2015 Health Benefits

2015 Health Benefits Product Cost Sharing - Member's Responsibility Health Care Reform Compliant Health Care Reform Compliant Health Care Reform Compliant Deductible (DED) (Per Person/Family Aggregate) In-Network NA $600 / $1,800 $600 / $1,800 Out-of-Network NA Combined w/ INN Combined w/ INN Coinsurance (BCBSF pays / Member pays) In-Network 80% / 20% 80% / 20% 80% / 20% Out-of-Network Not Covered 60% / 40% 70% / 30% Out of Pocket Maximum (Per Person/Family Aggregate) Includes Pharmacy Includes Pharmacy Includes Pharmacy In-Network $6,000 / $12,000 $6,000 / $12,000 $6,000 / $12,000 Out-of-Network N/A Combined w/ INN Combined w/ INN Medical Pharmacy OOP Maximum (Per Person Per Calendar Month) In-Network (Preferred) $200 $200 $200 In-Network (Non-Preferred) $700 Combined with Preferred OOP Combined with Preferred OOP Out-of-Network NA NA NA Medical / Surgical Care by a Physician E-Office Visit Services In-Network Family Physician $30 $10 $10 In-Network Specialist $50 $10 $10 Office Services In-Network Family Physician $30 $30 $30 In-Network Specialist $50 $50 $50 Allergy Injections (Office) In-Network Family Physician $10 $10 $10 In-Network Specialist $10 $10 $10

Allergy Testing (Office) In-Network Family Physician $30 In-Network Specialist $50 Out-of-Network Not Covered Health Care Professional Administered Medications in the Office (Medical Pharmacy) In-Network (Preferred) 15% 20% 20% In-Network (Non-Preferred) 35% 20% 20% Out-of-Network Not Covered DED + 50% DED + 30% pregnancy applicable at delivery. Additional services outside of routine pregnancy Maternity Office Services (e.g.,amniocentesis) may require additional cost share. In-Network Family Physician $30 $30 $30 Convenient Care Center Physician Services at Hospital Included under other physician services Included under other physician services In-Network Specialist $50 $50 $50 In-Network $30 $30 $30

In-Network $0 $100 DED + 20% Out-of-Network Not Covered $100 INN DED + 20% Radiology, Pathology and Anesthesiology Provider Services at Hospital In-Network $0 $100 DED + 20% Out-of-Network Not Covered $100 INN DED + 20% Radiology, Pathology and Anesthesiology Provider Services at ASC In-Network $0 $60 DED + 20% Out-of-Network Not Covered $60 INN DED + 20% Physician Services at Locations other than Office, Hospital and ER In-Network Family Physician $30 $30 DED + 20% In-Network Specialist $50 $50 DED + 20% Out-of-Network Not Covered Ded + 40% Ded + 30% Preventive Services (Adult & Well Child) Office Services In-Network Family Physician $0 $0 $0 In-Network Specialist $0 $0 $0 Convenient Care Center Urgent Care Centers Independent Clinical Laboratory Independent Diagnostic Testing Center Physician Services at Hospital Facility Inpatient Hospital Facility (per admit) In-Network

Outpatient Hospital Facility (per visit) Mammograms Colonoscopies In-Network $0 Out-of-Network Not Covered $0 $0 Out-of-Network Not Covered $0 $0 Medical / Surgical Care at a Facility Ambulatory Surgical Center (ASC) In-Network $400 Ded + 20% $75 Out-of-Network Not Covered Ded + 40% Ded + 30% Inpatient Hospital Facility (per admit) In-Network $300 per day up to $1,500 max Option 1: Ded + 20% Option 2: Ded + 20% Option 1: $750 Option 2: $1,500 Out-of-Network Not Covered Ded + 40% $2,500 Outpatient Hospital Facility (per visit) (Surgical) In-Network $500 Option 1: Ded + 20% Option 2: Ded + 20% Option 1:$150 Option 2: $250 Out-of-Network Not Covered Ded + 40% Ded + 30% Outpatient Hospital Facility (per visit) (Non- Surgical) In-Network $500 Out-of-Network Not Covered Included with Surgical Services Included with Surgical Services Non-Routine Colonoscopy (Medically Nec.) Emergency and Urgent Care

Emergency Room Facility (per visit) (Surgery performed or with admit) Out-of-Network 20% INN DED + 20% $100 + 20% Physician Services at ER (Surgery performed or with admit) In-Network $0 $100 DED + 20% Out-of-Network $0 $100 INN DED + 20% Physician Services at ER (No surgery performed or not admitted) In-Network $0 $100 DED + 20% Out-of-Network $0 $100 INN DED + 20% Urgent Care Centers If admitted as an inpatient from ER, the hospital will submit an inpatient hospital claim instead of an ER facility claim. ER Copay will not apply on the claim; only inpatient facility cost share will apply. In-Network 20% DED + 20% $100 + 20% Out-of-Network 20% INN DED + 20% $100 + 20% If admitted as an inpatient from ER, the hospital will submit an inpatient Emergency Room Facility (per visit) (No surgery performed or not admitted) hospital claim instead of an ER facility claim. ER Copay will not apply on the claim; only inpatient facility cost share will apply. In-Network 20% DED + 20% $100 + 20% In-Network $80 $65 $50 Ambulance Out-of-Network 20% INN DED + 20% INN DED + 20% Diagnostic Testing (e.g., Lab, x-ray) Physician Office In-Network Family Physician $30 $30 $30 In-Network Specialist $50 $50 $50 Independent Clinical Laboratory Independent Diagnostic Testing Center In-Network $80 $50 DED + 20% Outpatient Hospital Facility Option 1: Ded + 20% Option 1:$150 In-Network $500 Option 2: Ded + 20% Option 2: $250 Out-of-Network Not Covered Ded + 40% $350

Advanced Imaging (AIS) (MRE, MRA, PET, CT & Nuclear Medicine) Physician Office In-Network Family Physician $300 Ded + 20% $30 In-Network Specialist $300 Ded + 20% $50 Independent Diagnostic Testing Center In-Network $150 Ded + 20% DED + 20% Outpatient Hospital Facility In-Network $500 Option 1: Ded + 20% Option 2: Ded + 20% Option 1:$150 Option 2: $250 Out-of-Network Not Covered Ded + 40% $350 Outpatient Therapy Physician Office In-Network Family Physician $30 $30 $30 In-Network Specialist $50 $50 $50 Outpatient Rehabilitation Facility In-Network $50 $50 $50 Outpatient Hospital Facility Option 1: $30 Option 1: $45 In-Network $100 Option 2: $50 Option 2: $60 Mental Health and Substance Dependency Services Physician Office In-Network Family Physician $0 $0 $0 Inpatient Hospital Facility In-Network Specialist $0 $0 $0 Out-of-Network Not Covered 40% 30% Outpatient Hospital Facility Option 1: $0 $0 In-Network $0 Option 2: $0 $0 Out-of-Network Not Covered 40% 30% Option 1: $0 $0 In-Network $0 Option 2: $0 $0 Out-of-Network Not Covered 40% 30%

Emergency Room Facility(per visit) Physician Services at Hospital Out-of-Network $0 $0 $0 Out-of-Network Not Covered $0 $0 Physician Services at ER Out-of-Network $0 $0 $0 Physician Services at Locations other than Office, Hospital and ER In-Network Family Physician $0 $0 $0 In-Network Specialist $0 $0 $0 Out-of-Network Not Covered 40% 30% Other Special Services and Locations Durable Medical Equipment In-Network Motorized Wheelchairs 20% DED + 20% DED + 20% In-Network All Other 20% DED + 20% DED + 20% Orthotics & Prosthetics In-Network Family Physician 20% DED + 20% DED + 20% Skilled Nursing Facility Home Health Care Hospice Dialysis In-Network Specialist 20% DED + 20% DED + 20% In-Network $0 DED + 20% DED + 20% Medications in Home Health Setting In-Network (Preferred) 15% DED + 20% DED + 20% Birthing Center In-Network (Non-Preferred) 35% DED + 20% DED + 20%

Diabetic Equipment & Supplies Enteral Formula Second Medical Opinion Additional Services Benefit Maximums Ambulance Enteral Formula Gastric Bypass High Risk Colonoscopy Home Health Care Inpatient Rehabilitation Therapy In-Network $80 Copayment Out-of-Network DED + 40% Out-of-Network Not Covered DED + 40% DED + 30% Combined (INN & OON) N/A N/A N/A Combined (INN & OON) N/A N/A N/A 1 PBP 1 PBP 1 PBP In-Network 1 / 2 years N/A N/A Combined (INN & OON) N/A 1 / 2 years 1 / 2 years In-Network 60 Visits PBP N/A N/A Combined (INN & OON) N/A 20 Visits PBP 20 Visits PBP In-Network 30 Days PBP N/A N/A Combined (INN & OON) N/A 30 Days PBP 30 Days PBP Outpatient therapy for autism will continue to be covered after the benefit Outpatient Therapy & Spinal Manipulations In-Network 30 Visits PBP maximum is met. N/A N/A Outpatient Therapy Modalities Preventive Colonoscopy Skilled Nursing Facility Included under other physician services Included under other physician services Combined (INN & OON) N/A 35 Visits PBP 35 Visits PBP In-Network 4 / 1 day N/A N/A Combined (INN & OON) N/A 4 / 1 day 4 / 1 day In-Network 1 / 10 years N/A N/A Combined (INN & OON) N/A 1 / 10 years 1 / 10 years In-Network 45 Days PBP N/A N/A Combined (INN & OON) N/A 60 Days PBP 60 Days PBP

Spinal Manipulations In-Network 30 PBP N/A N/A Combined (INN & OON) N/A 26 PBP 26 PBP Prescription Drugs Deductible N/A N/A N/A In-Network - Retail - Mail Order Generic/Brand/Non-Preferred $15 / $45 / $65 $15 / $45 / $65 $15 / $60 / $100 Out-of-Network - Retail - Mail Order Generic/Brand/Non-Preferred $30 / $90 / $130 $30 / $90 / $130 $30 / $120 / $200 Generic/Brand/Non-Preferred 50% 50% 50% Generic/Brand/Non-Preferred 50% p y 50% 50% Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc., an Independent Licensee of the Blue Cross and Blue Shield Association.