SMALL GROUP PRODUCT PORTFOLIO

SECOND QUARTER 2020 – AGE 26 RATES

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Dedicated teamOur dedicated account executives and account specialists have you covered, with a single point of contact for you and a more seamless experience for your employees.

BlueConnectOur online health management platform helps you manage costs while delivering benefits to your employees in a more efficient manner. Visit bcbswny.com/blueconnect today.

• Streamlined new group registration

• Easy enrollment and management

• Convenient auto-deductions through eBilling (never miss a payment)

• Real-time reporting

Blue Flex ServicesWe offer integrated health reimbursement accounts (HRAs), flexible spending accounts (FSAs), and transit expense administration (TEA).

Vision programsIncluded with all medical plans:

• Pediatric vision benefit

• Adult vision discount program

Pediatric and adult dental plans availableDental care is an important part of overall health. Optional dental can be added to your medical plan or purchased separately.

A Better Health Care ExperienceBlueCross BlueShield of Western New York’s personalized member account offers access to valuable information whenever and wherever your employees need it, online or on the go. Members can manage prescriptions, find the right treatment options, and feel confident about their care.

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Keeping You and Your Employees Healthy$0 Telemedicine*Your employees can access quality, convenient care from any mobile device or computer with a front-facing camera. With Telemedicine hosted by Doctor On Demand, a personal doctor is always on call for nonemergency health issues or concerns.

$250 wellness debit card with every planOur members enjoy the freedom of health and wellness with a $250 no-strings-attached wellness debit card for:

• Gym memberships, fitness classes, and personal training sessions

• Weight Watchers®

• Sports programs, camps, and lessons

• Health food stores and nutritional supplements (including GNC®, Feel Rite, and Vitamin World®)

• Acupuncture treatments

• Massage therapy

• Chiropractic visits

• Races and fun walks

• Products purchased from fitbit.com

Health assessmentEach subscriber receives $25 for taking a health assessment, plus an additional $25 when a covered spouse or domestic partner also takes the health assessment.

Preventive servicesOur plans include more than 65 free checkups and preventive services. Additional $0 preventive drugs are available on all plans.

$25

*Deductible must first be met for HSA-qualified plans.

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Free personalized health coachingMembers have access to our health coaching team of registered nurses, nutritionists, and exercise experts. They work one-on-one with your employees and their family members to answer questions, develop personal health plans, and find the right resources. Health coaches can be reached at 1-877-878-8785 (option 2).

Case managementIf complex health care is needed, our team is here to help members make informed health care decisions, ensuring they receive the care they need.

Members also have access to the following case management programs:

• General case management• Behavioral health• Transplant case management

• Palliative care• Rare conditions case management• Right Start Prenatal Program

• Attention deficit hyperactivity disorder (ADHD)

• Asthma

• Cardiac

• Chronic obstructive pulmonary disease (COPD)

• Diabetes

• Spine

Disease management Our disease management team can help members managing a chronic condition. We help them stay on track and make improvements by empowering them with the tools to create positive health changes.

Members also have access to the following disease management programs:

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We offer a variety of diverse, expansive networks — so you can choose the coverage that best suits your unique needs. The following information explains what to expect with our network options.

Preferred Provider Organization (PPO): Services received by a participating provider both inside and outside of Western New York are considered in-network through the national Blues network.

Expanded network (EX): For employees who live or work in a Western New York county but are close to other counties and receive services in both areas.* This network offers an extensive variety of quality health care professionals both locally and across the country — all at the same in-network cost. A local primary care physician (PCP) must be on fi le and seen for your routine physical.

Health Maintenance Organization (HMO)/Point-of-Service (POS): All participating health care services received within the eight counties of Western New York* are considered “in-network,” and are provided at the lowest cost-share available to you.

HMO plans do not have out-of-network coverage.

Full-network tiered benefi t plans: Tiered plans offer lower cost-sharing options for members who choose Kaleida Health (align Tiered) or Catholic Health (focus Tiered) hospitals and specialists. Members also have the option to seek services from any BlueCross BlueShield provider with higher out-of-pocket costs.**

Select network(s): These are also offered for both align and focus. With this network, employees are required to use Kaleida Health hospitals (align Select) or Catholic Health hospitals (focus Select).***

* Network expands to surrounding border counties.

** Both align and focus Tiered plans are available to employers in Erie and Niagara counties.

*** Both align and focus Select plans are available to employers in Erie and Niagara counties.

Choose Your Network

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Platinum Classic Platinum Plus Gold Classic Gold 7100 Gold Complete Gold Aqua Silver Classic Silver 7100 Silver 8100 Silver Aqua Bronze Classic Bronze 8000 Bronze align/focus

N/A N/A N/A N/A N/A $600/$1,200 N/A N/A N/A $300/$600 N/A N/A N/A

N/A N/A $600/$1,200embedded

$1,400/$2,800true family

$ 3,000/$ 6,000true family

$ 1,000/$ 2,000embedded

$ 1,300/$ 2,600embedded

$1,900/$3,800true family

$2,900/$5,800true family

$ 2,500/$ 5,000embedded

$4,425/$8,850embedded

$6,900/$13,800embedded

$ 8,000/$ 16,000embedded

N/A N/A N/A N/A 0% after deductible

40% after deductible N/A N/A 40%

after deductible50%

after deductible50%

after deductible0%

after deductible50%

after deductible$ 2,000/$ 4,000

embedded$3,500/$7,000

embedded$ 4,000/$ 8,000

embedded$3,900/$7,800

embedded$ 3,000/$ 6,000

true family$8,150/$16,300

embedded$7,900/$15,800

embedded$6,900/$13,800

embedded$6,900/$13,800

embedded$8,150/$16,300

embedded$8,150/$16,300

embedded$6,900/$13,800

embedded$8,150/$16,300

embedded

$ 15/$ 35 $5/$25 $ 25/$ 40after deductible

$ 20/$ 40after deductible

0%after deductible

40% after first dollar and deductible

$ 30/$ 50after deductible

$ 25/$ 50after deductible

40%after deductible

50% after first dollar and deductible

Initial 3 PCP visits free50% after deductible

0%after deductible

50% after deductible

$ 35 Covered in full $ 40after deductible

$ 40after deductible

0%after deductible

40% after first dollar and deductible

$ 50after deductible

$ 50after deductible

40%after deductible

50% after first dollar and deductible

50%after deductible

0% after deductible

50%after deductible

$ 35 $ 25 $ 40after deductible

$ 40after deductible

0%after deductible

40% after first dollar and deductible

$ 50after deductible

$ 50after deductible

40%after deductible

50% after first dollar and deductible

50%after deductible

0%after deductible

50%after deductible

$ 0 $ 0 $ 0 $ 0after deductible

0%after deductible $ 0 $ 0 $ 0

after deductible0%

after deductible $ 0 $ 0 0%after deductible $ 0

$ 15 $ 5 $ 25after deductible

$ 20after deductible

0%after deductible $ 15 $ 30

after deductible$ 25

after deductible40%

after deductible $ 15 50%after deductible

0%after deductible

50%after deductible

$500 $500 $ 1,000after deductible

$500after deductible

0%after deductible

40% after first dollar and deductible

$1,500after deductible

$ 750after deductible

40%after deductible

50% after first dollar and deductible

50%after deductible

0%after deductible

50%after deductible

$ 100 $ 150 $ 100after deductible

$ 150after deductible

0%after deductible

40% after first dollar and deductible

$ 150after deductible

$ 150after deductible

40%after deductible

50% after first dollar and deductible

50%after deductible

0%after deductible

50%after deductible

$ 100 $ 150 $ 150after deductible

$ 200after deductible

0%after deductible

40% after first dollar and deductible

$ 250after deductible

$ 250after deductible

40%after deductible

50% after first dollar and deductible

50%after deductible

0%after deductible

50%after deductible

$55 $ 40 $ 60after deductible

$ 50after deductible

0%after deductible

40% after first dollar and deductible

$ 70after deductible

$ 75after deductible

40%after deductible

50% after first dollar and deductible

50%after deductible

0%after deductible

50%after deductible

$10/$30/$60 $5/$25/50% $ 10/$ 35/$ 70 $ 5/$ 30/50%after deductible

Covered in fullafter deductible $ 15/$ 50/50% $ 10/$ 35/$ 70 $ 5/$ 30/50%

after deductible$ 5/$ 30/50%

after deductible $ 15/$ 50/50% $ 10/$ 35/$ 70after deductible

Covered in fullafter deductible

$10/50%/50%after deductible

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No

No No No Yes Yes No No Yes Yes No No Yes NoYes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No

Platinum Classic Platinum Plus Gold Classic Gold 7100 Gold Complete Gold Aqua Silver Classic Silver 7100 Silver 8100 Silver Aqua Bronze Classic Bronze 8000 Bronze align/focus

N/A $803.23 N/A $664.08 N/A N/A N/A $604.06 $547.60 N/A N/A N/A N/AN/A $656.95 N/A $544.04 N/A N/A N/A $495.35 $449.54 N/A N/A $401.54 N/A

$640.58 $630.44 $563.16 $522.28 $503.20 $508.77 $508.67 $475.65 $431.77 $462.40 $391.68 N/A N/AN/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $385.09 N/AN/A $590.35 N/A $492.06 N/A N/A N/A $446.56 $407.32 N/A N/A N/A $347.96N/A $567.25 N/A $470.44 N/A N/A N/A $428.69 $389.41 N/A N/A $353.55 $338.76

Highlighted items are changes for 2020

Plan/Market Name

In-Network

Medical Services

Hospital Services

Prescription Drugs

First dollar (single/family)

Deductible (single/family)

Out-of-pocket maximum (single/family)

Coinsurance

Diabetic equipment and supplies

Telemedicine

Diagnostic X-rays and radiology

Laboratory services

PCP/specialist

Urgent care

Emergency room visit

Outpatient facility

Inpatient hospital (per admission)

Generic/Brand/Non-Preferred Brand

align/focus Selectalign/focus TieredHMOPOSEXPPO

Plan/Market Name

Age 26 Single coverage only*

Misc.

For more information, including Out-of-Network coverage, see the Plan Benefit Summary

Creditable coverageHSA qualified

Enhanced preventive drug list**

** All plans include Affordable Care Act (ACA) preventive drug coverage* Refer to page 11 for a complete list of rates

Age 26 Second Quarter 2020

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Platinum Classic Platinum Plus Gold Classic Gold 7100 Gold Complete Gold Aqua Silver Classic Silver 7100 Silver 8100 Silver Aqua Bronze Classic Bronze 8000 Bronze align/focus

N/A N/A N/A N/A N/A $600/$1,200 N/A N/A N/A $300/$600 N/A N/A N/A

N/A N/A $600/$1,200embedded

$1,400/$2,800true family

$ 3,000/$ 6,000true family

$ 1,000/$ 2,000embedded

$ 1,300/$ 2,600embedded

$1,900/$3,800true family

$2,900/$5,800true family

$ 2,500/$ 5,000embedded

$4,425/$8,850embedded

$6,900/$13,800embedded

$ 8,000/$ 16,000embedded

N/A N/A N/A N/A 0% after deductible

40% after deductible N/A N/A 40%

after deductible50%

after deductible50%

after deductible0%

after deductible50%

after deductible$ 2,000/$ 4,000

embedded$3,500/$7,000

embedded$ 4,000/$ 8,000

embedded$3,900/$7,800

embedded$ 3,000/$ 6,000

true family$8,150/$16,300

embedded$7,900/$15,800

embedded$6,900/$13,800

embedded$6,900/$13,800

embedded$8,150/$16,300

embedded$8,150/$16,300

embedded$6,900/$13,800

embedded$8,150/$16,300

embedded

$ 15/$ 35 $5/$25 $ 25/$ 40after deductible

$ 20/$ 40after deductible

0%after deductible

40% after first dollar and deductible

$ 30/$ 50after deductible

$ 25/$ 50after deductible

40%after deductible

50% after first dollar and deductible

Initial 3 PCP visits free50% after deductible

0%after deductible

50% after deductible

$ 35 Covered in full $ 40after deductible

$ 40after deductible

0%after deductible

40% after first dollar and deductible

$ 50after deductible

$ 50after deductible

40%after deductible

50% after first dollar and deductible

50%after deductible

0% after deductible

50%after deductible

$ 35 $ 25 $ 40after deductible

$ 40after deductible

0%after deductible

40% after first dollar and deductible

$ 50after deductible

$ 50after deductible

40%after deductible

50% after first dollar and deductible

50%after deductible

0%after deductible

50%after deductible

$ 0 $ 0 $ 0 $ 0after deductible

0%after deductible $ 0 $ 0 $ 0

after deductible0%

after deductible $ 0 $ 0 0%after deductible $ 0

$ 15 $ 5 $ 25after deductible

$ 20after deductible

0%after deductible $ 15 $ 30

after deductible$ 25

after deductible40%

after deductible $ 15 50%after deductible

0%after deductible

50%after deductible

$500 $500 $ 1,000after deductible

$500after deductible

0%after deductible

40% after first dollar and deductible

$1,500after deductible

$ 750after deductible

40%after deductible

50% after first dollar and deductible

50%after deductible

0%after deductible

50%after deductible

$ 100 $ 150 $ 100after deductible

$ 150after deductible

0%after deductible

40% after first dollar and deductible

$ 150after deductible

$ 150after deductible

40%after deductible

50% after first dollar and deductible

50%after deductible

0%after deductible

50%after deductible

$ 100 $ 150 $ 150after deductible

$ 200after deductible

0%after deductible

40% after first dollar and deductible

$ 250after deductible

$ 250after deductible

40%after deductible

50% after first dollar and deductible

50%after deductible

0%after deductible

50%after deductible

$55 $ 40 $ 60after deductible

$ 50after deductible

0%after deductible

40% after first dollar and deductible

$ 70after deductible

$ 75after deductible

40%after deductible

50% after first dollar and deductible

50%after deductible

0%after deductible

50%after deductible

$10/$30/$60 $5/$25/50% $ 10/$ 35/$ 70 $ 5/$ 30/50%after deductible

Covered in fullafter deductible $ 15/$ 50/50% $ 10/$ 35/$ 70 $ 5/$ 30/50%

after deductible$ 5/$ 30/50%

after deductible $ 15/$ 50/50% $ 10/$ 35/$ 70after deductible

Covered in fullafter deductible

$10/50%/50%after deductible

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No

No No No Yes Yes No No Yes Yes No No Yes NoYes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No

Platinum Classic Platinum Plus Gold Classic Gold 7100 Gold Complete Gold Aqua Silver Classic Silver 7100 Silver 8100 Silver Aqua Bronze Classic Bronze 8000 Bronze align/focus

N/A $803.23 N/A $664.08 N/A N/A N/A $604.06 $547.60 N/A N/A N/A N/AN/A $656.95 N/A $544.04 N/A N/A N/A $495.35 $449.54 N/A N/A $401.54 N/A

$640.58 $630.44 $563.16 $522.28 $503.20 $508.77 $508.67 $475.65 $431.77 $462.40 $391.68 N/A N/AN/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $385.09 N/AN/A $590.35 N/A $492.06 N/A N/A N/A $446.56 $407.32 N/A N/A N/A $347.96N/A $567.25 N/A $470.44 N/A N/A N/A $428.69 $389.41 N/A N/A $353.55 $338.76

Highlighted items are changes for 2020

Plan/Market Name

In-Network

Medical Services

Hospital Services

Prescription Drugs

First dollar (single/family)

Deductible (single/family)

Out-of-pocket maximum (single/family)

Coinsurance

Diabetic equipment and supplies

Telemedicine

Diagnostic X-rays and radiology

Laboratory services

PCP/specialist

Urgent care

Emergency room visit

Outpatient facility

Inpatient hospital (per admission)

Generic/Brand/Non-Preferred Brand

align/focus Selectalign/focus TieredHMOPOSEXPPO

Plan/Market Name

Age 26 Single coverage only*

Misc.

For more information, including Out-of-Network coverage, see the Plan Benefit Summary

Creditable coverageHSA qualified

Enhanced preventive drug list**

** All plans include Affordable Care Act (ACA) preventive drug coverage* Refer to page 11 for a complete list of rates

Platinum Classic Platinum Plus Gold Classic Gold 7100 Gold Complete Gold Aqua Silver Classic Silver 7100 Silver 8100 Silver Aqua Bronze Classic Bronze 8000 Bronze align/focus

N/A N/A N/A N/A N/A $600/$1,200 N/A N/A N/A $300/$600 N/A N/A N/A

N/A N/A $600/$1,200embedded

$1,400/$2,800true family

$ 3,000/$ 6,000true family

$ 1,000/$ 2,000embedded

$ 1,300/$ 2,600embedded

$1,900/$3,800true family

$2,900/$5,800true family

$ 2,500/$ 5,000embedded

$4,425/$8,850embedded

$6,900/$13,800embedded

$ 8,000/$ 16,000embedded

N/A N/A N/A N/A 0% after deductible

40% after deductible N/A N/A 40%

after deductible50%

after deductible50%

after deductible0%

after deductible50%

after deductible$ 2,000/$ 4,000

embedded$3,500/$7,000

embedded$ 4,000/$ 8,000

embedded$3,900/$7,800

embedded$ 3,000/$ 6,000

true family$8,150/$16,300

embedded$7,900/$15,800

embedded$6,900/$13,800

embedded$6,900/$13,800

embedded$8,150/$16,300

embedded$8,150/$16,300

embedded$6,900/$13,800

embedded$8,150/$16,300

embedded

$ 15/$ 35 $5/$25 $ 25/$ 40after deductible

$ 20/$ 40after deductible

0%after deductible

40% after first dollar and deductible

$ 30/$ 50after deductible

$ 25/$ 50after deductible

40%after deductible

50% after first dollar and deductible

Initial 3 PCP visits free50% after deductible

0%after deductible

50% after deductible

$ 35 Covered in full $ 40after deductible

$ 40after deductible

0%after deductible

40% after first dollar and deductible

$ 50after deductible

$ 50after deductible

40%after deductible

50% after first dollar and deductible

50%after deductible

0% after deductible

50%after deductible

$ 35 $ 25 $ 40after deductible

$ 40after deductible

0%after deductible

40% after first dollar and deductible

$ 50after deductible

$ 50after deductible

40%after deductible

50% after first dollar and deductible

50%after deductible

0%after deductible

50%after deductible

$ 0 $ 0 $ 0 $ 0after deductible

0%after deductible $ 0 $ 0 $ 0

after deductible0%

after deductible $ 0 $ 0 0%after deductible $ 0

$ 15 $ 5 $ 25after deductible

$ 20after deductible

0%after deductible $ 15 $ 30

after deductible$ 25

after deductible40%

after deductible $ 15 50%after deductible

0%after deductible

50%after deductible

$500 $500 $ 1,000after deductible

$500after deductible

0%after deductible

40% after first dollar and deductible

$1,500after deductible

$ 750after deductible

40%after deductible

50% after first dollar and deductible

50%after deductible

0%after deductible

50%after deductible

$ 100 $ 150 $ 100after deductible

$ 150after deductible

0%after deductible

40% after first dollar and deductible

$ 150after deductible

$ 150after deductible

40%after deductible

50% after first dollar and deductible

50%after deductible

0%after deductible

50%after deductible

$ 100 $ 150 $ 150after deductible

$ 200after deductible

0%after deductible

40% after first dollar and deductible

$ 250after deductible

$ 250after deductible

40%after deductible

50% after first dollar and deductible

50%after deductible

0%after deductible

50%after deductible

$55 $ 40 $ 60after deductible

$ 50after deductible

0%after deductible

40% after first dollar and deductible

$ 70after deductible

$ 75after deductible

40%after deductible

50% after first dollar and deductible

50%after deductible

0%after deductible

50%after deductible

$10/$30/$60 $5/$25/50% $ 10/$ 35/$ 70 $ 5/$ 30/50%after deductible

Covered in fullafter deductible $ 15/$ 50/50% $ 10/$ 35/$ 70 $ 5/$ 30/50%

after deductible$ 5/$ 30/50%

after deductible $ 15/$ 50/50% $ 10/$ 35/$ 70after deductible

Covered in fullafter deductible

$10/50%/50%after deductible

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No

No No No Yes Yes No No Yes Yes No No Yes NoYes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No

Platinum Classic Platinum Plus Gold Classic Gold 7100 Gold Complete Gold Aqua Silver Classic Silver 7100 Silver 8100 Silver Aqua Bronze Classic Bronze 8000 Bronze align/focus

N/A $803.23 N/A $664.08 N/A N/A N/A $604.06 $547.60 N/A N/A N/A N/AN/A $656.95 N/A $544.04 N/A N/A N/A $495.35 $449.54 N/A N/A $401.54 N/A

$640.58 $630.44 $563.16 $522.28 $503.20 $508.77 $508.67 $475.65 $431.77 $462.40 $391.68 N/A N/AN/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $385.09 N/AN/A $590.35 N/A $492.06 N/A N/A N/A $446.56 $407.32 N/A N/A N/A $347.96N/A $567.25 N/A $470.44 N/A N/A N/A $428.69 $389.41 N/A N/A $353.55 $338.76

Highlighted items are changes for 2020

Plan/Market Name

In-Network

Medical Services

Hospital Services

Prescription Drugs

First dollar (single/family)

Deductible (single/family)

Out-of-pocket maximum (single/family)

Coinsurance

Diabetic equipment and supplies

Telemedicine

Diagnostic X-rays and radiology

Laboratory services

PCP/specialist

Urgent care

Emergency room visit

Outpatient facility

Inpatient hospital (per admission)

Generic/Brand/Non-Preferred Brand

align/focus Selectalign/focus TieredHMOPOSEXPPO

Plan/Market Name

Age 26 Single coverage only*

Misc.

For more information, including Out-of-Network coverage, see the Plan Benefit Summary

Creditable coverageHSA qualified

Enhanced preventive drug list**

** All plans include Affordable Care Act (ACA) preventive drug coverage* Refer to page 11 for a complete list of rates

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Plan ClassID Subscriber Subscriber and

Child(ren)

Subscriber and Spouse/

Domestic PartnerFamily

Platinum Classic 5701 $640.58 $1,088.99 $1,281.16 $1,825.65Platinum PPO Plus 1601 $803.23 $1,365.49 $1,606.46 $2,289.21Platinum EX Plus 5901 $656.95 $1,116.82 $1,313.90 $1,872.31Platinum POS Plus 1501 $630.44 $1,071.75 $1,260.88 $1,796.75Platinum align Tiered Plus 2501 $590.35 $1,003.60 $1,180.70 $1,682.50Platinum focus Tiered Plus 7501 $590.35 $1,003.60 $1,180.70 $1,682.50Platinum align Select Plus 6201 $567.25 $964.33 $1,134.50 $1,616.66Platinum focus Select Plus 6401 $567.25 $964.33 $1,134.50 $1,616.66Gold Classic 9101 $563.16 $957.37 $1,126.32 $1,605.01Gold PPO 7100 4701 $664.08 $1,128.94 $1,328.16 $1,892.63Gold 7100EX 4601 $544.04 $924.87 $1,088.08 $1,550.51Gold POS 7100 4501 $522.28 $887.88 $1,044.56 $1,488.50Gold 7100 align Tiered 2601 $492.06 $836.50 $984.12 $1,402.37Gold 7100 focus Tiered 7601 $492.06 $836.50 $984.12 $1,402.37Gold 7100 align Select 9901 $470.44 $799.75 $940.88 $1,340.75Gold 7100 focus Select 9501 $470.44 $799.75 $940.88 $1,340.75Gold Complete 7401 $503.20 $855.44 $1,006.40 $1,434.12Gold Aqua 4401 $508.77 $864.91 $1,017.54 $1,449.99Silver Classic 4801 $508.67 $864.74 $1,017.34 $1,449.71Silver PPO 7100 9701 $604.06 $1,026.90 $1,208.12 $1,721.57Silver 7100EX 9601 $495.35 $842.10 $990.70 $1,411.75Silver POS 7100 5301 $475.65 $808.61 $951.30 $1,355.60Silver 7100 align Tiered 1301 $446.56 $759.15 $893.12 $1,272.70Silver 7100 focus Tiered 1401 $446.56 $759.15 $893.12 $1,272.70Silver 7100 align Select 1801 $428.69 $728.77 $857.38 $1,221.77Silver 7100 focus Select 2301 $428.69 $728.77 $857.38 $1,221.77Silver PPO 8100 4901 $547.60 $930.92 $1,095.20 $1,560.66Silver 8100EX 2101 $449.54 $764.22 $899.08 $1,281.19Silver POS 8100 1901 $431.77 $734.01 $863.54 $1,230.54Silver 8100 align Tiered 3001 $407.32 $692.44 $814.64 $1,160.86Silver 8100 focus Tiered 4001 $407.32 $692.44 $814.64 $1,160.86Silver 8100 align Select 5001 $389.41 $662.00 $778.82 $1,109.82Silver 8100 focus Select 6001 $389.41 $662.00 $778.82 $1,109.82Silver Aqua 7901 $462.40 $786.08 $924.80 $1,317.84Bronze Classic 2401 $391.68 $665.86 $783.36 $1,116.29Bronze 8000EX 5401 $401.54 $682.62 $803.08 $1,144.39Bronze HMO 8000 5101 $385.09 $654.65 $770.18 $1,097.51Bronze 8000 align Select 5201 $353.55 $601.04 $707.10 $1,007.62Bronze 8000 focus Select 5501 $353.55 $601.04 $707.10 $1,007.62Bronze align Tiered 2201 $347.96 $591.53 $695.92 $991.69Bronze focus Tiered 7801 $347.96 $591.53 $695.92 $991.69Bronze align Select 9301 $338.76 $575.89 $677.52 $965.47Bronze focus Select 8901 $338.76 $575.89 $677.52 $965.47

AGE 26 RATES

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Pediatric and Adult Dental PlansDental care is important to overall health. That’s why our dental plans include essential benefits to ensure members receive complete oral health coverage through our own dental network. Blue Value dental plans have no participation requirements — add to your medical plan or purchase one separately. Groups can choose one Blue Value dental plan to offer their employees in addition to Blue Pediatric dental.

* Blue Value Dental 3 includes coverage for children up to age 19 for medically necessary orthodontics subject to an out-of-pocket maximum (see Blue Pediatric Benefits) and cosmetic orthodontics (routine braces) subject to a lifetime maximum per member. Adults and adult dependents have coverage for cosmetic orthodontics (routine braces) subject to a lifetime maximum per member.

** Blue Pediatric dental benefits and cost-sharing are included in all Blue Value dental plans. Adults and adult dependents, ages 19–26, are covered in Blue Value Dental plans.

Note: Members can receive dental services from a provider who does not participate in the BlueCross BlueShield contracted network of providers. Out-of-network services are reimbursed at 100% of the in-network fee schedule and the nonparticipating provider may balance bill the member for the remainder.

Blue Pediatric Dental (PPO) Blue Value Dental 1 (PPO) Blue Value Dental 2 (PPO) Blue Value Dental 3* (PPO)

Benefits Children up to age 19 years Adult/family** Adult/family** Adult/family**

Deductible (embedded) N/A $50 per member/$150 family maximum

$50 per member/$150 family maximum

$50 per member/$150 family maximum

Annual benefit maximum N/A $750 per memberper plan year

$1,250 per memberper plan year

$1,500 per memberper plan year

Out-of-pocket maximum $350 per one child

$700 for two or more children(per plan year)

N/A N/A N/A

Orthodontic lifetime maximum (pediatric and adult cosmetic, routine braces)

N/A N/A N/A $1,000 per memberper lifetime

Preventive/diagnostic(exams, cleaning, X-rays) $20 copay $0 copay $0 copay $0 copay

Basic restorative (fillings, extractions, periodontics, endodontics)

50% coinsurance 50% coinsuranceafter deductible

20% coinsuranceafter deductible

20% coinsuranceafter deductible

Major dental (bridges, crowns, dentures) 50% coinsurance 50% coinsurance

after deductible50% coinsuranceafter deductible

50% coinsuranceafter deductible

Orthodontics

50% coinsurance(medically necessary only, routine

braces not covered), subject to out-of-pocket max

Not covered Not covered

50% coinsurance(adult and pediatric cosmetic

orthodontics); subject to lifetime max

Product Name Blue Pediatric Dental (PPO) Blue Value Dental 1 (PPO) Blue Value Dental 2 (PPO) Blue Value Dental 3* (PPO)

Monthly Premium

Subscriber

$20.46 (per child)

$19.20 $25.72 $27.48

Subscriber and child(ren) $52.87 $63.57 $69.42

Subscriber and spouse/ domestic partner $38.40 $51.44 $54.96

Family $73.81 $90.69 $98.59

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Adult Vision Discount Program

* EyeMed®, an independent company, administers vision programs on behalf of BlueCross BlueShield of Western New York. Members must receive services from an EyeMed provider, and services out-of-network are not covered.

** Since LASIK or PRK vision correction is an elective procedure, performed by specially trained providers. This discount may not always be available from a provider in your immediate location. For a location near you and the discount authorization, please call 1-877-5LASER6.

Adult Vision Discount Program Vision Enhanced Discount Program*

Benefits Member cost

Eye exam $0 annual cost

Frames 40% off retail price

Standard plastic lenses(single vision, bifocal, trifocal, lenticular) First purchase covered in full, additional purchases 40% off total cost

Lens options (for example, tint, UV and antireflective coating) Member cost varies based on lens options

Contact Lens Materials

Disposable $40 allowance toward first purchase, additional purchases 0% discount

Conventional $40 allowance toward first purchase, additional purchases 15% discount

Other Add-ons and Services

Sunglasses, contact lens solutions, etc. 20% discount

Laser vision correction** (LASIK or PRK) 15% off retail price or 5% off promotional price

Frequency

Examination Annual

Frames Unlimited

Lenses Covered in full annually

Contact lenses $40 allowance annually

BlueCross BlueShield plan benefits include eye care services for pediatric members (under age 19) and adult members. Pediatric members are covered for essential health benefits, including routine eye exams, frames, and lenses under their medical plan.

Note: Members can receive dental services from a provider who does not participate in the BlueCross BlueShield contracted network of providers. Out-of-network services are reimbursed at 100% of the in-network fee schedule and the nonparticipating provider may balance bill the member for the remainder.

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Annual Benefit LimitsHabilitation (PT/OT/ST) 60 combined visits per condition, per plan year

Rehabilitation, outpatient (PT/OT/ST) 60 combined visits per condition, per plan year

Rehabilitation, inpatient (PT/OT/ST) 60 combined visits, per plan year

Home health care 40 visits per plan year

Hearing aids Single purchase every three years

• Members must choose hearing aids from John R. Oishei Children’s Hospital or Beckes Optical & Hearing Aids

• Members are entitled to discounts through TruHearing®

Hospice 210 days per plan year, five visits per plan year for family bereavement

Substance abuse, outpatient Unlimited, 20 visits per plan year for family counseling

Skilled nursing facility Unlimited

THE NAME TRUSTEDFOR OVER 80 YEARS.

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Printed by the proud members of OPEIU, Local 153.

bcbswny.com

BlueCross BlueShield of Western New York (BCBSWNY) is a division of HealthNow New York Inc., an independent licensee of the Blue Cross and Blue Shield Association. Weight Watchers®, GNC®, and Vitamin World® are separate companies that accept the BCBSWNY wellness debit card. EyeMed®, an independent company, administers vision programs on behalf of BCBSWNY. TruHearing® is a registered trademark of TruHearing, Inc. TruHearing is an independent company that administers the routine hearing exam and hearing-aid benefi t.

BCBSWNY complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-544-2583 (TTY 711).注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-544-2583 (TTY 711)。

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