by Capital Advantage Insurance Company, a wholly owned subsidiary of Capital BlueCross. ^ Excluded from out-of-pocket maximum; continues once out-of-pocket maximum is met. This information highlights our product offerings and is not intended to be a complete list or complete description of available services. All coverages are subject to contract terms, conditions, exclusions and limitations, including but not limited to, preauthorization requirements for certain treatments or procedures and exclusions for medical care that is experimental, not medically necessary and appropriate, and for injuries caused by the use or maintenance of a motor vehicle or covered under worker's compensation. Please contact your marketing representative for additional information on conditions, exclusions or limitations. Programs subject to change.

3 PPO Plus With PPO Plus, you can voluntarily designate a primary care physician (PCP) and pay a lower copayment for offi ce-based services provided by that PCP. You can also receive covered services from any participating PCP or specialist and pay the standard copayment for offi ce-based services (see below). Whether or not you choose a PCP, no referrals are required for special care. Note: The voluntary PCP benefi t is available only to those members who select a PCP from the list of voluntary PCPs in the Capital BlueCross directory. PPO Plus covers the following benefi ts. Voluntary PCP No PCP referral required Other Network Provider Non-Network Services Annual deductible None None $1,000 per person $3,000 per family Out-of-pocket maximum Does not apply Does not apply $3,000 per person $6,000 per family No deductible No deductible Deductible applies to all services unless otherwise noted Preventative care services $ 10 copayment per offi ce visit $20 copayment per offi ce visit 50% coinsurance; up to a $400 maximum per benefi t period Physician offi ce visits $ 10 copayment per offi ce visit $ 20 copayment per offi ce visit 50% coinsurance Maternity care Covered in full Covered in full 50% coinsurance Outpatient hospital services Covered in full Covered in full 50% professional coinsurance Inpatient hospital services Covered in full Covered in full 50% professional coinsurance Ambulance services Covered in full; $50 emergency room copayment (waived if admitted); deductible waived Covered in full for emergency care Covered in full for emergency care Covered in full for emergency care, deductible waived Durable medical equipment Covered in full Covered in full 50% coinsurance Inpatient mental health care* Covered in full Covered in full 50% professional and facility coinsurance (30 days per benefi t period) Outpatient mental health care* $ 10 copayment per offi ce visit $ 20 copayment per offi ce visit 50% professional and facility coinsurance (60 days per benefi t period) Substance abuse care* Covered in full Covered in full Not covered Lifetime maximum benefit Unlimited Unlimited Unlimited A variety of prescription drug programs are available to fi t your needs. A variety of supplemental products are available, including dental, vision, life, Stop Loss, short-term and long-term disability. * Standard products include Pennsylvania mandated benefi ts. Deductible, copayments, and/or coinsurance may be waived for some products. Please contact Customer Service for more detailed information. Issued by Capital Advantage Insurance Company, a wholly owned subsidiary of Capital BlueCross. This information highlights our product offerings and is not intended to be a complete list or complete description of available services. All coverages are subject to contract terms, conditions, exclusions, and limitations, including, but not limited to, preauthorization requirements for certain treatments or procedures and exclusions for medical care that is experimental, not medically necessary and appropriate, and for injuries caused by the use or maintenance of a motor vehicle or covered under worker s compensation. Please contact your marketing representative for additional information on conditions, exclusions, or limitations. Programs subject to change. GR-M indd (6/2/2005)

4 Capital Blue Cross offers a variety of health care choices. P o i n t - o f - S e rvice (POS) * * Our Point-Of-Service (POS) managed care plan with freedom of choice. The plan s comprehensive coverage emphasizes preventive health care. For maximum benefits, most services need to be coordinated or provided by your primary care physician. Point-of-Service (POS) covers the following benefits. PCP Coordinated Self-Referred Annual deductible N o n e $250 per person $500 per family Out-of-pocket maximum N o n e $1,000 per person $2,000 per family Preventive care services $10 copayment per office visit Physician office visits $10 copayment Maternity care Covered in full Outpatient hospital services Covered in full Inpatient hospital services Covered in full $35 emergency room copyament, $35 copayment, waived if admitted; waived if admitted if emergency criteria not met Ambulance services Covered in full Covered in full, deductible waived Durable medical equipment Covered in full ($2,500 limit per benefit period) Inpatient mental health care* Covered in full (must be obtained (must be obtained from a network provider); from a network provider) 30 days per benefit period Outpatient mental health care* $10 copayment (must be obtained from (must be obtained from a network provider); a network provider) 20 visits; Additional 60 visits may apply for serious mental illness Substance abuse care* Covered in full (must be obtained from a (must be obtained from a network provider) network provider) Lifetime maximum bene f i t U n l i m i t e d U n l i m i t e d long-term disability. Issued by Capital Advantage Insurance Company, a wholly owned subsidiary of Capital BlueCross. **This managed care plan may not cover all your health care expenses. Read your contract of Certificate of Coverage carefully to determine which health care services are covered. For more information, contact Capital BlueCross Customer Service toll-free at

5 C o m p rehensive Part of the Major Medical family of traditional products, this plan is easy to use, has limited paperwork and offers total freedom to choose your physician, specialist or hospital. You minimize your out-of-pocket costs by receiving covered services from a participating health care provider. C o m p r e h e n s i v e covers the following benefits when you see a participating provider. Annual deductible Out-of-pocket maximum Preventive care services Physician office visits Maternity care Outpatient hospital services Inpatient hospital services $250 per person $750 per family $1,000 per person $3,000 per person Some services are covered; 20 percent coinsurance for home & o ffice visits Covered in full, deductible waived Ambulance services Covered in full for emergency care Durable medical equipment Inpatient mental health care* Outpatient mental health care* Substance abuse care* (30 days per benefit period) 50% coinsurance (60 visits per benefit period) Lifetime maximum bene f i t $ 1, 0 0 0, long-term disability. *Standard products include Pennsylvania mandated benefits. Deductible, copayments and/or coinsurance may be waived for some products. Please contact your marketing representative or broker for more detailed information. Issued by Capital Advantage Insurance Company, a wholly owned subsidiary of Capital BlueCross. This information highlights our product offerings and is not intended to be a complete list or complete description of available services. All coverages are subject to contract terms, conditions, exclusions and limitations, including but not limited to, preauthorization requirements for certain treatments or procedures and exclusions for medical care that is experimental, not medically necessary and appropriate, and for injuries caused by the use or maintenance of a motor vehicle or covered under worker's compensation. Please contact Customer Service for additional information on conditions, exclusions or limitations. Programs subject to change.

6 Keystone HMO* A Health Maintenance Organization (HMO) plan is designed to keep members healthy, covering services such as doctor visits, well-baby care, immunizations, gynecological care, preventive pediatric care, and more. Your Primary Care Physician coordinates most of the medical services you need. As long as your care is coordinated through your PCP and properly authorized, you will seldom have to pay more than a modest copayment. This information highlights one of the many plans designs available. It is not intended to be a complete list and description of available services. With certain exceptions, your care must be coordinated or provided by your Primary Care Physician (PCP) in order to receive benefi ts. Certain services are limited in scope and duration; certain services may require preauthorization in advance of the service being rendered. Please consult your Certifi cate of Coverage for more information. PCP Coordinated Annual deductible Out-of-pocket maximum Preventive care services Physician offi ce visits Maternity and newborn care (Copayment applies to fi rst visit only) Outpatient hospital services Inpatient hospital services Urgent Medical Care Outside service area Urgent Medical Care In service area Emergency ambulance services Durable medical equipment and supplies Inpatient mental health care** None None PCP: $15 copayment per visit PCP: $15 copayment per visit (additional $10 copayment for after-hours visit); Specialist: $30 copayment per visit PCP: $15 copayment per visit; Specialist: $30 copayment per visit Covered in full Covered in full after $200 copayment per admission Covered in full after $100 emergency room copayment (waived if admitted) Covered in full after $100 copayment Covered in full after $15 copayment (additional $10 copayment for after-hours visit) Covered in full Covered in full Covered in full after $200 copayment per admission Outpatient mental health care** Inpatient substance abuse care** Outpatient substance abuse care** Lifetime Maximum Benefi t Individual session: $25 copayment per visit; Group session: $5 copayment per visit Covered in full after $200 copayment per admission $25 copayment per visit after fi rst course of treatment Unlimited A variety of prescription drug programs are available to fi t your needs. Contact your marketing representative or broker for more information. A variety of supplemental products are available, including dental, vision, life, Stop-Loss and short-term and long-term disability. Contact your marketing representative or broker for more information. *Issued by Keystone Health Plan Central, a wholly owned subsidiary of Capital BlueCross. **Standard products include Pennsylvania-mandated benefits. All coverages are subject to contract terms, conditions, exclusions, and limitations, including but not limited to, preauthorization requirements for certain treatments or procedures and exclusions for medical care that is experimental, not medically necessary and appropriate, and for injuries caused by the use or maintenance of a motor vehicle or covered under worker s compensation. Please contact your account executive for additional information on conditions, exclusions, or limitations. Programs subject to change. This managed care plan may not cover all your health care expenses. Read your contract carefully to determine which health care services are covered. For more information, call Keystone Health Plan Central Customer Service at GR-M indd (6/23/2005)