for groups with 2-50 employees - summary of benefits...

2015 Small Group GuideFor groups with 2-50 employees

Effective January 1, 2015

37046GABENBGA Rev. 08/14

The Affordable Care Act (ACA) is transforming the health care marketplace

Access to the latest range of plans

Introduced in 2014, Blue Cross and Blue Shield of Georgia (BCBSGa) plans are well-positioned for the changing market. You’ll find they offer all the essential health benefits (EHB) such as emergency care, hospital stays, maternity and newborn care, prescription drugs and preventive care, as well as other features needed to comply with the Affordable Care Act (ACA). Yet they still deliver on our longstanding portfolio strengths, including network value, plan variety, pharmacy coverage and comprehensive care.

Built from the ground up — with the strengths you’ve come to expect from the BCBSGa product portfolio

We think you’ll find the BCBSGa plans are well-positioned for the changing market. They provide all the essential health benefits and other features required for ACA compliance. At the same time, you’ll see that they were carefully designed to be as cost-effective as possible, while still maintaining our traditional portfolio strengths:

}} Network Value — BCBSGa works with a large network of doctors and hospitals to ensure that employees and their families get access to high-quality care at a lower cost.

}} Plan Variety — We provide a wide choice of plans and designs to suit evolving needs and provide extensive tools and guidance to help employers find the best match.

}} Pharmacy – We provide pharmacy coverage with a variety of options and features to help employers — and employees — control costs.

}} Comprehensive Care — With free preventive care, free access to the 24/7 NurseLine and integrated clinical and wellness programs, we can provide a complete health and wellness solution for employees.

}} Stability — Our companies have been providing health care benefits to millions of Americans, and we use that experience to your advantage every day.

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The BCBSGa product portfolioEvery plan in our portfolio is ACA-compliant, covering everything from emergencies to counseling services to preventive care, and more, including:

}} Preventive, wellness and chronic disease management services }} Outpatient (ambulatory) care}} Emergency services, including emergency room or urgent care}} Inpatient care (hospital stays) }} Laboratory services}} Prescription drugs}} Mental health and substance abuse}} Maternity (pregnancy) and newborn care

}} Pediatric dental and vision essential health benefits}} Rehabilitative and habilitative services and devices (habilitative services help a person learn, keep or improve skills they may not be developing normally)

Bundle BCBSGa’s leading dental, vision, life and disability products with our health plans for a more comprehensive, easy-to-administer offering for your employees.

To find a network doctor, hospital or pharmacy, use our online Provider Directory at bcbsga.com.

What’s NewBCBSGa is providing the portfolio of plans you have come to know and trust, offered on the networks you have relied on. The plan names may have changed, but the plans have not. Plans are now categorized as Platinum, Gold, Silver, and Bronze for our off-exchange products, but we are still offering them on the same networks: HMO BlueChoice Healthcare Plan, Blue Open Access POS and Blue Choice PPO, and Pathway.

The chart starting on page 6 shows our plan names on the associated networks, to help guide you to the plan that is right for you and your employees. Also, our online plan comparison tool at bcbsgaplancomparison.com will compare plans side by side.

Balance Funding

Our new balance funding product may be a good option for groups 10-99.

Changes to look for in 2015Updated naming structure is clearer and more completeThe plan names include the following elements: BCBSHP + metal tier + network name + product type + deductible /coinsurance/out-of-pocket maximum.

Example: BCBSHP Silver Blue Open Access POS 4000/20%/6600 Our plans meet ACA-metal level requirements: platinum, gold, silver and bronze. The difference between these levels is the actuarial value. In other words, a plan, on aver-age, must cover a defined percentage of medical costs in order to meet the metal level requirements.

Here’s what it means when you see the “Plus” in theplan nameWhen the “Plus” is added to a plan name (as in “BCBSHPGold Pathway Enhanced POS 500/20%/5000 Plus”), it means the plan contains the following:

}} Healthy Support Package B — A robust health and wellness offering with online resources and webinars, plus fitness reimbursements and health incentives of up to $600/year.

Pediatric dental is embedded within all plansThe ACA is written so all children have access to affordabledental care to keep their teeth and gums healthy. It’s part of the essential health benefits (EHB) included in allmedical plans. Other required EHBs that are embedded inmember medical plans include emergency care, hospitalstays, maternity and newborn care, prescription drugs andpreventive care.

Composite Rating/PremiumComposite rating, as it’s been applied in the past, is no longer allowed. However, “composite premiums” may be used. They must be equal to the sum of the age-rated premium for all covered employees and dependents of the group, divided by the number of members covered:

}} A composite premium structure may be used for small business plan years, starting on or after January 1, 2015.

}} The composite premiums calculated at the time of issue or renewal must be locked in for the entire plan year, regardless of changes in the group’s composition throughout the year.

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4

Plan Name Platinum plans — These provide the highest level of benefits, and employees often pay less when they get care. However, these plans have the highest monthly premiums.

Gold plans — These provide richer benefits than the Silver and Bronze plans, and employees pay less when they get care. However, the monthly premium is higher than with those plans.

Silver plans — These offer affordable monthly premiums, but compared to the Bronze plans, employees pay less when they get care.

Bronze plans — These feature broad benefits and the lowest monthly premiums, but employees pay more when they get care: deductibles, copays and cost shares may be higher than the other plans.

Metal equivalent naming structure — Actuarial values can be used to compare different plan designs to determine how overall cost sharing differs across plans with different cost-sharing provisions.

Minimum AV Maximum AV

Platinum 88% 92%

Gold 78% 82%

Silver 68% 72%

Bronze 58% 62%

Product Type Non-gatekeeper (PPO/POS) — Allows members to go directly to any in-network provider. There is no need to choose a primary care physician (PCP) or get a referral to see other doctors.

Gatekeeper (HMO) — Requires members to choose a primary care physician (PCP); a referral may be required to see other doctors.

Health Savings Account (HSA) — A savings account for certain plans that members can fund with pre-tax dollars and used to pay for qualified health care expenses, including prescriptions. This is often used with a Consumer Driven Health Plan.

Health Reimbursement Arrangements (HRA) — A health plan that comes with a special type of bank account. The employer puts money into the account and the members use the money to pay for qualified (certain) health costs that are not covered by the health plan.

Pharmacy The BCBSGa drug list is a list of FDA-approved generic and brand-name medications. The list is divided into four tiers. Tier 1 drugs have the lowest out-of-pocket costs. Tier 2 drugs are slightly higher. Tier 3 and Tier 4 drugs have the highest out-of-pocket costs. In evaluating a plan, it is important to look at the drug list to understand which drugs are covered.

All of our ACA-compliant products include our BCBSGa Select Drug List. Our Balance Funding products use the National Formulary List.

Products & featuresOn the pages that follow, you will find product grids that provide a top line description of the complete range of BCBSGa plans. The explanations below correspond to column headers found on those grids. Deductibles, copays and coinsurance amounts are also listed to simplify plan comparison.

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Pediatric Vision EHB All of our small group medical plans include pediatric vision essential health benefits, which provide coverage for vision exams and glasses or contacts. Members can see any provider in the Blue View Vision network, which includes retailers such as LensCrafters® and Target Optical®, as well as 1-800 CONTACTS.

Covered children can choose from a selection of frames and contact lenses. Glasses with Transitions® lenses (to protect eyes from UV rays) and polycarbonate lenses with scratch coating (to protect lenses from damage) are available at no extra charge.

w BCBSGa Vision Pediatric

In-network

Routine eye exam (once every calendar year) $0 copay

Lenses - single, bifocal, trifocal (once every calendar year) $0 copay

Lens treatments Covered in full

UV coating Covered in full

Standard factory scratch coating Covered in full

Standard polycarbonate Covered in full

Standard Transitions® Covered in full

Standard progressive lenses Covered in full

Frames (once every calendar year) $0 copay, Formulary

Elective contact lenses (once every calendar year - in lieu of eyeglasses) $0 copay, Formulary

Non-elective contact lenses Covered in full

If you have a PPO/POS medical plan, it will include out-of-network benefits for vision.

Pediatric Dental EHB All of our small group health plans include pediatric dental EHBs, which provide important coverage for kids up to age 19, including preventive care, fillings and more extensive services like medically necessary orthodontia. Members can see any provider in the Dental Prime network.

In and out-of-network

Diagnostic and preventive services (cleanings, exams and X-rays) – not subject to deductible 90%

Basic services (fillings) 60%

Endodontic, periodontal, oral surgery and major services 60%

Medically necessary orthodontia (12-month waiting period)] 60%

Because these benefits are part of a medical plan, they share a combined deductible and out-of-pocket maximum. Diagnostic and preventive services like cleanings, exams and X-rays are not subject to the deductible, so members can take advantage of them right away. These benefits have no annual maximum. * If the member’s medical plan includes out-of-network benefits, the dental benefits will also be available through out-of-network providers. If the member’s medical plan only includes in-network benefits, the dental benefits

will only be available through in-network providers.

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Healthy Support Healthy Support Package B — }} Includes Healthy Lifestyles online and webinars}} Includes Fitness Reimbursement (up to $400/yr in cash)}} Includes Healthy Incentives (up to $200/yr in gift cards)}} FitOrbit (online trainers and nutrition plans) with member cost share ($99/yr)

Includes Vision (annual exam + $100 for lenses/frames)

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Contract code

Offered on/off exchange

Product name

Network name

Network type

Metal OOP OOP family

Deductible Deductible family

Other coins

PCP Tier 1 SPC

Home health

1KHK Off BCBSHP Silver Blue Open Access POS 4000/30%/6350

Blue Open Access POS

POS Silver $6,350 $12,700 $4,000 $8,000 30% $35 $50 $35

1KGC Off BCBSHP Silver Blue Open Access POS 3000/20%/6600


POS Silver $6,600 $13,200 $3,000 $6,000 20% $35 $60 $35

1KBQ Off BCBSHP Platinum Blue Open Access POS 10%/2500


POS Platinum $2,500 $5,000 N/A N/A 10% $10 $20 $10

1KBT Off BCBSHP Platinum BlueChoice HMO 10%/2500

BlueChoice HMO

HMO Platinum $2,500 $5,000 N/A N/A 10% $10 $20 $10

1KE2 Off BCBSHP Gold Blue Open Access POS 2000/0%/4000


POS Gold $4,000 $8,000 $2,000 $4,000 0% $30 $50 $30

1KCL Off BCBSHP Gold Blue Open Access POS 1500/0%/2500


POS Gold $2,500 $5,000 $1,500 $3,000 0% $30 $60 $30

1KE6 Off BCBSHP Gold Blue Open Access POS 1000/0%/4500


POS Gold $4,500 $9,000 $1,000 $3,000 0% $30 $60 $30

1KD9 Off BCBSHP Gold Blue Open Access POS 1500/15%/4000


POS Gold $4,000 $8,000 $1,500 $3,000 15% $30 $50 $25

1KCG Off BCBSHP Gold Blue Open Access POS 1000/25%/5000


POS Gold $5,000 $10,000 $1,000 $3,000 25% $10 $50 $10

1KCD Off BCBSHP Bronze Blue Open Access POS 5900/0%/6600 Plus


POS Bronze $6,600 $13,200 $5,900 $11,800 0% $35 $35 0%

1KDM Off BCBSHP Bronze Pathway Enhanced POS 5900/0%/6600 Plus

Pathway Enhanced

POS Bronze $6,600 $13,200 $5,900 $11,800 0% $35 $35 0%

1KC2 Off BCBSHP Gold Blue Open Access POS 1000/20%/3000 Plus


POS Gold $3,000 $6,000 $1,000 $3,000 20% $20 $20 20%

1KC7 Off BCBSHP Gold Pathway Enhanced POS 1000/20%/3000 Plus

Pathway Enhanced

POS Gold $3,000 $6,000 $1,000 $3,000 20% $20 $20 20%

1KC3 Off BCBSHP Silver Blue Open Access POS 3500/0%/4500 Plus


POS Silver $4,500 $9,000 $3,500 $7,000 0% $30 $30 0%

1KBY Off BCBSHP Silver Pathway Enhanced POS 3500/0%/4500 Plus

Pathway Enhanced

POS Silver $4,500 $9,000 $3,500 $7,000 0% $30 $30 0%

1KCA Off BCBSHP Silver Pathway Enhanced POS 1500/35%/5500 Plus

Pathway Enhanced

POS Silver $5,500 $11,000 $1,500 $3,000 35% $35 $35 35%



POS Silver $5,500 $11,000 $1,500 $3,000 35% $35 $35 35%

1KCC Off BCBSHP Silver Pathway Enhanced POS 3000/20%/4500 Plus

Pathway Enhanced

POS Silver $4,500 $9,000 $3,000 $6,000 20% $30 $30 20%

1KBS Off BCBSHP Silver Blue Open Access POS 3000/20%/4500 Plus


POS Silver $4,500 $9,000 $3,000 $6,000 20% $30 $30 20%

1KBZ Off BCBSHP Silver Pathway Enhanced POS 2000/30%/5500 Plus

Pathway Enhanced

POS Silver $5,500 $11,000 $2,000 $4,000 30% $35 $35 30%

7

Urgent care copay

Urgent care percent

ER copay ER coins Outpatient copay

Output percent

Inpatient max days

Inpatient copay

Inpatient percent

RX benefit Formulary

$50 N/A $200 30% N/A 30% N/A N/A 30% $15/$35/$70/25%/$250 Select formulary


$20 N/A $150 N/A $150 NA 3 $250 N/A $10/$30/$60/25% Select formulary

$20 N/A $150 N/A $150 NA 3 $250 N/A $10/$30/$60/25% Select formulary

$50 N/A $200 0% N/A 0% N/A N/A 0% $15/$35/$70/25% Select formulary





N/A 0% N/A 0% N/A 0% N/A N/A 0% $15/$35/$70/30%/$500 Select formulary


N/A 20% N/A 20% N/A 20% N/A N/A 20% $15/$35/$70/30% Select formulary









8

Contract code


Product name

Network name

Network type



Other coins

PCP Tier 1 SPC

Home health



POS Silver $5,500 $11,000 $2,000 $4,000 30% $35 $35 30%

1KCU Off BCBSHP Bronze Blue Open Access POS 6000/30%/6600 Plus


POS Bronze $6,600 $13,200 $6,000 $12,000 30% $35 $35 30%

1KER Off BCBSHP Bronze Pathway Enhanced POS 6000/30%/6600 Plus

Pathway Enhanced

POS Bronze $6,600 $13,200 $6,000 $12,000 30% $35 $35 30%

1KDF Off BCBSHP Silver Pathway Enhanced POS 2500/20%/6350 Plus

Pathway Enhanced

POS Silver $6,350 $12,700 $2,500 $5,000 20% $30 $60 $30

1KDD Off BCBSHP Silver Blue Open Access POS 2500/20%/6350 Plus


POS Silver $6,350 $12,700 $2,500 $5,000 20% $30 $60 $30

1KCR Off BCBSHP Silver Pathway Enhanced POS 6350/0%/6350 Plus

Pathway Enhanced

POS Silver $6,350 $12,700 $6,350 $12,700 0% $30 $60 $30

1KD0 Off BCBSHP Silver Blue Open Access POS 6350/0%/6350 Plus


POS Silver $6,350 $12,700 $6,350 $12,700 0% $30 $60 $30

1KDP Off BCBSHP Gold Blue Open Access POS 30%/5500


POS Gold $5,500 $11,000 N/A N/A 30% $35 $60 $35

1KDR Off BCBSHP Gold BlueChoice HMO 30%/5500

BlueChoice HMO

HMO Gold $5,500 $11,000 N/A N/A 30% $35 $60 $35

1KD2 Off BCBSHP Platinum Blue Open Access POS 0%/2000


POS Platinum $2,000 $4,000 N/A N/A 0% $20 $40 $20

1KCS Off BCBSHP Platinum BlueChoice HMO 0%/2000

BlueChoice HMO

HMO Platinum $2,000 $4,000 N/A N/A 0% $20 $40 $20

1KG0 Off BCBSHP Gold Blue Open Access POS 1000/20%/4500


POS Gold $4,500 $9,000 $1,000 $3,000 20% $15 $35 $15

1KH6 Off BCBSHP Gold Blue Open Access POS 1500/20%/6000


POS Gold $6,000 $12,000 $1,500 $3,000 20% $10 $35 $10

1KGU Off BCBSGA Gold BlueChoice PPO 1500/20%/6000

BlueChoice PPO

PPO Gold $6,000 $12,000 $1,500 $3,000 20% $10 $35 $10

1KFY Off BCBSHP Gold Blue Open Access POS 1500/30%/4500


POS Gold $4,500 $9,000 $1,500 $3,000 30% $20 $40 $20

1KGF Off BCBSHP Gold Blue Open Access POS 2500/0%/3000


POS Gold $3,000 $6,000 $2,500 $5,000 0% $30 $60 $30

1KGK Off BCBSHP Gold Blue Open Access POS 4500/0%/4500


POS Gold $4,500 $9,000 $4,500 $9,000 0% $30 $60 $30

1KGP Off BCBSGA Gold BlueChoice PPO 3500/0%/4250

BlueChoice PPO

PPO Gold $4,250 $8,500 $3,500 $7,000 0% $20 $40 $20



POS Gold $4,250 $8,500 $3,500 $7,000 0% $20 $40 $20

1KGT Off BCBSGA Gold BlueChoice PPO 3000/0%/4000

BlueChoice PPO

PPO Gold $4,000 $8,000 $3,000 $6,000 0% $15 $35 $15

9

Urgent care copay

Urgent care percent


Output percent

Inpatient max days

Inpatient copay

Inpatient percent



N/A 30% $250 30% $250 30% N/A $500 30% $15/$35/$70/30%/$250 Select formulary






$60 N/A $200 N/A $250 N/A 3 $750 N/A $15/$35/$70/25% Select formulary


$40 N/A $150 NA $200 N/A 3 $500 N/A $10/$30/$60/25% Select formulary











10

Contract code


Product name

Network name

Network type



Other coins

PCP Tier 1 SPC

Home health

1KGV Off BCBSHP Gold Blue Open Access POS 3000/0%/4000


POS Gold $4,000 $8,000 $3,000 $6,000 0% $15 $35 $15

1KGZ Off BCBSGA Gold BlueChoice PPO 500/20%/3500

BlueChoice PPO

PPO Gold $3,500 $7,000 $500 $1,500 20% $25 $50 $25



POS Gold $3,500 $7,000 $500 $1,500 20% $25 $50 $25

1KH4 Off BCBSGA Gold BlueChoice PPO 1000/20%/4000

BlueChoice PPO

PPO Gold $4,000 $8,000 $1,000 $3,000 20% $15 $50 $15

1KHT Off BCBSHP Gold Blue Open Access POS 1000/20%/4000


POS Gold $4,000 $8,000 $1,000 $3,000 20% $15 $50 $15

1KHM Off BCBSHP Gold Blue Open Access POS 2500/20%/4250


POS Gold $4,250 $8,500 $2,500 $5,000 20% $20 $40 $20



POS Gold $3,750 $7,500 $1,000 $3,000 20% $30 $60 $30

1KHX Off BCBSHP Gold Blue Open Access POS 2000/20%/4000


POS Gold $4,000 $8,000 $2,000 $4,000 20% $25 $50 $25

1KHD Off BCBSHP Gold Blue Open Access POS 1000/20%/3000


POS Gold $3,000 $6,000 $1,000 $3,000 20% $25 $50 $25

1KHJ Off BCBSHP Silver Blue Open Access POS 1750/40%/6350


POS Silver $6,350 $12,700 $1,750 $3,500 40% $50 $75 $50

1KHZ Off BCBSGA Silver BlueChoice PPO 4000/20%/6350

BlueChoice PPO

PPO Silver $6,350 $12,700 $4,000 $8,000 20% $50 $75 $50

1KJ5 Off BCBSHP Silver Blue Open Access POS 4000/20%/6350


POS Silver $6,350 $12,700 $4,000 $8,000 20% $50 $75 $50

1KEF Off BCBSGA Silver BlueChoice PPO 5000/20%/6350

BlueChoice PPO

PPO Silver $6,350 $12,700 $5,000 $10,000 20% $40 $60 $40

1KDU Off BCBSHP Silver Blue Open Access POS 5000/20%/6350


POS Silver $6,350 $12,700 $5,000 $10,000 20% $40 $60 $40

1KF5 Off BCBSHP Silver Blue Open Access POS 5500/30%/6350


POS Silver $6,350 $12,700 $5,500 $11,000 30% $35 $60 $35

1KFB Off BCBSHP Bronze Blue Open Access POS 3500/30%/6350 w/ HSA


POS Bronze $6,350 $12,700 $3,500 $7,000 30% 30% 30% 30%

1KFF Off BCBSHP Bronze Blue Open Access POS 5500/0%/5500 w/ HSA


POS Bronze $5,500 $11,000 $5,500 $11,000 0% 0% 0% 0%

1KF9 Off BCBSHP Bronze Blue Open Access POS 6300/0%/6300 w/ HSA


POS Bronze $6,300 $12,600 $6,300 $12,600 0% 0% 0% 0%

1KD7 Off BCBSHP Bronze Blue Open Access POS 5000/20%/6350 w/HSA


POS Bronze $6,350 $12,700 $5,000 $10,000 20% $30 $60 20%

1KCV Off BCBSHP Bronze Blue Open Access POS 4500/0%/6350 w/ HSA


POS Bronze $6,350 $12,700 $4,500 $9,000 0% $30 $60 0%

11

Urgent care copay

Urgent care percent


Output percent

Inpatient max days

Inpatient copay

Inpatient percent

















N/A 30% N/A 30% N/A 30% N/A N/A 30% Ded/30% Select formulary



$60 N/A N/A 20% N/A 20% N/A N/A 20% Ded/$15/$35/$70/25% Select formulary


12

Contract code


Product name

Network name

Network type



Other coins

PCP Tier 1 SPC

Home health

1KEN Off BCBSHP Silver Blue Open Access POS 3000/0%/3500 w/ HSA


POS Silver $3,500 $7,000 $3,000 $6,000 0% $20 $40 0%

1KEC Off BCBSHP Silver Blue Open Access POS 2800/20%/3800 w/ HSA


POS Silver $3,800 $7,600 $2,800 $5,600 20% $20 $35 20%

1KEM Off BCBSHP Gold Blue Open Access POS 3500/0%/3500 w/ HSA


POS Gold $3,500 $7,000 $3,500 $7,000 0% 0% 0% 0%

1KFH Off BCBSHP Gold Blue Open Access POS 3500/0%/3500 w/ HRA


POS Gold $3,500 $7,000 $3,500 $7,000 0% 0% 0% 0%

1KFN Off BCBSHP Silver Blue Open Access POS 3000/0%/3000 w/ HSA


POS Silver $3,000 $6,000 $3,000 $6,000 0% 0% 0% 0%

1KFS Off BCBSHP Silver Blue Open Access POS 3500/0%/3500 w/ HSA


POS Silver $3,500 $7,000 $3,500 $7,000 0% 0% 0% 0%

1KE4 Off BCBSHP Silver Blue Open Access POS 6350/0%/6350 w/ HSA


POS Silver $6,350 $12,700 $6,350 $12,700 0% 0% 0% 0%

1KCN Off BCBSHP Silver Blue Open Access POS 6000/0%/6000 w/ HRA


POS Silver $6,000 $12,000 $6,000 $12,000 0% 0% 0% 0%

1KEK Both BCBSHP Gold Pathway X Enhanced POS 500/20%/5000 Plus

Pathway X Enhanced

POS Gold $5,000 $10,000 $500 $1,500 20% $20 $20 20%

1KEJ Both BCBSHP Silver Pathway X Enhanced POS 1500/30%/5500 Plus

Pathway X Enhanced

POS Silver $5,500 $11,000 $1,500 $3,000 30% $35 $35 30%

1KDG Both BCBSHP Bronze Pathway X Enhanced POS 5000/30%/6600 Plus

Pathway X Enhanced

POS Bronze $6,600 $13,200 $5,000 $10,000 30% $30 $30 30%

1KD5 Off BCBSHP Bronze Pathway Enhanced POS 5000/20%/6350 w/ HSA

Pathway Enhanced

POS Bronze $6,350 $12,700 $5,000 $10,000 20% $30 $60 20%

1KEV Off BCBSHP Bronze Pathway Enhanced POS 4500/0%/6350 w/HSA

Pathway Enhanced

POS Bronze $6,350 $12,700 $4,500 $9,000 0% $30 $60 0%

1KEQ Off BCBSHP Silver Pathway Enhanced POS 3000/0%/3500 w/ HSA

Pathway Enhanced

POS Silver $3,500 $7,000 $3,000 $6,000 0% $20 $40 0%

1KEX Off BCBSHP Silver Pathway Enhanced POS 2800/20%/3800 w /HSA

Pathway Enhanced

POS Silver $3,800 $7,600 $2,800 $5,600 20% $20 $35 20%

1KCX Off BCBSHP Bronze Pathway Enhanced POS 5500/0%/5500 w/ HSA

Pathway Enhanced

POS Bronze $5,500 $11,000 $5,500 $11,000 0% 0% 0% 0%

1KCQ Off BCBSHP Bronze Pathway Enhanced POS 6300/0%/6300 w/ HSA

Pathway Enhanced

POS Bronze $6,300 $12,600 $6,300 $12,600 0% 0% 0% 0%

1KFK Off BCBSHP Gold Pathway Enhanced POS 3500/0%/3500 w /HSA

Pathway Enhanced

POS Gold $3,500 $7,000 $3,500 $7,000 0% 0% 0% 0%

1KET Off BCBSHP Gold Pathway Enhanced POS 3500/0%/3500 w/ HRA

Pathway Enhanced

POS Gold $3,500 $7,000 $3,500 $7,000 0% 0% 0% 0%

1KFQ Off BCBSHP Silver Pathway Enhanced POS 3000/0%/3000 w / HSA

Pathway Enhanced

POS Silver $3,000 $6,000 $3,000 $6,000 0% 0% 0% 0%

13

Urgent care copay

Urgent care percent


Output percent

Inpatient max days

Inpatient copay

Inpatient percent






















14

Contract code


Product name

Network name

Network type



Other coins

PCP Tier 1 SPC

Home health

1KEP Off BCBSHP Silver Pathway Enhanced POS 3500/0%/3500 w/ HSA

Pathway Enhanced

POS Silver $3,500 $7,000 $3,500 $7,000 0% 0% 0% 0%

1KEG Off BCBSHP Silver Pathway Enhanced POS 6350/0%/6350 w/ HSA

Pathway Enhanced

POS Silver $6,350 $12,700 $6,350 $12,700 0% 0% 0% 0%

1KDJ Off BCBSHP Silver Pathway Enhanced POS 6000/0%/6000 w/ HRA

Pathway Enhanced

POS Silver $6,000 $12,000 $6,000 $12,000 0% 0% 0% 0%

1KE0 Off BCBSHP Gold Pathway Enhanced POS 2000/0%/4000

Pathway Enhanced

POS Gold $4,000 $8,000 $2,000 $4,000 0% $30 $50 $30

1KDY Off BCBSHP Gold Pathway Enhanced POS 1500/0%/2500

Pathway Enhanced

POS Gold $2,500 $5,000 $1,500 $3,000 0% $30 $60 $30

1KDW Off BCBSHP Gold Pathway Enhanced POS 1000/0%/4500

Pathway Enhanced

POS Gold $4,500 $9,000 $1,000 $3,000 0% $30 $60 $30

1KDC Off BCBSHP Gold Pathway Enhanced POS 1500/15%/4000

Pathway Enhanced

POS Gold $4,000 $8,000 $1,500 $3,000 15% $30 $50 $25

1KCJ Off BCBSHP Gold Pathway Enhanced POS 1000/25%/5000

Pathway Enhanced

POS Gold $5,000 $10,000 $1,000 $3,000 25% $10 $50 $10

1KG2 Off BCBSHP Gold Pathway Enhanced POS 1000/20%/4500

Pathway Enhanced

POS Gold $4,500 $9,000 $1,000 $3,000 20% $15 $35 $15


Pathway Enhanced

POS Gold $6,000 $12,000 $1,500 $3,000 20% $10 $35 $10


Pathway Enhanced

POS Gold $4,500 $9,000 $1,500 $3,000 30% $20 $40 $20

1KGH Off BCBSHP Gold Pathway Enhanced POS 2500/0%/3000

Pathway Enhanced

POS Gold $3,000 $6,000 $2,500 $5,000 0% $30 $60 $30

1KGM Off BCBSHP Gold Pathway Enhanced POS 4500/0%/4500

Pathway Enhanced

POS Gold $4,500 $9,000 $4,500 $9,000 0% $30 $60 $30

1KGR Off BCBSHP Gold Pathway Enhanced POS 3500/0%/4250

Pathway Enhanced

POS Gold $4,250 $8,500 $3,500 $7,000 0% $20 $40 $20

1KGX Off BCBSHP Gold Pathway Enhanced POS 3000/0%/4000

Pathway Enhanced

POS Gold $4,000 $8,000 $3,000 $6,000 0% $15 $35 $15

1KH3 Off BCBSHP Gold Pathway Enhanced POS 500/20%/3500

Pathway Enhanced

POS Gold $3,500 $7,000 $500 $1,500 20% $25 $50 $25

1KHF Off BCBSHP Gold Pathway Enhanced POS 1000/20%/4000

Pathway Enhanced

POS Gold $4,000 $8,000 $1,000 $3,000 20% $15 $50 $15

1KHY Off BCBSHP Gold Pathway Enhanced POS 2500/20%/4250

Pathway Enhanced

POS Gold $4,250 $8,500 $2,500 $5,000 20% $20 $40 $20

1KHP Off BCBSHP Gold Pathway Enhanced POS 1000/20%/3750

Pathway Enhanced

POS Gold $3,750 $7,500 $1,000 $3,000 20% $30 $60 $30

1KHR Off BCBSHP Gold Pathway Enhanced POS 2000/20%/4000

Pathway Enhanced

POS Gold $4,000 $8,000 $2,000 $4,000 20% $25 $50 $25

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Urgent care copay

Urgent care percent


Output percent

Inpatient max days

Inpatient copay

Inpatient percent






















16

Contract code


Product name

Network name

Network type



Other coins

PCP Tier 1 SPC

Home health

1KHV Off BCBSHP Gold Pathway Enhanced POS 1000/20%/3000

Pathway Enhanced

POS Gold $3,000 $6,000 $1,000 $3,000 20% $25 $50 $25

1KGB Off BCBSHP Silver Pathway Enhanced POS 3000/20%/6600

Pathway Enhanced

POS Silver $6,600 $13,200 $3,000 $6,000 20% $35 $60 $35

1KJ1 Off BCBSHP Silver Pathway Enhanced POS 1750/40%/6350

Pathway Enhanced

POS Silver $6,350 $12,700 $1,750 $3,500 40% $50 $75 $50

1KJ7 Off BCBSHP Silver Pathway Enhanced POS 4000/20%/6350

Pathway Enhanced

POS Silver $6,350 $12,700 $4,000 $8,000 20% $50 $75 $50

1KHB Off BCBSHP Silver Pathway Enhanced 4000/30%/6350

Pathway Enhanced

POS Silver $6,350 $12,700 $4,000 $8,000 30% $35 $50 $35

1KF3 Off BCBSHP Silver Pathway Enhanced POS 5000/20%/6350

Pathway Enhanced

POS Silver $6,350 $12,700 $5,000 $10,000 20% $40 $60 $40

1KF7 Off BCBSHP Silver Pathway Enhanced POS 5500/30%/6350

Pathway Enhanced

POS Silver $6,350 $12,700 $5,500 $11,000 30% $35 $60 $35

1KFD Off BCBSHP Bronze Pathway Enhanced POS 3500/30%/6350 w/ HSA

Pathway Enhanced

POS Bronze $6,350 $12,700 $3,500 $7,000 30% 30% 30% 30%

1717

Urgent care copay

Urgent care percent


Output percent

Inpatient max days

Inpatient copay

Inpatient percent










Participation requirements

The standard group participation requirement for a Blue Cross and Blue Shield of Georgia Small Group health plan is a minimum of 75% of the eligible employees.

Participation requirements are waived beginning November 15 through December 15 of each year. BCBSGa may conduct periodic audits to confirm participation levels.

Small businesses considerations

Rating rule change}} Rates will adjust for age at contract renewal

}} New Hires will be rated based on the age that they were at the inception of the contract

}} Rates will include premiums for all dependents 21 to 26 years of age

}} Rates will be capped at three dependents under the age of 21

How will waiting periods be impacted for small business

}} BCBSGa will offer the following waiting period options:

— Date of hire.

— First of the month following date of hire.

— One month.

— First of the month following one month.

— Two months.

— First of the month following two months.

— Ninety (90) days.

}} Existing small groups with waiting periods in excess of 90 days will be mapped to a waiting period that conforms to the new regulation.

How rates are calculated

Pre-ACA rate structure

Based on the family tier

Pre-ACA rates

Employee (Single) $563

Employee/Spouse (Couple) $1,170

Employee/Child(ren) (Parent/Child(ren))

$928

Employee/Spouse/Child(ren) (Family) $1,495 ACA-Compliant Rate Structure

Based on each family member age

Illustrative ACA-compliant rates

Age Rate Age Rate

0-20 $196 43 $418

21 $308 44 $430

22 $308 45 $445

23 $308 46 $462

24 $308 47 $481

25 $309 48 $503

26 $315 49 $525

27 $323 50 $550

28 $335 51 $574

29 $345 52 $601

30 $350 53 $628

31 $357 54 $657

32 $364 55 $687

33 $369 56 $718

34 $374 57 $750

35 $376 58 $785

36 $379 59 $802

37 $381 60 $836

38 $384 61 $865

39 $389 62 $885

40 $394 63 $909

41 $401 64+ $924

42 $408

18

19

Example 1 of ACA Rating Method

ACA-compliant member rates

Age Rate Age Rate Age Rate

0-20 $196 35 $376 50 $550

21 $308 36 $379 51 $574

22 $308 37 $381 52 $601

23 $308 38 $384 53 $628

24 $308 39 $389 54 $657

25 $309 40 $394 55 $687

26 $315 41 $401 56 $718

27 $323 42 $408 57 $750

28 $335 43 $418 58 $785

29 $345 44 $430 59 $802

30 $350 45 $445 60 $836

31 $357 46 $462 61 $865

32 $364 47 $481 62 $885

33 $369 48 $503 63 $909

34 $374 49 $525 64+ $924

Example 2 of ACA-Compliant Composite Premium Rate Structure

ACA-compliant member rates

Employee (Single) $525

Employee/Spouse (Couple) $1,050

Employee/Child(ren) (Parent/Child(ren)) $919

Employee/Spouse/Child(ren) (Family) $1,627

Member Level Rating Family Premium:

Age Rate

Joe 53 $628

Spouse 48 $503

Child 18 $196

Child 16 $196

Child 14 $196

Child 12 $0} $1,719

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A full medical wellness offering to help keep members healthierBCBSGa offers one of the most comprehensive suites of wellness and clinical care in the industry, because we believe healthy members are happier, more productive and more successful. So we offer a range of options that balance attractiveness and cost, letting employers choose the most appropriate and affordable solutions for their needs.

}} 24/7 NurseLine — Members can call anytime to speak to a registered nurse trained to answer general health questions, help them understand symptoms, help them determine the right care at the right time.

}} Utilization Management — Includes precertification of medical procedures, imaging services and hospitalization to authorize care and align medical services with the member’s benefits.

}} Imaging Cost and Quality — A member outreach program designed to lower the costs of expensive imaging procedures. If the member qualifies they are contacted about equal-quality, lower cost imaging alternatives in their area. The program is voluntary and available in larger metropolitan markets.

}} Case Management — Offers telephonic and video chat nursing support following a major hospitalization or procedure due to illness or injury. Cancer, NICU and transplant services included. Case Management helps members maximize medical benefits, arrange post-discharge care, and community health services.

}} ComplexCare — The ComplexCare program is for members with multiple health care issues or those who may require more frequent medical care. Working with a personal nurse coach, members receive individualized care and are able to create a personalized care plan for greater well-being and self-management of their condition.

}} Quick Care Options — An initiative to educate members about non-emergency/avoidable ER visits and steer them to lower-cost settings with shorter wait times, including urgent care centers, walk-in doctors’ offices and retail health clinics. The Quick Care Options program includes resources to help members make better decisions and targeted education opportunities after members have an avoidable ER visit.

}} LiveHealth Online — the quick and easy way to see a doctor anywhere you have an Internet connection. LiveHealth Online is a new communications tool that lets members talk to doctors through their mobile device or online by two-way video on a computer. Doctors can answer questions, make a diagnosis and may prescribe basic medications.

}} ConditionCare — For members with chronic conditions like asthma, diabetes or heart disease, the ConditionCare disease management program provides targeted information, guidance and support. With 24/7 access to health professionals, members are equipped to better understand and manage their condition, and make healthier choices for optimal wellness.

}} Future Moms — The Future Moms program provides mothers-to-be with personalized support and guidance, helping them achieve healthier pregnancies and deliveries. With their own team of obstetric specialists, expectant members get access to expert information and direction throughout their pregnancy and postpartum period.

}} MyHealth Advantage — Communicates gaps in care and health savings opportunities to targeted members (via mailed MyHealth Notes) and gaps in care to their treating providers (via mailed notices). MyHealth Advantage analyzes comprehensive health information and suggests ways members can be healthier and reduce out-of-pocket expenses. The program aims to reduce health care costs by increasing member compliance with medical best practices and improving health care quality.

}} Behavioral Health UM/CM/DM — Offers immediate and longer-term mental health management and information to eligible members.

}} Employee Assistance Programs — Provides employees and household members with up to three counseling sessions with a licensed social worker, counselor or psychologist to help with issues ranging from stress management to family and work related concerns. Other services that are also available include limited financial and legal consultations at no cost. Employees also get full access to a specialized website with personal assistance resources such as an online child care/elder care locator.

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1 Customer service results: 2012 year-to-date results through September 24, 2012.

2 The International Emergency Dental Program is managed by DeCare Dental. DeCare Dental is an independent company offering dental management services to BCBSGa plans.

3 The national Dental GRID is managed by the GRID Dental Corporation (GDC), a separate company that provides access to dental networks and services on behalf of BCBSGa Life and Health Insurance Company.

Offer a well-rounded benefits package from BCBSGa

Dental plan choices to fit your unique needs

With BCBSGa Dental, you have options from essential health benefit plans to flexible plans with additional options to build more robust benefits. Employers can also choose from employer paid and voluntary choices with BCBSGa Dental. We’ll help you find the right mix of benefits that can have the best impact on your employees’ health. And no matter which dental plans you choose, you can count on:

}} Solid coverage at a good price.

}} Benefits that make sense for dental health — and total health.

}} Lots of participating providers to choose from.

BCBSGa Dental offers a variety of dental plan options that include or are available with optional pediatric dental essential health benefits (EHBs).

}} We offer a choice of several plan types and networks to fit your needs and budget.

}} Dental Pediatric EHB Plans. Our medical plans include the pediatric EHB benefit. We also offer a stand-alone pediatric EHB plan.

With all BCBSGa Dental plans, you and your employees will enjoy these standard services:

}} Easy-to-access information. Your employees can go online any time to get their claims and dental plan details. Plus, they’ll find helpful materials that promote dental health.

}} Expert customer service. We’re committed to giving our members the best service. Calls are answered quickly (typically within 30 seconds)1 by reps with dental expertise.

}} Swift claims payments and data-based benefits. On average, we pay claims in three days or less. We also track data from the millions of claims we process each year. And, we’ve got financial accuracy rates of more than 99%.1 So you can be sure payments are prompt and correct.

}} International Emergency Dental Program.2 Members who travel outside of the U.S. have access to emergency dental services. With one call, we’ll help them find a credentialed, English-speaking dentist for urgent dental care. We can even help them with translation services when they call the dentist’s office. Services members receive through this program don’t count toward their annual maximum, if their plan has one.

Dental Prime and Dental Complete

Plans with more coverage choices

When we created the new Dental Prime and Dental Complete plans, we made sure they could be custom fit. That means lots of choices in coverage, including options for:

}} Choice of deductibles, annual maximums, and provider programs.

}} Orthodontic benefits for kids and adults, or kids only.

}} Annual maximum carryover, which lets members carry over some unused benefits to the next year.

Lots of participating dentists to choose from

Dental Prime and Dental Complete members have access to many participating dentists through the national Dental GRID.3 The national Dental GRID links dental programs, including the dental programs of many of the nation’s Blue plans, and includes dentists in all 50 states — so your employees can find a participating dentist wherever they live or visit:

}} Dental Prime members have access to more than 75,000 unique providers (more than 189,000 access points) nationwide.

}} Dental Complete members have access to more than 97,000 unique providers (more than 235,000 access points) nationwide.

Preventive dental services

Preventive dental services are used more than any other dental services. They can help find dental and other health problems early on. That’s why most of our Dental Prime and Dental Complete plans cover routine cleanings, exams and X-rays 100% at participating dentists. Other preventive services include:

}} Brush biopsy benefits.* A brush biopsy may help diagnose oral cancer when combined with a lab analysis and a surgical biopsy with lab analysis.

}} Extra services for members who are pregnant or living with diabetes. We offer an extra cleaning or periodontal maintenance procedure each year for members who are pregnant or living with diabetes.

* Brush biopsy benefits paid at the Basic Services level.

23

Plan Name

Annual benefit

maximum

Deductible (per

person/ per family) waived for diagnostic

and preventive

Diagnostic/ preventive

services (cleanings,

X-rays, exams)

Basic services (filings)

Endodontic, periodontic and

oral surgery services (root canal, tooth

extraction, etc.)

Major services (crowns, bridges,

dentures, etc.)

Orthodontic coverage(lifetime

maximum to matchannual

maximum)

Annual maximum carryover

Dental implants Network

Out-of- network

reimbursementIn Out In Out In Out In Out

Value Complete GA-1A

$1,000 $50/ $150 100% 100% 80% 80% 80% 80% Not Covered Not covered Not included Not included Dental Complete

90th percentile Fair Health

Classic Complete GA-2E

$1,000 $50/ $150 100% 100% 80% 80% 50% 50% 50% 50% Not covered Not included Included Dental Complete


Classic Complete GA-2F



Classic Complete GA-2G

$1,000 $50/ $150 100% 100% 80% 80% 80% 80% 50% 50% Not covered Included Included Dental Complete


Classic Complete GA-2H



Classic Complete GA-2J

$1,000 $50/ $150 100% 100% 80% 80% 80% 80% 50% 50% 50% children only Not included Included Dental Complete


Classic Complete GA-2K


Maximum allowable charge (MAC)

Classic Complete GA-2L



Classic Complete GA-2M



Classic Complete GA-2N



Classic Complete GA-2P


90th percentile Fair Healthh

Classic Complete GA-2Q



Classic Complete GA-2R



Classic Complete GA-2S



Classic Prime GA-2A

$1,000 $50/ $150 100% 100% 80% 80% 50% 50% 50% 50% Not covered Not included Included Dental Prime


Classic Prime GA-2B


Maximum allowable charge (MAC)

Classic Prime GA-2C



Classic Prime GA-2D



Enhanced Prime GA-3A



Enhanced Complete GA-3B



Enhanced Complete GA-3C



Enhanced Complete GA-3D



Enhanced Complete GA-3E

$2,000 $50/ $150 100% 100% 90% 90% 90% 90% 60% 60%50% adults and children

Not included Included Dental Complete


Enhanced Complete GA-3F



Dental Prime and Dental Complete plans

24

The above is a summary. See the Certificate of Coverage with the Schedule of Benefits and any riders associated with the plan for complete coverage details and related terms and conditions.

25

Stand-alone Dental Pediatric and Family EHB plansA stand-alone pediatric dental plan may be added to your dental or medical plan if it does not currently include pediatric EHB. This will allow you to be in compliance with the ACA, and will provide your employee’s children with valuable dental benefits they need to stay healthy. We also offer adult plans that have annual maximums of $750 or $1,000. These plans can be combined with our pediatric EHB plans to create a family plan. Family plans offer several advantages:

}} We will not charge for more than three children.

}} Families will not be charged more than two times the out-of-pocket maximum, regardless of how many children they have.

}} When you purchase BCBSGa Dental Family Enhanced coverage, it comes with a cosmetic orthodontia benefit. The lifetime maximum for this benefit is $1,000.

When members see providers who participate in Dental Prime, there are no annual maximums. And out-of-pocket costs are limited to $700 a year.

Family and Family Enhanced plans include the dental pediatric EHB benefits.

Plan nameBenefit age

range DeductibleAnnual

maximum

Annual out-of-pocket maximum*

Diagnostic and preventive

services (cleanings, exams and

X-rays)

Basic services (fillings)

Endodontic/ periodontal/oral surgery

Major services (crowns)

Medically necessary

orthodontia

Medically necessary

orthodontia lifetime

maximum

combined In Out In Out In Out In Out In Out In Out In Out In Out

Dental pediatricPediatric benefits

through age 18$50 (applies

to all)None None $350* None 100% 70% 60% 50% 50% 50% 50% 50% 50% 50% None None

Dental family

Pediatric benefits through age 18

$50 (applies to all)

None None $350* None 100% 70% 60% 50% 50% 50% 50% 50% 50% 50% None None

Adult benefits 19+


$750 None None 100% 50% 50% 25% 30% 15% 30% 15% Not covered n/a

Dental family enhanced

Pediatric benefits through age 18


None None $350* None 100% 80% 80% 60% 80% 50% 50% 50% 50% 50% None None

Adult benefits 19+


$1,000 None None 100% 50% 80% 40% 50% 25% 50% 25% Not covered n/a

* Per child, up to two children per family. FFM States no longer allowing Stand-Alone Pediatric Only on the SHOP exchange.

Plan Name

Annual benefit

maximum

Deductible (per

person/ per family) waived for diagnostic

and preventive

Diagnostic/ preventive

services (cleanings,

X-rays, exams)

Basic services (filings)

Endodontic, periodontic and

oral surgery services (root canal, tooth

extraction, etc.)

Major services (crowns, bridges,

dentures, etc.)

Orthodontic coverage(lifetime

maximum to matchannual

maximum)

Annual maximum carryover

Dental implants Network

Out-of- network

reimbursementIn Out In Out In Out In Out

Voluntary Complete GA-4A



Voluntary Complete GA-4B

$1,000 $50/ $150 100% 80% 80% 80% 50% 50% 50% 50% Not covered Not included Included Dental

Complete Maximum allowable

charge (MAC)

Voluntary Complete GA-4C



Dental Prime and Dental Complete plans (con’t)

The above is a summary. See the Certificate of Coverage with the Schedule of Benefits and any riders associated with the plan for complete coverage details and related terms and conditions.

Get vision coverage and see increased productivity

Vision plans can play a role in managing the overall health and well-being of your employees. It’s been shown that regular eye exams and wearing corrective eyewear when needed can greatly decrease the risk of more serious, long-term eye diseases and can even result in early detection of other health conditions1 — increasing your employees’ productivity and performance. You get the picture, and so do we. That’s why we’ve created our Blue View VisionSM plans with multiple options to best suit your employees’ needs.

Blue View VisionSM features:

}} A broad, convenient, national network — The Blue View Vision network has over 30,000 private practice doctors and more than 25,000 locations, including the nation’s leading retail stores like LensCrafters®, Pearle Vision®, Sears OpticalSM, Target Optical® and JCPenney® Optical. These retail locations offer convenient evening and weekend hours, allowing your employees to schedule appointments outside their normal work day. Members can also use their in-network benefits at 1-800 CONTACTS.

}} Powerful, two-way communication between eye care and health care providers — With Blue View Vision, network eye care providers can now see data relevant to their patient’s eye health -- including patient summaries, diagnoses, lab results, prescriptions and care alerts. And they, in turn, can share member eye health information with other network providers. So when any network doctor, eye doctor or nurse care manager pulls up the health history, each one understands the member’s whole health better. So they can give better, more holistic care. In fact, in a recent survey of vision providers, nearly 100% responded that clinical coordination of vision and medical will lead to improved employee health.2

26

Blue View Vision Plans

Option Copay Exam/Lenses

Frame/Contact

Allowance

Frequency

Routine Eye Exam Eyeglass Frames Eyeglass Lenses Contacts*

A1 $10/$0 $130/$130 Once per calendar year Once per calendar year Once per calendar year Once per calendar year





B1 $10/$0 $130/$130 Once per calendar year Once every other calendar year Once per calendar year Once per calendar year




C1 $10/$0 $130/$130 Once per calendar year Once every other calendar year Once every other calendar year Once every other calendar year




MO1 Not covered/$10 $130/$130 Not covered Once per calendar year Once per calendar year Once per calendar year

MO2 Not covered/$10 $130/$130 Not covered Once every other calendar year Once per calendar year Once per calendar year

*Non-elective contacts covered in full.

All product offerings are subject to regulatory review and approval.

1 American Optometric Association, aoanet.org.

2 Blue Cross and Blue Shield of Georgia Provider Survey 2012.

3 Discounts (lowered costs) do not apply on frames for which a manufacturer has imposed a no-discount policy.

}} “Add ons” at no additional charge — Factory scratch coating on eyeglass lenses included at no additional cost, and Transitions® and polycarbonate lenses for kids under 19 years old can be added at no additional cost.

}} Negotiated rates for other “add ons” — Includes Transitions lenses for adults at a fixed price of $75, as well as tiered pricing for premium progressive lenses and premium anti-reflective coatings, which limits members’ out-of-pocket costs.

}} Value-added savings:

— 40% off additional pairs of glasses.

— 20% off any balance over the frame allowance.3

— 15% off additional conventional contact lenses.

— 20% off other upgrades and eyewear accessories to help keep more money in our members pockets.

And members can get a lowered cost on LASIK laser vision corrective surgery through our SpecialOffersSM program.

}} Customer care — Our award-winning Customer Care center has live representatives available seven days a week. We offer longer evening hours and an afterhours IVR system so members can reach us at any time with their questions.

}} Connecting the dots — Only BCBSGa leads the way in helping eye doctors and primary care doctors work together so they can share information — all through one company. This approach makes the eye exam far less routine. If an eye doctor finds a high-risk health problem such as diabetes or high blood pressure during a routine eye exam, they can share that information with the member’s primary care doctor. The information is tracked in a digital health record so our members can get the follow-up care and support they need.

27

Why Life Insurance from Greater Georgia Life Insurance Company?}} Rated “A (Excellent)” for financial strength by A.M. Best Company.

}} Life claim turnaround time is among the fastest in the industry — usually within two days.7

Get life and disability insurance from Greater Georgia Life Insurance Company … and share the benefits of your employees’ security

Life insurance is an easy, inexpensive way to help your employees improve their families’ financial security.

Our insurance products include:

}} Basic term life

}} Dependent life

}} Optional life

}} Voluntary life

}} Short-term disability

}} Voluntary short-term disability

}} Long-term disability

}} Voluntary long-term disability

Greater Georgia Life Insurance Company offers:

}} Integration — Short-term disability coverage integrates with our ConditionCare and/or Future Moms programs — providing additional guidance, resources and health management for employees who are pregnant or have chronic health conditions.

}} Strength — We have over 50 years of skill and know-how in the industry, and an A.M. Best financial rating of “A (Excellent).”

28

6 Members who have an BCBSGa health plan and with a diagnosis of asthma, coronary obstructive pulmonary disease, coronary artery disease, congestive heart failure and diabetes.

7 Claims handled in an average of 6.9 business days from claim receipt in 2012.

28

}} Extra Features — Our plans offer more than just a benefit check — we include support services to help employees get back to their normal life.

— Resource Advisor gives employees counseling and consultations regarding emotional, financial and legal concerns, as well as identity theft prevention and recovery services.

— Employees and family members traveling 100 or more miles from home have access to travel assistance services. This program includes emergency medical assistance and transportation (up to $1M), travel services and pre-departure information for business or personal travel.

— New mothers with approved short-term disability claims can get eight weeks of personalized parent coaching and support through Newborn and Parenting Resources to help them transition back to work while balancing motherhood, family duties and work life.

29

30

Exclusions and limitations Request a copy of the Combined Evidence of Coverage/Certificate for comprehensive details on covered services, limitations and exclusions.

All Exclusions and Limitations are subject to regulatory review and approval.

1. Acts of War, Disasters, or Nuclear Accidents. In the event of a major disaster, epidemic, war, or other event beyond BCBSGa’s control, BCBSGa will make a good faith effort to give you Covered Services. BCBSGa will not be responsible for any delay or failure to give services due to lack of available facilities or staff. Benefits will not be given for any illness or injury that is a result of war, service in the armed forces, a nuclear explosion, nuclear accident, release of nuclear energy, a riot, or civil disobedience.

2. Administrative Charges.

a. Charges to complete claim forms.

b. Charges to get medical records or reports.

c. Membership, administrative, or access fees charged by Doctors or other Providers. Examples include, but are not limited to, fees for educational brochures or calling you to give you test results.

3. Alternative/Complementary Medicine. Services or supplies for alternative or complementary medicine. This includes, but is not limited to:

a. Acupuncture.

b. Holistic medicine.

c. Homeopathic medicine.

d. Hypnosis.

e. Aroma therapy.

f. Massage and massage therapy.

g. Reiki therapy.

h. Herbal, vitamin or dietary products or therapies.

i. Naturopathy.

j. Thermography.

k. Orthomolecular therapy.

l. Contact reflex analysis.

m. Bioenergial synchronization technique (BEST).

n. Iridology-study of the iris.

o. Auditory integration therapy (AIT).

p. Colonic irrigation.

q. Magnetic innervation therapy.

r. Electromagnetic therapy.

s. Neurofeedback/Biofeedback.

4. Before Effective Date or After Termination Date. Charges for care you get before your Effective Date or after your coverage ends, except as written in this Plan.

5. Charges Over the Maximum Allowed Amount. Charges over the Maximum Allowed Amount for Covered Services.

6. Charges Not Supported by Medical Records. Charges for services not described in your medical records.

7. Complications of Non-Covered Services. Care for problems directly related to a service that is not covered by this Plan. Directly related means that the care took place as a direct result of the non-Covered Service and would not have taken place without the non-Covered Service.

8. Cosmetic Services. Treatments, services, Prescription drugs, equipment, or supplies given for cosmetic services. Cosmetic services are meant to preserve, change, or improve how you look or are given for psychiatric, psychological, or social reasons. No benefits are available for surgery or treatments to change the texture or look of your skin or to change the size, shape or look of facial or body features (such as your nose, eyes, ears, cheeks, chin, chest or breasts).

This Exclusion does not apply to “Reconstructive Surgery” as stated under “Surgery” in the “What’s Covered” section.

9. Crime. Treatment of an injury or illness that results from a crime you committed, or tried to commit. This Exclusion does not apply if you were the victim of a crime, including domestic violence.

10. Custodial Care. Custodial Care, convalescent care or rest cures. This Exclusion does not apply to Hospice services.

11. Dental. Treatment Dental treatment, except as listed below.

Excluded treatment includes but is not limited to preventive care and fluoride treatments; dental X-rays, supplies, appliances and all associated costs; and diagnosis and treatment for the teeth, jaw or gums such as:

}} Removing, restoring, or replacing teeth.

}} Medical care or surgery for dental problems (unless listed as a Covered Service in this Booklet).

}} Services to help dental clinical outcomes.

Dental treatment for injuries that are a result of biting or chewing is also excluded.

This Exclusion does not apply to services that we must cover by law or to the “Dental Services” described in the “What’s Covered” section of this Booklet.

12. Educational Services. Services or supplies for teaching, vocational, or self-training purposes, except as listed in this Booklet.

13. Experimental or Investigational Services. Services or supplies that are Experimental/Investigational as defined in the “Definitions” section of this Booklet. Except as stated under “Clinical Trials” in the “What’s Covered” section, this exclusion also applies to services related to Experimental/Investigational services, whether you get them before, during, or after you get the Experimental/Investigational service or supply.

The fact that a service or supply is the only available treatment will not make it Covered Service if it is Experimental/Investigational.

14. Eyeglasses and Contact Lenses. Eyeglasses and contact lenses to correct your eyesight unless listed as covered in this Booklet. This Exclusion does not apply to lenses needed after a covered eye surgery.

15. Eye Exercises. Orthoptics and vision therapy.

16. Eye Surgery. Eye surgery to fix errors of refraction, such as near sightedness. This includes, but is not limited to, LASIK, radial keratotomy or keratomileusis, and excimer laser refractive keratectomy.

17. Family Members. Services prescribed, ordered, referred by or given by a member of your immediate family, including your spouse, child, brother, sister, parent, in-law, or self.

18. Foot Care. Routine foot care unless Medically Necessary. This Exclusion applies to cutting or removing corns and calluses; trimming nails; cleaning and preventive foot care, including but not limited to:

a. Cleaning and soaking the feet.

b. Applying skin creams to care for skin tone.

c. Other services that are given when there is not an illness, injury or symptom involving the foot.

19. Foot Orthotics. Foot orthotics, orthopedic shoes or footwear or support items unless used for an illness affecting the lower limbs, such as severe diabetes.

20. Foot Surgery. Surgical treatment of flat feet; subluxation of the foot; weak, strained, unstable feet; tarsalgia; metatarsalgia; hyperkeratoses.

21. Free Care. Services you would not have to pay for if you didn’t have this Plan. This includes, but is not limited to government programs, services during a jail or prison sentence, services you get from Workers’ Compensation, and services from free clinics.

If Workers’ Compensation benefits are not available to you, this Exclusion does not apply. This Exclusion will apply if you get the benefits in whole or in part. This Exclusion also applies whether or not you claim the benefits or compensation, and whether or not you get payments from any third party.

22. Health Club Memberships and Fitness Services. Health club memberships, workout equipment, charges from a physical fitness or personal trainer, or any other charges for activities, equipment, or facilities used for physical fitness, even if ordered by a Doctor. This Exclusion also applies to health spas.

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23. Home Care.

a. Services given by registered nurses and other health workers who are not employees of or working under an approved arrangement with a Home Health Care Provider.

b. Private duty nursing.

c. Food, housing, and home delivered meals.

d. Homemaker services, except for the homemaker visits described in the “What’s Covered” section under “Home Care” (prenatal and post partum visits) and under “Hospice.”

24. Infertility Treatment. Infertility testing, treatment or procedures not specified in this Booklet.

25. Maintenance Therapy. Treatment given when no further gains are clear or likely to occur. Maintenance therapy includes care that helps you keep your current level of function and prevents loss of that function, but does not result in any change for the better.

26. Medical Equipment and Supplies.

a. Replacement or repair of purchased or rental equipment because of misuse, abuse, or loss/theft.

b. Surgical supports, corsets, or articles of clothing unless needed to recover from surgery or injury.

c. Non-Medically Necessary enhancements to standard equipment and devices.

27. Medicare. Services for which benefits are payable under Medicare Parts A, B, and/or D, or would have been payable if you had applied for Parts A and/or B and/or D, except as listed in this Booklet or as required by the federal law described under “Medicare” in the “General Provision” section. If you do not enroll in Medicare Part B, BCBSGa will calculate benefits as if you had enrolled. You should sign up for Medicare Part B as soon as possible to avoid large out-of-pocket costs.

28. Missed or Canceled Appointments. Charges for missed or canceled appointments.

29. Non-Medically Necessary Services. Services that are not Medically Necessary as defined in the “Definitions” section of this Booklet.

30. Nutritional or Dietary Supplements. Nutritional and/or dietary supplements, except as described in this Booklet or that we must cover by law. This Exclusion includes, but is not limited to, nutritional formulas and dietary supplements that you can buy over the counter and those you can get without a written Prescription or from a licensed pharmacist.

31. Out-of-Network Care. Services from a Provider that is not in BCBSGa’s network. This does not apply to Emergency Care, Urgent Care, or Authorized Services.

32. Oral Surgery. Extraction of teeth, surgery for impacted teeth and other oral surgeries to treat the teeth or bones and gums directly supporting the teeth, except as listed in this Booklet.

33. Personal Care and Convenience.

a. Items for personal comfort, convenience, protection, cleanliness such as air conditioners, humidifiers, water purifiers, sports helmets, raised toilet seats, and shower chairs.

b. First aid supplies and other items kept in the home for general use (bandages, cotton-tipped applicators, thermometers, petroleum jelly, tape, non-sterile gloves, heating pads).

c. Home work out or therapy equipment, including treadmills and home gyms.

d. Pools, whirlpools, spas, or hydrotherapy equipment.

e. Hypoallergenic pillows, mattresses, or waterbeds.

f. Residential, auto, or place of business structural changes (ramps, lifts, elevator chairs, escalators, elevators, stair glides, emergency alert equipment, handrails).

34. Private Duty Nursing. Private Duty Nursing Services.

35. Prosthetics. Prosthetics for sports or cosmetic purposes.

36. Providers. Services you get from a non-covered Provider, as defined in this Booklet. Examples of non-covered Providers include, but are not limited to, masseurs or masseuses (massage therapists), physical therapist technicians, and athletic trainers.

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37. Sex Change. Services and supplies for a sex change and/or the reversal of a sex change.

38. Sexual Dysfunction. Services or supplies for male or female sexual problems.

39. Smoking Cessation. Programs to help you stop smoking.

40. Stand-By. Charges Stand-by charges of a Doctor or other Provider.

41. Reversal of Elective Sterilization.

42. Surrogate Mother Services. Services or supplies for a person not covered under this Plan for a surrogate pregnancy (including, but not limited to, the bearing of a child by another woman for an infertile couple).

43. Travel Costs. Mileage, lodging, meals, and other Member-related travel costs except as described under “Ambulance Services” in the “What’s Covered” section of this Booklet.

44. Vein Treatment. Treatment of varicose veins or telangiectatic dermal veins (spider veins) by any method (including sclerotherapy or other surgeries) for cosmetic purposes.

45. Vision Services.

a. Vision services for Members age 19 or older, unless listed as covered in this Booklet.

b. Eyeglass lenses, frames, or contact lenses for Members age 19 and older, unless listed as covered in this Booklet.

c. Safety glasses and accompanying frames.

d. For two pairs of glasses in lieu of bifocals.

e. Plano lenses (lenses that have no refractive power)

f. Lost or broken lenses or frames if the Member has already received benefits during a Benefit Period.

g. Vision services not listed as covered in this Booklet.

h. Cosmetic lenses or options.

i. Blended lenses.

j. Oversize lenses.

k. Sunglasses and accompanying frames.

l. For services or supplies combined with any other offer, coupon or in-store advertisement.

m. For Members through age 18, no benefits are available for frames not on the BCBSGa formulary.

n. Certain frames in which the manufacturer imposes a no discount policy.

46. Weight Loss Programs. Programs, whether or not under medical supervision, unless listed as covered in this Booklet.

This Exclusion includes, but is not limited to, commercial weight loss programs (Weight Watchers, Jenny Craig, LA Weight Loss) and fasting programs.

This Exclusion does not apply to the “Diabetes Management” or “Preventive Care” benefits or to “Surgery for conditions caused by obesity” under “Surgery” in the “What’s Covered” section.

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Life and Disability products are underwritten by Greater Georgia Life Insurance Company (GGL) using the trade name Anthem Life. Blue Cross and Blue Shield of Georgia, Inc., Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. and GGL are independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered trademarks of the Blue Cross and Blue Shield Association.

Make the Affordable Care Act work better for you.Contact your broker or your BCBSGa representative for more information about our plans.

for groups with 2-50 employees - summary of benefits...

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