BluePreferred HSA MD

Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Coverage Period: 06/01/2013 - 05/31/2014 Coverage for: Individual | Plan Type: PPO

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document
at www.carefirst.com or by calling 1-855-258-6518. Important Questions What is the overall deductible? Are there other deductibles for specific services? Is there an outofpocket limit on my expenses? What is not included in the outofpocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesnt cover? Answers For participating providers $2,700 person/ $5,400 family For non-participating providers $5,400 person/ $10,800 family No. Yes. For participating providers $3,200 person/ $6,400 family For non-participating providers $6,400 person/ $12,800 family Premiums, balance-billed charges, and health care this plan doesn't cover. No. Yes. For a list of preferred providers, see www.carefirst.com or call 1-855-258-6518. No. Yes. Why this Matters: You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. You dont have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they dont count toward the out-of-pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the services this plan doesnt cover are listed on page 6. See your policy or plan document for additional information about excluded services.

Questions: If you are a member please call the number on your ID card or visit www.carefirst.com. Otherwise, please call 1-855-258-6518. If you arent clear about any of the underlined terms used in this form, see the Glossary at www.carefirst.com/sbcg. CareFirst SBC ID: SBC20130513MANBPHMM02RXCMMN17N062013 Page 1 of 10

 Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plans
allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you havent met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use participating providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event Your cost if you use a Services You May Need Participating Provider Deductible, then $30 co-pay per visit Deductible, then $30 co-pay per visit Deductible, then No Charge for Chiropractic Non-Participating Provider Deductible, then 20% of Allowed Benefit Deductible, then 20% of Allowed Benefit Deductible, then 20% of Allowed Benefit for Chiropractic 20% of Allowed Benefit Deductible, then 20% of Allowed Benefit Deductible, then 20% of Allowed Benefit Limitations & Exceptions Some services may have limitations or exclusions based on your contract. Some services may have limitations or exclusions based on your contract. Some services may have limitations or exclusions based on your contract. Some screenings are limited to 1 per benefit period. Please refer to your contract for specific limitations per service. Some services may have limitations or exclusions based on your contract. Some services may have limitations or exclusions based on your contract.

Primary care visit to treat an injury or illness Specialist visit

If you visit a health care providers office or clinic

Other practitioner office visit

Preventive care/screening/immunization

No Charge Deductible, then No Charge Deductible, then No Charge

Diagnostic test (x-ray, blood work) If you have a test Imaging (CT/PET scans, MRIs)

CareFirst SBC ID: SBC20130513MANBPHMM02RXCMMN17N062013

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Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.carefirst.com

Your cost if you use a Services You May Need Participating Provider $10 co-pay $25 co-pay $45 co-pay 50% co-insurance up to a maximum of $75 Deductible, then No Charge Deductible, then No Charge Deductible, then No Charge Deductible, then No Charge Deductible, then $30 co-pay per visit Deductible, then No Charge Deductible, then No Charge Non-Participating Provider Not Covered Not Covered Not Covered Not Covered Deductible, then 20% of Allowed Benefit Deductible, then 20% of Allowed Benefit Deductible, then No Charge Deductible, then 20% of Allowed Benefit Deductible, then 20% of Allowed Benefit Deductible, then 20% of Allowed Benefit Deductible, then 20% of Allowed Benefit Limitations & Exceptions

Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency room services

Covers up to a 34 day supply Covers up to a 34 day supply Covers up to a 34 day supply Covers up to a 34 day supply Some services may have limitations or exclusions based on your contract. Some services may have limitations or exclusions based on your contract. Limited to emergency services Some services may have limitations or exclusions based on your contract. Some services may have limitations or exclusions based on your contract. Requires prior authorization Some services may have limitations or exclusions based on your contract.

If you have outpatient surgery

If you need immediate medical attention

Emergency medical transportation Urgent care Facility fee (e.g., hospital room)

If you have a hospital stay

Physician/surgeon fee

CareFirst SBC ID: SBC20130513MANBPHMM02RXCMMN17N062013

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Common Medical Event

Your cost if you use a Services You May Need Participating Provider Non-Participating Provider Limitations & Exceptions Visits 6-30 are subject to Deductible, then 35% of Allowed Benefit Visits 30+ are subject to Deductible, then 50% of Allowed Benefit Requires prior authorization Visits 6-30 are subject to Deductible, then 35% of Allowed Benefit Visits 30+ are subject to Deductible, then 50% of Allowed Benefit Require prior authorization 1 postnatal visit is included as part of delivery Some services may have limitations or exclusions based on your contract.

Mental/Behavioral health outpatient services

Deductible, then 20% of Allowed Benefit

Deductible, then 20% of Allowed Benefit

If you have mental health, behavioral health, or substance abuse needs

Mental/Behavioral health inpatient services

Deductible, then No Charge

Deductible, then 20% of Allowed Benefit

Substance use disorder outpatient services

Deductible, then 20% of Allowed Benefit

Deductible, then 20% of Allowed Benefit

Substance use disorder inpatient services Prenatal and postnatal care If you are pregnant Delivery and all inpatient services

Deductible, then No Charge No Charge Deductible, then No Charge

Deductible, then 20% of Allowed Benefit Deductible, then 20% of Allowed Benefit Deductible, then 20% of Allowed Benefit

CareFirst SBC ID: SBC20130513MANBPHMM02RXCMMN17N062013

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Common Medical Event

Your cost if you use a Services You May Need Participating Provider Deductible, then No Charge Deductible, then No Charge Deductible, then No Charge Deductible, then No Charge Deductible, then No Charge Deductible, then No Charge Not Covered Not Covered Not Covered Non-Participating Provider Deductible, then 20% of Allowed Benefit Deductible, then 20% of Allowed Benefit Deductible, then 20% of Allowed Benefit Deductible, then 20% of Allowed Benefit Deductible, then 20% of Allowed Benefit Deductible, then 20% of Allowed Benefit Not Covered Not Covered Not Covered Limitations & Exceptions Requires prior authorization Limited to 40 visits, up to 4 hours/visit/episode of care Limited to 30 visits/ benefit period Requires prior authorization Limited to members under age 19 Requires prior authorization Limited to 60 days/benefit period Some services may have limitations or exclusions based on your contract. Requires prior authorization Limited to a maximum 180 day Eligibility Period Some services may have limitations or exclusions based on your contract. Some services may have limitations or exclusions based on your contract. Some services may have limitations or exclusions based on your contract.

Home health care Rehabilitation services Habilitation services

If you need help recovering or have other special health needs

Skilled nursing care

Durable medical equipment

Hospice service

Eye exam If your child needs dental or eye care Glasses Dental check-up

CareFirst SBC ID: SBC20130513MANBPHMM02RXCMMN17N062013

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Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isnt a complete list. Check your policy or plan document for other excluded services.) Acupuncture Cosmetic surgery Dental care (Adult) Long-term care Private-duty nursing Routine eye care (Adult) Routine foot care Weight loss programs

Other Covered Services (This isnt a complete list. Check your policy or plan document for other covered services and your costs for these services.) Bariatric surgery Chiropractic care Hearing aids (Up to 18) Infertility treatment Most coverage provided outside the United States. Non-emergency care when traveling outside the U.S.

CareFirst SBC ID: SBC20130513MANBPHMM02RXCMMN17N062013

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Your Rights to Continue Coverage:

** Individual health insurance Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are exceptions, however, such as if: You commit fraud The insurer stops offering services in the State You move outside the coverage area ** Group health coverage If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at 1-855-258-6518. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.

OR

For more information on your rights to continue coverage, contact the insurer at 1-855-258-6518. You may also contact your state insurance department at Maryland -1-800-492-6116 or http://www.mdinsurance.state.md.us DC 1-877-685-6391 or www.disb.dc.gov Virginia 1-877-310-6560 or www.scc.virginia.gov/boi

Your Grievance and Appeals Rights:

If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: www.carefirst.com or 1-855-258-6518. You may also contact state consumer Assistance Program Maryland -1-800-492-6116 or http://www.mdinsurance.state.md.us DC 1-877-685-6391 or www.disb.dc.gov Virginia 1-877-310-6560 or www.scc.virginia.gov/boi

For group health coverage subject to ERISA you may also contact the Department of Labors Employee Benefits Security Administration at 1-866444-EBSA (3272) or www.dol.gov/ebsa/healthreform. CareFirst SBC ID: SBC20130513MANBPHMM02RXCMMN17N062013 Page 7 of 10

Language Access Services:

To see examples of how this plan might cover costs for a sample medical situation, see the next page.

CareFirst SBC ID: SBC20130513MANBPHMM02RXCMMN17N062013

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About these Coverage Examples:

These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.

Having a baby
Amount owed to providers: $7,540 Plan pays: $4,670 Patient pays: $2,870 Sample care costs: Hospital charges (mother) Routine obstetric care Hospital charges (baby) Anesthesia Laboratory tests Prescriptions Radiology Vaccines, other preventive Total Patient pays: Deductibles Copays Coinsurance Limits or exclusions Total $2,700 $2,100 $900 $900 $500 $200 $200 $40 $7,540 $2,700 $20 $0 $150 $2,870

Managing type 2 diabetes

(routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays: $2,270 Patient pays: $3,130 Sample care costs: Prescriptions Medical Equipment and Supplies Office Visits and Procedures Education Laboratory tests Vaccines, other preventive Total Patient pays: Deductibles Copays Coinsurance Limits or exclusions Total $2,900 $1,300 $700 $300 $100 $100 $5,400 $2,700 $350 $0 $80 $3,130

This is not a cost estimator.

Dont use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples.

Note: These coverage examples calculations are based on Individual Coverage Tier numbers for this plan.

Note: These numbers assume the patient is participating in our diabetes wellness program. If you have diabetes and do not participate in the wellness program, your costs may be higher. For more information about the diabetes wellness program, please contact: www.carefirst.com .

CareFirst SBC ID: SBC20130513MANBPHMM02RXCMMN17N062013

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Questions and answers about the Coverage Examples:

What are some of the assumptions behind the Coverage Examples?
Costs dont include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and arent specific to a particular geographic area or health plan. The patients condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher.

What does a Coverage Example show?

For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isnt covered or payment is limited.

you receive, the prices your providers charge, and the reimbursement your health plan allows.

Can I use Coverage Examples to compare plans?

Yes. When you look at the Summary of

Benefits and Coverage for other plans, youll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides.

Does the Coverage Example predict my own care needs?

No. Treatments shown are just examples.

The care you would receive for this condition could be different based on your doctors advice, your age, how serious your condition is, and many other factors.

Are there other costs I should consider when comparing plans?

Yes. An important cost is the premium you

pay. Generally, the lower your premium, the more youll pay in out-of-pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses.

Does the Coverage Example predict my future expenses?

No. Coverage Examples are not cost

estimators. You cant use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care Questions: If you are a member please call the number on your ID card or visit www.carefirst.com. Otherwise, please call 1-855-258-6518. If you arent clear about any of the underlined terms used in this form, see the Glossary at www.carefirst.com/sbcg. CareFirst BlueCross BlueShield is the business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. which are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. ' Registered trademark of CareFirst of Maryland, Inc. CareFirst SBC ID: SBC20130513MANBPHMM02RXCMMN17N062013 Page 10 of 10