[Mailing Month] [Year]

<<Member First Last>><<Member Address Line 1>><<Member City, State, Zip>>

Renewal Date: <<Month Day>>

Dear Blue Cross of Idaho Member,

Thank you for choosing a Blue Cross of Idaho health insurance plan. This packet includes importantinformation about your insurance renewal.

Under the Affordable Care Act, catastrophic plans—like the one you have—are only available to peopleyounger than 30 or those who qualify for a hardship exemption. Our records show that someone on yourplan will be 30 years old before January 2015.

This means you can no longer keep your <<Choice>><<Connect>> plan unless you qualify for a hardshipexemption. The enclosed notice has information about hardship exemptions. If you qualify for one, youwill need to reapply for your Blue Cross of Idaho catastrophic plan through Your Health Idaho beforeDecember 15, 2014.

If we do not hear from you by December 15, 2014, we will enroll you in one of our<<Choice>><<Connect>> plans, which is similar to the qualified health plan you now have.

In this packet, you’ll find important documents to review at your convenience, including:

A required healthcare reform notice listing the 2015 monthly premium for your new plan A brochure that shows the differences between your current <<Choice>><<Connect>> plan and

the <<Choice>><<Connect>> plan we will move you to. Please read this information carefully. A copy of the Women’s Health and Cancer Rights Act of 1998 notice

We will mail you a new medical contract (also called a policy), an ID card and an updated copy of ourmember handbook in January.

We understand that health insurance can be confusing. We are here to help when you need us.If you have questions regarding your existing policy, please call Blue Cross of Idaho customer service at855-230-6862. If you need help figuring out other plan options for 2015 coverage, contact your insuranceagent or give us a call at 800-365-2345.

Enclosures(1-15) Jan QHP Ind Catastrophic Over Age 30

<<Broker Name>><<Broker Address>><<Broker City, State, Zip>><<Broker Phone Number>>

Notice for Catastrophic Plan Age 30 or Older

— Rate Information Below; Please Read Carefully —

Important: You May Need to Enroll in a New Health Plan for Next Year

Dear Member:

In 2014, you and/or your family enrolled in a catastrophic health insurance plan through

Your Health Idaho. To stay in this plan in 2015, you and any enrolled family members

must be under 30 years of age as of January 1, 2015, or must be unable to afford a

non-catastrophic health plan in 2015 due to a financial hardship.

If you and/or your family members will be 30 years old or older as of January 1,

and you wish to remain in your current health plan in 2015, you must apply for a

2015 hardship exemption with Your Health Idaho. If you do not apply for this

exemption, and you do not select another health plan by December 15, 2014, you and

any enrolled family members will be automatically enrolled into a new, non-catastrophic

plan.

We have selected a new Blue Cross of Idaho non-catastrophic plan that’s similar to your

current plan. You will be automatically enrolled in this plan unless you select

another option and notify us of that by December 15, 2014.

Your new plan will take effect January 1, 2015. The premium for this plan is $[dollar

amount] per month. You can compare this to other plan options or check if you can get

a tax credit to help you pay the premium at yourhealthidaho.org.

Please review the enclosed plan materials for information on your 2015 plan, including

the annual deductible, copayments, coinsurance and out-of-pocket maximums. You

may also call us at 855-230-6862 or visit our website at members.bcidaho.com to

review all the benefits and coverage for this plan.

Getting help paying for your health coverage

If you enroll in a health insurance plan through Your Health Idaho, you may be able to

qualify for help in paying your monthly premiums and out-of-pocket costs. Your Health

Idaho will also check if you or family members qualify for Medicaid or the Children’s

Health Insurance Program (CHIP). Your Health Idaho’s certified agents and brokers or

consumer connectors are available to help you select the health plan that fits your

family’s needs.

Your options for 2015

You have the option of selecting a different health plan for 2015 during the Open

Enrollment period that begins November 15, 2014 and runs through February 15, 2015.

© 2014 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association

ALL ABout your new pLAnBlue Cross of Idaho is happy to offer a variety of options to help ensure you have health insurance that meets your coverage needs. As you know, our Covered Connect plan is only available to people under age 30 so we can no longer offer you that plan. But we want to make your move to a new plan as easy as possible.

the chart on the back of this sheet shows you some of the differences between your existing Covered Connect plan and the Bronze Connect plan we will transfer you to unless you let us know differently by December 15, 2014. this chart does not include any rate information. please see the enclosed documents for your 2015 premium rate.

If you want more information about your options or to learn if you qualify for a break on your monthly premium costs or out of pocket healthcare expenses, contact your insurance agent or call Blue Cross of Idaho customer service at 1-855-230-6862.

Please note: This chart does not provide a complete list of the services covered by your health insurance plan. For a complete list of covered services, please refer to your health insurance policy, or contact the customer service number on the back of your Blue Cross of Idaho member ID card.

DRAFT

©2014 by Blue Cross of Idaho, an independent licensee of the Blue Cross and Blue Shield Association Based on 3-1021 (08-14)

Blue CroSS of IdAho heAlth InSurAnCe PlAnS

this 2015 benefit grid outlines coverage for some in-network and out-of-network services. this is not a comprehensive list of benefits. Visit bcidaho.com/SBC for Summary of Benefits and Coverage for this plan.

A look At Your new PlAnMetal level Covered ConneCt* Bronze ConneCt

Benefit details In-network out-of-network In-network out-of-network

deductible $6,600 per person or $13,200 per family

$6,600 per person or $13,200 per family

$6,350 per person or $12,700 per family

$6,350 per person or $12,700 per family

Coinsurance The percentage you pay

of the allowed amount for covered services after

meeting your deductible.

once you’ve met your deductible, you pay nothing.

once you’ve met your deductible, you pay 30% of the

cost of your covered care.you pay no coinsurance

once you’ve met your deductible.once you’ve met your

deductible, you pay 30% of the cost of your covered care.

annual out-of-Pocket Maximum

Includes your deductible, copayments, coinsurance,

and prescription deductible.

For in-network care, the most you’ll pay over the course of a year is $6,600 (individual)

or $13,200 (family).

For covered care, the most you’ll pay over the course of

a year is $10,000 (individual) or $20,000 (family).

For in-network care, the most you’ll pay over the course of a year is $6,350 (individual)

or $12,700 (family).

For covered care, the most you’ll pay over the course of

a year is $10,000 (individual) or $20,000 (family).

W hat Yo u’ ll PaY uP to Your annual out- of - Po Cket M axIMu M

doctor’s office visit/urgent Care

you pay $30 copayment per visit for the first 3 primary care visits

per person. For additional visits, and specialists, you pay

costs up to your deductible.

once you’ve met your deductible, you pay 30% of the

cost of your covered care.

you pay $30 copayment for primary care $50 copayment

for specialist visits, up to a combined total of 5 visits

per person.1 For additional visits, once you’ve met your deductible, you pay nothing.

once you’ve met your deductible, you pay 30% of the

cost of your covered care.

emergency room Services

once you’ve met your deductible, you pay nothing for covered care.

once you’ve met your deductible, you pay 30% of the

cost of your covered care.2

once you’ve met your deductible, you pay nothing.

once you’ve met your deductible, you pay 30% of the

cost of your covered care.2

Prescription drugs Prescription drug costs count toward

your out-of-pocket maximum.

once you’ve met your deductible, you pay nothing for covered prescriptions. once you’ve met your deductible, you pay nothing.

diagnostic x-ray and lab Services

Inpatient hospital Services

outpatient rehab Services3

Physician, Surgical & Medical Services

Pregnancy Services

once you’ve met your deductible, you pay nothing

for covered care.

once you’ve met your deductible, you pay 30% of the

cost of your covered care.once you’ve met your

deductible, you pay nothing.once you’ve met your

deductible, you pay 30% of the cost of your covered care.

Chiropractic Care4once you’ve met your

deductible, you pay nothing for covered care.

once you’ve met your deductible, you pay 50% of the

cost of your covered care.once you’ve met your

deductible, you pay nothing.once you’ve met your

deductible, you pay 50% of the cost of your covered care.

diabetes education Services

once you’ve met your deductible, you pay nothing

for covered care.

once you’ve met your deductible, you pay 30% of the

cost of your covered care.you pay $30 copayment

per visit. once you’ve met your

deductible, you pay 30% of the cost of your covered care.

outpatient Mental health & Substance

abuse Services

once you’ve met your deductible, you pay nothing

for covered care.

once you’ve met your deductible, you pay 30% of the

cost of your covered care.you pay $30 copayment

per visit. once you’ve met your

deductible, you pay 30% of the cost of your covered care.

Preventive Care you pay nothing for listed preventive care.

once you’ve met your deductible, you pay 30% of the

cost of your covered care.you pay nothing for listed

preventive care.once you’ve met your

deductible, you pay 30% of the cost of your covered care.

Immunizations you pay nothing for listed immunizations. you pay nothing for listed immunizations.

* Catastrophic plans are only available to people under the age of 30, or to people who qualify for a hardship exemption through the exchange.1 Preventive visits are not included in this total. 2 For treatment of emergency medical conditions as defined in the policy, Blue Cross of Idaho will provide in-network benefits for covered services.3 Includes physical, occupational, and speech therapy services. You have a combined total of up to 20 in- and out-of-network visits for covered

therapy services per member per year.4 You have up to a combined total of 18 in- and out-of-network visits for covered chiropractic services per member per year.

DRAFT

3000 E. Pine Avenue, Meridian, ID 83642-5995 • P.O. Box 7408, Boise, ID 83707-1408 • (208) 345-4550 • www.bcidaho.com

An Independent Licensee of the Blue Cross and Blue Shield Association

Form No. 3-436 (12-06)

Important Notice

In 1998, Congress passed HR 4328, also known as the Women’s Health and Cancer Rights Act of 1998. This legislation requires health insurance issuers of individual health insurance policies to cover reconstructive surgery following a mastectomy/lumpectomy and to notify you annually.

Specifically, if insurers cover mastectomies/lumpectomies, they must also cover, in a manner determined in consultation with the attending physician and the patient:

1. reconstruction of the breast on which the mastectomy/lumpectomy was performed;

2. surgery and reconstruction of the other breast to produce a symmetrical appearance; and

3. prostheses and treatment of physical complications at all stages of the mastectomy/ lumpectomy, including lymphedemas.

Benefits are subject to the standard surgical deductibles, copayments and coinsurance amounts of your policy. If you have any questions, please contact our Customer Services Department at 331-7347 or (800) 627-1188.

Originated 09-99