2015 ANNUAL ENROLLMENT GUIDE

2015 ANNUAL ENROLLMENT GUIDE State of Louisiana Employees and Retirees Administered by Blue Cross and Blue Shield of Louisiana Blue Cross and Blue Shield of Louisiana is incorporated as Louisiana Health Service & Indemnity Company and is an independent licensee of the Blue Cross and Blue Shield Association. 01MK4360 R05/15

TABLE OF CONTENTS Introduction... 1 PELICAN HRA 1000... 3-15 PELICAN HSA 775... 17-27 MAGNOLIA LOCAL... 29-41 MAGNOLIA LOCAL PLUS... 43-55 MAGNOLIA OPEN ACCESS... 57-71 Applies to ALL Plans... 72-83 Mental Health and Substance Abuse Benefits... 72 Provider Network... 73 Care Management Programs... 75 General Information... 77 Online Tools... 78 Wellness Programs... 80 Healthy Discounts... 82 Balance Billing Disclosure... 84 This Annual Enrollment Guide is presented for general information only. It is not a benefit plan, nor intended to be construed as the Blue Cross benefit plan document. If there is any discrepancy between this Annual Enrollment Guide and the Blue Cross benefit plan document and Schedule of Benefits, the FINAL Blue Cross benefit plan document and Schedule of Benefits will govern the benefits and plan payments.

Blue Cross and Blue Shield of Louisiana is proud to serve your healthcare needs. Your Blue Cross plan offers many benefits and features, including: a large network of doctors and hospitals physician office visits direct access to specialty care without a referral member discounts and savings through Blue365 a comprehensive new wellness and prevention program online tools to help you get the most from your health plan an ID card recognized around the world local customer service Service Blue Cross is committed to meeting the challenging demands of healthcare in the 21st century. As part of this commitment, we constantly strive for excellence in customer service. Our goal is to bring Blue Cross plan members the high level of service they expect and deserve. Survey results from polling the state of Louisiana employees and retirees reveal that 89 percent of those members were satisfied overall with their Blue Cross experience. CUSTOMER SERVICE online: www.bcbsla.com/ogb by phone: 1.800.392.4089 by email: ogbhelp@bcbsla.com To view the Summary of Benefits and Coverage (SBC), go to www.bcbsla.com/ogb. Ready to Enroll? Visit the OGB online enrollment portal at www.annualenrollment.groupbenefits.org, or Complete the paper annual enrollment form, or Contact human resources if you are an active employee or OGB if you are a retiree. 1

2 This Annual Enrollment Guide is presented for general information only. It is not a benefit plan, nor intended to be construed as the Blue Cross benefit plan document. If there is any discrepancy between this Annual Enrollment Guide and the Blue Cross benefit plan document and Schedule of Benefits, the FINAL Blue Cross benefit plan document and Schedule of Benefits will govern the benefits and plan payments.

PELICAN HRA 1000 3

PELICAN HRA 1000 SCHEDULE OF BENEFITS Nationwide Network Coverage Preferred Care Providers and BCBS National Providers OGB BENEFIT PLAN PELICAN FORM NUMBER HRA 1000 40HR2031 03/15 SCHEDULE OF BENEFITS: Actives, Retirees without Medicare, Retirees With Medicare COMPREHENSIVE CDHP MEDICAL BENEFIT PLAN PLAN NAME SCHEDULE OF BENEFITS PLAN NUMBER State of Louisiana Office of Group Benefits ST222ERC Nationwide Network Coverage PLAN'S ORIGINAL EFFECTIVE Preferred DATECare Providers and BCBS National Providers PLAN'S ANNIVERSARY DATE January 1, 2013 January 1 BENEFIT PLAN FORM NUMBER 40HR2031 03/15 Lifetime Maximum Benefit:..Unlimited PLAN Benefit NAME Period:...03/01/15 PLAN NUMBER 12/31/15 State of Louisiana Office of Group Benefits ST222ERC PLAN'S ORIGINAL EFFECTIVE DATE PLAN'S ANNIVERSARY DATE January Deductible 1, 2013 Amount per Benefit Period: Network January 1 Non-Network Individual: $2,000.00 $4,000.00 Lifetime Maximum Benefit:..Unlimited Family: $4,000.00 $8,000.00 Benefit Period:...03/01/15 12/31/15 SPECIAL NOTES Deductible Amount Deductible Amount per Benefit Period: Network Non-Network Eligible Expenses for services of a Network Provider that apply to the Deductible Amount for Network Individual: Providers will not count toward to the Deductible Amount for Non-Network $2,000.00 Providers. $4,000.00 Family: Eligible Expenses for services of Non-Network Providers that apply $4,000.00 to the Deductible Amounts $8,000.00 for Non-Network Providers will not count toward to the Deductible Amount for Network Providers. SPECIAL NOTES Deductible Coinsurance: Amount Plan Plan Participant Eligible Network Expenses Providers... for services of a Network that apply to the 80% Deductible Amount 20% for Network Providers will not count toward to the Deductible Amount for Non-Network Providers. Non-Network Providers... 60% 40% Eligible Expenses for services of Non-Network Providers that apply to the Deductible Amounts for Non-Network Providers will not count toward to the Deductible Amount for Network Providers. Out-of-Pocket Maximum per Benefit Period: Coinsurance: Plan Plan Participant Includes all all eligible Coinsurance Amounts, Deductibles and Network Providers... Prescription Drug Copayments 80% 20% 40HR2032 03/15 Network 1 Non-Network Non-Network Individual Providers... $5,000.00 $10,000.00 60% 40% Family $10,000.00 $20,000.00 SPECIAL NOTES 40HR2032 03/15 1 Out-of-Pocket Maximum Eligible Expenses for for services of of a a Network Provider that apply to to the the Deductible and Out-of-Pocket Maximum for for Network Providers will not count toward to to the the Out-of-Pocket Maximum for for Non-Network Providers. 4 Eligible Expenses for for services of of Non-Network Providers that apply to to the the Out-of-Pocket Maximum for for Non- Network Providers will not count toward to to the the Out-of-Pocket Maximum for for Network Providers.

Includes all eligible Coinsurance Amounts, Deductibles and Prescription Drug Copayments Network Non-Network Individual $5,000.00 $10,000.00 PELICAN HRA 1000 Family $10,000.00 $20,000.00 SPECIAL NOTES Out-of-Pocket Maximum Eligible Expenses for services of a Network Provider that apply to the Deductible and Out-of-Pocket Maximum for Network Providers will not count toward to the Out-of-Pocket Maximum for Non-Network Providers. Eligible Expenses for services of Non-Network Providers that apply to the Out-of-Pocket Maximum for Non- Network Providers will not count toward to the Out-of-Pocket Maximum for Network Providers. When the maximum Out-of-Pocket amounts, as shown above have been satisfied, this Plan will pay 100% of the Allowable Charge toward Eligible Expenses for the remainder of the Plan Year. There may be a significant Out-of-Pocket expense to the Plan Participant when using a Non-Network Provider. Eligible Expenses Eligible Expenses are reimbursed in accordance with a fee schedule of maximum Allowable Charges; not billed charges. All Eligible Expenses are determined in accordance with plan Limitations and Exclusions. Eligibility The Plan Administrator assigns Eligibility to all Plan Participants. 40HR2032 03/15 2 5

PELICAN HRA 1000 COINSURANCE Physician s Office Visits including surgery performed in an office setting: General Practice Family Practice Internal Medicine OB/GYN Pediatrics NETWORK PROVIDERS NON-NETWORK PROVIDERS 80% - 20% 1 60% - 40% 1 Allied Health/Other Office Visits Chiropractors Retail Health Clinics Nurse Practitioner Physician s Assistant 80% - 20% 1 60% - 40% 1 Specialist Office Visits including surgery performed in an office setting. Physician Podiatrist Optometrist Midwife Audiologist Registered Dietician Sleep Disorder Clinic Ambulance Services (For Emergency Medical Transportation Only) Ground Transportation Air Ambulance 80% - 20% 1 60% - 40% 1 80% - 20% 1,2 80% - 20% 1,2 Ambulatory Surgical Center and Outpatient Surgical Facility 80% - 20% 1,2 60% - 40% 1,2 Autism Spectrum Disorders (ASD) Office Visits 80% - 20% 1,3 60% - 40% 1,3 Autism Spectrum Disorders(ASD) Inpatient Hospital Birth Control Devices - Insertion and Removal (As listed in the Preventive and Wellness Article in the Benefit Plan.) Cardiac Rehabilitation (Must begin within six months of qualifying event; Limit of 26 Visits per Plan Year ) 80% - 20% 1,2 60% - 40% 1,2 100% - 0% 60% - 40% 1 80% - 20% 1,2,3 60% - 40% 1,2,3 1 Subject to Plan Year Deductible 2 Pre-Authorization Required 3 Age and/or time restrictions apply 6 40HR2032 03/15 3

PELICAN HRA 1000 COINSURANCE Chemotherapy/Radiation Therapy (Authorization not required when performed in Physician s office.) NETWORK PROVIDERS NON-NETWORK PROVIDERS 80% - 20% 1,2 60% - 40% 1,2 Diabetes Treatment 80% - 20% 1 60% - 40% 1 Diabetic/Nutritional Counseling - Clinics and Outpatient Facilities 80% - 20% 1 Not Covered Dialysis 80% - 20% 1,2 60% - 40% 1,2 Durable Medical Equipment (DME), Prosthetic Appliances and Orthotic Devices 80% - 20% 1,2 60% - 40% 1,2 Emergency Room (Facility Charge) 80% - 20% 1 80% - 20% 1 Emergency Medical Services (Non-Facility Charge) Flu Shots and H1N1 vaccines (Administered at Network Providers, Non- Network Providers, Pharmacy, Job Site or Health Fair) Hearing Aids (Hearing Aids are not covered for individuals age eighteen (18) and older.) High-Tech Imaging Outpatient (CT Scans, MRI/MRA, Nuclear Cardiology, PET Scans) Home Health Care (Limit of 60 Visits per Plan Year, combination of Network and Non-Network) (One Visit = 4 hours) Hospice Care (Limit of 180 Days per Plan Year, combination of Network and Non-Network) 80% - 20% 1 80% - 20% 1 100% - 0% 100% - 0% 80% - 20% 1,3 Not Covered 80% - 20% 1,2 60% - 40% 1,2 80% - 20% 1,2 60% - 40% 1,2 80% - 20% 1,2 60% - 40% 1,2 Injections Received in a Physician s Office (When no other health services is received) 80% - 20% 1 per injection 60% - 40% 1 per injection Inpatient Hospital Admission (All Inpatient Hospital services included) Inpatient and Outpatient Professional Services 80% - 20% 1,2 60% - 40% 1,2 80% - 20% 1 60% - 40% 1 1 Subject to Plan Year Deductible 2 Pre-Authorization Required 3 Age and/or time restrictions apply 40HR2032 03/15 4 7

PELICAN HRA 1000 COINSURANCE Mastectomy Bras - Ortho-Mammary Surgical (Limited to two (2) per Plan Year) Mental Health/Substance Abuse - Inpatient Treatment Mental Health/Substance Abuse - Outpatient Treatment NETWORK PROVIDERS NON-NETWORK PROVIDERS 80% - 20% 1,2 60% - 40% 1,2 80% - 20% 1,2 60% - 40% 1,2 80% - 20% 1 60% - 40% 1 Newborn Sick, Services excluding Facility 80% - 20% 1 60% - 40% 1 Newborn Sick, Facility 80% - 20% 1,2 60% - 40% 1,2 Oral Surgery for Impacted Teeth (Authorization is not required when performed in Physician s office.) 80% - 20% 1,2 60% - 40% 1,2 Pregnancy Care Physician Services 80% - 20% 1 60% - 40% 1 Preventive Care Services include screening to detect illness or health risks during a Physician office visit. The Covered Services are based on prevailing medical standards and may vary according to age and family history. (For a complete list of benefits, refer to the Preventive and Wellness/Routine Care Article in the Benefit Plan.) Rehabilitation Services Outpatient: Speech Physical/Occupational 2 (Limit of 50 Visits combined PT/OT per Plan Year. Authorization required for visits over the combined limit of 50.) Pulmonary Therapies (Limit 30 Visits per Plan Year) (Visit limits are combination of Network and Non-Network Benefits; Visit limits do not apply when services are provided for Autism Spectrum Disorders.) Skilled Nursing Facility (Limit of 90 days per Plan Year) 3 100% - 0%3 100% - 0% 80% - 20% 1 60% - 40% 1 80% - 20% 1,2 60% - 40% 1,2 Sonograms and Ultrasounds - Outpatient 80% - 20% 1 60% - 40% 1 Urgent Care Center 80% - 20% 1 60% - 40% 1 1 Subject to Plan Year Deductible 2 Pre-Authorization Required 3 Age and/or time restrictions apply 8 40HR2032 03/15 5

PELICAN HRA 1000 COINSURANCE COINSURANCE NETWORK PROVIDERS NETWORK PROVIDERS NON-NETWORK NON-NETWORK PROVIDERS PROVIDERS Vision Care (Non-Routine) Exam Vision Care (Non-Routine) Exam 80% - 20% 1 80% - 20% 1 60% - 40% 1 60% - 40% 1 X-Ray and Laboratory Services X-Ray and Laboratory Services 80% - 20% 1 80% - 20% 1 60% - 40% 1 60% - 40% 1 1 1 Subject to Plan Year Deductible Subject 2 to Plan Year Deductible 2 Pre-Authorization Required Pre-Authorization 3 Required 3 Age and/or time restrictions apply Age and/or time restrictions apply ORGAN, TISSUE AND BONE MARROW TRANSPLANTS ORGAN, TISSUE AND BONE MARROW TRANSPLANTS Authorization is Required Prior to Services Being Performed Authorization is Required Prior to Services Being Performed Organ, Tissue and Bone Marrow Transplants and evaluation for a Plan Participant s suitability for Organ, Organ, Tissue and Bone Marrow Transplants and evaluation for a Plan Participant s suitability for Organ, Tissue Bone Marrow transplants will not be covered unless a Plan Participant obtains written authorization Tissue Bone Marrow transplants will not be covered unless a Plan Participant obtains written authorization from the Claims Administrator, prior to services being rendered. from the Claims Administrator, prior to services being rendered. Network Benefits..80% - 20% Network Benefits..80% - 20% Non-Network Benefits.Not Covered Non-Network Benefits.Not Covered CARE MANAGEMENT CARE MANAGEMENT If a required Authorization is not requested prior to Admission or receiving other Covered Services and supplies, If a required Authorization is not requested prior to Admission or receiving other Covered Services and supplies, the Plan will have the right to determine if the Admission or other Covered Services or supplies were Medically the Plan will have the right to determine if the Admission or other Covered Services or supplies were Medically Necessary. Necessary. If the Admission or other Covered Services and supplies were not Medically Necessary, the Admission or other If the Admission or other Covered Services and supplies were not Medically Necessary, the Admission or other Covered Services and supplies will not be covered and the Plan Participant must pay all charges incurred. Covered Services and supplies will not be covered and the Plan Participant must pay all charges incurred. If the Admission or other Covered Services and supplies were Medically Necessary, Benefits will be provided If the Admission or other Covered Services and supplies were Medically Necessary, Benefits will be provided based on the Network status of the Provider rendering the services. based on the Network status of the Provider rendering the services. Authorization of Inpatient and Emergency Admissions Authorization of Inpatient and Emergency Admissions Inpatient Admissions must be Authorized. Refer to Care Management and if applicable Pregnancy Care and Inpatient Admissions must be Authorized. Refer to Care Management and if applicable Pregnancy Care and Newborn Care Benefits sections of the Benefit Plan for complete information. Requests for Authorization of Newborn Care Benefits sections of the Benefit Plan for complete information. Requests for Authorization of Inpatient Admissions and for Concurrent Review of an Admission in progress, or other Covered Services and Inpatient Admissions and for Concurrent Review of an Admission in progress, or other Covered Services and supplies must be made to Blue Cross and Blue Shield of Louisiana by calling 1-800-392-4089. supplies must be made to Blue Cross and Blue Shield of Louisiana by calling 1-800-392-4089. If a Blue Cross and Blue Shield of Louisiana Network Provider fails to obtain a required Authorization, no Benefits If a Blue Cross and Blue Shield of Louisiana Network Provider fails to obtain a required Authorization, no Benefits are payable. The Network Provider is responsible for all charges not covered. The Plan Participant remains are payable. The Network Provider is responsible for all charges not covered. The Plan Participant remains responsible for any applicable Deductible Amount and Coinsurance percentage shown in the Schedule of responsible for any applicable Deductible Amount and Coinsurance percentage shown in the Schedule of Benefits. Benefits. If a Network Provider in another Blue Cross and Blue Shield plan fails to obtain a required Authorization, the If a Network Provider in another Blue Cross and Blue Shield plan fails to obtain a required Authorization, the Claims Administrator will reduce Allowable Charges by the penalty amount stipulated in the Provider s contract Claims Administrator will reduce Allowable Charges by the penalty amount stipulated in the Provider s contract with the other Blue Cross and Blue Shield plan. This penalty applies to all covered Inpatient charges. The Network with the other Blue Cross and Blue Shield plan. This penalty applies to all covered Inpatient charges. The Network Provider of the other Blue Cross and Blue Shield plan is responsible for all charges not covered. The Plan Provider of the other Blue Cross and Blue Shield plan is responsible for all charges not covered. The Plan Participant remains responsible for his applicable Deductible and Coinsurance percentage. Participant remains responsible for his applicable Deductible and Coinsurance percentage. 40HR2032 03/15 6 40HR2032 03/15 6 9

PELICAN HRA 1000 If a Non-Network Provider fails to obtain a required Authorization, the Claims Administrator will reduce Allowable Charges by the amount shown below. This penalty applies to all covered Inpatient charges. The Plan Participant is responsible for all charges not covered and for any applicable Deductible Amount and Coinsurance percentage shown in the Schedule of Benefits. Additional Plan Participant responsibility if Authorization is not requested for an Inpatient Admission to a Non- Network Provider Hospital: FIFTY PERCENT (50%) reduction of the Allowable Charges. The following services and supplies require Authorization prior to the services being rendered or supplies being received. Requests for Authorization must be made to Blue Cross and Blue Shield of Louisiana by calling 1-800- 392-4089. Inpatient Hospital Admissions (Except routine maternity stays) Inpatient Mental Health and Substance Abuse Admissions Inpatient Organ, Tissue and Bone Marrow Transplant Services Inpatient Skilled Nursing Facility Services NOTE: Emergency services (life and limb threatening emergencies) received outside of the United States (out of country) are covered at the Network Benefit level. Non-emergency services received outside of the United States (out of country) are covered at the Non-Network Benefit level. Authorization of Outpatient Services, Including Other Services and Supplies If a Network Provider fails to obtain a required Authorization, no Benefits are payable. The Network Provider is responsible for all charges not covered. The Plan Participant remains responsible for his applicable Deductible and Coinsurance percentage. If a Network Provider in another Blue Cross and Blue Shield plan fails to obtain a required Authorization, no Benefits are payable. The Network Provider of the other Blue Cross and Blue Shield plan is responsible for all charges not covered. The Plan Participant remains responsible for his applicable Deductible and Coinsurance percentage. If a Non-Network Provider fails to obtain a required Authorization, the Claims Administrator will reduce Allowable Charges by the amount shown below. This penalty applies to all services and supplies requiring an Authorization. The Plan Participant is responsible for all charges not covered and remains responsible for his Deductible and applicable Coinsurance percentage. The following services and supplies require Authorization prior to the services being rendered or supplies being received. Requests for Authorization must be made to Blue Cross and Blue Shield of Louisiana by calling 1-800- 392-4089. 10 Air Ambulance Non-Emergency Applied Behavior Analysis Bone growth stimulator Cardiac Rehabilitation CT Scans Day Rehabilitation Programs Dialysis Durable Medical Equipment (Greater than $300.00) Electric & Custom Wheelchairs Home Health Care Hospice Hyperbarics Implantable Medical Devices over $2000.00, such as Implantable Defibrillator and Insulin Pump Infusion Therapy (Exception: Infusion Therapy performed in a Physician s office does not require prior Authorization. The Drug to be infused may require prior Authorization). Intensive Outpatient Programs Low Protein Food Products MRI/MRA Nuclear Cardiology 40HR2032 03/15 7

Dialysis Durable Medical Equipment (Greater than $300.00) Electric & Custom Wheelchairs Home Health Care Hospice Hyperbarics Implantable Medical Devices over $2000.00, such as Implantable Defibrillator and Insulin Pump Infusion Therapy (Exception: Infusion Therapy performed in a Physician s office does not require prior Authorization. The Drug to be infused may require prior Authorization). Intensive Outpatient Programs Low Protein Food Products MRI/MRA Nuclear Cardiology 40HR2032 Oral Surgery 03/15 (not required when performed in a Physician s 7 office) Organ Transplant Evaluation Orthotic Devices (Greater than $300.00) Outpatient surgical procedures not performed in a Physician s office Outpatient non-surgical procedures (Exceptions: X-rays, lab work, Speech Therapy and Chiropractic Services do not require prior Authorization. Non-surgical procedures performed in a Physician's office do not require prior Authorization). Outpatient pain rehabilitation or pain control programs Partial Hospitalization Programs PET Scans Physical/Occupational Therapy (Greater than 50 visits) Prosthetic Appliances (Greater than $300.00) Residential Treatment Centers Sleep Studies Specialty Pharmacy (Complete list of drugs available online at www.bcbsla.com> I m a Provider>Pharmacy Management>Specialty Pharmacy Program Drug List.pdf) Stereotactic Radiosurgery, including but not limited to gamma knife and cyberknife procedures Vacuum Assisted Wound Closure Therapy PELICAN HRA 1000 Population Health In Health: Blue Health The Population Health program targets populations with one or more of these five(5) chronic health conditions diabetes, coronary artery disease, heart failure, asthma and chronic obstructive pulmonary disease (COPD). (The In Health: Blue Health Services program is not available to Plan Participants with Medicare primary.) Through the In Health: Blue Health Services program, OGB offers an incentive to Plan Participants on Prescription Drugs used to treat the five chronic conditions listed above. a. OGB Plan Participants participating in the program qualify for $0 Copayment for certain Generic Prescription Drugs approved by the U. S. Food and Drug Administration (FDA) for any of the 5 chronic health conditions. b. OGB Plan Participants participating in the program qualify for $15 Copayment for certain Brand-Name Prescription Drugs for which an FDA-approved Generic version is not available. c. If a Generic is available and the OGB Plan Participant chooses the Brand-Name Drug, the OGB Plan Participant pays the difference between the Brand-Name and Generic cost plus the $15 Brand-Name Copayment. The In Health: Blue Health Services prescription incentive does not apply to any Prescription Drugs not used to treat one of these five health conditions with which you have been diagnosed. Please refer to the Care Management article, Population Health In Health: Blue Health section of the Benefit Plan for complete information on how to qualify for this incentive. PRESCRIPTION DRUGS Prescription Drug Benefits are provided under the Hospital Benefits and Medical and Surgical Benefits Articles of the medical plan, and under the Pharmacy Plan provided by OGB s Pharmacy Benefits Manager (sometimes PBM ). Blue Cross and Blue Shield of Louisiana Blue Cross and Blue Shield of Louisiana provides Claims Administration services only for Prescription Drugs dispensed as follows: Prescription Drugs Covered Under Hospital Benefits and Medical and Surgical Benefits 11

The In Health: Blue Health Services prescription incentive does not apply to any Prescription Drugs not used to treat one of these five health conditions with which you have been diagnosed. Please refer to the Care Management article, Population Health In Health: Blue Health section of the Benefit Plan for complete information on how to qualify for this incentive. PELICAN HRA 1000 2. 2. Medically necessary/non-investigational Prescription Drugs requiring parenteral administration in in a 40HR2032 Physician s 03/15 Office are payable under the Medical 8 and Surgical Benefits. 3. 3. Prescription Drugs that can be self-administered and are providedto to a Plan Participantinin a Physician s office are payable under the Medical and Surgical Benefits. Authorizations The following Prescription Drug categories require Prior Authorization. The Plan Participant s Physician must call 1-800-842-2015 to to obtain Authorization. The Plan Participant or or his Physician should call the Customer Service number on the back of of the ID ID card, or or go to to the Claims Administrator s website at at www.bcbsla.com/ogb for the most current list of of Prescription Drugs that require Prior Authorization: Growth hormones* Anti-tumor necrosis factor drugs* Intravenous immune globulins* Interferons Monoclonal antibodies Hyaluronic acid derivatives for joint injection* ** Shall include all drugs that are in in this category. Therapeutic/Treatment Vaccines Examples include, but are not limited to to vaccines to to treat the following conditions: Allergic Rhinitis Alzheimer s Disease Cancers Multiple Sclerosis Therapeutic/Treatment Vaccines Network Provider:... 100% -- 0% Non-Network Provider:... 70% -- 30% (After Deductible is is Met) OGB S Pharmacy Benefits Manager MedImpact Formulary: 3-Tier Plan Design* PRESCRIPTION DRUGS Prescription Drug Benefits are provided under the Hospital Benefits and Medical and Surgical Benefits Articles of the medical plan, and under the Pharmacy Plan provided by OGB s Pharmacy Benefits Manager (sometimes PBM ). Blue Cross and Blue Shield of Louisiana Blue Cross and Blue Shield of Louisiana provides Claims Administration services only for Prescription Drugs dispensed as follows: Prescription Drugs Covered Under Hospital Benefits and Medical and Surgical Benefits 1. Prescription Drugs dispensed during an Inpatient or Outpatient Hospital stay, or in an Ambulatory Surgical Center are payable under the Hospital Benefits. 12 OGB will begin using the MedImpact Formulary to to help Plan Participants select the most appropriate, lowest-cost options. The formulary is is reviewed on a quarterly basis to to reassess drug tiers based on the current prescription drug market. Plan Participants will continue to to pay a portion of of the cost of of their prescriptions in in the form of of a copayment or or coinsurance. The amount Plan Participants pay toward their prescription depends on whether they receive a generic, preferred brand or or non-preferred brand name drug.

Therapeutic/Treatment Vaccines PELICAN HRA 1000 Network Provider:... 100% - - 0% Non-Network Provider:... 70% - - 30% (After Deductible is is Met) OGB S Pharmacy Benefits Manager MedImpact Formulary: 3-Tier Plan Design* OGB will begin using the MedImpact Formulary to to help Plan Participants select the most appropriate, lowest-cost options. The formulary is is reviewed on on a a quarterly basis to to reassess drug tiers based on on the current prescription drug market. Plan Participants will continue to to pay a a portion of of the cost of of their prescriptions in in the form of of a a copayment or or coinsurance. The amount Plan Participants pay toward their prescription depends on on whether they receive a a generic, preferred brand or or non-preferred brand name drug. *These changes do do not affect Plan Participants with Medicare as as their primary coverage. PRESCRIPTION DRUG PLAN PARTICIPANT PAYS Generic 50% up up to to $30 Preferred 50% up up to to $55 Non-Preferred 65% up up to to $80 Specialty 50% up up to to $80 The pharmacy out-of-pocket maximum has been changed from $1,200 to to $1,500. Once met: Generic $0 $0 co-pay Preferred $20 co-pay Non-Preferred $40 co-pay Specialty $40 co-pay There 40HR2032 may 03/15 be more than one drug available to treat 99 your condition. We encourage you to speak with your Physician regularly about which drugs meet your needs at the lowest cost to you. Compound Drugs Compound Drugs over $400 require prior Authorization from MedImpact. 90-day fill option at retail or mail order network pharmacies For maintenance medications, 90-day prescriptions fills may be filled for the applicable coinsurance with a maximum that is two and a half times the maximum copayment. For example, if your share of the cost of a generic drug is $30, you can fill your 30-day prescription for $30 or a 90-day prescription for $75. Over-the-counter drugs Medications available over-the-counter in the same prescribed strength will no longer be covered under the pharmacy plan. What is a formulary? A formulary is a list of medications available to Plan Participants under the plan s pharmacy benefit. Inclusion on the list is based on consideration of a medication s safety, effectiveness and associated clinical outcomes. The formulary is updated regularly and divides drugs into four main categories: generic, preferred brand, non-preferred brand, and specialty. A generic drug is effectively equivalent to a brand name drug in intended use, dosage, strength, and safety. For a generic drug to be approved by the FDA, it must meet the same quality standards as the brand name product. Even the generic manufacturing, packaging, and testing sites must meet the same standards. Many generics are produced in the same manufacturing plant as their branded counterparts. Preferred brand drugs are generally those that have been on the market for a while and do not have a generic equivalent available. They are effective alternatives to other brands that may be more expensive. Non-preferred brand drugs are recently branded medications. In most cases, a lower cost alternative is available. Specialty medications higher cost drugs. 1. In the event the Plan Participant does not present his identification card to the Network pharmacy at the time 13

PELICAN HRA 1000 Over-the-counter drugs Medications available over-the-counter in the same prescribed strength will no longer be covered under the pharmacy plan. What is a formulary? A formulary is a list of medications available to Plan Participants under the plan s pharmacy benefit. Inclusion on the list is based on consideration of a medication s safety, effectiveness and associated clinical outcomes. The formulary is updated regularly and divides drugs into four main categories: generic, preferred brand, non-preferred brand, and specialty. A generic drug is effectively equivalent to a brand name drug in intended use, dosage, strength, and safety. For a generic drug to be approved by the FDA, it must meet the same quality standards as the brand name product. Even the generic manufacturing, packaging, and testing sites must meet the same standards. Many generics are produced in the same manufacturing plant as their branded counterparts. Preferred brand drugs are generally those that have been on the market for a while and do not have a generic equivalent available. They are effective alternatives to other brands that may be more expensive. Non-preferred brand drugs are recently branded medications. In most cases, a lower cost alternative is available. Specialty medications higher cost drugs. 1. In the event the Plan Participant does not present his identification card to the Network pharmacy at the time of purchase, the Plan Participant will be responsible for full payment for the drug and must then file a claim with the Pharmacy Benefits Manager for reimbursement. Reimbursement is limited to the rates established for Non-Network pharmacies. If a Plan Participant chooses a Brand-Name Drug for which an FDA-approved Generic version is available, the OGB Plan Participant pays the difference between the Brand-Name and Generic cost, plus a $40 Copayment for a 31 day supply. 2. Regardless of where the Prescription Drug is obtained, Eligible Expenses for Brand Name Drugs will be limited to: a. The Pharmacy Benefits Manager's maximum Allowable Charge for the Generic, when available; or b. The Pharmacy Benefits Manager's maximum Allowable Charge for the Brand Drug dispensed, when a Generic is not available. c. There is no per prescription maximum on the Plan Participant's responsibility for payment of costs in excess of the Eligible Expense. Plan Participant payments for such excess costs are not applied toward satisfaction of the annual Out-of-Pocket threshold (above). 3. 40HR2032 This 03/15 Plan allows Benefits for drugs and medicines 10 approved by the Food and Drug Administration or its successor that require a prescription. Utilization management criteria may apply to specific drugs or drug categories to be determined by the PBM. 4. Retirees with Medicare will be automatically enrolled in OGB s Medicare Part D coverage with a commercial wrap benefit. 5. In addition, this Plan allows Benefits limited to $200.00 per month for expenses incurred for the purchase of low protein food products for the treatment of inherited metabolic diseases if the low protein food products are Medically Necessary and are obtained from a source approved by the OGB. Such expenses shall be subject to Coinsurance and Copayments relating to Prescription Drug Benefits. In connection with this Benefit, the following words shall have the following meanings: a. Inherited metabolic disease shall mean a disease caused by an inherited abnormality of body chemistry and shall be limited to: 14 Phenylketonuria (PKU) Maple Syrup Urine Disease (MSUD) Methylmalonic Acidemia (MMA) Isovaleric Adicemia (IVA) Propionic Acidemia Glutaric Acidemia

successor that require a prescription. Utilization management criteria may apply to specific drugs or drug categories to be determined by the PBM. 4. Retirees with Medicare will be automatically enrolled in OGB s Medicare Part D coverage with a commercial wrap benefit. 5. In addition, this Plan allows Benefits limited to $200.00 per month for expenses incurred for the purchase of low protein food products for the treatment of inherited metabolic diseases if the low protein food products are Medically Necessary and are obtained from a source approved by the OGB. Such expenses shall be subject to Coinsurance and Copayments relating to Prescription Drug Benefits. In connection with this Benefit, the following words shall have the following meanings: a. Inherited metabolic disease shall mean a disease caused by an inherited abnormality of body chemistry and shall be limited to: Phenylketonuria (PKU) Maple Syrup Urine Disease (MSUD) Methylmalonic Acidemia (MMA) Isovaleric Adicemia (IVA) Propionic Acidemia Glutaric Acidemia Urea Cycle Defects Tyrosinemia b. Low protein food products mean food products that are especially formulated to have less than one gram of protein per serving and are intended to be used under the direction of a Physician for the dietary treatment of an inherited metabolic disease. Low protein food products shall not include natural foods that are naturally low in protein. 6. Benefits are available for Prescription and over-the-counter (OTC) smoking cessation medications when prescribed by a physician. (Prescription is required for over-the-counter medications). Smoking cessation medications are not subject to the Prescription Drug deductible and are covered at 100%. Smoking cessation screening and counseling are covered under the Preventive or Wellness Care article of the Benefit Plan. 7. The following drugs, medicines, and related services and supplies are not covered: Drugs used to treat anorexia, weight loss or weight gain Drugs used to promote fertility Dietary supplements; Medical Foods Bulk Chemicals Drugs for cosmetic purposes or to promote hair growth Nutritional or parenteral therapy; Vitamins and minerals; Drugs available over the counter (OTC) (unless expressly covered by this Plan) Prescription drugs (federal legend) with an OTC equivalent PELICAN HRA 1000 For more information on the pharmacy benefit, visit the MedImpact website at https://mp.medimpact.com/ogb or call MedImpact member services at 1-800-910-1831. 40HR2032 03/15 11 15

16 This Annual Enrollment Guide is presented for general information only. It is not a benefit plan, nor intended to be construed as the Blue Cross benefit plan document. If there is any discrepancy between this Annual Enrollment Guide and the Blue Cross benefit plan document and Schedule of Benefits, the FINAL Blue Cross benefit plan document and Schedule of Benefits will govern the benefits and plan payments.

PELICAN HSA 775 17

PELICAN HSA 775 SCHEDULE OF BENEFITS: Actives SCHEDULE OF BENEFITS Nationwide Network Coverage Preferred Care Providers and BCBS National Providers OGB BENEFIT PLAN PELICAN FORM NUMBER HSA 775 40HR1697 R03/15 COMPREHENSIVE CDHP MEDICAL BENEFIT PLAN PLAN NAME SCHEDULE OF BENEFITS PLAN NUMBER State of Louisiana Office of Group Benefits ST222ERC Nationwide Network Coverage PLAN'S ORIGINAL EFFECTIVE Preferred DATECare Providers and BCBS National Providers PLAN'S ANNIVERSARY DATE January 1, 2013 January 1 BENEFIT PLAN FORM NUMBER 40HR1697 R03/15 Lifetime Maximum Benefit:... Unlimited PLAN Benefit NAME Period:...03/01/15 PLAN NUMBER 12/31/15 State of Louisiana Office of Group Benefits ST222ERC PLAN'S Deductible ORIGINAL Amount EFFECTIVE per Benefit DATE Period: Network PLAN'S ANNIVERSARY Non-Network DATE January 1, 2013 January 1 Individual: $2,000.00 $4,000.00 Lifetime Family: Maximum Benefit:... $4,000.00 $8,000.00 Unlimited Benefit SPECIAL Period: NOTES...03/01/15 12/31/15 Deductible Amounts Deductible Amount per Benefit Period: Network Non-Network Eligible Expenses for services of a Network Provider that apply to the Deductible Amount for Network Individual: Providers will not count toward to the Deductible Amount for Non-Network $2,000.00 Providers. $4,000.00 Family: Eligible Expenses for services of Non-Network Providers that apply $4,000.00 to the Deductible Amounts $8,000.00 for Non-Network Providers will not count toward to the Deductible Amount for Network Providers. SPECIAL NOTES Deductible Coinsurance: Amounts Plan Plan Participant Eligible Network Expenses Providers... for services of a Network that apply to the 80% Deductible Amount 20% for Network Providers will not count toward to the Deductible Amount for Non-Network Providers. Non-Network Providers... 60% 40% Eligible Expenses for services of Non-Network Providers that apply to the Deductible Amounts for Non-Network Providers will not count toward to the Deductible Amount for Network Providers. Out-of-Pocket Maximum per Benefit Period: Coinsurance: Plan Plan Participant Includes all all eligible Coinsurance Amounts, Deductibles and Network Providers... Prescription Drug Copayments 80% 20% Network Providers Non-Network Providers Non-Network 40HR1698 R03/15 Providers... 1 60% 40% Individual $5,000.00 $10,000.00 Family $10,000.00 $20,000.00 SPECIAL NOTES 40HR1698 Out-of-Pocket R03/15 Maximum 1 Eligible Expenses for for services of of a a Network Provider that apply to to the the Deductible and Out-of-Pocket Maximum for for Network Providers will not count toward to to the the Out-of-Pocket Maximum for for Non-Network Providers. Eligible Expenses for for services of of Non-Network Providers that apply to to the the Out-of-Pocket Maximum for for Non- Network Providers will not count toward to to the the Out-of-Pocket Maximum for for Network Providers. 18 When the the maximum Out-of-Pocket amounts, as as shown above have been satisfied, this Plan will will pay 100% of of

Includes all eligible Coinsurance Amounts, Deductibles and Prescription Drug Copayments Network Providers Non-Network Providers PELICAN HSA 775 Individual $5,000.00 $10,000.00 Family $10,000.00 $20,000.00 SPECIAL NOTES Out-of-Pocket Maximum Eligible Expenses for services of a Network Provider that apply to the Deductible and Out-of-Pocket Maximum for Network Providers will not count toward to the Out-of-Pocket Maximum for Non-Network Providers. Eligible Expenses for services of Non-Network Providers that apply to the Out-of-Pocket Maximum for Non- Network Providers will not count toward to the Out-of-Pocket Maximum for Network Providers. When the maximum Out-of-Pocket amounts, as shown above have been satisfied, this Plan will pay 100% of the Allowable Charge toward Eligible Expenses for the remainder of the Plan Year. There may be a significant Out-of-Pocket expense to the Plan Participant when using a Non-Network Provider. Eligible Expenses Eligible Expenses are reimbursed in accordance with a fee schedule of maximum Allowable Charges; not billed charges. All Eligible Expenses are determined in accordance with plan Limitations and Exclusions. Eligibility The Plan Administrator assigns Eligibility to all Plan Participants. 40HR1698 R03/15 2 19

PELICAN HSA 775 COINSURANCE NETWORK PROVIDERS NON-NETWORK PROVIDERS Physician s Office Visits including surgery performed in an office setting: General Practice Family Practice Internal Medicine OB/GYN Pediatrics 80% - 20% 1 60% - 40% 1 Allied Health/Other Office Visits Chiropractors Retail Health Clinics Nurse Practitioner Physician s Assistant 80% - 20% 1 60% - 40% 1 Specialist Office Visits including surgery performed in an office setting. Physician Podiatrist Optometrist Midwife Audiologist Registered Dietician Sleep Disorder Clinic Ambulance Services (For Emergency Medical Transportation Only) Ground Transportation Air Ambulance Ambulatory Surgical Center and Outpatient Surgical Facility 80% - 20% 1 60% - 40% 1 80% - 20% 1,2 80% - 20% 1,2 80% - 20% 1,2 60% - 40% 1,2 Autism Spectrum Disorders (ASD) Office Visits 80% - 20% 1,3 60% - 40% 1,3 1 Subject to Plan Year Deductible 2 Pre-Authorization Required 3 Age and/or time restrictions apply 40HR1698 R03/15 3 20

PELICAN HSA 775 COINSURANCE NETWORK PROVIDERS NON-NETWORK PROVIDERS Autism Spectrum Disorders(ASD) Inpatient Hospital Birth Control Devices - Insertion and Removal (As listed in the Preventive and Wellness Article in the Benefit Plan.) Cardiac Rehabilitation (Must begin within six months of qualifying event; Limited to 26 visits per Plan Year ) Chemotherapy/Radiation Therapy (Authorization not required when performed in Physician s office.) 80% - 20% 1,2 60% - 40% 1,2 100% - 0% 60% - 40% 1 80% - 20% 1,2,3 60% - 40% 1,2,3 80% - 20% 1,2 60% - 40% 1,2 Diabetes Treatment 80% - 20% 1 60% - 40% 1 Diabetic/Nutritional Counseling - Clinics and Outpatient Facilities 80% - 20% 1 Not Covered Dialysis 80% - 20% 1,2 60% - 40% 1,2 Durable Medical Equipment (DME), Prosthetic Appliances and Orthotic Devices 80% - 20% 1,2 60% - 40% 1,2 Emergency Room (Facility Charge) 80% - 20% 1 80% - 20% 1 Emergency Medical Services (Non-Facility Charge) Flu Shots and H1N1 vaccines (Administered at Network Providers, Non- Network Providers, Pharmacy, Job Site or Health Fair) Hearing Aids (Hearing Aids are not covered for individuals age eighteen (18) and older.) 80% - 20% 1 80% - 20% 1 100% - 0% 100% - 0% 80% - 20% 1,3 Not Covered High-Tech Imaging Outpatient (CT Scans, MRI/MRA, Nuclear Cardiology, PET Scans) Home Health Care (Limit of 60 Visits per Plan Year, Combination of Network and Non-Network) (One Visit = 4 hours) 80% - 20% 1,2 60% - 40% 1,2 80% - 20% 1,2 60% - 40% 1,2 1 Subject to Plan Year Deductible 2 Pre-Authorization Required 3 Age and/or time restrictions apply 40HR1698 R03/15 4 21

PELICAN HSA 775 COINSURANCE NETWORK PROVIDERS NON-NETWORK PROVIDERS Hospice Care (Limit of 180 Days per Plan Year, combination of Network and Non-Network) 80% - 20% 1,2 60% - 40% 1,2 Injections Received in a Physician s Office (When no other health services is received) Inpatient Hospital Admission (All Inpatient Hospital services included) Inpatient and Outpatient Professional Services Mastectomy Bras - Ortho-Mammary Surgical (Limited to two (2) per Plan Year) Mental Health/Substance Abuse - Inpatient Treatment Mental Health/Substance Abuse - Outpatient Treatment 80% - 20% 1 per injection 60% - 40% 1 per injection 80% - 20% 1,2 60% - 40% 1,2 80% - 20% 1 60% - 40% 1 80% - 20% 1,2 60% - 40% 1,2 80% - 20% 1,2 60% - 40% 1,2 80% - 20% 1 60% - 40% 1 Newborn Sick, Services excluding Facility 80% - 20% 1 60% - 40% 1 Newborn Sick, Facility 80% - 20% 1,2 60% - 40% 1,2 Oral Surgery for Impacted Teeth (Authorization is not required when performed in Physician s office.) 80% - 20% 1,2 60% - 40% 1,2 Pregnancy Care Physician Services 80% - 20% 1 60% - 40% 1 Preventive Care Services include screening to detect illness or health risks during a Physician office visit. The Covered Services are based on prevailing medical standards and may vary according to age and family history. (For a complete list of benefits, refer to the Preventive and Wellness/ Routine Care Article in the Benefit Plan.) 3 100% - 0%3 100% - 0% 1 Subject to Plan Year Deductible 2 Pre-Authorization Required 3 Age and/or time restrictions apply 22 40HR1698 R03/15 5

PELICAN HSA 775 COINSURANCE NETWORK PROVIDERS NON-NETWORK PROVIDERS Hospice Care Rehabilitation Services Outpatient: (Limit of 180 Days per Plan Year, Speech combination of Network and Non-Network) Physical/Occupational 2 80% - 20% 1,2 60% - 40% 1,2 (Limit (Limit of of 50 50 Visits Visits combined PT/OT per per Plan Plan Year. Year. Authorization required for for Injections visits visits Received over over the the in combined a Physician s limit limit of Office of 50.) 50.) 80% - 20% 1 60% - 40% 1 (When no Pulmonary other health Therapies services (Limit (Limit is 30 received) 30 Visits Visits per per per injection per injection Inpatient Plan Plan Hospital Year) Year) Admission 80% - 20% 1,2 60% - 40% 1,2 (All Inpatient Hospital services included) 80% 80% - 20% - 20% 1,2 60% 60% - 40% - 40% 1,2 (Visit (Visit limits limits are are combination of of Network and and Inpatient Non-Network and Outpatient Benefits; Visit Professional Visit limits limits do do not not apply apply 80% - 20% 1 60% - 40% 1 Services when when services are are provided for for Autism Mastectomy Spectrum Disorders.) Bras - Ortho-Mammary Surgical (Limited to two (2) per Plan Year) 80% - 20% 1,2 60% - 40% 1,2 Mental Health/Substance Abuse - Inpatient 80% - 20% 1,2 60% - 40% 1,2 Treatment Skilled Nursing Facility (Limit (Limit of of 90 90 days days per per 80% 80% - 20% - 20% 1,2 60% 60% - 40% - 40% 1,2 Mental Plan Plan Year) Health/Substance Year) Abuse - Outpatient 80% - 20% 1 60% - 40% 1 Treatment Sonograms and and Ultrasounds - - Outpatient 80% 80% - 20% - 20% 1 60% 60% - 40% - 40% 1 Newborn Sick, Services excluding Facility 80% - 20% 1 60% - 40% 1 Urgent Care Care Center 80% 80% - 20% - 20% 1 60% 60% - 40% - 40% 1 Newborn Sick, Facility 80% - 20% 1,2 60% - 40% 1,2 Vision Vision Care Care (Non-Routine) Exam Exam Oral Surgery for Impacted Teeth (Authorization is not required when performed in Physician s X-Ray and and Laboratory office.) Services 80% 80% - 20% - 20% 1 80% 20% 1,2 80% 80% - 20% - 20% 1 60% 60% - 40% - 40% 1 60% - 40% 1,2 60% 60% - 40% - 40% 1 Pregnancy 1 1 Subject to Care to Plan Plan Year Physician Year Deductible Services 80% - 20% 1 60% - 40% 1 Preventive 2 2 Pre-Authorization Care Services Required include screening to 3 Age 3 detect Age and/or illness time time or health restrictions risks apply during apply a Physician office visit. The Covered Services are based on prevailing medical 3 100% - 0%3 standards and may vary according to age 100% - 0% and family history. (For a complete ORGAN, list TISSUE of AND AND BONE MARROW TRANSPLANTS benefits, refer to the Preventive and Wellness/ Routine Care Article Authorization in the is is required prior prior to to services being being rendered. Benefit Plan.) Organ, Tissue and and Bone Bone Marrow Transplants and and evaluation for for a Plan a Plan Participant s suitability for for Organ, 1 Tissue Subject Bone Bone to Plan Marrow Year Deductible transplants will will not not be be covered unless a Plan a Plan Participant obtains written authorization from 2 from Pre-Authorization the the Claims Administrator, Required prior prior to to services being being rendered. 3 Age and/or time restrictions apply Network Benefits.........80%- 20% - 20% Non-Network Benefits..... Not Not Covered CARE MANAGEMENT If a If a required Authorization is not is not requested prior prior to to Admission or or receiving other other Covered Services and and supplies, the the Plan Plan will will have have the the right right to to determine if the if the Admission or or other other Covered Services or or supplies were were Medically Necessary. If the If the Admission or or other other Covered Services and and supplies were were not not Medically Necessary, the the Admission or or other other Covered Services and and supplies will will not not be be covered and and the the Plan Plan Participant must must pay pay all all charges incurred. If the If the Admission or or other other Covered Services and and supplies were were Medically Necessary, Benefits will will be be provided 40HR1698 R03/15 5 based based on on the the Network status status of of the the Provider rendering the the services. 23

from the Claims Administrator, prior to services being rendered. PELICAN HSA 775 Network Benefits......80% - 20% Non-Network Benefits..... Not Covered 40HR1698 R03/15 6 CARE MANAGEMENT If a required Authorization is not requested prior to Admission or receiving other Covered Services and supplies, the Plan will have the right to determine if the Admission or other Covered Services or supplies were Medically Necessary. If the Admission or other Covered Services and supplies were not Medically Necessary, the Admission or other Covered Services and supplies will not be covered and the Plan Participant must pay all charges incurred. If the Admission or other Covered Services and supplies were Medically Necessary, Benefits will be provided based on the Network status of the Provider rendering the services. Authorization of Inpatient and Emergency Admissions Inpatient Admissions must be Authorized. Refer to Care Management and if applicable Pregnancy Care and Newborn Care Benefits sections of the Benefit Plan for complete information. Requests for Authorization of Inpatient Admissions and for Concurrent Review of an Admission in progress, or other Covered Services and supplies must be made to Blue Cross and Blue Shield of Louisiana by calling 1-800-392-4089. If a Blue Cross and Blue Shield of Louisiana Network Provider fails to obtain a required Authorization, no Benefits are payable. The Network Provider is responsible for all charges not covered. The Plan Participant remains responsible for any applicable Deductible Amount and Coinsurance percentage shown in the Schedule of Benefits. If a Network Provider in another Blue Cross and Blue Shield plan fails to obtain a required Authorization, the Claims Administrator will reduce Allowable Charges by the penalty amount stipulated in the Provider s contract with the other Blue Cross and Blue Shield plan. This penalty applies to all covered Inpatient charges. The Network Provider of the other Blue Cross and Blue Shield plan is responsible for all charges not covered. The Plan Participant remains responsible for his applicable Deductible and Coinsurance percentage. If a Non-Network Provider fails to obtain a required Authorization, the Claims Administrator will reduce Allowable Charges by the amount shown below. This penalty applies to all covered Inpatient charges. The Plan Participant is responsible for all charges not covered and for any applicable Deductible Amount and Coinsurance percentage shown in the Schedule of Benefits. Additional Plan Participant responsibility if Authorization is not requested for an Inpatient Admission to a Non- Network Provider Hospital: FIFTY PERCENT (50%) reduction of the Allowable Charges. The following services and supplies require Authorization prior to the services being rendered or supplies being received. Requests for Authorization must be made to Blue Cross and Blue Shield of Louisiana by calling 1-800- 392-4089. Inpatient Hospital Admissions (Except routine maternity stays) Inpatient Mental Health and Substance Abuse Admissions Inpatient Organ, Tissue and Bone Marrow Transplant Services Inpatient Skilled Nursing Facility Services NOTE: Emergency services (life and limb threatening emergencies) received outside of the United States (out of country) are covered at the Network Benefit level. Non-emergency services received outside of the United States (out of country) are covered at the Non-Network Benefit level. Authorization of Outpatient Services, Including Other Services and Supplies If a Network Provider fails to obtain a required Authorization, no Benefits are payable. The Network Provider is responsible for all charges not covered. The Plan Participant remains responsible for his applicable Deductible and Coinsurance percentage. 24 If a Network Provider in another Blue Cross and Blue Shield plan fails to obtain a required Authorization, no Benefits are payable. The Network Provider of the other Blue Cross and Blue Shield plan is responsible for all charges not covered. The Plan Participant remains responsible for his applicable Deductible and Coinsurance

Inpatient Skilled Nursing Facility Services PELICAN HSA 775 NOTE: Emergency services (life and limb threatening emergencies) received outside of the United States (out of country) are covered at the Network Benefit level. Non-emergency services received outside of the United States (out of country) are covered at the Non-Network Benefit level. Authorization of Outpatient Services, Including Other Services and Supplies If a Network Provider fails to obtain a required Authorization, no Benefits are payable. The Network Provider is responsible for all charges not covered. The Plan Participant remains responsible for his applicable Deductible and Coinsurance percentage. If a Network Provider in another Blue Cross and Blue Shield plan fails to obtain a required Authorization, no Benefits are payable. The Network Provider of the other Blue Cross and Blue Shield plan is responsible for all charges not covered. The Plan Participant remains responsible for his applicable Deductible and Coinsurance percentage. If a Non-Network Provider fails to obtain a required Authorization, no Benefits are payable. The Plan Participant is responsible for all charges not covered and remains responsible for his Deductible and applicable Coinsurance percentage. The following services and supplies require Authorization prior to the services being rendered or supplies being received. Requests for Authorization must be made to Blue Cross and Blue Shield of Louisiana by calling 1-800- 392-4089. 40HR1698 Air Ambulance R03/15 Non-Emergency 7 Applied Behavior Analysis Bone growth stimulator Cardiac Rehabilitation CT Scans Day Rehabilitation Programs Dialysis Durable Medical Equipment (Greater than $300.00) Electric & Custom Wheelchairs Home Health Care Hospice Hyperbarics Implantable Medical Devices over $2000.00, such as Implantable Defibrillator and Insulin Pump Infusion Therapy (Exception: Infusion Therapy performed in a Physician s office does not require prior Authorization. The Drug to be infused may require prior Authorization). Intensive Outpatient Programs Low Protein Food Products MRI/MRA Nuclear Cardiology Oral Surgery (not required when performed in a Physician s office) Organ Transplant Evaluation Orthotic Devices (Greater than $300.00) Outpatient surgical procedures not performed in a Physician s office Outpatient non-surgical procedures (Exceptions: X-rays, lab work, Speech Therapy and Chiropractic Services do not require prior Authorization. Non-surgical procedures performed in a Physician's office do not require prior Authorization). Outpatient pain rehabilitation or pain control programs Partial Hospitalization Programs PET Scans Physical/Occupational Therapy (greater than 50 visits) Prosthetic Appliances (Greater than $300.00) Residential Treatment Centers Sleep Studies Specialty Pharmacy (Complete list of drugs available online at www.bcbsla.com> I m a Provider>Pharmacy Management>Specialty Pharmacy Program Drug List.pdf) Stereotactic Radiosurgery, including but not limited to gamma knife and cyberknife procedures Vacuum Assisted Wound Closure Therapy Population Health In Health: Blue Health The Population Health program targets populations with one or more of these five(5) chronic health conditions diabetes, coronary artery disease, heart failure, asthma and chronic obstructive pulmonary disease (COPD). (The 25

Specialty Pharmacy (Complete list of drugs available online at www.bcbsla.com> I m a Provider>Pharmacy Management>Specialty Pharmacy Program Drug List.pdf) Stereotactic Radiosurgery, including but not limited to gamma knife and cyberknife procedures Vacuum Assisted Wound Closure Therapy PELICAN HSA 775 Population Health In Health: Blue Health The Population Health program targets populations with one or more of these five(5) chronic health conditions diabetes, coronary artery disease, heart failure, asthma and chronic obstructive pulmonary disease (COPD). (The In Health: Blue Health Services program is not available to Plan Participants with Medicare primary.) Through the In Health: Blue Health Services program, OGB offers an incentive to Plan Participants on Prescription Drugs used to treat the five chronic conditions listed above. a. OGB Plan Participants participating in the program qualify for $0 Copayment for certain Generic Prescription Drugs approved by the U. S. Food and Drug Administration (FDA) for any of the 5 chronic health conditions. b. OGB Plan Participants participating in the program qualify for $15 Copayment for certain Brand-Name Prescription Drugs for which an FDA-approved Generic version is not available. c. If a Generic is available and the OGB Plan Participant chooses the Brand-Name Drug, the OGB Plan Participant pays the difference between the Brand-Name and Generic cost plus the $15 Brand-Name Copayment. 40HR1698 R03/15 8 The In Health: Blue Health Services prescription incentive does not apply to any Prescription Drugs not used to treat one of these five health conditions with which you have been diagnosed. Please refer to the Care Management article, Population Health In Health: Blue Health section of the Benefit Plan for complete information on how to qualify for this incentive. PRESCRIPTION DRUGS Blue Cross and Blue Shield of Louisiana (BCBSLA) works in partnership with Express Scripts, an independent pharmacy benefits management company, to administer your prescription drug program for the OGB Consumer Driven Health Plan (CDHP). RETAIL AND MAIL ORDER - Subject to Deductible and applicable Copayments: $10 Copayment per 31 day supply Generic (Up to a 93 day supply/3 Copayments) $25 Copayment per 31 day supply Preferred Brand (Up to a 93 day supply/3 Copayments) $50 Copayment per 31 day supply Non-Preferred Brand (Up to a 93 day supply/3 Copayments) $50 Copayment per 31 day supply Specialty (Up to a 31 day supply/1 Copayment) Select Maintenance Drugs (Up to a 93 day supply) Not subject to deductible: Copayments same as above. ESI s Maintenance/Preventive List is a list of the most commonly prescribed preventive drugs and is not allinclusive. Please refer to ESI s Maintenance/Preventive Drug List for more information. www.bcbsla.com/ogb. If the Plan Participant chooses to purchase a Brand-Name prescription for which an approved Generic is available, the Plan Participant will pay the cost difference between the Brand-Name Drug and the Generic version, plus the Preferred Brand-Name Copayment. Benefits are available for contraceptive drugs. Therapeutic/Treatment Vaccines are subject to payment of Deductible and Coinsurance. Compound Drugs Authorization is required for Compound Drugs over $400.00 Growth Hormone Therapy 26 Benefits are available for growth hormone therapy for the treatment of chronic renal insufficiency, AIDS wasting, Turners Syndrome, Prader-Willi syndrome, Noonan Syndrome, wound healing in burn patients, growth delay in patients with severe burns, short bowel syndrome, short stature homeobox-containing gene (SHOX) deficiency, or growth hormone deficiency when a Physician confirms the growth hormone deficiency with abnormal provocative stimulation testing.

plus the Preferred Brand-Name Copayment. Benefits are available for contraceptive drugs. PELICAN HSA 775 Therapeutic/Treatment Vaccines are subject to payment of Deductible and Coinsurance. Compound Drugs Authorization is required for Compound Drugs over $400.00 Growth Hormone Therapy Benefits are available for growth hormone therapy for the treatment of chronic renal insufficiency, AIDS wasting, Turners Syndrome, Prader-Willi syndrome, Noonan Syndrome, wound healing in burn patients, growth delay in patients with severe burns, short bowel syndrome, short stature homeobox-containing gene (SHOX) deficiency, or growth hormone deficiency when a Physician confirms the growth hormone deficiency with abnormal provocative stimulation testing. Smoking Cessation Medications Benefits are available for Prescription and over-the-counter (OTC) smoking cessation medications when prescribed by a Physician. (Prescription is required for over-the-counter medications). Smoking cessation medications are covered at 100%. Prescription Drug Step Therapy Lead with Generics, our prescription step therapy program, promotes the use of Generic Drugs as your first step to treat your condition. The program is designed to help you get effective treatment while keeping your Prescription 40HR1698 R03/15 Drugs affordable. Lead with Generics 9requires you to try a Generic option or similar alternative medication (in certain drug classes) before you use a Brand-Name Drug. For example, if Drug A and Drug B both treat the Plan Participant s medical condition, the Plan may require the Plan Participant s Physician to prescribe Drug A first. If Drug A does not work for the Plan Participant, then the Plan will cover a prescription written for Drug B. However, if Your Physician s request for a Step B drug does not meet the necessary criteria to start a Step B drug without first trying a Step A drug, or if You choose a Step B Brand-Name Drug included in the Step Therapy program without first trying a Step A Generic alternative, You will be responsible for the full cost of the drug. Categories of Prescription Drugs that require Step Therapy As these categories may change from time to time, the Plan Participant should call the customer service number on their ID card or check our website at www.bcbsla.com to determine what categories of Prescription Drugs are subject to step therapy: Examples may include but are not limited to the following: Blood Pressure Medications: (example: Angiotensin Converting Enzyme Inhibitors, Angiotensin II Receptor Blockers, Direct Renin Inhibitors) Pain Medications: (example: Non-Steroidal Anti-Inflammatory Drugs, COX-2 Inhibitors) Cholesterol Medications: (example: HMG-CoA Reductase Inhibitors) Sleep Medications: (example: Sedatives, Hypnotics) Stomach Acid Medications: (example: Proton Pump Inhibitors) Respiratory/Allergy Medications: (example: Nasal Antihistamines, Non-Sedating Antihistamines, Nasal Steroids) Depression Medications: (example: Selective Serotonin Reuptake Inhibitors, Serotonin/Norepinephrine Reuptake Inhibitors) Frequent Urination Medications (example: Antimuscarinics) Long-Acting Pain Medications (example: Opiate Analgesics) Acne Treatment Medications (example: Tetracycline Antibiotics) Oral Diabetes Medications (example: Biguanides, Thiazolidinediones) Bone Medications (example: Bisphosphonates) Migraine Medications (example: Selective Serotonin Receptor Agonists) Topical Acne Medications (example: Topical Antibiotics, Retinoid Compounds) Topical Corticosteroids 27

28 This Annual Enrollment Guide is presented for general information only. It is not a benefit plan, nor intended to be construed as the Blue Cross benefit plan document. If there is any discrepancy between this Annual Enrollment Guide and the Blue Cross benefit plan document and Schedule of Benefits, the FINAL Blue Cross benefit plan document and Schedule of Benefits will govern the benefits and plan payments.

MAGNOLIA LOCAL 29

Blue Connect and Community Blue MAGNOLIA LOCAL BENEFIT PLAN FORM NUMBER 40HR2027 03/15 PLAN NAME OGB State of Louisiana Office of Group MAGNOLIA Benefits LOCAL PLAN NUMBER ST222ERC SCHEDULE OF BENEFITS: Actives, Retirees Without Medicare, Retirees With Medicare COMPREHENSIVE MEDICAL BENEFIT PLAN PLAN S ORIGINAL BENEFIT SCHEDULE PLAN DATEOF BENEFITS PLAN S ANNIVERSARY DATE July 1, 2010 January 1 Network coverage available only in Baton Rouge, New Orleans and Shreveport Blue Connect and Community Blue Network coverage available only in Baton Rouge, New Orleans and Shreveport BENEFIT PLAN Blue FORM Connect NUMBER and Community 40HR2027Blue 03/15 Lifetime Maximum Benefit: Unlimited PLAN NAME PLAN NUMBER State Benefit of Louisiana Period:...03/01/2015 Office of Group Benefits ST222ERC 12/31/2015 Deductible Amount Per Benefit Period: PLAN S ORIGINAL BENEFIT PLAN DATE PLAN S ANNIVERSARY DATE July Individual: 1, 2010 January 1 Network Providers: Network coverage available only in Baton Rouge, New Orleans and Shreveport Active Employees and Retirees Blue on or Connect after 3/1/15 and (With Community and Without BlueMedicare) $400.00 Lifetime Retirees prior Maximum to 03/01/15 Benefit: (With and Without Medicare) Unlimited $0 Benefit Non-Network Period: Providers:...03/01/2015 No Coverage 12/31/2015 Deductible Individual + Amount 1 Dependent: Per Benefit Period: Network Individual: Providers: Network Active Employees Providers: and Retirees on or after 3/1/15 (With and Without Medicare) $800.00 Active Retirees Employees prior to 03/01/15 and Retirees (With and on or Without after 3/1/15 Medicare) (With and Without Medicare) $400.00 $0 Retirees Non-Network prior Providers: to 03/01/15 (With and Without Medicare) $0 Family Non-Network (Individual Providers: + 2 or more Dependents): Network Individual Providers: + 1 Dependent: Network Active Employees Providers: and Retirees on or after 3/1/15 (With and Without Medicare) $1,200.00 Retirees Active Employees prior to 03/01/15 and Retirees (With and on or Without after 3/1/15 Medicare) (With and Without Medicare) $800.00 1 $0 40HR2028 Retirees 03/15 Non-Network prior Providers: to 03/01/15 (With and Without Medicare) $0 Non-Network Providers: Out-of-Pocket Maximum per Benefit Period: Family (Individual + 2 or more Dependents): Includes all eligible Copayments, Coinsurance Amounts, and Deductibles Network Providers: Active Employees and Retirees on or after 3/1/15 (With and Without Medicare) $1,200.00 40HR2028 03/15 1 Active Employees and Retirees on or after 3/1/2015 (With and Without Medicare) Retirees prior to 3/1/2015 (With and Without Medicare) 30 Network Non-Network Network Non-Network

Retirees Retirees prior prior to prior 03/01/15 to to 03/01/15 (With (With and (With Without and and Without Medicare) Medicare) $0 $0 $0 MAGNOLIA LOCAL Non-Network Non-Network Providers: Providers: No Out-of-Pocket Out-of-Pocket Maximum Maximum per Benefit per per Benefit Period: Period: Includes Includes all eligible all all eligible Copayments, Copayments, Coinsurance Coinsurance Amounts, Amounts, and Deductibles and and Deductibles Active Active Employees Employees and and and Retirees Retirees prior prior to prior 3/1/2015 to to 3/1/2015 (With (With and (With and and Retirees Retirees on or on after on or or after 3/1/2015 after 3/1/2015 Without Without Medicare) Medicare) (With (With and (With Without and and Without Medicare) Medicare) Network Network Non-Network Non-Network Network Network Non-Network Non-Network Individual Individual $2,500 $2,500 No $1,000 $1,000 No Individual Individual + 1 Dependent + 1 + Dependent 1 $5,000 $5,000 No $2,000 $2,000 No Family Family (Individual (Individual + 2 or + more 2 + 2 more more $7,500 $7,500 No $3,000 $3,000 Dependents) Dependents) No SPECIAL SPECIAL NOTES NOTES Out-of-Pocket Out-of-Pocket Maximum Maximum When When the Out-of-Pocket the the Out-of-Pocket Maximum, Maximum, as shown as as shown above, above, has been has has been satisfied, been satisfied, this Plan this this Plan will Plan pay will will 100% pay pay 100% of theof of the the Allowable Allowable Charge Charge toward toward eligible eligible expenses expenses for the foremainder the the remainder of theof Plan of the the Plan Year. Plan Year. Year. Eligible Eligible Expenses Expenses Eligible Eligible Expenses Expenses are reimbursed are are reimbursed in accordance in in accordance with a with fee with a schedule fee a fee schedule of maximum of of maximum Allowable Allowable Charges, Charges, not billed not not billed charges. billed charges. All Eligible All All Eligible Expenses Expenses are determined are are determined accordance in in accordance with with Plan with Plan Limitations Plan Limitations and Exclusions. and and Exclusions. Eligibility Eligibility The Plan The The Plan Administrator Plan Administrator determines determines Eligibility Eligibility for all for Plan for all all Plan Participants. Plan Participants. Network Network Coverage Coverage Community Community Blue Blue and Blue Blue and and Blue Connect Blue Connect networks networks in Shreveport, in in Shreveport, New New Orleans New Orleans and Baton and and Baton Rouge Rouge are available are are available for OGB for for OGB members. OGB members. These These plans plans are plans ideal are are ideal for ideal members for for members who live who who in live the live in parishes in the the parishes within within the available the the available networks networks and don t and and don t plan don t to plan plan to to use out-of-network use use out-of-network care. care. However, care. However, out-of-network out-of-network care care is care provided is provided is in emergencies. in in emergencies. Community Community Blue Blue is a Blue select, is a is select, a local local network local network designed designed for members for for members who live who who in live the live in communities in the the communities of Baton of of Baton Rouge Rouge (East (East and (East West and and West Baton West Baton Rouge Rouge and Ascension and and Ascension parishes) parishes) or Shreveport Shreveport (Caddo (Caddo and Bossier and and Bossier parishes). parishes). Blue Blue Connect Blue Connect is a select, is a is select, a local local network local network designed designed for members for for members who live who who in live the live in New in the the New Orleans New Orleans community community (Orleans (Orleans and Jefferson and and Jefferson parishes). parishes). 2 2 2 40HR2028 40HR2028 03/15 03/15 03/15 31

MAGNOLIA LOCAL COPAYMENTS and COINSURANCE Physician Office Visits including surgery performed in an office setting: General Practice Family Practice Internal Medicine OB/GYN Pediatrics Allied Health/Other Professional Visits: Chiropractors Federally Funded Qualified Rural Health Clinics Nurse Practitioners Retail Health Clinics Physician Assistants Specialist Office Visits including surgery performed in an office setting: Physician Podiatrist Optometrist Midwife Audiologist Registered Dietician Sleep Disorder Clinic NETWORK PROVIDERS $25 Copayment per Visit $25 Copayment per Visit $50 Copayment per Visit NON-NETWORK PROVIDERS Ambulance Services Ground $50 Copayment Ambulance Services Air $250 Copayment 2 Ambulatory Surgical Center and Outpatient Surgical Facility $100 Copayment 2 Autism Spectrum Disorders (ASD) $25/$50 Copayment 3 per Visit depending on Provider Birth Control Devices Insertion and Removal (as listed in the Preventive and Wellness Article in the Benefit Plan.) 100% - 0% 1 Subject to Plan Year Deductible, if applicable 2 Pre-Authorization Required, if applicable. Not applicable for Medicare primary. 3 Age and/or Time Restrictions Apply 32

MAGNOLIA LOCAL COPAYMENTS and COINSURANCE COPAYMENTS and COINSURANCE NETWORK PROVIDERS NON-NETWORK PROVIDERS NETWORK PROVIDERS NON-NETWORK PROVIDERS $25/$50 Copayment $25/$50 per day Copayment depending Cardiac Rehabilitation (limit of 48 visits per peron day Provider depending Cardiac Rehabilitation (limit of 48 visits per on Provider Plan Year) Plan Year) $50 Copayment Outpatient $50 Copayment Facility 2 Outpatient Facility 2 Office $25 Copayment Chemotherapy/Radiation Therapy Office per $25Visit Copayment (Authorization Chemotherapy/Radiation not required Therapy when per Visit performed (Authorization in Physician s not required office) when Outpatient Facility performed in Physician s office) Diabetes Treatment Outpatient 100% - 0% Facility 100% - 0% 1,2 80% - 20% 1 Diabetes Treatment 80% - 20% 1 Diabetic/Nutritional Counseling Clinics and Diabetic/Nutritional Counseling Clinics and $25 Copayment Outpatient Facilities $25 Copayment Outpatient Facilities Dialysis 100% - 0% 1,2 Dialysis 100% - 0% 1,2 80% - 20% 1,2 of first $5,000 80% Allowable - 20% 1,2 per of Plan first $5,000 Year; Durable Medical Equipment (DME), Allowable per Plan Year; Durable Medical Equipment (DME), 100% - 0% of Allowable Prosthetic Appliances and Orthotic Devices 100% - 0% of Allowable Prosthetic Appliances and Orthotic Devices in Excess of $5,000 in Excess per Planof Year $5,000 per Plan Year Emergency Room (Facility Charge) $150 Copayment; Waived if Admitted Emergency Room (Facility Charge) $150 Copayment; Waived if Admitted Emergency Medical Services Emergency Medical Services 100% - 0% 1 100% - 0% 1 (Non-Facility Charges) 100% - 0% 1 100% - 0% 1 (Non-Facility Charges) Eyeglass Frames and One Pair of Eyeglass Eyeglass Frames and One Pair of Eyeglass Eyeglass Frames Lenses or One Pair of Contact Lenses Eyeglass Frames Lenses or One Pair of Contact Lenses Limited to a Maximum (purchased within six months following Limited to a Maximum (purchased within six months following Benefit of $50 1,3 cataract surgery) Benefit of $50 1,3 cataract surgery) Flu shots and H1N1 vaccines (administered Flu shots and H1N1 at Network vaccines Providers, (administered at Network Providers, 100% - 0% Non-Network Providers, Pharmacy, Job Site 100% - 0% 100% - 0% or Non-Network Health Fair) Providers, Pharmacy, Job Site 100% - 0% or Health Fair) Hearing Aids (Hearing Aids are not covered Hearing Aids (Hearing Aids are not covered 80% - 20% 1,3 for individuals age eighteen (18) and older.) 80% - 20% 1,3 for individuals age eighteen (18) and older.) Hearing Impaired Interpreter expense 100% - 0% 1 Hearing Impaired Interpreter expense 100% - 0% 1 High-Tech Imaging Outpatient High-Tech CT Imaging Scans Outpatient MRA/MRI CT Scans $50 Copayment 2 Nuclear MRA/MRI Cardiology $50 Copayment 2 Nuclear PET/SPECT Cardiology Scans PET/SPECT Scans 1 Subject to Plan Year Deductible, if applicable 12 Subject Pre-Authorization to Plan Year Required, Deductible, if applicable. if applicable Not Pre-Authorization applicable for Required, Medicare if primary. applicable. Not Age applicable and/or Time for Restrictions Medicare Apply primary. Age and/or Time Restrictions Apply 33

MAGNOLIA LOCAL COPAYMENTS and COINSURANCE COPAYMENTS and COINSURANCE NETWORK PROVIDERS NETWORK PROVIDERS NON-NETWORK NON-NETWORK PROVIDERS PROVIDERS Home Health Care (limit of 60 Visits Home Health Care (limit of 60 Visits per Plan Year) per Plan Year) 100% - 0% 100% 0% 1,2 Hospice Care (limit of 180 Days per Hospice Care (limit of 180 Days per Plan Year) Plan Year) 100% - 0% 100% 0% 1,2 Injections Received in a Physician s Injections Received in Physician s Office (allergy and allergy serum) Office (allergy and allergy serum) 100% - 0% 100% 0% 1 $100 Copayment Inpatient Hospital Admission, All Inpatient $100 Copayment Inpatient Hospital Admission, All Inpatient per day per day 2, maximum of Hospital Services Included maximum of Hospital Services Included $300 per Admission $300 per Admission Inpatient and Outpatient Professional Inpatient and Outpatient Professional Services for Which a Copayment Is Services for Which Copayment Is Not Applicable Not Applicable 100% - 0% 100% 0% 1 80% - 20% 80% 20% 1,2 of first $5,000 of first $5,000 Allowable per Plan Year; Mastectomy Bras Ortho-Mammary Surgical Allowable per Plan Year; Mastectomy Bras Ortho-Mammary Surgical 100% - 0% of Allowable in (limited to two (2) per Plan Year) 100% 0% of Allowable in (limited to two (2) per Plan Year) Excess of $5,000 Excess of $5,000 per Plan Year per Plan Year $100 Copayment per day $100 Copayment per day 2, Mental Health/Substance Abuse Mental Health/Substance Abuse maximum of $300 Inpatient Treatment maximum of $300 Inpatient Treatment per Admission per Admission Mental Health/Substance Abuse Mental Health/Substance Abuse Outpatient Treatment Outpatient Treatment $25 Copayment per Visit $25 Copayment per Visit Newborn Sick, Services excluding Facility Newborn Sick, Services excluding Facility 100% - 0% 100% 0% 1 Newborn Sick, Facility Newborn Sick, Facility $100 Copayment per day $100 Copayment per day 2, maximum of $300 maximum of $300 per Admission per Admission Oral Surgery (Authorization not required when Oral Surgery (Authorization not required when performed in Physician s office) performed in Physician s office) 100% - 0% 100% 0% 1,2 Pregnancy Care Physician Services Pregnancy Care Physician Services $90 Copayment $90 Copayment per pregnancy per pregnancy Preventive Care Services include screening to Preventive Care Services include screening to detect illness or health risks during a Physician detect illness or health risks during Physician office visit. The Covered Services are based on office visit. The Covered Services are based on prevailing medical standards and may vary prevailing medical standards and may vary according to age and family history. (For a according to age and family history. (For complete list of benefits, refer to the Preventive complete list of benefits, refer to the Preventive and Wellness Article in the Benefit Plan.) and Wellness Article in the Benefit Plan.) 100% - 0% 100% 0% 3 3 1 1 Subject to Plan Year Deductible, if applicable Subject to Plan Year Deductible, if applicable 2 2 Pre-Authorization Required, if applicable. Pre-Authorization Required, if applicable. Not applicable for Medicare primary. Not applicable for Medicare primary. 3 3 Age and/or Time Restrictions Apply Age and/or Time Restrictions Apply 34

MAGNOLIA LOCAL COPAYMENTS and COINSURANCE Rehabilitation Services Outpatient: Physical/Occupational (Limited to 50 Visits Combined PT/OT per Plan Year. Authorization required for visits over the Combined limit of 50.) Speech Cognitive Hearing Therapy Skilled Nursing Facility Network (limit of 90 days per Plan Year) NETWORK PROVIDERS $25 Copayment per Visit $100 Copayment per day 2, maximum of $300 per Admission NON-NETWORK PROVIDERS Sonograms and Ultrasounds (Outpatient) $50 Copayment Urgent Care Center $50 Copayment Vision Care (Non-Routine) Exam X-ray and Laboratory Services (low-tech imaging) $25/$50 Copayment depending on Provider Office or Independent Lab 100% - 0% Hospital Facility 100% - 0% 1 1 Subject to Plan Year Deductible, if applicable 2 Pre-Authorization Required, if applicable. Not Applicable for Medicare primary. 3 Age and/or Time Restrictions Apply ORGAN, TISSUE AND BONE MARROW TRANSPLANTS Authorization is Required Prior to Services Being Performed Organ, Tissue and Bone Marrow Transplants and evaluation for a Plan Participant s suitability for Organ, Tissue Bone Marrow transplants will not be covered unless a Plan Participant obtains written authorization from the Claims Administrator, prior to services being rendered. Network Benefits:... 100% - 0% after deductible Non-Network Benefits:...Not Covered CARE MANAGEMENT If a required Authorization is not requested prior to Admission or receiving other Covered Services and supplies, the Plan will have the right to determine if the Admission or other Covered Services or supplies were Medically Necessary. If the Admission or other Covered Services and supplies were not Medically Necessary, the Admission or other Covered Services and supplies will not be covered and the Plan Participant must pay all charges incurred. 35

MAGNOLIA LOCAL If the Admission or other Covered Services and supplies were Medically Necessary, Benefits will be provided based on the Network status of the Provider rendering the services. Authorization of Inpatient and Emergency Admissions Inpatient Admissions must be Authorized. Refer to Care Management and if applicable Pregnancy Care and Newborn Care Benefits sections of the Benefit Plan for complete information. Requests for Authorization of Inpatient Admissions and for Concurrent Review of an Admission in progress, or other Covered Services and supplies must be made to Blue Cross and Blue Shield of Louisiana by calling 1-800-392-4089. If a Blue Cross and Blue Shield of Louisiana Network Provider fails to obtain a required Authorization, no Benefits are payable. The Network Provider is responsible for all charges not covered. The Plan Participant remains responsible for any applicable Copayment or Deductible Amount and Coinsurance percentage shown in the Schedule of Benefits. If Network Provider in another Blue Cross and Blue Shield plan fails to obtain a required Authorization, the Claims Administrator will reduce Allowable Charges by the penalty amount stipulated in the Provider s contract with the other Blue Cross and Blue Shield plan. This penalty applies to covered Inpatient charges. The Network Provider of the other Blue Cross and Blue Shield plan is responsible for all charges not covered. The Plan Participant remains responsible for his applicable Copayment, Deductible and Coinsurance percentage. The following services and supplies require Authorization prior to the services being rendered or supplies being received. Requests for Authorization must be made to Blue Cross and Blue Shield of Louisiana by calling 1-800- 392-4089. Inpatient Hospital Admissions (Except routine maternity stays) Inpatient Mental Health and Substance Abuse Admissions Inpatient Organ, Tissue and Bone Marrow Transplant Services Inpatient Skilled Nursing Facility Services Authorization of Outpatient Services, Including Other Services and Supplies: If a Network Provider fails to obtain a required Authorization, no Benefits are payable. The Network Provider is responsible for all charges not covered. The Plan Participant remains responsible for his applicable Copayment, Deductible and Coinsurance percentage. If Network Provider in another Blue Cross and Blue Shield plan fails to obtain a required Authorization, no Benefits are payable. The Network Provider of the other Blue Cross and Blue Shield plan is responsible for all charges not covered. The Plan Participant remains responsible for his applicable Copayment, Deductible and Coinsurance percentage. The following services and supplies require Authorization prior to the services being rendered or supplies being received. Requests for Authorization must be made to Blue Cross and Blue Shield of Louisiana by calling 1-800- 392-4089. Air Ambulance Non Emergency Applied Behavior Analysis Bone growth stimulator Cardiac Rehabilitation CT Scans Day Rehabilitation Programs Dialysis Durable Medical Equipment (Greater than $300.00) Electric & Custom Wheelchairs Home Health Care Hospice Hyperbarics 36 7

MAGNOLIA LOCAL Implantable Medical Devices over $2000.00, such as Implantable Defibrillator and Insulin Pump Infusion Therapy (Exception: Infusion Therapy performed in a Physician s office does not require prior Authorization. The Drug to be infused may require prior Authorization). Intensive Outpatient Programs MRI/MRA Nuclear Cardiology Oral Surgery (not required when performed in a Physician s office) Organ Transplant Evaluation Orthotic Devices (Greater than $300.00) Outpatient surgical procedures not performed in a Physician s office Outpatient non-surgical procedures (Exceptions: X-rays, lab work, Speech Therapy and Chiropractic Services do not require prior Authorization. Non-surgical procedures performed in a Physician's office do not require prior Authorization). Outpatient pain rehabilitation or pain control programs Partial Hospitalization Programs PET/SPCET Scans Physical/Occupational Therapy (greater than 50 visits) Prosthetic Appliances (Greater than $300.00) Residential Treatment Centers Sleep Studies Specialty Pharmacy (Complete list of drugs available online at www.bcbsla.com> I m a Provider>Pharmacy Management>Specialty Pharmacy Program Drug List.pdf) Stereotactic Radiosurgery, including but not limited to gamma knife and cyberknife procedures Vacuum Assisted Wound Closure Therapy Population Health In Health: Blue Health The Population Health program targets populations with one or more of these five(5) chronic health conditions diabetes, coronary artery disease, heart failure, asthma and chronic obstructive pulmonary disease (COPD). (The In Health: Blue Health Services program is not available to Plan Participants with Medicare primary.) Through the In Health: Blue Health Services program, OGB offers an incentive to Plan Participants on Prescription Drugs used to treat the five chronic conditions listed above. a. OGB Plan Participants participating in the program qualify for $0 Copayment for certain Generic Prescription Drugs approved by the U. S. Food and Drug Administration (FDA) for any of the 5 chronic health conditions. b. OGB Plan Participants participating in the program qualify for $20 Copayment (31 day supply), $40 Copayment (62 day supply) or $50 Copayment (93 day supply) for certain Preferred Brand-Name Prescription Drugs for which an FDA-approved Generic version is not available. c. OGB Plan Participants participating in the program qualify for $40 Copayment (31 day supply), $80 Copayment (62 day supply) or $100 Copayment (93 day supply) for certain Non-Preferred Brand-Name Prescription Drug. Non-Preferred drugs typically have lower cost alternatives available in the same drug class. d. If an OGB Plan Participant chooses a Brand-Name Drug for which an FDA-approved Generic version is available, the OGB Plan Participant pays the difference between the Brand-Name and Generic cost, plus a $40 Copayment for a 31 day supply. The In Health: Blue Health Services prescription incentive does not apply to any Prescription Drugs not used to treat one of these five health conditions with which you have been diagnosed. Please refer to the Care Management article, Population Health In Health: Blue Health section of the Benefit Plan for complete information on how to qualify for this incentive. 8 37

MAGNOLIA LOCAL PRESCRIPTION DRUGS Prescription Drug Benefits are provided under the Hospital Benefits and Medical and Surgical Benefits Articles of the medical plan, and under the pharmacy plan provided by OGB s Pharmacy Benefits Manager (sometimes PBM ). Blue Cross and Blue Shield of Louisiana Blue Cross and Blue Shield of Louisiana provides Claims Administration services only for Prescription Drugs dispensed as follows: Prescription Drugs Covered Under Hospital Benefits and Medical and Surgical Benefits 1. Prescription Drugs dispensed during an Inpatient or Outpatient Hospital stay, or in an Ambulatory Surgical Center are payable under the Hospital Benefits. 2. Medically necessary/non-investigational Prescription Drugs requiring parenteral administration in a Physician s Office are payable under the Medical and Surgical Benefits. 3. Prescription Drugs that can be self-administered and are provided to a Plan Participant in a Physician s office are payable under the Medical and Surgical Benefits. All other pharmacy benefits will be provided by OGB S PBM. Authorizations The following categories of Prescription Drugs require Prior Authorization. The Plan Participant s Physician must call 1-800-842-2015 to obtain the Authorization. The Plan Participant or his Physician should call the Customer Service number on the Plan Participant s ID card, or check the Claims Administrator s website at www.bcbsla.com/ogb for the most current list of Prescription Drugs that require Prior Authorization: Growth hormones* Anti-tumor necrosis factor drugs* Intravenous immune globulins* Interferons Monoclonal antibodies Hyaluronic acid derivatives for joint injection* * Shall include all drugs that are in this category. Therapeutic/Treatment Vaccines Examples include, but are not limited to vaccines to treat the following conditions: Allergic Rhinitis Alzheimer s Disease Cancers Multiple Sclerosis Therapeutic/Treatment Vaccines: Network Providers:... 100% - 0% Non-Network Providers:...Not Covered OGB S Pharmacy Benefit Manager MedImpact Formulary: 3-Tier Plan Design* OGB will begin using the MedImpact Formulary to help Plan Participants select the most appropriate, lowest-cost options. The formulary is reviewed on a quarterly basis to reassess drug tiers based on the current prescription 38 9

MAGNOLIA LOCAL drug market. Plan Participants will will continue to to pay a a portion of of the the cost of of their prescriptions in in the the form of of a a copayment or or coinsurance. The amount Plan Participants pay toward their prescription depends on on whether they receive a a generic, preferred brand or or non-preferred brand name drug. *These changes do do not not affect Plan Participants with Medicare as as their primary coverage. PRESCRIPTION DRUG PLAN PARTICIPANT PAYS Generic 50% up up to to $30 Preferred 50% up up to to $55 Non-Preferred 65% up up to to $80 Specialty 50% up up to to $80 The pharmacy out-of-pocket maximum has been changed from $1,200 to to $1,500. Once met: Generic $0 $0 co-pay Preferred $20 co-pay Non-Preferred $40 co-pay Specialty $40 co-pay co- There may be be more than one drug available to to treat your condition. We encourage you to to speak with your Physician regularly about which drugs meet your needs at at the the lowest cost to to you. Compound Drugs Compound Drugs over $400 require prior Authorization from MedImpact. 90-day fill fill option at at retail or or mail order network pharmacies For For maintenance medications, 90-day prescriptions fills fills may be be filled for for the the applicable coinsurance with a a maximum that is is two and a a half times the the maximum copayment. For For example, if if your share of of the the cost of of a a generic drug is is $30, you can fill fill your 30-day prescription for for $30 or or a a 90-day prescription for for $75. Over-the-counter drugs Medications available over-the-counter in in the the same prescribed strength will will no no longer be be covered under the the pharmacy plan. What is is a a formulary? A A formulary is is a a list list of of medications available to to Plan Participants under the the Plan s pharmacy benefit. Inclusion on on the the list list is is based on on consideration of of a a medication s safety, effectiveness and associated clinical outcomes. The formulary is is updated regularly and divides drugs into four main categories: generic, preferred brand, non-preferred brand, and specialty. A A generic drug is is effectively equivalent to to a a brand name drug in in intended use, dosage, strength, and safety. For For a a generic drug to to be be approved by by the the FDA, it it must meet the the same quality standards as as the the brand name product. Even the the generic manufacturing, packaging, and testing sites must meet the the same standards. Many generics are are produced in in the the same manufacturing plant as as their branded counterparts. Preferred brand drugs are are generally those that have been on on the the market for for a a while and do do not not have a a generic equivalent available. They are are effective alternatives to to other brands that may be be more expensive. Non-preferred brand drugs are are recently branded medications. In In most cases, a a lower cost alternative is is available. Specialty medications higher cost drugs. 10 10 39

MAGNOLIA LOCAL 1. In the event the Plan Participant does not present his identification card to the Network pharmacy at the time of purchase, the Plan Participant will be responsible for full payment for the drug and must then file a claim with the Pharmacy Benefits Manager for reimbursement. Reimbursement is limited to the rates established for Non-Network pharmacies. If a Plan Participant chooses a Brand-Name Drug for which an FDA-approved Generic version is available, the Plan Participant pays the difference between the Brand-Name and Generic cost, plus a $40 Copayment for a 31 day supply. 2. Regardless of where the Prescription Drug is obtained, Eligible Expenses for Brand Name Drugs will be limited to: a. The Pharmacy Benefits Manager's maximum Allowable Charge for the Generic, when available; or b. The Pharmacy Benefits Manager's maximum Allowable Charge for the Brand Drug dispensed, when a Generic is not available. c. There is no per prescription maximum on the Plan Participant's responsibility for payment of costs in excess of the Eligible Expense. Plan Participant payments for such excess costs are not applied toward satisfaction of the annual Out-of-Pocket threshold (above). 3. This Plan allows Benefits for drugs and medicines approved by the Food and Drug Administration or its successor that require a prescription. Utilization management criteria may apply to specific drugs or drug categories to be determined by the PBM. 4. Retirees with Medicare will be automatically enrolled in OGB s Medicare Part D coverage with a commercial wrap benefit. 5. In addition, this Plan allows Benefits limited to $200.00 per month for expenses incurred for the purchase of low protein food products for the treatment of inherited metabolic diseases if the low protein food products are Medically Necessary and are obtained from a source approved by the OGB. Such expenses shall be subject to Coinsurance and Copayments relating to Prescription Drug Benefits. In connection with this Benefit, the following words shall have the following meanings: a. Inherited metabolic disease shall mean a disease caused by an inherited abnormality of body chemistry and shall be limited to: Phenylketonuria (PKU) Maple Syrup Urine Disease (MSUD) Methylmalonic Acidemia (MMA) Isovaleric Adicemia (IVA) Propionic Acidemia Glutaric Acidemia Urea Cycle Defects Tyrosinemia b. Low protein food products mean food products that are especially formulated to have less than one gram of protein per serving and are intended to be used under the direction of a physician for the dietary treatment of an inherited metabolic disease. Low protein food products shall not include natural foods that are naturally low in protein. 6. Benefits are available for Prescription and over-the-counter (OTC) smoking cessation medications when prescribed by a Physician. (Prescription is required for over-the-counter medications). Smoking cessation medications are not subject to the Prescription Drug deductible and are covered at 100%. Smoking cessation screening and counseling are covered under the Preventive or Wellness Care section of this Plan. 40 11

7. The following drugs, medicines, and related services and supplies are not covered: Drugs used to treat anorexia, weight loss or weight gain Drugs used to promote fertility 11 40HR2028 Dietary 03/15supplements; Medical Foods Bulk Chemicals Drugs for cosmetic purposes or to promote hair growth Nutritional or parenteral therapy; Vitamins and minerals; Drugs available over the counter (OTC) (unless expressly covered by this Plan) Prescription drugs (federal legend) with an OTC equivalent MAGNOLIA LOCAL b. Low protein food products mean food products that are especially formulated to have less than one gram of protein per serving and are intended to be used under the direction of a physician for the dietary treatment of an inherited metabolic disease. Low protein food products shall not include natural foods that are naturally low in protein. 6. Benefits are available for Prescription and over-the-counter (OTC) smoking cessation medications when prescribed by a Physician. (Prescription is required for over-the-counter medications). Smoking cessation medications are not subject to the Prescription Drug deductible and are covered at 100%. Smoking cessation screening and counseling are covered under the Preventive or Wellness Care section of this Plan. For more information on the pharmacy benefit, visit the MedImpact website at https://mp.medimpact.com/ogb or call MedImpact member services at 1-800-910-1831. 41

42 This Annual Enrollment Guide is presented for general information only. It is not a benefit plan, nor intended to be construed as the Blue Cross benefit plan document. If there is any discrepancy between this Annual Enrollment Guide and the Blue Cross benefit plan document and Schedule of Benefits, the FINAL Blue Cross benefit plan document and Schedule of Benefits will govern the benefits and plan payments.

MAGNOLIA LOCAL PLUS 43

MAGNOLIA LOCAL PLUS Preferred Care Providers and BCBS National Providers BENEFIT PLAN FORM NUMBER 40HR1607 03/15 OGB MAGNOLIA LOCAL PLUS SCHEDULE OF BENEFITS: Actives, Retirees Without PLAN Medicare, NUMBER Retirees With Medicare PLAN NAME State of LouisianaCOMPREHENSIVE Office of Group Benefits HMO MEDICAL BENEFIT PLAN ST222ERC SCHEDULE OF BENEFITS PLAN S ORIGINAL BENEFIT PLAN Nationwide DATE Network CoveragePLAN S ANNIVERSARY DATE July 1, 2010 Preferred Care Providers and BCBS National January Providers 1 BENEFIT PLAN FORM NUMBER 40HR1607 03/15 Lifetime Maximum Benefit: Unlimited PLAN Benefit NAME Period:...03/01/2015 PLAN NUMBER 12/31/2015 State of Louisiana Office of Group Benefits ST222ERC Deductible Amount Per Benefit Period: PLAN S Individual: ORIGINAL BENEFIT PLAN DATE PLAN S ANNIVERSARY DATE July 1, 2010 January 1 Network Providers: Active Employees and Retirees on or after 3/1/15 (With and Without Medicare) $400.00 Lifetime Maximum Benefit: Unlimited Retirees prior to 03/01/15 (With and Without Medicare) $0 Benefit Period:...03/01/2015 12/31/2015 Non-Network Providers: Deductible Amount Per Benefit Period: Individual + 1 Dependent: Individual: Network Providers: Network Providers: Active Employees and Retirees on or after 3/1/15 (With and Without Medicare) $800.00 Active Employees and Retirees on or after 3/1/15 (With and Without Medicare) $400.00 Retirees prior to 03/01/15 (With and Without Medicare) $0 Retirees prior to 03/01/15 (With and Without Medicare) $0 Non-Network Providers: Non-Network Providers: Family (Individual + 2 or more Dependents): Individual + 1 Dependent: Network Providers: Network Providers: Active Employees and Retirees on or after 3/1/15 (With and Without Medicare) $1,200.00 Active Employees and Retirees on or after 3/1/15 (With and Without Medicare) $800.00 Retirees prior to 03/01/15 (With and Without Medicare) $0 Retirees prior to 03/01/15 (With and Without Medicare) $0 1 40HR1608 Non-Network Providers: Non-Network R03/15 Providers: Out-of-Pocket Maximum per Benefit Period: Includes all eligible Copayments, Coinsurance Amounts, and Deductibles 40HR1608 R03/15 1 Active Employees and Retirees on or after 3/1/2015 (With and Without Medicare) Retirees prior to 3/1/2015 (With and Without Medicare) 44 Network Non-Network Network Non-Network

Network Network Providers: Providers: MAGNOLIA LOCAL PLUS Active Active Employees Employees and Retirees and Retirees on or on after or after 3/1/15 3/1/15 (With (With and Without and Without Medicare) Medicare) $1,200.00 $1,200.00 Retirees Retirees prior prior to 03/01/15 to 03/01/15 (With (With and Without and Without Medicare) Medicare) $0 $0 Non-Network Providers: Providers: Out-of-Pocket Maximum Maximum per Benefit per Benefit Period: Period: Includes Includes all eligible all eligible Copayments, Coinsurance Amounts, Amounts, and Deductibles and Active Active Employees Employees and and Retirees Retirees prior prior to 3/1/2015 to 3/1/2015 (With (With and and Retirees Retirees on or on after or after 3/1/2015 3/1/2015 Without Without Medicare) Medicare) (With (With and Without and Without Medicare) Medicare) Network NetworkNon-Network Network Network Non-Network Individual Individual $2,500 $2,500 $1,000 $1,000 Individual Individual + 1 Dependent + 1 Dependent $5,000 $5,000 $2,000 $2,000 Family Family (Individual (Individual + 2 or + more 2 more Dependents) $7,500 $7,500 $3,000 $3,000 SPECIAL SPECIAL NOTES NOTES Out-of-Pocket Maximum Maximum When When the Out-of-Pocket the Maximum, Maximum, as shown as shown above, above, has been has been satisfied, satisfied, this Plan this Plan will pay will100% pay 100% of theof the Allowable Allowable Charge Charge toward toward eligible eligible expenses expenses for the foremainder the remainder of theof Plan the Plan Year. Year. Eligible Eligible Expenses Expenses Eligible Eligible Expenses Expenses are reimbursed are reimbursed in accordance in accordance with a with fee a schedule fee schedule of maximum of maximum Allowable Allowable Charges, Charges, not billed not billed charges. charges. All Eligible All Eligible Expenses Expenses are determined are determined accordance in with with Plan Plan Limitations Limitations and Exclusions. and Eligibility Eligibility The Plan The Plan Administrator determines determines Eligibility Eligibility for all for Plan all Plan Participants. Participants. 40HR1608 40HR1608 R03/15 R03/15 2 2 45

MAGNOLIA LOCAL PLUS COPAYMENTS and COINSURANCE Physician Office Visits including surgery performed in an office setting: General Practice Family Practice Internal Medicine OB/GYN Pediatrics Allied Health/Other Professional Visits: Chiropractors Federally Funded Qualified Rural Health Clinics Nurse Practitioners Retail Health Clinics Physician Assistants Specialist Office Visits including surgery performed in an office setting: Physician Podiatrist Optometrist Midwife Audiologist Registered Dietician Sleep Disorder Clinic NETWORK PROVIDERS $25 Copayment per Visit $25 Copayment per Visit $50 Copayment per Visit NON-NETWORK PROVIDERS Ambulance Services Ground $50 Copayment Ambulance Services Air $250 Copayment 2 Ambulatory Surgical Center and Outpatient Surgical Facility $100 Copayment 2 Autism Spectrum Disorders (ASD) $25/$50 Copayment 3 per Visit depending on Provider Birth Control Devices Insertion and Removal (as listed in the Preventive and Wellness Article in the Benefit Plan.) 100% - 0% 1 Subject to Plan Year Deductible, if applicable 2 Pre-Authorization Required, if applicable. Not applicable for Medicare primary. 3 Age and/or Time Restrictions Apply 46

MAGNOLIA LOCAL PLUS COPAYMENTS and COINSURANCE NETWORK PROVIDERS NON-NETWORK PROVIDERS Cardiac Rehabilitation (limit of 48 visits per Plan Year) Chemotherapy/Radiation Therapy (Authorization not required when performed in Physician s office) $25/$50 Copayment per day depending on Provider $50 Copayment Outpatient Facility 2 Office $25 Copayment per Visit Outpatient Facility 100% - 0% 1,2 Diabetes Treatment 80% - 20% 1 Diabetic/Nutritional Counseling Clinics and Outpatient Facilities $25 Copayment Dialysis 100% - 0% 1,2 Durable Medical Equipment (DME), Prosthetic Appliances and Orthotic Devices 80% - 20% 1,2 of first $5,000 Allowable per Plan Year; 100% - 0% of Allowable in Excess of $5,000 per Plan Year Emergency Room (Facility Charge) Emergency Medical Services (Non-Facility Charges) $150 Copayment; Waived if Admitted 100% - 0% 1 100% - 0% 1 Eyeglass Frames and One Pair of Eyeglass Lenses or One Pair of Contact Lenses (purchased within six months following cataract surgery) Flu shots and H1N1 vaccines (administered at Network Providers, Non-Network Providers, Pharmacy, Job Site or Health Fair) Eyeglass Frames Limited to a Maximum Benefit of $50 1,3 100% - 0% 100% - 0% Hearing Aids (Hearing Aids are not covered for individuals age eighteen (18) and older.) 80% - 20% 1,3 Hearing Impaired Interpreter expense 100% - 0% 1 High-Tech Imaging Outpatient CT Scans MRA/MRI Nuclear Cardiology PET/SPECT Scans $50 Copayment 2 1 Subject to Plan Year Deductible, if applicable 2 Pre-Authorization Required, if applicable. Not applicable for Medicare primary. 3 Age and/or Time Restrictions Apply 47

MAGNOLIA LOCAL PLUS COPAYMENTS and COINSURANCE Home Health Care (limit of 60 Visits per Plan Year) Hospice Care (limit of 180 Days per Plan Year) Injections Received in a Physician s Office (allergy and allergy serum) NETWORK PROVIDERS NON-NETWORK PROVIDERS 100% - 0% 1,2 100% - 0% 1,2 100% - 0% 1 Inpatient Hospital Admission, All Inpatient Hospital Services Included $100 Copayment per day 2, maximum of $300 per Admission Inpatient and Outpatient Professional Services for Which a Copayment Is Not Applicable 100% - 0% 1 Mastectomy Bras Ortho-Mammary Surgical (limited to two (2) per Plan Year) 80% - 20% 1,2 of first $5,000 Allowable per Plan Year; 100% - 0% of Allowable in Excess of $5,000 per Plan Year Mental Health/Substance Abuse Inpatient Treatment Mental Health/Substance Abuse Outpatient Treatment $100 Copayment per day 2, maximum of $300 per Admission $25 Copayment per Visit Newborn Sick, Services excluding Facility 100% - 0% 1 Newborn Sick, Facility $100 Copayment per day 2, maximum of $300 per Admission Oral Surgery (Authorization not required when performed in Physician s office) 100% - 0% 1,2 Pregnancy Care Physician Services $90 Copayment per pregnancy 1 Subject to Plan Year Deductible, if applicable 2 Pre-Authorization Required, if applicable. Not applicable for Medicare primary. 3 Age and/or Time Restrictions Apply 48

MAGNOLIA LOCAL PLUS COPAYMENTS and COINSURANCE NETWORK PROVIDERS NON-NETWORK PROVIDERS Preventive Care Services include screening to detect illness or health risks during a Physician office visit. The Covered Services are based on prevailing medical standards and may vary according to age and family history. (For a complete list of benefits, refer to the Preventive and Wellness Article in the Benefit Plan.) 100% - 0% 3 Rehabilitation Services Outpatient: Physical/Occupational (Limited to 50 Visits Combined PT/OT per Plan Year. Authorization required for visits over the Combined limit of 50.) Speech Cognitive Hearing Therapy Skilled Nursing Facility Network (limit of 90 days per Plan Year) $25 Copayment per Visit $100 Copayment per day 2, maximum of $300 per Admission Sonograms and Ultrasounds (Outpatient) $50 Copayment Urgent Care Center $50 Copayment Vision Care (Non-Routine) Exam X-ray and Laboratory Services (low-tech imaging) $25/$50 Copayment depending on Provider Office or Independent Lab 100% - 0% Hospital Facility 100% - 0% 1 1 Subject to Plan Year Deductible, if applicable 2 Pre-Authorization Required, if applicable. Not applicable for Medicare primary. 3 Age and/or Time Restrictions Apply 49

MAGNOLIA LOCAL PLUS ORGAN, TISSUE AND BONE MARROW TRANSPLANTS Authorization is Required Prior to Services Being Performed Organ, Tissue and Bone Marrow Transplants and evaluation for a Plan Participant s suitability for Organ, Tissue Bone Marrow transplants will not be covered unless a Plan Participant obtains written authorization from the Claims Administrator, prior to services being rendered. Network Benefits:... 100% - 0% after deductible Non-Network Benefits:...Not Covered CARE MANAGEMENT If a required Authorization is not requested prior to Admission or receiving other Covered Services and supplies, the Plan will have the right to determine if the Admission or other Covered Services or supplies were Medically Necessary. If the Admission or other Covered Services and supplies were not Medically Necessary, the Admission or other Covered Services and supplies will not be covered and the Plan Participant must pay all charges incurred. If the Admission or other Covered Services and supplies were Medically Necessary, Benefits will be provided based on the Network status of the Provider rendering the services. Authorization of Inpatient and Emergency Admissions Inpatient Admissions must be Authorized. Refer to Care Management and if applicable Pregnancy Care and Newborn Care Benefits sections of the Benefit Plan for complete information. Requests for Authorization of Inpatient Admissions, and for Concurrent Review of an Admission in progress, or other Covered Services and supplies must be made to Blue Cross and Blue Shield of Louisiana by calling 1-800-392-4089. If a Blue Cross and Blue Shield of Louisiana Network Provider fails to obtain a required Authorization, no Benefits are payable. The Network Provider is responsible for all charges not covered. The Plan Participant remains responsible for any applicable Copayment or Deductible Amount and Coinsurance percentage shown in the Schedule of Benefits. If Network Provider in another Blue Cross and Blue Shield plan fails to obtain a required Authorization, the Claims Administrator will reduce Allowable Charges by the penalty amount stipulated in the Provider s contract with the other Blue Cross and Blue Shield plan. This penalty applies to covered Inpatient charges. The Network Provider of the other Blue Cross and Blue Shield plan is responsible for all charges not covered. The Plan Participant remains responsible for his applicable Copayment, Deductible and Coinsurance percentage. The following services and supplies require Authorization prior to the services being rendered or supplies being received. Requests for Authorization must be made to Blue Cross and Blue Shield of Louisiana by calling 1-800- 392-4089. Inpatient Hospital Admissions (Except routine maternity stays) Inpatient Mental Health and Substance Abuse Admissions Inpatient Organ, Tissue and Bone Marrow Transplant Services Inpatient Skilled Nursing Facility Services Authorization of Outpatient Services, Including Other Services and Supplies: If a Network Provider fails to obtain a required Authorization, no Benefits are payable. The Network Provider is responsible for all charges not covered. The Plan Participant remains responsible for his applicable Copayment, Deductible and Coinsurance percentage. 50 7

MAGNOLIA LOCAL PLUS If Network Provider in another Blue Cross and Blue Shield plan fails to obtain a required Authorization, no Benefits are payable. The Network Provider of the other Blue Cross and Blue Shield plan is responsible for all charges not covered. The Plan Participant remains responsible for his applicable Copayment, Deductible and Coinsurance percentage. The following services and supplies require Authorization prior to the services being rendered or supplies being received. Requests for Authorization must be made to Blue Cross and Blue Shield of Louisiana by calling 1-800- 392-4089. Air Ambulance Non Emergency Applied Behavior Analysis Bone growth stimulator Cardiac Rehabilitation CT Scans Day Rehabilitation Programs Dialysis Durable Medical Equipment (Greater than $300.00) Electric & Custom Wheelchairs Home Health Care Hospice Hyperbarics Implantable Medical Devices over $2000.00, such as Implantable Defibrillator and Insulin Pump Infusion Therapy (Exception: Infusion Therapy performed in a Physician s office does not require prior Authorization. The Drug to be infused may require prior Authorization). Intensive Outpatient Programs MRI/MRA Nuclear Cardiology Oral Surgery (not required when performed in a Physician s office) Organ Transplant Evaluation Orthotic Devices (Greater than $300.00) Outpatient surgical procedures not performed in a Physician s office Outpatient non-surgical procedures (Exceptions: X-rays, lab work, Speech Therapy and Chiropractic Services do not require prior Authorization. Non-surgical procedures performed in a Physician's office do not require prior Authorization). Outpatient pain rehabilitation or pain control programs Partial Hospitalization Programs PET/SPECT Scans Physical/Occupational Therapy (Greater than 50 visits) Prosthetic Appliances (Greater than $300.00) Residential Treatment Centers Sleep Studies Specialty Pharmacy (Complete list of drugs available online at www.bcbsla.com> I m a Provider>Pharmacy Management>Specialty Pharmacy Program Drug List.pdf) Stereotactic Radiosurgery, including but not limited to gamma knife and cyberknife procedures Vacuum Assisted Wound Closure Therapy Population Health In Health: Blue Health The Population Health program targets populations with one or more of these five(5) chronic health conditions diabetes, coronary artery disease, heart failure, asthma and chronic obstructive pulmonary disease (COPD). (The In Health: Blue Health Services program is not available to Plan Participants with Medicare primary.) Through the In Health: Blue Health Services program, OGB offers an incentive to Plan Participants on Prescription Drugs used to treat the five chronic conditions listed above. a. OGB Plan Participants participating in the program qualify for $0 Copayment for certain Generic Prescription Drugs approved by the U. S. Food and Drug Administration (FDA) for any of the 5 chronic health conditions. 8 51

MAGNOLIA LOCAL PLUS b. OGB Plan Participants participating in the program qualify for $20 Copayment (31 day supply), $40 Copayment (62 day supply) or $50 Copayment (93 day supply) for certain Preferred Brand-Name Prescription Drugs for which an FDA-approved Generic version is not available. c. OGB Plan Participants participating in the program qualify for $40 Copayment (31 day supply), $80 Copayment (62 day supply) or $100 Copayment (93 day supply) for certain Non-Preferred Brand-Name Prescription Drug. Non-Preferred drugs typically have lower cost alternatives available in the same drug class. d. If an OGB Plan Participant chooses a Brand-Name Drug for which an FDA-approved Generic version is available, the OGB Plan Participant pays the difference between the Brand-Name and Generic cost, plus a $40 Copayment for a 31 day supply. The In Health: Blue Health Services prescription incentive does not apply to any Prescription Drugs not used to treat one of these five health conditions with which you have been diagnosed. Please refer to the Care Management article, Population Health In Health: Blue Health section of the Benefit Plan for complete information on how to qualify for this incentive. PRESCRIPTION DRUGS Prescription Drug Benefits are provided under the Hospital Benefits and Medical and Surgical Benefits Articles of the medical plan, and under the Pharmacy Plan provided by OGB s Pharmacy Benefits Manager (sometimes PBM ). Blue Cross and Blue Shield of Louisiana Blue Cross and Blue Shield of Louisiana provides Claims Administration services only for Prescription Drugs dispensed as follows: Prescription Drugs Covered Under Hospital Benefits and Medical and Surgical Benefits 1. Prescription Drugs dispensed during an Inpatient or Outpatient Hospital stay, or in an Ambulatory Surgical Center are payable under the Hospital Benefits. 2. Medically necessary/non-investigational Prescription Drugs requiring parenteral administration in a Physician s Office are payable under the Medical and Surgical Benefits. 3. Prescription Drugs that can be self-administered and are provided to a Plan Participant in a Physician s office are payable under the Medical and Surgical Benefits. All other pharmacy benefits will be provided by OGB S Pharmacy Benefit Manager. Authorizations The following categories of Prescription Drugs require Prior Authorization. The Plan Participant s Physician must call 1-800-842-2015 to obtain the Authorization. The Plan Participant or his Physician should call the Customer Service number on the Plan Participant s ID card, or check the Claims Administrator s website at www.bcbsla.com/ogb for the most current list of Prescription Drugs that require Prior Authorization: Growth hormones* Anti-tumor necrosis factor drugs* Intravenous immune globulins* Interferons Monoclonal antibodies Hyaluronic acid derivatives for joint injection* * Shall include all drugs that are in this category. 52 9

MAGNOLIA LOCAL PLUS Therapeutic/Treatment Vaccines Examples include, but are not limited to to vaccines to to treat the following conditions: Allergic Rhinitis Alzheimer s Disease Cancers Multiple Sclerosis Therapeutic/Treatment Vaccines: Network Providers:... 100% - - 0% Non-Network Providers:...Not Covered OGB S Pharmacy Benefit Manager MedImpact Formulary: 3-Tier Plan Design* OGB will begin using the MedImpact Formulary to to help Plan Participants select the most appropriate, lowest-cost options. The formulary is is reviewed on on a a quarterly basis to to reassess drug tiers based on on the current prescription drug market. Plan Participants will continue to to pay a a portion of of the cost of of their prescriptions in in the form of of a a copay or or co-insurance. The amount Plan Participants pay toward their prescription depends on on whether they receive a a generic, preferred brand or or non-preferred brand name drug. *These changes do do not affect Plan Participants with Medicare as as their primary coverage. PRESCRIPTION DRUG PLAN PARTICIPANT PAYS Generic 50% up up to to $30 Preferred 50% up up to to $55 Non-Preferred 65% up up to to $80 Specialty 50% up up to to $80 The pharmacy out-of-pocket maximum has been changed from $1,200 to to $1,500. Once met: Generic $0 $0 co-pay Preferred $20 co-pay Non-Preferred $40 co-pay Specialty $40 co-pay There may be be more than one drug available to to treat your condition. We encourage you to to speak with your Physician regularly about which drugs meet your needs at at the lowest cost to to you. Compound Drugs Compound Drugs over $400 require prior Authorization from MedImpact. 90-day fill fill option at at retail or or mail order network pharmacies For maintenance medications, 90-day prescriptions fills may be be filled for for the applicable coinsurance with a a maximum that is is two and a a half times the maximum copayment. For example, if if your share of of the cost of of a a generic drug is is $30, you can fill fill your 30-day prescription for for $30 or or a a 90-day prescription for for $75. Over-the-counter drugs Medications available over-the-counter in in the same prescribed strength will no no longer be be covered under the pharmacy plan. 10 10 53

MAGNOLIA LOCAL PLUS What is a formulary? A formulary is a list of medications available to Plan Participants under the plan s pharmacy benefit. Inclusion on the list is based on consideration of a medication s safety, effectiveness and associated clinical outcomes. The formulary is updated regularly and divides drugs into four main categories: generic, preferred brand, non-preferred brand, and specialty. A generic drug is effectively equivalent to a brand name drug in intended use, dosage, strength, and safety. For a generic drug to be approved by the FDA, it must meet the same quality standards as the brand name product. Even the generic manufacturing, packaging, and testing sites must meet the same standards. Many generics are produced in the same manufacturing plant as their branded counterparts. Preferred brand drugs are generally those that have been on the market for a while and do not have a generic equivalent available. They are effective alternatives to other brands that may be more expensive. Non-preferred brand drugs are recently branded medications. In most cases, a lower cost alternative is available. Specialty medications higher cost drugs. 1. In the event the Plan Participant does not present his identification card to the Network pharmacy at the time of purchase, the Plan Participant will be responsible for full payment for the drug and must then file a claim with the Pharmacy Benefits Manager for reimbursement. Reimbursement is limited to the rates established for Non-Network pharmacies. If a Plan Participant chooses a Brand-Name Drug for which an FDA-approved Generic version is available, the Plan Participant pays the difference between the Brand-Name and Generic cost, plus a $40 Copayment for a 31 day supply. 2. Regardless of where the Prescription Drug is obtained, Eligible Expenses for Brand Name Drugs will be limited to: a. The Pharmacy Benefits Manager's maximum Allowable Charge for the Generic, when available; or b. The Pharmacy Benefits Manager's maximum Allowable Charge for the Brand Drug dispensed, when a Generic is not available. c. There is no per prescription maximum on the Plan Participant's responsibility for payment of costs in excess of the Eligible Expense. Plan Participant payments for such excess costs are not applied toward satisfaction of the annual Out-of-Pocket threshold (above). 3. This Plan allows Benefits for drugs and medicines approved by the Food and Drug Administration or its successor that require a prescription. Utilization management criteria may apply to specific drugs or drug categories to be determined by the PBM. 4. Retirees with Medicare will be automatically enrolled in OGB s Medicare Part D coverage with a commercial wrap benefit. 5. In addition, this Plan allows Benefits limited to $200.00 per month for expenses incurred for the purchase of low protein food products for the treatment of inherited metabolic diseases if the low protein food products are Medically Necessary and are obtained from a source approved by the OGB. Such expenses shall be subject to Coinsurance and Copayments relating to Prescription Drug Benefits. In connection with this Benefit, the following words shall have the following meanings: a. Inherited metabolic disease shall mean a disease caused by an inherited abnormality of body chemistry and shall be limited to: 54 Phenylketonuria (PKU) Maple Syrup Urine Disease (MSUD) Methylmalonic Acidemia (MMA) Isovaleric Adicemia (IVA)

successor that require a prescription. Utilization management criteria may apply to specific drugs or drug categories to be determined by the PBM. MAGNOLIA LOCAL PLUS 4. Retirees with Medicare will be automatically enrolled in OGB s Medicare Part D coverage with a commercial wrap benefit. 5. In addition, this Plan allows Benefits limited to $200.00 per month for expenses incurred for the purchase of low protein food products for the treatment of inherited metabolic diseases if the low protein food products are Medically Necessary and are obtained from a source approved by the OGB. Such expenses shall be subject to Coinsurance and Copayments relating to Prescription Drug Benefits. In connection with this Benefit, the following words shall have the following meanings: a. Inherited metabolic disease shall mean a disease caused by an inherited abnormality of body chemistry and shall be limited to: Phenylketonuria (PKU) Maple Syrup Urine Disease (MSUD) Methylmalonic Acidemia (MMA) Isovaleric Adicemia (IVA) Propionic Acidemia Glutaric Acidemia 40HR1608 R03/15 Urea Cycle Defects Tyrosinemia 11 b. Low protein food products mean food products that are especially formulated to have less than one gram of protein per serving and are intended to be used under the direction of a Physician for the dietary treatment of an inherited metabolic disease. Low protein food products shall not include natural foods that are naturally low in protein. 6. Benefits are available for Prescription and over-the-counter (OTC) smoking cessation medications when prescribed by a Physician. (Prescription is required for over-the-counter medications). Smoking cessation medications are not subject to the Prescription Drug deductible and are covered at 100%. Smoking cessation screening and counseling are covered under the Preventive or Wellness Care section of this Plan. 7. The following drugs, medicines, and related services and supplies are not covered: Drugs used to treat anorexia, weight loss or weight gain Drugs used to promote fertility Dietary supplements; Medical Foods Bulk Chemicals Drugs for cosmetic purposes or to promote hair growth Nutritional or parenteral therapy; Vitamins and minerals; Drugs available over the counter (OTC) (unless expressly covered in this Plan) Prescription drugs (federal legend) with an OTC equivalent For more information on the pharmacy benefit, visit the MedImpact website at https://mp.medimpact.com/ogb or call MedImpact member services at 1-800-910-1831. 55

56 This Annual Enrollment Guide is presented for general information only. It is not a benefit plan, nor intended to be construed as the Blue Cross benefit plan document. If there is any discrepancy between this Annual Enrollment Guide and the Blue Cross benefit plan document and Schedule of Benefits, the FINAL Blue Cross benefit plan document and Schedule of Benefits will govern the benefits and plan payments.

MAGNOLIA OPEN ACCESS 57

SCHEDULE OF BENEFITS MAGNOLIA OPEN ACCESS Nationwide Network Coverage Preferred Care Providers and BCBS National Providers OGB BENEFIT PLAN FORM NUMBER 40HR1695 03/15 MAGNOLIA OPEN ACCESS SCHEDULE OF BENEFITS: Actives, Retirees Without Medicare, Retirees With Medicare COMPREHENSIVE PPO MEDICAL BENEFIT PLAN PLAN NAME SCHEDULE OF BENEFITS PLAN NUMBER State of Louisiana Office of Group Benefits ST222ERC Nationwide Network Coverage PLAN S ORIGINAL BENEFIT Preferred PLAN DATE Care Providers and BCBS PLAN S National ANNIVERSARY Providers DATE January 1, 2013 January 1 BENEFIT PLAN FORM NUMBER 40HR1695 03/15 Lifetime Maximum Benefit:...Unlimited Benefit PLAN NAME Period:... PLAN NUMBER 03/01/15 12/31/15 State of Louisiana Office of Group Benefits ST222ERC Deductible PLAN S ORIGINAL Amount BENEFIT Per Benefit PLAN Period: DATE PLAN S ANNIVERSARY DATE January 1, 2013 January 1 Individual: Lifetime Network Providers: Maximum Benefit:...Unlimited Benefit Active Employees Period:... and Retirees on or after 3/1/15 (With and Without Medicare) 03/01/15 $900.00 12/31/15 Retirees prior to 03/01/15 (With and Without Medicare) $300.00 Deductible Amount Per Benefit Period: Non-Network Providers: Individual: Active Employees and Retirees on or after 3/1/15 (With and Without Medicare) $900.00 Network Providers: Retirees prior to 03/01/15 (With and Without Medicare) $300.00 Active Employees and Retirees on or after 3/1/15 (With and Without Medicare) $900.00 Individual + 1 Dependent: Retirees prior to 03/01/15 (With and Without Medicare) $300.00 Network Providers: Non-Network Providers: Active Employees and Retirees on or after 3/1/15 (With and Without Medicare) $1,800.00 Active Employees and Retirees on or after 3/1/15 (With and Without Medicare) $900.00 Retirees prior to 03/01/15 (With and Without Medicare) $600.00 Retirees prior to 03/01/15 (With and Without Medicare) $300.00 Non-Network Providers: Individual + 1 Dependent: Active Employees and Retirees on or after 3/1/15 (With and Without Medicare) $1,800.00 Network Providers: Retirees prior to 03/01/15 (With and Without Medicare) $600.00 Active 40HR1696 Employees R03/15 and Retirees on or after 3/1/15 (With 1 and Without Medicare) $1,800.00 Family (Individual + 2 or more Dependents): Retirees prior to 03/01/15 (With and Without Medicare) $600.00 Network Providers: Active Employees and Retirees on or after 3/1/15 (With and Without Medicare) $2,700.00 Retirees prior to 03/01/15 (With and Without Medicare) $900.00 40HR1696 Non-Network R03/15 Providers: 1 Active Employees and Retirees on or after 3/1/15 (With and Without Medicare) $2,700.00 Retirees prior to 03/01/15 (With and Without Medicare) $900.00 SPECIAL NOTES 58 Deductible Amounts

Active Employees and Retirees on or after 3/1/15 (With and Without Medicare) $2,700.00 Active Employees and Retirees on or after 3/1/15 (With and Without Medicare) $2,700.00 Retirees prior to 03/01/15 (With and Without Medicare) $900.00 Retirees prior to 03/01/15 (With and Without Medicare) $900.00 Non-Network Providers: Non-Network Providers: Active Employees and Retirees on or after 3/1/15 (With and Without Medicare) $2,700.00 Active Employees and Retirees on or after 3/1/15 (With and Without Medicare) $2,700.00 Retirees prior to 03/01/15 (With and Without Medicare) $900.00 Retirees prior to 03/01/15 (With and Without Medicare) $900.00 SPECIAL NOTES SPECIAL NOTES Deductible Amounts Deductible Amounts Active and Retirees on or after March 1, 2015: Active and Retirees on or after March 1, 2015: Eligible Expenses for services of a Network Provider that apply to the Deductible Amount for Network Eligible Providers Expenses will notfor count services toward of to a the Network Deductible Provider Amount that for apply Non-Network to the Deductible Providers. Amount for Network Providers will not count toward to the Deductible Amount for Non-Network Providers. Eligible Expenses for services of Non-Network Providers that apply to the Deductible Amounts for Non- Eligible Network Expenses Providers for will services not count of Non-Network toward to the Deductible Providers that Amount apply for to Network the Deductible Providers. Amounts for Non- Network Providers will not count toward to the Deductible Amount for Network Providers. Retirees With or Without Medicare Prior to March 1, 2015: Retirees With or Without Medicare Prior to March 1, 2015: The Deductible Amount is a single amount that includes eligible charges incurred from all Providers The combined. Deductible Amount is a single amount that includes eligible charges incurred from all Providers combined. Out-of-Pocket Maximum per Benefit Period: Out-of-Pocket Maximum per Benefit Period: MAGNOLIA OPEN ACCESS Includes all eligible Copayments, Coinsurance Amounts and Deductibles Includes all eligible Copayments, Coinsurance Amounts and Deductibles Active Employee/Retirees Retirees prior to March 1, Retirees prior to Active on or Employee/Retirees after March 1, 2015 Retirees 2015 without prior to Medicare March 1, Retirees March prior 1, 2015 to on or after March 1, 2015 2015 without Medicare March with Medicare 1, 2015 with Network Medicare and Network Non-Network Network Non-Network Network and Network Non-Network Network Non-Network Non-Network Individual Only $2,500 $3,700 $1,300 $3,300 Non-Network $2,300 Individual Individual Only Plus One $2,500 $3,700 $1,300 $3,300 $2,300 Individual Plus One $5,000 $7,500 $2,600 $6,600 $4,600 (Spouse or Child) $5,000 $7,500 $2,600 $6,600 $4,600 (Spouse Individual or Plus Child) Two $7,500 $11,250 $3,900 $9,900 $6,900 Individual Individual Plus Plus Two Three $7,500 $7,500 $11,250 $11,250 $3,900 $4,900 $9,900 $12,700 $6,900 $8,900 Individual Individual Plus Plus Three Four $7,500 $7,500 $11,250 $11,250 $4,900 $5,900 $12,700 $12,700 $8,900 $10,900 Individual Individual Plus Plus Four Five $7,500 $7,500 $11,250 $11,250 $5,900 $6,900 $12,700 $12,700 $10,900 $12,700 Individual Individual Plus Plus Five Six $7,500 $7,500 $11,250 $11,250 $6,900 $7,900 $12,700 $12,700 $12,700 $12,700 Individual Individual Plus Plus Six Seven $7,500 $7,500 $11,250 $11,250 $7,900 $8,900 $12,700 $12,700 $12,700 $12,700 Individual Individual Plus Plus Seven Eight $7,500 $7,500 $11,250 $11,250 $8,900 $9,900 $12,700 $12,700 $12,700 $12,700 Individual Individual Plus Plus Eight Nine $7,500 $7,500 $11,250 $11,250 $9,900 $10,900 $12,700 $12,700 $12,700 $12,700 Individual Individual Plus Plus Nine Ten $7,500 $7,500 $11,250 $11,250 $10,900 $11,900 $12,700 $12,700 $12,700 $12,700 Individual Individual Plus Plus Ten Eleven $7,500 $11,250 $11,900 $12,700 $12,700 Individual Plus Eleven $7,500 $11,250 $12,700 $12,700 $12,700 or More $7,500 $11,250 $12,700 $12,700 $12,700 or More 40HR1696 R03/15 2 40HR1696 R03/15 2 59

MAGNOLIA OPEN ACCESS SPECIAL NOTES Out-of-Pocket Maximum Active and Retirees on or after March 1, 2015: Eligible Expenses for services of a Network Provider that apply to the Deductible and Out-of-Pocket Maximum for Network Providers will not count toward to the Out-of-Pocket Maximum for Non-Network Providers. Eligible Expenses for services of Non-Network Providers that apply to the Out-of-Pocket Maximum for Non- Network Providers will not count toward to the Out-of-Pocket Maximum for Network Providers. Retirees With Medicare Prior to March 1, 2015: The Out of Pocket Amount is a single amount that includes eligible charges incurred from all Providers combined. When the Out-of-Pocket Maximums, as shown above, have been satisfied, this Plan will pay 100% of the Allowable Charge toward Eligible Expenses for the remainder of the Plan Year. Retirees Without Medicare Prior to March 1, 2015: Eligible Expenses for services of a Network Provider that apply to the Deductible and Out-of-Pocket Maximum for Network Providers will count toward to the Out-of-Pocket Maximum for Non-Network Providers. Eligible Expenses for services of Non-Network Providers that apply to the Out-of-Pocket Maximum for Non- Network Providers will count toward to the Out-of-Pocket Maximum for Network Providers. When the Out-of-Pocket Maximums, as shown above, have been satisfied, this Plan will pay 100% of the Allowable Charge toward Eligible Expenses for the remainder of the Plan Year. There may be a significant Out-of-Pocket expense to the Plan Participant when services are received from a Non-Network Provider. Eligible Expenses Eligible Expenses are reimbursed in accordance with a fee schedule of maximum Allowable Charges, not billed charges. All Eligible Expenses are determined in accordance with Plan Limitations and Exclusions. Eligibility The Plan Administrator assigns Eligibility to all Plan Participants. 60 40HR1696 R03/15 3

MAGNOLIA OPEN ACCESS COINSURANCE Physician Office Visits including surgery performed in an office setting: General Practice Family Practice Internal Medicine OB/GYN Pediatrics Allied Health/Other Professional Visits Chiropractors Nurse Practitioners Retail Health Clinics Optometrist Osteopath Physician Assistants ACTIVE EMPLOYEES/NON-MEDICARE RETIREES Network Providers Non-Network Providers RETIREES WITH MEDICARE Network and Non- Network/Providers 90%-10% 1 70% - 30% 1 80% - 20% 1 90%-10% 1 70% - 30% 1 80% - 20% 1 Specialist (Physician) Office Visits including surgery performed in an office setting. Physician Podiatrist Midwife Audiologist Registered Dietician Sleep Disorder Clinic Ambulance Services - Ground Ambulance Services - Air Ambulatory Surgical Center and Outpatient Surgical Facility 90%-10% 1 70% - 30% 1 80% - 20% 1 90%-10% 1 70% - 30% 1 80% - 20% 1 90%-10% 1,2 70% - 30% 1 80% - 20% 1 90%-10% 1,2 70% - 30% 1,2 80% - 20% 1 Autism Spectrum Disorders (ASD) 90%-10% 1,3 70% - 30% 1,3 80% - 20% 1,3 Birth Control Devices - Insertion and Removal (As listed in the Preventive and Wellness Care Article in the Benefit Plan.) 100% - 0% 70% - 30% 1 Network Providers 100% - 0% Non-Network Providers 80% - 20% 1 1 Subject to Plan Year Deductible, if applicable 2 Pre-Authorization Required, if applicable. Not applicable for Medicare primary. 3 Age and/or Time Restrictions Apply 40HR1696 R03/15 4 61

MAGNOLIA OPEN ACCESS COINSURANCE Cardiac Rehabilitation (Must begin within six months of qualifying event) ACTIVE EMPLOYEES/NON-MEDICARE RETIREES Network Providers Non-Network Providers RETIREES WITH MEDICARE Network and Non- Network/Providers 90%-10% 1,2,3 70% - 30% 1,2,3 80% - 20% 1,3 Chemotherapy/Radiation Therapy (Authorization not required if performed in Physician s office.) 90% -10% 1,2 70% - 30% 1,2 80% - 20% 1 Diabetes Treatment 90% -10% 1 70% - 30% 1 80% - 20% 1 Diabetic/Nutritional Counseling - Clinics and Outpatient Facilities 90% -10% 1 Not Covered 80% - 20% 1 Dialysis 90% -10% 1,2 70% - 30% 1,2 80% - 20% 1 Durable Medical Equipment (DME), Prosthetic Appliances and Orthotic Devices Emergency Room (Facility Charge) Emergency Medical Services (Non-Facility Charges) Eyeglass frames and One pair of Eyeglass Lenses or One Pair of Contact Lenses (Purchased within 6 months following cataract surgery) Flu shots and H1N1 vaccines (Administered at Network Providers, Non- Network Providers, Pharmacy, Job Site or Health Fair) Hearing Aids Home (Hearing Health Aids Care not (Limit covered of 60for visits per Plan individuals Year) age eighteen (18) and older.) Hospice High-Tech Care Imaging (Limit of Outpatient 180 days per Plan Year) CT Scans MRA/MRI Injections Nuclear Received Cardiology in a Physician s Office (When No PET/SPECT Other Health Scans Service is Received) 90% -10% 1,2 70% - 30% 1,2 80% - 20% 1 $150 Separate Deductible 1 ; Waived if Admitted 90% -10% 1 90% -10% 1 80% - 20% 1 90% -10% 1 90% -10% 1 80% - 20% 1 Eyeglass Frames - Limited to a Maximum Benefit of $50 1,3 100% - 0% 100% - 0% 100% - 0% 90% -10% 1,2 1,3 70% - 30% 1,2 1,3 Not 80% Covered - 20% 1,3 80% -20% 1,2 70% - 30% 1,2 Not Covered 90% -10% 1,2 70% - 30% 1,2 80% - 20% 1 90% -10% 1 70% - 30% 1 80% - 20% 1 1 Subject to Plan Year Deductible, if applicable 2 Pre-Authorization Required, if applicable. Not applicable for Medicare primary. 3 Age and/or Time Restrictions Apply 62 40HR1696 R03/15 5 COINSURANCE RETIREES WITH

Home 1 Subject Health Care to Plan (Limit Year of Deductible, 60 visits per if applicable90% -10% 1,2 70% - 30% 1,2 Not Covered Plan 2 Year) Pre-Authorization Required, if applicable. Not applicable for Medicare primary. 3 Age and/or Time Restrictions Apply Hospice Care (Limit of 180 days per Plan 80% -20% 1,2 70% - 30% 1,2 Not Covered Year) Injections Received in a Physician s Office (When No Other Health Service is Received) 1 Subject to Plan Year Deductible, if applicable Network Providers 2 Pre-Authorization Required, if applicable. Inpatient Hospital Admission, All Inpatient Not applicable for Medicare primary. Hospital Home Health Services Care Included Age and/or Time (Limit Restrictions of 60 visits Apply per 90% -10% 1,2 70% - 30% 1,2 Not Covered Plan Per Year) Day Copayment $0 $50 $0 Day Maximum Not Applicable 5 Days Not Applicable Hospice Coinsurance Care (Limit of 180 days per Plan 90% 80% -10% -20% 70% COINSURANCE - 30% 1,2 Year) Not 80% Covered - 20% 1 Injections Inpatient and Received Outpatient in a Physician s Professional RETIREES WITH Office ACTIVE 90% EMPLOYEES/NON-MEDICARE -10% 1 70% RETIREES - 30% 1 80% (When No Other Health Service is 90% -10% 1 70% - 30% 1 MEDICARE - 20% 1 Services Non-Network Network 80% - and 20% Non- 1 Received) Network Providers Mastectomy Bras - Ortho-Mammary Providers Network/Providers Inpatient Hospital Admission, All Inpatient 90% -10% 1,2 70% - 30% 1,2 80% - 20% 1 Surgical (Limit Hospital 1 Subject of three Services to (3) Plan per Included Year Plan Year) Deductible, if applicable Per 2 Pre-Authorization Day Copayment Required, if applicable. $0 Mental Not Health/Substance applicable for Medicare Abuse - $50 $0 primary. Inpatient Day 3 Maximum Age Treatment Not Applicable 5 Days Not Applicable and/or Time Restrictions Apply Coinsurance Per Day Copayment 90% $0-10% 1,2 70% $50-30% 1,2 80% $0-20% 1 Day Maximum Not Applicable 5 Days Not Applicable Inpatient and Outpatient Professional Coinsurance 90% -10% 1,2 1 70% COINSURANCE - 30% 1,2 1 80% - 20% 1 Services Mental Health/Substance Abuse - RETIREES WITH ACTIVE 90% EMPLOYEES/NON-MEDICARE - 10% 1 Mastectomy Outpatient Treatment Bras - Ortho-Mammary 70% RETIREES - 30% 1 80% - 20% 1 90% -10% 1,2 70% - 30% 1,2 80% MEDICARE - 20% 1 Surgical Non-Network Network and Non- (Limit Newborn of three Sick, (3) Services per Plan Year) Excluding Network Providers 90% -10% 1 70% Providers - 30% 1 Network/Providers 80% - 20% 1 Facility Inpatient Mental Health/Substance Hospital Admission, Abuse All Inpatient - Hospital Inpatient Services Treatment Included Newborn Sick, Facility Per Day Copayment $0 $50 $0 Day Per Day Maximum Copayment Not $0 Applicable 5 Days $50 Not Applicable $0 Coinsurance Day Maximum Not 90% Applicable -10% 1,2 70% 5 -Days 30% 1,2 Not 80% Applicable - 20% 1 Coinsurance 90% -10% 1,2 70% - 30% 1,2 80% - 20% 1 Mental Health/Substance Abuse - Inpatient and Outpatient Professional 90% Outpatient Treatment 90% - -10% 10% 1 70% 70% - 30% - 30% 1 80% 80% - 20% 20% 1 Services Subject to Plan Year Deductible, if applicable Newborn Pre-Authorization Sick, Services Required, Excluding if applicable. Facility Mastectomy Not applicable Bras - Ortho-Mammary for Medicare primary. Surgical Age and/or Time Restrictions Apply 90% -10% 1 90% -10% 1,2 70% - 30% 1 70% - 30% 1,2 80% - 20% 1 80% - 20% 1 (Limit Newborn of three Sick, (3) Facility per Plan Year) Mental Health/Substance Abuse - Inpatient Per Day Treatment Copayment $0 $50 $0 40HR1696 R03/15 6 Day Per Day Maximum Copayment Not Applicable $0 5 $50 Days Not Applicable $0 Day Coinsurance Maximum 90% Not -10% Applicable 70% 5 Days - 30% 1,2 Not 80% Applicable - 20% 1 Coinsurance 90% -10% 1,2 Subject to Plan Year Deductible, if applicable 70% - 30% 1,2 80% - 20% 1 Mental Pre-Authorization Health/Substance Required, Abuse - if applicable. 90% - 10% 1 Outpatient Treatment 70% - 30% 1 80% - 20% 1 Not applicable for Medicare primary. Age and/or Time Restrictions Apply Newborn Sick, Services Excluding 90% -10% 1 70% - 30% 1 80% - 20% 1 Facility Newborn 40HR1696 Sick, R03/15 Facility 6 COINSURANCE 90% -10% 1 70% - 30% 1 80% - 20% 1 ACTIVE EMPLOYEES/NON-MEDICARE RETIREES Non-Network Providers MAGNOLIA OPEN ACCESS RETIREES WITH MEDICARE Network and Non- Network/Providers Per Day Copayment $0 $50 $0 Day Maximum Not Applicable 5 Days Not Applicable Coinsurance 90% -10% 1,2 70% - 30% 1,2 80% - 20% 1 1 Subject to Plan Year Deductible, if applicable 63

MAGNOLIA OPEN ACCESS COINSURANCE COINSURANCE COINSURANCE RETIREES WITH ACTIVE EMPLOYEES/NON-MEDICARE RETIREES RETIREES MEDICARE WITH ACTIVE EMPLOYEES/NON-MEDICARE RETIREES Non-Network Network RETIREES MEDICARE and WITH Non- Network ACTIVE EMPLOYEES/NON-MEDICARE Providers RETIREES Non-Network Providers Network/Providers MEDICARE and Non- Network Providers Non-Network Providers Network/Providers and Non- Network Providers Oral Surgery for Impacted Teeth Providers Network/Providers (Authorization Oral Surgery for not Impacted required Teeth when 90% 10% 1,2 70% - 30% 1,2 80% - 20% 1 (Authorization performed Oral Surgery in Physician s for not Impacted required Office) Teeth when (Authorization performed in Physician s not required Office) when 90% 10% 1,2 90% 10% 1,2 70% - 30% 1,2 70% - 30% 1,2 80% - 20% 1 80% - 20% 1 performed Pregnancyin Care Physician s Physician Office) Services 90% -10% 1 70% - 30% 1 80% - 20% 1 Pregnancy Care Physician Services 90% -10% 1 70% - 30% 1 80% - 20% 1 Pregnancy Preventive Care Care Services Physician include Services 90% -10% 1 70% - 30% 1 80% - 20% 1 screening Preventive to Care detect Services illness or include health risks Network - 100% - 0 3 screening during Preventive a Physician to Care detect Services office illness visit. or include health The risks Network - 100% - 0 3 screening during Covered a Physician Services to detect are office illness based visit. or on health The prevailing risks 100% -0% 3 70% - 30% 1,3 Network - 100% - 0 3 medical during Covered a standards Physician Services are and office based may visit. vary on The prevailing 100% -0% 3 70% - 30% 1,3 medical according Coveredstandards Services to age and are and family based may vary history. on prevailing (For Non-Network 100% -0% 3 70% - 30% 1,3 medical according a complete standards to list age of and benefits, and family may refer vary history. the (For Non-Network 80% - 20% 1,3 according a Preventive complete to and list age of Wellness and benefits, family Care refer history. Article the (For in Non-Network 80% - 20% 1,3 a Preventive thecomplete Benefit and Plan.) list of Wellness benefits, Care refer Article to the in 80% - 20% 1,3 Preventive the Benefit and Plan.) Wellness Care Article in the Benefit Plan.) Rehabilitation Services Outpatient: Rehabilitation Speech Services Outpatient: Rehabilitation Speech Services Outpatient: Speech Physical/Occupational (Combined Physical/Occupational limit of 50 Visits per Plan 90% - 10% 1 1 80% - 20%1 70% - 30% (Combined Year. Physical/Occupational Authorization limit of 50 Visits per Plan 90% - 10% 1 1 80% - 20%1 70% - 30% (Combined Year. required Authorization forlimit visits of over 50 Visits the combined per Plan 90% - 10% 1 1 80% - 20%1 limit 70% - 30% Year. required ofauthorization 50.) for visits over the combined limit required of 50.) for visits over the combined (Visit limits ofdo 50.) not apply when services are Provided (Visit limits for do Autism not apply Spectrum when services Disorders) are Provided (Visit limits for do Autism not apply Spectrum when services Disorders) are Provided Skilled Nursing for Autism Facility Spectrum (Limit of Disorders) 90 days Skilled per Plan Nursing Year) Facility (Limit of 90 days 90% - 10% 1,2 70% - 30% 1,2 80% - 20% 1 Skilled per Plan Nursing Year) Facility (Limit of 90 days 90% - 10% 1,2 70% - 30% 1,2 80% - 20% 1 Sonograms and Ultrasounds per Plan Year) 90% - 10% 1,2 70% - 30% 1,2 80% 20% 1 (Outpatient) Sonograms and Ultrasounds 90% - 10% 1 70% - 30% 1 80% - 20% 1 (Outpatient) Sonograms and Ultrasounds 90% - 10% 1 70% - 30% 1 80% - 20% 1 (Outpatient) 90% 10% 1 70% 30% 1 80% - 20% 1 Urgent Care Center 90% - 10% 1 70% - 30% 1 80% - 20% 1 Urgent Care Center 90% - 10% 1 70% - 30% 1 80% - 20% 1 Urgent Care Center Vision Care (Non-Routine) Exam 90% 90% - 10% 10% 1 70% 70% - 30% 30% 1 80% - 20% 1 Vision Care (Non-Routine) Exam 90% - 10% 1 70% - 30% 1 80% - 20% 1 Vision X-ray and Care Laboratory (Non-Routine) Services Exam 90% 10% 70% 30% 80% - 20% 1 90% - 10% 1 70% - 30% 1 80% - 20% 1 X-ray and Laboratory Services 90% - 10% 1 70% - 30% 1 80% - 20% 1 X-ray and Laboratory Services Subject to Plan Year Deductible, if applicable 90% - 10% 1 70% - 30% 1 80% - 20% 1 Subject Pre-Authorization to Plan Year Required, Deductible, if applicable. if applicable Subject Pre-Authorization Not applicable to Plan Year for Required, Medicare Deductible, if primary. applicable. if applicable Pre-Authorization Age Not applicable and/or Time for Restrictions Required, Medicare if Apply primary. applicable. Age Not applicable and/or Time for Restrictions Medicare Apply primary. 3 Age and/or Time Restrictions Apply 64 40HR1696 R03/15 7 40HR1696 R03/15 7 40HR1696 R03/15 7

MAGNOLIA OPEN ACCESS ORGAN, TISSUE AND BONE MARROW TRANSPLANTS Authorization is Required Prior to Services Being Performed Organ, Tissue and Bone Marrow Transplants and evaluation for a Plan Participant s suitability for Organ, Tissue Bone Marrow transplants will not be covered unless a Plan Participant obtains written authorization from the Claims Administrator prior to services being rendered. Benefits are subject to the Deductible and Coinsurance and Inpatient Facility Copayments. Active Employees and Non-Medicare Retirees: Network Providers:... 90% - 10% Non-Network Providers:... 70% - 30% Retirees with Medicare: Network/Non-Network Providers:... 80% - 20% CARE MANAGEMENT If a required Authorization is not requested prior to Admission or receiving other Covered Services and supplies, the Plan will have the right to determine if the Admission or other Covered Services or supplies were Medically Necessary. If the Admission or other Covered Services and supplies were not Medically Necessary, the Admission or other Covered Services and supplies will not be covered and the Plan Participant must pay all charges incurred. If the Admission or other Covered Services and supplies were Medically Necessary, Benefits will be provided based on the Network status of the Provider rendering the services. Authorization of Inpatient and Emergency Admissions Inpatient Admissions must be Authorized. Refer to Care Management and if applicable Pregnancy Care and Newborn Care Benefits sections of the Benefit Plan for complete information. Requests for Authorization of Inpatient Admissions and for Concurrent Review of an Admission in progress, or other Covered Services and supplies must be made to Blue Cross and Blue Shield of Louisiana by calling 1-800-392-4089. If a Blue Cross and Blue Shield of Louisiana Network Provider fails to obtain a required Authorization, no Benefits are payable. The Network Provider is responsible for all charges not covered. The Plan Participant remains responsible for any applicable Copayment or Deductible Amount and Coinsurance percentage shown in the Schedule of Benefits. If Network Provider in another Blue Cross and Blue Shield plan fails to obtain a required Authorization, the Claims Administrator will reduce Allowable Charges by the penalty amount stipulated in the Provider s contract with the other Blue Cross and Blue Shield plan. This penalty applies to all services and supplies requiring an Authorization. The Network Provider of the other Blue Cross and Blue Shield plan is responsible for all charges not covered. The Plan Participant remains responsible for his applicable Copayment, Deductible and Coinsurance percentage. If a Non-Network Provider fails to obtain a required Authorization, the Claims Administrator will reduce Allowable Charges by the amount shown below. This penalty applies to all services and supplies requiring an Authorization. The Plan Participant is responsible for all charges not covered and for any applicable Copayment or Deductible Amount and Coinsurance percentage shown in the Schedule of Benefits. 40HR1696 R03/15 8 65

MAGNOLIA OPEN ACCESS Additional Plan Participant responsibility if Authorization is not requested for an Inpatient Admission to a Non- Network Provider Hospital: TWENTY-FIVE PERCENT (25%) reduction of the Allowable Charges. The following services and supplies require Authorization prior to the services being rendered or supplies being received. Requests for Authorization must be made to Blue Cross and Blue Shield of Louisiana by calling 1-800-392-4089. Inpatient Hospital Admissions (Except routine maternity stays) Inpatient Mental Health and Substance Abuse Admissions Inpatient Organ, Tissue and Bone Marrow Transplant Services Inpatient Skilled Nursing Facility Services NOTE: Emergency services (life and limb threatening emergencies) received outside of the United States (out of country) are covered at the Network Benefit level. Non-emergency services received outside of the United States (out of country) are covered at the Non-Network Benefit level. Authorization of Outpatient Services, Including Other Covered Services and Supplies If a Network Provider fails to obtain a required Authorization, no Benefits are payable. The Network Provider is responsible for all charges not covered. The Plan Participant remains responsible for his applicable Copayment, Deductible and Coinsurance percentage. If Network Provider in another Blue Cross and Blue Shield plan fails to obtain a required Authorization, no Benefits are payable. The Network Provider of the other Blue Cross and Blue Shield plan is responsible for all charges not covered. The Plan Participant remains responsible for his applicable Copayment, Deductible and Coinsurance percentage. If a Non-Network Provider fails to obtain a required Authorization, no Benefits are payable. The Plan Participant is responsible for all charges not covered and remains responsible for his Copayment, Deductible and applicable Coinsurance percentage. The following services and supplies require Authorization prior to the services being rendered or supplies being received. Requests for Authorization must be made to Blue Cross and Blue Shield of Louisiana by calling 1-800-392-4089. Air Ambulance Non-Emergency Applied Behavior Analysis Bone growth stimulator Cardiac Rehabilitation CT Scans Day Rehabilitation Programs Dialysis Durable Medical Equipment (Greater than $300.00) Electric & Custom Wheelchairs Home Health Care Hospice Hyperbarics Implantable Medical Devices over $2000.00, such as Implantable Defibrillator and Insulin Pump Infusion Therapy (Exception: Infusion Therapy performed in a Physician s office does not require prior Authorization. The Drug to be infused may require prior Authorization). Intensive Outpatient Programs MRI/MRA Nuclear Cardiology Oral Surgery (not required when performed in a Physician s office) 66 40HR1696 R03/15 9

MAGNOLIA OPEN ACCESS Organ Transplant Evaluation Orthotic Devices (Greater than $300.00) Outpatient surgical procedures not performed in a Physician s office Outpatient non-surgical procedures (Exceptions: X-rays, lab work, Speech Therapy and Chiropractic Services do not require prior Authorization. Non-surgical procedures performed in a Physician's office do not require prior Authorization). Outpatient pain rehabilitation or pain control programs Partial Hospitalization Programs PET/SPECT Scans Physical/Occupational Therapy (Greater than 50 visits) Prosthetic Appliances (Greater than $300.00) Residential Treatment Centers Sleep Studies Specialty Pharmacy (Complete list of drugs available online at www.bcbsla.com> I m a Provider>Pharmacy Management>Specialty Pharmacy Program Drug List.pdf) Stereotactic Radiosurgery, including but not limited to gamma knife and cyberknife procedures Vacuum Assisted Wound Closure Therapy Population Health In Health: Blue Health The Population Health program targets populations with one or more of these five(5) chronic health conditions diabetes, coronary artery disease, heart failure, asthma and chronic obstructive pulmonary disease (COPD). (The In Health: Blue Health Services program is not available to Plan Participants with Medicare primary.) Through the In Health: Blue Health Services program, OGB offers an incentive to Plan Participants on Prescription Drugs used to treat the five chronic conditions listed above. a. OGB Plan Participants participating in the program qualify for $0 Copayment for certain Generic Prescription Drugs approved by the U. S. Food and Drug Administration (FDA) for any of the 5 chronic health conditions. b. OGB Plan Participants participating in the program qualify for $20 Copayment (31 day supply), $40 Copayment (62 day supply) or $50 Copayment (93 day supply) for certain Preferred Brand-Name Prescription Drugs. c. OGB Plan Participants participating in the program qualify for $40 Copayment (31 day supply), $80 Copayment (62 day supply) or $100 Copayment (93 day supply) for certain Non-Preferred Brand-Name Prescription Drug. Non-Preferred drugs typically have lower cost alternatives available in the same drug class. d. If an OGB Plan Participant chooses a Brand-Name Drug for which an FDA-approved Generic version is available, the OGB Plan Participant pays the difference between the Brand-Name and Generic cost, plus a $40 Copayment for a 31 day supply. The In Health: Blue Health Services prescription incentive does not apply to any Prescription Drugs not used to treat one of these five health conditions with which you have been diagnosed. Please refer to the Care Management article, Population Health In Health: Blue Health section of the Benefit Plan for complete information on how to qualify for this incentive. PRESCRIPTION DRUGS Prescription Drug Benefits are provided under the Hospital Benefits and Medical and Surgical Benefits Articles of the medical plan, and under the Pharmacy Plan provided by OGB s Pharmacy Benefits Manager (sometimes PBM ). Blue Cross and Blue Shield of Louisiana Blue Cross and Blue Shield of Louisiana provides Claims Administration services only for Prescription Drugs dispensed as follows: 40HR1696 R03/15 10 67

MAGNOLIA OPEN ACCESS Prescription Drugs Covered Under Hospital Benefits and Medical and Surgical Benefits 1. Prescription Drugs dispensed during an Inpatient or Outpatient Hospital stay, or in an Ambulatory Surgical Center are payable under the Hospital Benefits. 2. Medically necessary/non-investigational Prescription Drugs requiring parenteral administration in a Physician s Office are payable under the Medical and Surgical Benefits. 3. Prescription Drugs that can be self-administered and are provided to a Plan Participant in a Physician s office are payable under the Medical and Surgical Benefits. Authorizations The following Prescription Drug categories require Prior Authorization. The Plan Participant s Physician must call 1-800-842-2015 to obtain Authorization. The Plan Participant or his Physician should call the Customer Service number on the back of the ID card, or go to the Claims Administrator s website at www.bcbsla.com/ogb for the most current list of Prescription Drugs that require Prior Authorization: Growth hormones* Anti-tumor necrosis factor drugs* Intravenous immune globulins* Interferons Monoclonal antibodies Hyaluronic acid derivatives for joint injection* * Shall include all drugs that are in this category. Therapeutic/Treatment Vaccines Examples include, but are not limited to vaccines to treat the following conditions: Allergic Rhinitis Alzheimer s Disease Cancers Multiple Sclerosis Therapeutic/Treatment Vaccines Network Provider:... 100% - 0% Non-Network Provider:... 70% - 30% (After Deductible is Met) OGB S Pharmacy Benefits Manager MedImpact Formulary: 3-Tier Plan Design* OGB will begin using the MedImpact Formulary to help Plan Participants select the most appropriate, lowestcost options. The formulary is reviewed on a quarterly basis to reassess drug tiers based on the current prescription drug market. Plan Participants will continue to pay a portion of the cost of their prescriptions in the form of a copayment or coinsurance. The amount Plan Participants pay toward their prescription depends on whether they receive a generic, preferred brand or non-preferred brand name drug. *These changes do not affect Plan Participants with Medicare as their primary coverage. 68 40HR1696 R03/15 11

MAGNOLIA OPEN ACCESS PRESCRIPTION DRUG PLAN PARTICIPANT PAYS PRESCRIPTION DRUG PLAN PARTICIPANT PAYS Generic 50% up to $30 Generic 50% up to $30 Preferred 50% up to $55 Preferred 50% up to $55 Non-Preferred 65% up to $80 Non-Preferred 65% up to $80 Specialty 50% up to $80 Specialty 50% up to $80 The pharmacy out-of-pocket maximum has been changed from $1,200 to $1,500. Once met: The pharmacy out-of-pocket maximum has been changed from $1,200 to $1,500. Once met: Generic $0 co-pay Generic $0 co-pay Preferred $20 co-pay Preferred $20 co-pay Non-Preferred $40 co-pay Non-Preferred $40 co-pay Specialty $40 co-pay Specialty $40 co-pay There may be more than one drug available to treat your condition. We encourage you to speak with your There may be more than one drug available to treat your condition. We encourage you to speak with your Physician regularly about which drugs meet your needs at the lowest cost to you. Physician regularly about which drugs meet your needs at the lowest cost to you. Compound Drugs Compound Drugs Compound Drugs over $400 require prior Authorization from MedImpact. Compound Drugs over $400 require prior Authorization from MedImpact. 90-day fill option at retail or mail order network pharmacies 90-day fill option at retail or mail order network pharmacies For maintenance medications, 90-day prescriptions fills may be filled for the applicable coinsurance with a For maintenance medications, 90-day prescriptions fills may be filled for the applicable coinsurance with a maximum that is two and a half times the maximum copayment. For example, if your share of the cost of a maximum that is two and a half times the maximum copayment. For example, if your share of the cost of a generic drug is $30, you can fill your 30-day prescription for $30 or a 90-day prescription for $75. generic drug is $30, you can fill your 30-day prescription for $30 or a 90-day prescription for $75. Over-the-counter drugs Over-the-counter drugs Medications available over-the-counter in the same prescribed strength will no longer be covered under the Medications available over-the-counter in the same prescribed strength will no longer be covered under the pharmacy plan. pharmacy plan. What is a formulary? What is a formulary? A formulary is a list of medications available to Plan Participants under the plan s pharmacy benefit. Inclusion A formulary is a list of medications available to Plan Participants under the plan s pharmacy benefit. Inclusion on the list is based on consideration of a medication s safety, effectiveness and associated clinical outcomes. on the list is based on consideration of a medication s safety, effectiveness and associated clinical outcomes. The formulary is updated regularly and divides drugs into four main categories: generic, preferred brand, nonpreferred brand, and specialty. The formulary is updated regularly and divides drugs into four main categories: generic, preferred brand, nonpreferred brand, and specialty. A generic drug is effectively equivalent to a brand name drug in intended use, dosage, strength, and safety. A generic drug is effectively equivalent to a brand name drug in intended use, dosage, strength, and safety. For a generic drug to be approved by the FDA, it must meet the same quality standards as the brand name For a generic drug to be approved by the FDA, it must meet the same quality standards as the brand name product. Even the generic manufacturing, packaging, and testing sites must meet the same standards. product. Even the generic manufacturing, packaging, and testing sites must meet the same standards. Many generics are produced in the same manufacturing plant as their branded counterparts. Many generics are produced in the same manufacturing plant as their branded counterparts. Preferred brand drugs are generally those that have been on the market for a while and do not have a Preferred brand drugs are generally those that have been on the market for a while and do not have a generic equivalent available. They are effective alternatives to other brands that may be more expensive. generic equivalent available. They are effective alternatives to other brands that may be more expensive. Non-preferred brand drugs are recently branded medications. In most cases, a lower cost alternative is Non-preferred brand drugs are recently branded medications. In most cases, a lower cost alternative is available. available. Specialty medications higher cost drugs. Specialty medications higher cost drugs. 1. In the event the Plan Participant does not present his identification card to the Network pharmacy at the 1. In the event the Plan Participant does not present his identification card to the Network pharmacy at the time of purchase, the Plan Participant will be responsible for full payment for the drug and must then file time of purchase, the Plan Participant will be responsible for full payment for the drug and must then file a claim with the Pharmacy Benefits Manager for reimbursement. Reimbursement is limited to the rates a claim with the Pharmacy Benefits Manager for reimbursement. Reimbursement is limited to the rates established for Non-Network pharmacies. established for Non-Network pharmacies. If a Plan Participant chooses a Brand-Name Drug for which an FDA-approved Generic version is If a Plan Participant chooses a Brand-Name Drug for which an FDA-approved Generic version is available, the OGB Plan Participant pays the difference between the Brand-Name and Generic cost, available, the OGB Plan Participant pays the difference between the Brand-Name and Generic cost, plus a $40 Copayment for a 31 day supply. plus a $40 Copayment for a 31 day supply. 40HR1696 R03/15 12 40HR1696 R03/15 12 69

MAGNOLIA OPEN ACCESS 2. Regardless of where the Prescription Drug is obtained, Eligible Expenses for Brand Name Drugs will be limited to: a. The Pharmacy Benefits Manager's maximum Allowable Charge for the Generic, when available; or b. The Pharmacy Benefits Manager's maximum Allowable Charge for the Brand Drug dispensed, when a Generic is not available. c. There is no per prescription maximum on the Plan Participant's responsibility for payment of costs in excess of the Eligible Expense. Plan Participant payments for such excess costs are not applied toward satisfaction of the annual Out-of-Pocket threshold (above). 3. This Plan allows Benefits for drugs and medicines approved by the Food and Drug Administration or its successor that require a prescription. Utilization management criteria may apply to specific drugs or drug categories to be determined by the PBM. 4. Retirees with Medicare will be automatically enrolled in OGB s Medicare Part D coverage with a commercial wrap benefit. 5. In addition, this Plan allows Benefits limited to $200.00 per month for expenses incurred for the purchase of low protein food products for the treatment of inherited metabolic diseases if the low protein food products are Medically Necessary and are obtained from a source approved by the OGB. Such expenses shall be subject to Coinsurance and Copayments relating to Prescription Drug Benefits. In connection with this Benefit, the following words shall have the following meanings: a. Inherited metabolic disease shall mean a disease caused by an inherited abnormality of body chemistry and shall be limited to: Phenylketonuria (PKU) Maple Syrup Urine Disease (MSUD) Methylmalonic Acidemia (MMA) Isovaleric Adicemia (IVA) Propionic Acidemia Glutaric Acidemia Urea Cycle Defects Tyrosinemia b. Low protein food products mean food products that are especially formulated to have less than one gram of protein per serving and are intended to be used under the direction of a Physician for the dietary treatment of an inherited metabolic disease. Low protein food products shall not include natural foods that are naturally low in protein. 6. Benefits are available for Prescription and over-the-counter (OTC) smoking cessation medications when prescribed by a physician. (Prescription is required for over-the-counter medications). Smoking cessation medications are not subject to the Prescription Drug deductible and are covered at 100%. Smoking cessation screening and counseling are covered under the Preventive or Wellness Care article of the Benefit Plan. 7. The following drugs, medicines, and related services and supplies are not covered: Drugs used to treat anorexia, weight loss or weight gain Drugs used to promote fertility Dietary supplements; Medical Foods Bulk Chemicals Drugs for cosmetic purposes or to promote hair growth 70 40HR1696 R03/15 13

6. Benefits are available for Prescription and over-the-counter (OTC) smoking cessation medications when prescribed by a physician. (Prescription is required for over-the-counter medications). Smoking cessation medications are not subject to the Prescription Drug deductible and are covered at 100%. Smoking cessation screening and counseling are covered under the Preventive or Wellness Care article of the Benefit Plan. 7. The following drugs, medicines, and related services and supplies are not covered: Drugs used to treat anorexia, weight loss or weight gain Drugs used to promote fertility Dietary supplements; Medical Foods Bulk Chemicals Drugs for cosmetic purposes or to promote hair growth Nutritional or parenteral therapy; Vitamins and minerals; Drugs available over the counter (OTC) (unless expressly covered by this Plan) 40HR1696 Prescription R03/15 drugs (federal legend) with an OTC 13equivalent MAGNOLIA OPEN ACCESS For more information on the pharmacy benefit, visit the MedImpact website at https://mp.medimpact.com/ogb or call MedImpact member services at 1-800-910-1831. 71

MENTAL HEALTH AND SUBSTANCE ABUSE BENEFITS: Applies to All Plans MENTAL HEALTH AND SUBSTANCE ABUSE BENEFITS What s included as part of your OGB health plan? Magellan Behavioral Health manages the mental health and substance abuse benefits that are part of your OGB health plan. You and your covered dependents can receive outpatient, inpatient, partial hospitalization and residential treatment for mental health and substance abuse problems with Magellan. Here are some things you should know about Magellan and your benefits: Getting the Best Care with Magellan s Help Magellan will help you get high-quality care with your needs in mind giving you a better experience. By using Magellan, you get: Care Management Magellan s licensed mental health doctors, nurses and other providers help you find a provider and a treatment plan that will work best for you and your dependents. Coordinated Care Magellan works with health plans and employers to understand your needs and to create treatment programs that will meet those needs. High-Quality Care Magellan studies what care works best and compares results to help make your quality of care even stronger. Network Providers You can go to the Blue Cross Preferred Care behavioral health network of doctors and other mental health providers for your care for all plans except Magnolia Local. Members in the Magnolia Local plan should access the Magellan behavioral health network of doctors and other mental health providers. Authorizations for Care Magellan is responsible for all mental health and substance abuse care authorizations. Your doctor or provider must check with Magellan before you get care. This is true for all care, except outpatient care. Learn More Go online or call us to find out if your doctor is in your Blue Cross Preferred Care behavioral health network or to ask about your benefits: ONLINE: CALL: www.bcbsla.com/ogb Under OGB Find Care: Click Mental Health Substance Abuse to read more. Click Louisiana Provider Directory to find a provider. Blue Cross Customer Service 1.800.392.4089 Monday Friday 8 a.m. - 5 p.m. Magellan Health Services is an independent company that assists in the administration of behavioral health benefits for members of Blue Cross and Blue Shield of Louisiana and HMO Louisiana, Inc. 72

PROVIDER NETWORK: Applies to All Plans PROVIDER NETWORK How to Search for a Blue Cross Provider in Louisiana To search for a Blue Cross provider within the state of Louisiana, go to www.bcbsla.com/ogb. 1. Click on Louisiana Provider Directory under OGB Find Care. This will bring you to the Doctor & Hospital Search page. 2. Step 1 is pre-populated with OGB Preferred Care (for all plans except Magnolia Local) in the box marked Network. To find a provider for Magnolia Local, select Community Blue or Blue Connect. To find a Magellan behavioral health provider for Magnolia Local, select Other Directories. 3. Step 2 allows you to enter a name, specialty, city, parish and/or ZIP code as the search criteria. 4. Click on the Search button. 5. You may refine your search results by Radius, Specialty, Parish, Availability, Gender, Admitting Hospitals and Board Certification. 6. To view your search results, you may sort by Distance, City A Z, City Z A, Name A Z, Name Z A or Number of Reviews. You may compare multiple providers by checking the box under Compare. BCBSLA Mobile App Our mobile app allows you to search for Louisiana providers while you re on the go. Find urgent care or just look for directions to a network doctor near you. Download the BCBSLA mobile app for ios from your iphone s App Store. An Android version is coming soon! Call Customer Service at 1.800.392.4089 if you have any trouble locating a provider or if you have any questions. Customer Service is available 8 a.m. to 5 p.m., Monday through Friday. 73

PROVIDER NETWORK: Applies to All Plans, Except Magnolia Local Benefits That Travel The BlueCard Program is a national program that allows our members to receive healthcare services while traveling or living in another Blue Plan s service area. The program links participating healthcare providers with the independent Blue Plans across the country through a single electronic network. Our members have peace of mind knowing they ll find the care they need if they get sick or injured on the road. Please note: Magnolia Local members do not have access to the BCBS National BlueCard Providers. How to Search for a National BlueCard Provider To search for a provider outside of the state of Louisiana, go to www.bcbsla.com/ogb and click on National Provider Directory under OGB Find Care. 1. This will bring you to the National Doctor and Hospital Finder. 2. To see doctors and hospitals in your network, enter OGS as the first three letters of your member ID. 3. Search for providers by name, specialty and radius. The page opens with your current location, or you may enter a different location. National Doctor and Hospital Finder mobile apps are currently available on the iphone and Android platforms. Free app downloads and more information can be found on www.bcbs.com/mobile/. Call Customer Service at 1.800.392.4089 if you have any trouble locating a provider, or if you or your doctors have any questions. Customer Service is available 8 a.m. to 5 p.m., Monday through Friday. 4. Click on the GO button to continue. 74

CARE MANAGEMENT PROGRAMS: Applies to All Plans CARE MANAGEMENT PROGRAMS All the Blue Cross plans offered are strengthened by our Care Management programs that ensure your care is appropriate. Our in-house team of doctors, nurses and pharmacists oversees our members care through the following functions: Authorization of Elective Admissions and Other Covered Services 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 the authorization process that is used to determine whether hospitalization is necessary and an appropriate length of stay. Certain services and visits to certain providers require authorization from Blue Cross before services can be performed. Case Management Our Case Management Program, In Health: Blue Touch, works to coordinate the benefits with the physician s care during and following an acute illness episode, including long-term goals for members with certain conditions. Through this program, we may often: Help resolve issues that block your path to good health Help you coordinate your healthcare services Serve as an advocate for your healthcare needs Give you educational materials and information about community-based resources Promote a healthy lifestyle We will help you set positive healthcare goals and will coach you to reach them. Members may call 1.800.363.9159 for help with Case Management. Healthy Blue Beginnings This maternity support program provides information and confidential support before, during and after your pregnancy to help keep you and your baby healthy. This program is available at no extra cost and is open to members with potential for complicated pregnancies. We also offer support to help moms-to-be identify early warning signs of potential problems and special challenges. Members may call 1.800.363.9159 for more information about this program. Continuity of Care Under special circumstances such as a high-risk pregnancy or life-threatening illness, Blue Cross may allow members to continue receiving healthcare services from a non-network physician or other healthcare practitioner for a specified duration of time. Blue Cross members may request a Continuity of Care form by contacting Customer Service at 1.800.392.4089 or visiting www.bcbsla.com/ogb. 75

CARE MANAGEMENT PROGRAMS: Applies to All Plans InHealth: Blue Health Services... Helping You Manage Today for a Healthier Tomorrow Blue Cross and Blue Shield of Louisiana offers In Health: Blue Health Services a health management program to help you if you have a chronic health condition. At no additional cost to eligible members, In Health: Blue Health Services offers you health coaching, prescription incentives, educational materials and caring support. Can you participate in the program? As an OGB plan member, you can participate if you: Are enrolled in one of the Blue Cross health plans; Do not have Medicare as primary health coverage; and, Have been diagnosed with one or more of these ongoing health conditions: - Diabetes - Coronary artery disease - Heart failure - Asthma - Chronic obstructive pulmonary disease (COPD) What can the program do for you? Learn more about your condition and how it affects you. Find out how to work with your doctor to manage or improve your health. Understand more about the medicines you take and why you take them. Receive health information that will help you understand, manage and improve your condition. What is a health coach? Our health coaches are Blue Cross nurses or healthcare professionals who: Give you individual support and attention; Help you set healthcare goals; Assist with coordinating your care; Serve as your advocates and advisors; Give you important health information; Help you find qualified physicians; and, Reduce the barriers to good health outcomes. How can the program save you money on prescriptions? Pay only $20 (31-day supply), $40 (62-day supply) and $50 (93-day supply) for brandname drugs when a generic is not available. Pay $0 for generic drugs for a 31-day supply of covered drugs. Covered drugs include certain drugs specifically prescribed for treating diabetes, coronary artery disease, heart failure, asthma and COPD. How can you join the program? Simply call our toll-free number at 1.800.363.9159 and speak with one of our Health Services Specialists, who can get you started. We will assign you to a personal Blue Health Coach who will ask you a series of questions to assess your individual healthcare needs. Once that assessment is complete, together you and your Blue Cross Health Coach can plan to improve and maintain your overall health. Give us a call. We re here to help! 76

RESOURCES: Applies to All Plans RESOURCES: GENERAL INFORMATION General and Specialist Care If you need routine care, call your doctor and plan an office visit. Urgent Care If you cannot reach your doctor, urgent care or after-hours clinics are great alternatives to the emergency room when you do not have a true emergency. Emergency Care Call 911 or go to the nearest emergency room. An emergency medical condition, as defined by state law, is a medical condition of recent onset and severity, including severe pain, that would lead a prudent layperson, acting reasonably and possessing an average knowledge of health and medicine, to believe that the absence of immediate medical attention could reasonably be expected to result in: 1) Placing the health of the individual, or with respect to a pregnant woman the health of the woman and her unborn child, in serious jeopardy; 2) Serious impairment to bodily function; 3) Serious dysfunction of any bodily organ or part. Dental Discount Network Members can take advantage of special discounts on dental services by simply presenting their ID card to a participating provider and immediately receiving significant savings. To find a discount provider, visit www.bcbsla.com/ogb and under OGB Find Care, click on Louisiana Provider Directory. Next to Step 1, from the drop-down Network menu, choose Discount Dental. Member ID Card Blue Cross will issue two membership ID cards per family. Each ID card will list only the employee s name, but can be used for all covered dependents. Your ID card also includes the following information: your member number your physician and specialist copayment amounts or deductible/coinsurance Customer Service and authorization telephone numbers prescription drug information Please remember to carry your ID card with you at all times for instant recognition from your providers. If you lose your ID card, please call our Customer Service Department at 1.800.392.4089 for a new ID card or email us at ogbhelp@bcbsla.com. Your Right to Appeal If you or your provider disagree with a clinical decision Blue Cross has made about covered services, you have the right to appeal. You can submit appeals by writing to: Blue Cross and Blue Shield of Louisiana Appeal and Grievance Unit P.O. Box 98045 Baton Rouge, LA 70898-9045 If a member has questions or needs assistance putting the appeal in writing, he or she may call Customer Service at 1.800.392.4089. Please note these services are a separate discount program offered at no additional cost. The discount program is not part of the Blue Cross medical plans. 77

RESOURCES: Applies to All Plans RESOURCES: ONLINE TOOLS My Account Our members want more ways to manage their account and health information. That s why we offer password-protected online tools that allow you to review and manage your healthcare information 24 hours a day, seven days a week. To activate your online account, go to www.bcbsla.com/ogb and click LOG IN for instructions on how to register. If you need help registering or logging in, call the 24-hour support line at 1.800.821.2753. Your online account tools help you manage your health with access to a summary of your benefits, claims activity, health education, selfcare guides, treatment options, the Live Better Louisiana wellness program and discounts and deals. Claims Review See your latest plan activity or search past claims on the Claims screen: View your claims and the claims of covered dependents under 18. Easily see your costs in the highlighted columns. Search past claims by date, provider, etc. See claims payment status. Rate your doctor and write a review of a recent visit. Online Health Tools Use our free online health tools to learn your health risks and get help addressing them. You can also get a quick summary of past care for a new healthcare provider or even an emergency. Personal Health Assessment The Personal Health Assessment (PHA) is an online questionnaire that allows you to learn any health risks you might face and prioritize an action plan to address them. Blue Health Record Your Blue Health Record provides a quick threeyear summary of your medical care, based on claims and organized by episode of care. Moved to a new town? Give your new healthcare providers quick insight into any recent medical care. Evacuating from a hurricane? It may not seem likely, but your health record would be very useful in an emergency. 78

RESOURCES: Applies to All Plans Health Education It s important to understand your health and stay informed about ways to improve it. That s why Blue Cross provides an extensive online health library, as well as a video library with educational and entertaining videos on a number of health topics. We also offer: Preventive and Wellness Guides to help you stay current with medical guidelines for specific ages and gender. Health Condition Guides for a selection of common illnesses and injuries, such as asthma, diabetes, heart disease, joint replacement, mental health, pain management and more. Multimedia Self-Care Workbooks on asthma, diabetes, COPD, heart disease and heart failure that will help you learn more about living well with these conditions. Discounts and Deals Through our national association, we bring you Blue365, a health and wellness program for members of participating local Blue Companies. Blue365 helps you save on a healthier lifestyle, with deals on gym memberships, healthy eating options, hearing and vision products, family activities and more. Examples include: Exclusive $25/month membership to 8,000 gyms nationwide (with threemonth commitment) 20% off all Reebok fitness gear, including shoes and apparel, plus free shipping 10-40% off Davis Vision products Discounts of 20-50% to a network of dentists Mobile and Social Media If you like to get health information online and interact with others, check out our social media accounts for wellness tips, recipes, breaking health news and more as well as a sense of community. We ve also got a mobile app for when you re on the go. Mobile App Find a doctor, view your claims, find a plan all on your mobile device, thanks to our mobile-friendly website and our mobile app for ios (Android version coming soon). With your smart phone in hand, you can search for healthcare nearby using our Find a Doctor feature. Find urgent care if you need it, and get directions to doctors or hospitals. Already been to the doctor? Check out the status of your claim and see your costs and balances, right in the palm of your hand. Social Hub If you follow Facebook and Twitter, check out Blue Cross accounts on those services. On our social hub at bcbsla.com/social, you can access Blue Cross accounts on all of these social properties: Facebook (BlueCrossLA) offers daily health tips and news stories of interest to our membership. Twitter (@bcbsla) provides you with breaking news stories about health and healthcare. You can also follow our CEO, Mike Reitz (@MikeReitzCEO), our chief medical officer (@DrCarmouche) and our charitable giving foundation (@OurHomeLA) on Twitter. Watch our videos on YouTube, find health tips and infographics on Pinterest, or join us on Flickr or Google+ as well all connected easily from a central hub at bcbsla.com/social. This is just the tip of the iceberg when you visit www.bcbsla.com/ogb and log in. We are adding new tools and services all the time so log in often! 79

RESOURCES: Applies to All Plans RESOURCES: WELLNESS PROGRAMS Live Better Louisiana Live Better Louisiana is OGB s game plan for better health. The program gives Blue Cross plan members resources to help you better monitor your health, understand risk factors and make educated choices that keep you healthier. It s sponsored by Blue Cross and Blue Shield of Louisiana at no extra charge to members. Live Better Louisiana is a proactive approach a way to prevent illness and to manage any conditions that do appear. What s the Game Plan? 1. Fill out your Personal Health Assessment (PHA): This confidential online questionnaire provides you with a picture of your overall health and measures health risks and behaviors. It also gives you a personalized risk report and action plan for health improvement, with recommendations and access to the appropriate resources. How do I get there? If you have an online account, go to www.bcbsla.com/mypha. If you haven t yet activated your online account, go to www.bcbsla.com/activate. 2. Take your Preventive Onsite Health Checkup: Blue Cross has partnered with an industry leader, Catapult Health, to bring preventive checkups to sites near you all over the state. A calendar of events is available online where you can schedule a checkup with a licensed nurse practitioner and technician. You ll get lab-accurate diagnostic tests and receive a full, printed Personal Health Report with checkup results and recommendations. How do I get there? Visit www.bcbsla.com/ogb and then click the Live Better Louisiana Tab to download and review the onsite checkup flier with more details. Visit www.timeconfirm.com/ogb to schedule your appointment. 3. Take Charge of your Own Health with a Wealth of Resources: Live Better Louisiana gives you access to a wide range of healthy activities some of which may even be suggested in your personal action plan. Blue Cross also brings OGB plan members a number of wellness-related deals and discounts. How do I get there? Explore the Live Better Louisiana tab at www.bcbsla.com/ogb and review your Personal Health Assessment. If your wellness checkup or PHA shows you are eligible for one of the Disease Management programs, a Blue Cross nurse will contact you. 80

RESOURCES: Applies to All Plans In addition to Live Better Louisiana, all members have no-cost access to our My Health, My Way wellness program. The program includes: Interactive tools that let you track your weight, exercise and food intake. Fitness and nutrition plans that can be customized for you and your family. Online workshops on topics such as back care, nutrition, smoking cessation, stress management and weight management. Exclusive access to a national program, Blue 365, providing savings on fitness club memberships, nutrition programs and products, financial well-being services, family care services and healthy travel. You can even save on elective procedures for vision and hearing. It s all secure, confidential and at no extra cost to you! Find out more at www.bcbsla.com/ogb under Benefits > Health & Wellness Tools. Louisiana 2 Step Louisiana ranks near the highest in the nation in adult obesity and in deaths from diabetes. These are some of the reasons why Blue Cross created the Louisiana 2 Step, a free and fun statewide public health education campaign to encourage all Louisianians to eat right and move more. The award-winning interactive website, www.louisiana2step.com, brings this message to individuals and families. The 2 Step has tools and information to support your My Health, My Way wellness goals, such as local resources and Louisiana-style recipes. Security and Confidentiality: The Personal Health Assessment has been engineered to provide the same level of protection for your confidential health information that online banking and consumer websites offer their clients and account-holders. If you are identified as someone who may benefit from Care Management Services, your information may be shared with medical personnel, and you may be contacted by a Care Management nurse. The information you provide in the PHA will be used only as permitted by law. This information will not adversely affect your enrollment in your health plan. 81

RESOURCES: Applies to All Plans RESOURCES: HEALTHY DISCOUNTS Blue365 Living well means having healthy options every day. That s why we offer Blue365 to take our members beyond health insurance and give you access to exclusive deals on trusted health and wellness resources 365 days a year. As a Blue Cross member, you enjoy special deals on many services from top national and local retailers on fitness gear, gym memberships, family activities, healthy eating options and much more. Blue365 is a national program that s part of every plan, making it easier and more affordable to make healthy choices. If you choose to sign up, you ll receive great health and wellness deals straight to your email inbox every week. And it s easy to register. Just go to www.bcbsla.com/ ogb and have your Blue Cross and Blue Shield of Louisiana member ID card handy. Click LOG IN to access your online account, then click Blue365 under Discounts and Deals. Follow the instructions, and you ll have access to two types of good-for-you deals: standing deals, which you can redeem any time you like, and exclusive, limited-time offers designed for living well right in the moment. Weekly Deals Sign up for no-fuss emails, and you ll be the first to know about the latest deals from Blue365. You won t get any spam, and you ll only get one email a week. You can also browse deals anytime on the Blue365 website. Take a look at some past offers in the following categories: that gives you access to a network of 8,000+ gyms nationwide for only $25 per month and a low $25 enrollment fee. Participating Healthways gyms include Snap Fitness, Curves and more. Also, you get up to 30% off on more than 40,000 experienced health and well-being specialists, including massage therapists, personal trainers, nutrition counselors, yoga and Pilates instructors and more. Save on vitamins, exercise equipment, aromatherapy,organic products and unique gifts. Fitness Blue365 offers other fitness deals as well, including discounts from Reebok, Polar Heart Rate Monitors, Body Media FIT and Walkadoo (pedometer-based activity program), plus savings on other types of health club memberships. Diet/Weight Control Check out savings on programs, products and consultations at Jenny Craig 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. Members can also save 40 to 50% off the overall national average price for Lasik surgery through QualSight LASIK and LASIK Plus. Health & Wellness Healthways One of the most popular deals is Healthways Fitness Your Way, a program 82

RESOURCES: Applies to All Plans Financial Health Refinance and Purchase Loans Get cash back on qualified loans through Quicken Loans. Credit Monitoring Save on identity theft and credit monitoring. Family Care Programs for Kids Save on kids wellness products, such as Brush Buddies and GeoPalz pedometers. Also, get access to child safety and consumer product information. Senior Care Get discounts on care advisory services and eldercare support from organizations such as SeniorLink and CaringBridge. Long-Term Insurance Locate free guidelines and information. Managing Medicare Get resources to understand coverage options from Medicare. Travel Healthy Getaways Members can find savings on hotel programs, such as The Fairmont. Travel Tips Explore a wealth of online travel tips and resources. Members can browse all these healthy choices after logging in to My Account at www.bcbsla.com/ogb. Just click My Health, then Discounts. Discounts for Non-covered Prescription Drugs OGB members now have free access to a prescription coupon program that provides discounts on non-covered drugs that is, medications not covered by your pharmacy benefits. The program is accepted at more than 56,000 pharmacies nationwide. Get more information, including pharmacy locations, by visiting www.bcbsla.com/ogb. Under OGB Find Care, click Non-covered Drug Discount Program. Security and Confidentiality: 2000-2014 Blue Cross and Blue Shield Association - All Rights Reserved. The Blue Cross and Blue Shield Association is an association of independent, locally operated Blue Cross and Blue Shield Plans. Blue365 offers access to savings on items that Members may purchase directly from independent vendors, which are different from items that are covered under the policies with your Blue Cross and/or Blue Shield Company (each a Blue Company ), its contracts with Medicare, or any other applicable federal healthcare program. The products and services described herein are neither offered nor guaranteed under your Blue Company s contract with the Medicare program. In addition, they are not subject to the Medicare appeals process. Any disputes regarding these products and services may be subject to your Blue Company s grievance process. Blue Cross and Blue Shield Association (BCBSA) may receive payments from Blue365 vendors. BCBSA does not recommend, endorse, warrant or guarantee any specific Blue365 vendor or item. 83

BALANCE BILLING DISCLOSURE Blue Cross and Blue Shield of Louisiana (BCBSLA) is required by law to provide the notice below to all members at the time of enrollment and annually. The notice is provided as a reminder to make sure you choose a doctor or hospital in your provider network when you need healthcare. By choosing a network provider, you avoid the possibility of having your provider bill you for amounts in addition to applicable copayments, coinsurance, deductibles and non-covered services. BALANCE BILLING DISCLOSURE NOTICE: Healthcare Services may be provided to you at the 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 www.bcbsla.com or by calling the Customer Service Telephone Number of your Health Plan: 1.800.392.4089. 84