745504.0218

2018 Small Business PlansEmployers can select a variety of plans for their employees to choose from. As always, our members have access to plenty of features and benefits. Here are some highlights.

• Virtual Visits, powered by MDLIVE®: This service provides a live consultation between a doctor and a member for many non-emergency health needs. This year, employees who have closed or grandfathered plans will also get access to this service.

• Preferred pharmacy network: Members can save money by using an in-network pharmacy. If they go to an in-network pharmacy, all copays and/or coinsurance would apply to their in-network deductible (if applicable) and in-network out-of-pocket maximum. Members may save even more by going to a preferred, in-network pharmacy, where they may get the lowest copay or coinsurance amount. If they go to an out-of-network pharmacy, they will generally

have higher copays and/or coinsurance amounts. And all copays and/or coinsurance when going to an out-of-network pharmacy would apply to their out-of-network deductible (if applicable) and out-of-network out-of-pocket maximum. Any additional charge for using an out-of-network pharmacy would not apply to their out-of-pocket amounts.

• Prescription payment level change to six-tier: Prescription drug lists have different levels of coverage, which are called payment level tiers. Our pharmacy benefit now has six payment level tiers. Generic, brand and specialty drugs will each have preferred and non-preferred payment levels. Generally, if a drug is in a lower payment level tier, out-of-pocket costs for that drug will be less.

New Plans. Same Value.Blue Cross and Blue Shield of Texas (BCBSTX) has the flexibility and choice that growing companies want. We’re providing new plans this year, with the benefits you’ve come to expect, including a wide selection of:

• Copayments

• Prescription Drug Benefits

• Deductibles

• Networks

Questions? Please contact your BCBSTX Account Representative.

MDLIVE, an independent company, provides virtual visit services for Blue Cross and Blue Shield of Texas. MDLIVE operates and administers the virtual visit program and is solely responsible for its operations and that of its contracted providers.

MDLIVE and the MDLIVE logo are registered trademarks of MDLIVE, Inc. and may not be used without written permission.

MDLIVE is not an insurance product nor a prescription fulfillment warehouse. MDLIVE operates subject to state regulations and may not be available in certain states. MDLIVE does not guarantee that a prescription will be written. MDLIVE does not prescribe DEA-controlled substances, non-therapeutic drugs and certain other drugs that may be harmful because of their potential for abuse. MDLIVE physicians reserve the right to deny care for potential misuse of services.

BCBSTX 2018 Small Group Product Portfolio Calendar Year Deductibles Medical and Rx Out-of-Pocket Expense Coinsurance Copayments Per Occurrence Deductibles Pharmacy Benefits

Network Plan Name Plan ID Range of HSA Contribution

Individual (In/Out)

Family (In/Out)

Individual OPX (In/Out)

Family OPX (In/Out)

Coinsurance(In/Out)

Primary Care and Virtual Visits Office

Visit Copay 1

Specialist Office Visit Copay 1 Urgent Care1 Imaging 1, 3

Emergency Room Per Occurrence

Deductible1, 4

Inpatient Per Occurrence

Deductible1, 4

OP Surg Per Occurrence

Deductible1, 4

Preferred PharmacyNetwork

Non-Preferred Pharmacy Network

Pediatric Dental In/Out 5

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Blue Advantage Bronze HMOSM 806 B660ADT $0-$1006 $6,550/ 2 $13,100/ 2 $6,550/2 $13,100/2 100%/2 NA NA NA NA Ded and Coins Ded and Coins Ded and Coins 100% 100% 100%/100%

Blue Advantage Bronze HMOSM 833 B661ADT NA $7,350/2 $14,700/2 $7,350/2 $14,700/2 100%/2 NA NA NA NA Ded and Coins Ded and Coins Ded and Coins 100% 100% 100%/100%

Blue Advantage Gold HMOSM 801 G660ADT NA $3,000/2 $9,000/2 $3,000/2 $9,000/2 100%/2 $30 $60 $30 $250 $400 $200 $150 $0/$10/$35/$75/$150/$250 $10/$20/$55/$95/$150/$250 100%/100%

Blue Advantage Gold HMOSM 812 G661ADT NA $2,000/2 $6,000/2 $2,000/2 $6,000/2 100%/2 NA NA NA NA Ded and Coins Ded and Coins Ded and Coins 100% 100% 100%/100%

Blue Advantage Gold HMOSM 814 G662ADT NA $1,000/2 $3,000/2 $5,000/2 $14,700/2 80%/2 $25 $45 $25 $250 $500 Ded and Coins Ded and Coins $0/$10/$50/$100/$150/$250 $10/$20/$70/$120/$150/$250 70%/70%

Blue Advantage Gold HMOSM 816 G663ADT NA $1,500/2 $4,500/2 $3,500/2 $10,500/2 80%/2 $30 $60 $30 $250 $400 Ded and Coins Ded and Coins $0/$10/$50/$100/$150/$250 $10/$20/$70/$120/$150/$250 70%/70%

Blue Advantage Gold HMOSM 817 G664ADT NA $2,000/2 $6,000/2 $4,000/2 $14,700/2 100%/2 $30 $60 $30 $250 $300 $150 $100 $0/$10/$50/$100/$150/$250 $10/$20/$70/$120/$150/$250 70%/70%

Blue Advantage Gold HMOSM 822 G665ADT NA $0/2 $0/2 $7,350/2 $14,700/2 100%/2 $25 $45 $25 $200 $750 $150 $100 $0/$10/$50/$100/$150/$250 $10/$20/$70/$120/$150/$250 70%/70%

Blue Advantage Gold HMOSM 830 G666ADT $800-$1,1256 $4,000/2 $12,000/2 $4,000/2 $12,000/2 100%/2 NA NA NA NA Ded and Coins Ded and Coins Ded and Coins 100% 100% 100%/100%

Blue Advantage Platinum HMOSM 807 P610ADT NA $250/2 $750/2 $1,250/2 $3,750/2 80%/2 $25 $45 $25 $250 $300 $150 $100 $0/$10/$35/$75/$150/$250 $10/$20/$55/$95/$150/$250 70%/70%

Blue Advantage Platinum HMOSM 808 P611ADT NA $1,250/2 $3,750/2 $1,250/2 $3,750/2 100%/2 $25 $45 $25 $250 $400 $150 $100 $0/$10/$35/$75/$150/$250 $10/$20/$55/$95/$150/$250 100%/100%

Blue Advantage Silver HMOSM 803 S640ADT NA $6,000/2 $14,700/2 $6,000/2 $14,700/2 100%/2 $30 $60 $30 $250 $500 $250 $200 $0/$10/$50/$100/$150/$250 $10/$20/$70/$120/$150/$250 100%/100%

Blue Advantage Silver HMOSM 804 S641ADT NA $4,000/2 $12,000/2 $7,350/2 $14,700/2 80%/2 $40 $60 $40 $250 $500 $250 $200 $0/$10/$50/$100/$150/$250 $10/$20/$70/$120/$150/$250 70%/70%

Blue Advantage Silver HMOSM 818 S642ADT NA $3,500/2 $10,500/2 $7,350/2 $14,700/2 70%/2 $40 $80 $40 $250 $500 Ded and Coins Ded and Coins $0/$10/$50/$100/$150/$250 $10/$20/$70/$120/$150/$250 70%/70%

Blue Advantage Silver HMOSM 820 S643ADT NA $3,000/2 $9,000/2 $7,350/2 $14,700/2 70%/2 $40 $70 $40 $250 $500 $250 $200 $0/$10/$50/$100/$150/$250 $10/$20/$70/$120/$150/$250 70%/70%

Blue Advantage Silver HMOSM 846 S644ADT NA $7,350/2 $14,700/2 $7,350/2 $14,700/2 100%/2 $30 $60 $30 $250 $500 $250 $200 $0/$10/$50/$100/$150/$250 $10/$20/$70/$120/$150/$250 100%/100%

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Blue Choice Bronze PPOSM 805 B660CHC $0 $5,750/$11,000 $13,100/$26,200 $6,550/$13,100 $13,100/$39,300 70%/50% NA NA NA NA Ded and Coins Ded and Coins Ded and Coins 90%/90%/80%/70%/60%/50% 80%/80%/70%/60%/60%/50% 70%/70%

Blue Choice Bronze PPOSM 806 B661CHC $0 $6,550/$13,100 $13,100/$26,200 $6,550/$13,100 $13,100/$26,200 100%/100% NA NA NA NA Ded and Coins Ded and Coins Ded and Coins 100% 100% 100%/100%

Blue Choice Bronze PPOSM 833 B662CHC NA $7,350/$14,700 $14,700/$29,400 $7,350/$14,700 $14,700/$29,400 100%/100% NA NA NA NA Ded and Coins Ded and Coins Ded and Coins 100% 100% 100%/100%

Blue Choice Gold PPOSM 801 G650CHC NA $3,000/$6,000 $9,000/$18,000 $3,000/$6,000 $9,000/$18,000 100%/100% $30 $50 $30 NA $400 $200 $150 $0/$10/$50/$100/$150/$250 $10/$20/$70/$120/$150/$250 100%/100%

Blue Choice Gold PPOSM 819 G651CHC $325-$6006 $3,000/$6,000 $9,000/$18,000 $3,000/$6,000 $9,000/$18,000 100%/100% NA NA NA NA Ded and Coins Ded and Coins Ded and Coins 100% 100% 100%/100%

Blue Choice Gold PPOSM 820 G652CHC NA $1,500/$3,000 $4,500/$9,000 $5,000/$10,000 $14,700/$30,000 80%/60% $30 $60 $30 NA $400 Ded and Coins Ded and Coins $0/$10/$50/$100/$150/$250 $10/$20/$70/$120/$150/$250 70%/70%

Blue Choice Gold PPOSM 822 G653CHC NA $1,500/$3,000 $4,500/$9,000 $4,000/$8,000 $12,000/$24,000 80%/60% $30 $50 $30 NA $400 Ded and Coins Ded and Coins $0/$10/$50/$100/$150/$250 $10/$20/$70/$120/$150/$250 70%/70%

Blue Choice Gold PPOSM 823 G654CHC NA $1,250/$3,000 $4,500/$9,000 $6,500/$13,000 $14,700/$39,000 100%/80% $30 $60 $30 NA $400 $150 $100 $0/$10/$50/$100/$150/$250 $10/$20/$70/$120/$150/$250 70%/70%

Blue Choice Gold PPOSM 830 G656CHC $850-$1,1256 $4,000/$8,000 $12,000/$24,000 $4,000/$8,000 $12,000/$24,000 100%/100% NA NA NA NA Ded and Coins Ded and Coins Ded and Coins 100% 100% 100%/100%

Blue Choice Platinum PPOSM 810 P620CHC NA $250/$500 $750/$1,500 $1,250/$2,500 $3,750/$7,500 80%/60% $25 $45 $25 NA $300 $150 $100 $0/$10/$35/$75/$150/$250 $10/$20/$55/$95/$150/$250 100%/100%

Blue Choice Platinum PPOSM 811 P621CHC NA $1,250/$2,500 $3,750/$7,500 $1,250/$2,500 $3,750/$7,500 100%/100% $25 $45 $25 NA $300 $150 $100 $0/$10/$35/$75/$150/$250 $10/$20/$55/$95/$150/$250 100%/100%

Blue Choice Silver PPOSM 803 S660CHC NA $6,000/$12,000 $14,700/$29,400 $6,000/$12,000 $14,700/$36,000 100%/100% $25 $45 $25 NA $500 $250 $200 $0/$10/$50/$100/$150/$250 $10/$20/$70/$120/$150/$250 100%/100%

Blue Choice Silver PPOSM 824 S661CHC NA $3,500/$7,000 $10,500/$21,000 $7,350/$14,700 $14,700/$44,100 70%/50% $40 $80 $40 NA $600 Ded and Coins Ded and Coins $0/$10/$50/$100/$150/$250 $10/$20/$70/$120/$150/$250 70%/70%

Blue Choice Silver PPOSM 825 S662CHC $250-$5006 $5,000/$10,000 $13,100/$26,200 $5,000/$10,000 $13,100/$26,200 100%/100% NA NA NA NA Ded and Coins Ded and Coins Ded and Coins 100% 100% 100%/100%

Blue Choice Silver PPOSM 827 S663CHC NA $3,000/$6,000 $9,000/$18,000 $7,350/$14,700 $14,700/$44,100 70%/50% $40 $80 $40 $250 $500 $250 $200 $0/$10/$50/$100/$150/$250 $10/$20/$70/$120/$150/$250 70%/70%

Blue Choice Silver PPOSM 834 S665CHC NA $3,250/$8,000 $12,000/$24,000 $7,350/$14,700 $14,700/$44,100 80%/60% $40 $70 $40 NA $500 $250 $200 $0/$10/$50/$100/$150/$250 $10/$20/$70/$120/$150/$250 70%/70%

Blue Choice Silver PPOSM 844 S666CHC NA $4,000/$8,000 $12,000/$24,000 $7,350/$14,700 $14,700/$44,100 80%/60% $40 $70 $40 NA $750 $250 $200 $0/$10/$50/$100/$150/$250 $10/$20/$70/$120/$150/$250 70%/70%

Blue Choice Silver PPOSM 845 S667CHC NA $6,000/$8,000 $12,000/$24,000 $7,350/$14,700 $14,700/$44,100 80%/60% $40 $70 $40 NA $750 $250 $200 $0/$10/$50/$100/$150/$250 $10/$20/$70/$120/$150/$250 70%/70%

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Blue Essentials Access Bronze HMOSM 806 B601HMO $0 $6,550/2 $13,100/2 $6,550/2 $13,100/2 100%/2 NA NA NA NA Ded and Coins Ded and Coins Ded and Coins 100% 100% 100%/100%

Blue Essentials Access Gold HMO SM 801 G610HMO NA $1,500/2 $4,500/2 $5,000/2 $14,700/2 80%/2 $30 $60 $30 NA $400 Ded and Coins Ded and Coins $0/$10/$50/$100/$150/$250 $10/$20/$70/$120/$150/$250 70%/70%

Blue Essentials Access Silver HMOSM 802 S601HMO NA $3,000/2 $9,000/2 $7,350/2 $14,700/2 70%/2 $40 $80 $40 $250 $500 $250 $200 $0/$10/$50/$100/$150/$250 $10/$20/$70/$120/$150/$250 70%/70%

Blue Essentials Access Silver HMOSM 803 S602HMO NA $4,000/2 $12,000/2 $7,000/2 $14,700/2 80%/2 $30 $60 $30 NA $500 $250 $200 $0/$10/$50/$100/$150/$250 $10/$20/$70/$120/$150/$250 70%/70%

Blue Essentials Access Silver HMO SM 804 S603HMO $250-$5006 $5,000/2 $13,100/2 $5,000/2 $13,100/2 100%/2 NA NA NA NA Ded and Coins Ded and Coins Ded and Coins 100% 100% 100%/100%

Blue Essentials Access Silver HMOSM 805 S604HMO NA $6,000/2 $13,100/2 $6,000/2 $14,700/2 100%/2 $25 $45 $25 NA $500 $250 $200 $0/$10/$50/$100/$150/$250 $10/$20/$70/$120/$150/$250 100%/100%

Blue Essentials Access Silver HMOSM 809 S605HMO NA $7,350/2 $13,100/2 $7,350/2 $14,700/2 100%/ 2 $25 $45 $25 NA $500 $250 $200 $0/$10/$50/$100/$150/$250 $10/$20/$70/$120/$150/$250 100%/100%

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Blue Premier Access Bronze HMOSM 806 B640HMH $0 $6,550/2 $13,100/2 $6,550/2 $13,100/2 100%/2 NA NA NA NA Ded and Coins Ded and Coins Ded and Coins 100% 100% 100%/100%

Blue Premier Access Gold HMOSM 801 G630HMH NA $1,500/2 $4,500/2 $5,000/2 $14,700/2 80%/2 $30 $60 $30 NA $400 Ded and Coins Ded and Coins $0/$10/$50/$100/$150/$250 $10/$20/$70/$120/$150/$250 70%/70%

Blue Premier Access Silver HMOSM 802 S620HMH NA $3,000/2 $9,000/2 $7,350/2 $14,700/2 70%/2 $40 $80 $40 $250 $500 $250 $200 $0/$10/$50/$100/$150/$250 $10/$20/$70/$120/$150/$250 70%/70%

Blue Premier Access Silver HMOSM 803 S621HMH NA $4,000/2 $12,000/2 $7,000/2 $14,700/2 80%/2 $30 $60 $30 NA $500 $250 $200 $0/$10/$50/$100/$150/$250 $10/$20/$70/$120/$150/$250 70%/70%

Blue Premier Access Silver HMOSM 804 S622HMH $250-$5006 $5,000/2 $13,100/2 $5,000/2 $13,100/2 100%/2 NA NA NA NA Ded and Coins Ded and Coins Ded and Coins 100% 100% 100%/100%

Blue Premier Access Silver HMOSM 805 S623HMH NA $6,000/2 $13,100/2 $6,000/2 $14,700/2 100%/2 $25 $45 $25 NA $500 $250 $200 $0/$10/$50/$100/$150/$250 $10/$20/$70/$120/$150/$250 100%/100%

Blue Premier Access Silver HMOSM 809 S624HMH NA $7,350/2 $13,100/2 $7,350/2 $14,700/2 100%/2 $25 $45 $25 NA $500 $250 $200 $0/$10/$50/$100/$150/$250 $10/$20/$70/$120/$150/$250 100%/100%

All footnotes appear on the next page.

Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Angelina

San Augustine

Calhoun

La Salle

Kenedy

Roberts Hemphill

Parmer

Motley

Rockwall

PresidioKendall

Fayette

Galveston

Network Name

Blue Choice PPOSM, Blue EssentialsSM, and Blue Advantage HMOSM

Blue PremierSM, Blue Choice PPOSM, Blue EssentialsSM, and Blue Advantage HMOSM

2018 Texas Small Group (1-50) Networks by County

Notes: 1. These columns refer to in-network benefits only. Members will pay more if they receive services out of network. Please refer to your benefit booklet.2. HMO plans do not have benefits out-of-network, except emergencies.3. Imaging refers to high-dollar imaging services, such as MRIs, CT scans and PT scans. 4. Copay plus coinsurance after the deductible will apply until the deductible is met for plans with copay, waived if admitted. (If admitted, any charges

described in Inpatient Hospital Services will apply.) Please refer to your Benefit Booklet.5. Medical and pediatric dental coinsurance will apply after the deductible.6. These HSA plans have a mandatory employer contribution requirement.

Additional Notes:1. NA = Not Applicable. 2. All plans have an Embedded Deductible. This means that no more than one Individual Deductible will be required to be met by any one individual in a

family contract.3. When members visit a preferred pharmacy, they may pay a lower copay or coinsurance amount for a covered non-specialty prescription drug than when

visiting an in-network non-preferred pharmacy. Members can find a preferred pharmacy at myprime.com. Preferred pharmacies include Walgreens, Walmart, Albertsons (including Osco Drug), HEB, and AccessHealth (group of independent pharmacies).

4. Basic lab and X-ray services are covered at the deductible and coinsurance level, except for Blue Advantage Gold HMO 822, which covers basic Lab and x-ray at $100, with no additional charges after the copay.

5. All plans include prescription drug benefits. The benefit plan is based on the BCBSTX drug list. Benefits include clinical programs such as Prior Authorization and Step Therapy.

6. Pediatric dental benefits are subject to the medical deductible before coverage begins. In-network benefits refer to services provided by BlueCare Dental PPOSM providers.

7. Virtual visits are available through an in-network vendor.8. EyeMed Vision Care is an independent company that administers the vision benefits for BCBSTX.

This document does not contain a complete listing of the exclusions, limitations and conditions that apply to the benefits shown. For more information on these products, please contact your BCBSTX Account Representative.