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BusinessADVANTAGESM

2020 Employer Group Coverage (2 – 50)

The Power of Blue®

We have more than 30 years of experience serving our members throughout South Carolina. We offer affordable

plan options that provide more value, more benefits and more options. Not only do we have best in class

customer service when you have questions, we have negotiated discounts with providers throughout the state to

save your employees money. With BlueChoice, you get more!

Our PlansBusinessADVANTAGE is an affordable and comprehensive series of health plans with options to suit employers

with 2 − 50 employees. We can work with you to determine which features and benefits best fit your company and

your employees. Our plans include a variety of programs for medical, health and disease management. We have

your employees covered regardless of their needs.

BlueChoice routinely reviews our benefit plans and enhances them to meet your needs. This year we are offering 46

plans from which to choose. You can choose from several levels of products with multiple plan designs:

• 17 Gold plans

• 20 Silver plans

• Nine Bronze plans

• Seven of these are qualified high-deductible health plans (HDHPs)

You can offer dual options in any combination from any of these plans down to two lives. All plans are health

reimbursement arrangement-compatible and seven plans are health savings account-qualified.

Whole-Health SolutionsWhen you choose the plan design that’s best for your company, you can count on BlueChoice to deliver:

• Deductible and copayment amounts that help you manage your health care costs.

• Comprehensive mail-order and retail pharmacy benefits.

• Chiropractic care.

• Value-added services like routine vision, preventive dental, an employee assistance program, a discount

program and 24-hour video access to a certified physician.

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The Benefits of BusinessADVANTAGEAll BusinessADVANTAGE plans are comprehensive, open-access plans. In addition to the great benefits listed here,

your employees get the comfort and convenience of seeing any doctor they choose within the network without

getting a referral. This also includes full access to our in-network providers worldwide.

Through our BlueCard® program, BusinessADVANTAGE members living or traveling outside of South Carolina can

locate participating doctors and hospitals nationwide. When members use a doctor or hospital through BlueCard,

they receive the highest level of benefits.

Comprehensive Office Visit Copayments — Office visit copayments are comprehensive and cover all diagnostic

and treatment services (including X-rays) provided at a medical office of a participating provider. These services

include preventive services, diagnostic procedures, therapeutic procedures, surgical procedures, medical supplies,

consultations and treatments. OB-GYN providers are considered primary care physicians, excluding maternity care.

Comprehensive hospital, medical and Rx coverage PLUS routine vision care and preventive dental — All at no

additional cost!

Preventive Services — Automatically includes routine health screenings, well-baby and well-child visits that

in-network doctors provide, with no dollar maximums. Routine preventive care is not covered out of network.

Pediatric Vision — Children ages 0 – 18 are eligible for one routine eye exam and one pair of frames and lenses

from a designated selection per benefit period. We provide benefits for contact lenses when deemed medically

necessary. The Physicians Eyecare Network (PEN) provides vision services. PEN is an independent company that

offers a vision provider network on behalf of BlueChoice.

Routine Screening for Colonoscopy and Mammogram — Covered at 100 percent at in-network providers.

Freestanding imaging and ambulatory surgical centers — Our network of freestanding imaging and ambulatory surgical

centers can save your employees money when they need surgery or a procedure that doesn’t require an overnight stay.

Specialist Visits — No referral necessary! Members can stay within our national network or seek medical care

outside the network. If they use professionals within our network, they’ll typically receive higher benefits.

Lab Choices — More lab choices, generating savings and less out-of-pocket costs for our members.

Doctors Care visits for the same cost as primary care visits — Saving your employees money when an ER visit is unnecessary.

Please refer to the plan grids on pages 14 – 27 for benefit details.

EXAMPLE FACILITY FEE*You use a freestanding ambulatory surgical center. $200

You use the hospital or an outpatient facility affiliated with a hospital. Deductible, then 30%

* Benefits vary. Please check your Schedule of Benefits.

VISIT TYPE FOR A SILVER 5550 MEMBER EXAMPLE OF OUT-OF-POCKET COSTS*Doctors Care, Primary Care Physician or Blue CareOnDemandSM $45

Emergency Room $500 Copayment, then 20% after deductible

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Tiered Prescription Drug BenefitsBlueChoice offers pharmacy benefits programs that provide the highest level of clinical effectiveness and safety

for the lowest net spending. Our goal is to help our members get the appropriate drugs they need at the best

price. One way we do this is by developing and maintaining a covered drug list (CDL).

We continually evaluate our prescription drug formularies and drug management programs to ensure that quality

and costs are managed effectively. We work with a group of independent doctors and pharmacists to evaluate our

pharmacy programs and get their recommendations. This group also approves decisions about our CDL, specialty

drug list and drug management programs. They base their decisions on a drug’s effectiveness, safety and value.

To view the CDL, visit www.BlueChoiceSC.com, go to the Member Center, and select BusinessADVANTAGE.

Six-Tier Drug ProgramBlueChoice has a six-tier prescription drug plan. This program offers flexibility in drug treatments. The chart shows

the drugs that are typically in each tier.

MEMBER COST

DRUG TIER USUALLY INCLUDES

$ Tier 1 Lowest-cost prescription generic and some over-the-counter drugs

$$ Tier 2 Prescription generic and some over-the-counter drugs

$$$ Tier 3Brand-name drugs that don’t have a generic available. Also may include higher-priced generics that have more cost-effective options at lower tiers.

$$$$ Tier 4Brand-name drugs that have brand or generic options at lower tiers. Also may include higher-priced generics that have more cost-effective options at lower tiers.

$$$$$ Tier 5Specialty drugs that are more cost-effective than other specialty drugs that treat the same conditions. Also may include some non-specialty brand or generic drugs that have more cost-effective options at lower tiers.

$$$$$$ Tier 6Specialty drugs that have more cost-effective alternatives at Tier 5. Also may include some non-specialty brand or generic drugs that have more cost-effective options at lower tiers.

http://www.BlueChoiceSC.com

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Value-Added Benefits and ServicesAll BusinessADVANTAGE plans include value-added benefits. These benefits are non-essential and do not count

toward any maximum out-of-pocket (MOOP) expenses.

Adult Routine Vision CareAll plans include our routine adult vision coverage provided through PEN. The benefit covers one eye exam each

year and one pair of glasses from a designated selection or contact lenses every two years. For members outside

of the South Carolina service area, we allow $71 toward the routine eye exam and $120 toward the purchase of

eyewear. The member must file these claims.

Preventive Dental CareAll plans include a dental allowance for exams and cleanings for adults and children. This benefit covers these

amounts per benefit period for exams and cleanings by any South Carolina-licensed dentist:

• Preventive dental, one exam every six months: $50

• Preventive dental, one cleaning every six months: $50

Members can send a completed dental reimbursement form and the paid receipt to BlueChoice for

reimbursement of the allowed amount. If you would like to offer a comprehensive dental plan, you can choose

one of our Blue DentalSM plans. See page 10 for details.

Employee Assistance Program (EAP)First Sun EAP provides a broad array of services designed to help people and encourage success at all levels in an

organization so your employees are at their best! Because First Sun is a separate company from BlueChoice, First

Sun will be responsible for all services related to the employee assistance program. By offering your employees the

employee assistance program, you can help to reduce the number of days employees miss, help to increase productivity

and bring out the best in your employees. These services are free to members and those in their households.

EAP services include, but are not limited to:

• Three free face-to-face sessions per person for individual, couples and family counseling

• Three free life-management services per person about topics like financial services, adoption assistance or elder

care resources

• Employer assistance with training, workplace services and on-site support

DiscountsAt BlueChoice, members can take advantage of great discount programs and special services. We offer these

services and discounts to our members in addition to, but not included in, the services and benefits covered

under a BlueChoice policy. Through our value-added services, members have access to special discounts or

benefits on services such as:

• Blue365®, a program offering nationwide discounts

• Weight-loss programs and centers

• Lasik services

• Fitness center discounts

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FOCUSfwd® Wellness Incentive ProgramThe FOCUSfwd Wellness Incentive Program is being redesigned to showcase its four unique programs,

plus a few new perks!

FOCUS PointsMembers are now rewarded for

completing activities that are an important

start to their overall health!

SweepstakesMembers can still win $1,000 quarterly

and annual cash rewards of $5,000 for

completing activities in all areas

of FOCUSfwd!

GET FITMembers receive exclusive FOCUSfwd

prizes and rewards for stepping up

to the challenge.

NutritionWe are giving members the knowledge and

control needed to take control of their health.

Members can search recipes, create meal plans,

obtain nutritional overviews of their meals for the

entire day, and much more!

Connect Prevent Challenge For FF Sales Sheet

Physical Activity Monthly Wellness Video

getFIT Challenge

For FF Sales Sheet

For FF Sales Sheet

getFIT Reach getFIT Stretch

These are used within the getFIT program under FOCUSfwd

QuickEnroll

QuickBill

FOCUSfwd GreatExpectations

Hearing Aids

Biometric Screening

Learning Management System

TobaccoCessationBlueChoice

HealthPlan WireMy Health

ToolkitRewards

2018 Icons - Cumulative

Bases

Storefront

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Education Center

Laboratory Benefits Mgmt

Physician’s Office Manual

News

BlueOption

Blues Flash

ProducersGuide

Discounts andAdded Values

Business ADV Core ServicesCore ServicesHealth Care Reform

Video Carolina ADVAdvantage Plus MyChoice ADV Primary Choice Medical PoliciesFlexible Savings

AccountHealth

Reimbursement Account

EmployeeAssistanceProgram

Mobile App

QuickEnroll

QuickBill


Hearing Aids

Biometric Screening




ToolkitRewards


Bases

Storefront

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Education Center



News

BlueOption

Blues Flash

ProducersGuide




AccountHealth



Mobile App

QuickEnroll

QuickBill


Hearing Aids

Biometric Screening




ToolkitRewards


Bases

Storefront

REV: 11/27/2018

Education Center



News

BlueOption

Blues Flash

ProducersGuide




AccountHealth



Mobile App

Keep an eye out for more information!

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Find CareHelping your employees find a participating provider is quick and easy! You can view and print customized lists of

health care providers and facilities. Your list will show providers or facilities in the ADVANTAGE network. You can

find providers and facilities located near you. You can even create directories based on the types of doctors your

employees may need.

To see if a doctor is in the network, have your employees visit www.BlueChoiceSC.com and select Find Care on

the homepage.


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Doctor Visits Anytime, Anywhere With Blue CareOnDemand, your employees can visit with a doctor via smartphone,

tablet or computer, rather than visiting an office or urgent care facility. Each

Blue CareOnDemand visit costs the same amount as a trip to their primary care

doctor. Doctors will diagnose and write prescriptions, as appropriate.

What types of medical issues can these doctors treat?• Cold and flu symptoms

• Bronchitis and other respiratory infections

• Sinus infections

• Pinkeye

• Ear infections

• Allergies

• Migraines

• Rashes and other skin irritations

• Urinary tract infections

And more!

Mental health and breastfeeding support services are also available through Blue CareOnDemand.

When should members use video visits?• If they need to see a doctor, but can’t fit it into

their schedule

• If their doctor’s office is closed

• If they feel too sick to drive

• If they have children at home and don’t want to bring

them to a doctor’s office

• If they are on business travel and stuck in a hotel room

Get started now!There are two easy ways for your employees to use Blue CareOnDemand.

• From a mobile phone or tablet, download the Blue CareOnDemand app for an Apple or Android device.

• From a computer, go to www.BlueCareOnDemandSC.com.

http://www.BlueCareOnDemandSC.com

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Great Expectations for health Coaching ProgramsComprehensive health management is an integral part of the services we offer to our members. We use a 360-degree

approach in managing the health of our members. There are programs for all members that focus on the early detection

of illness and the prevention of disease. Members with chronic conditions also receive more targeted educational

information and contact with our staff of highly trained health specialists. Those with intensive needs receive care

coordination and the support of our caring team of nurses. Members can self-enroll by calling 855-838-5897 and selecting

option 2.

CONDITION NAME DESCRIPTION

Adult ADHD

The Adult Attention Deficit Hyperactivity Disorder (ADHD) Program is a coaching program that educates members on steps to take to better manage their ADHD. The program helps members understand ADHD and empowers them with tools to manage medications and appointments. Members are able to set their own goals and may also receive educational mailings, access to online resources and newsletters, as appropriate.

Asthma (adult and pediatric)

The Great Expectations Asthma program helps members learn how to manage their asthma and improve their quality of life. Through ongoing partnership, collaboration, and telephonic coaching calls, our experienced respiratory therapists provide education about asthma and support for complying with each member’s doctor’s plan of care. Members can request a free peak flow meter.

Back Care

The Great Expectations Back Care program helps members learn to be active members of their health care team. Participants receive information on how to effectively partner with their healthcare provider(s), questions to ask their doctor, and options for pain management, including physical and behavioral therapies, self-care, and building an action plan to prevent future problems. Members with severe, chronic back pain will be considered for case management.

Bipolar Support

The Bipolar Support Program is a coaching program that helps members better manage their bipolar disorder. Coaches work with members in developing strategies to deal with mood shifts. The program educates and empowers members, allowing them to identify and self-monitor their symptoms. Members are able to set their own goals and may also receive educational mailings, access to online resources and newsletters, as appropriate.

Case Management

Great Expectations Case Management is a high-touch health care advocacy program designed to help members get the answers and services they need. We use a proactive, member-centered strategy focused on intensive education, care coordination and member empowerment across the care delivery system and throughout the life cycle of the disease.

Chronic Kidney Disease

Great Expectations Chronic Kidney Disease is an individualized program for members with stages 1 – 3 kidney disease. The program helps members learn how to manage their condition and reduce the risk of developing complications. Members have access to individualized telephonic coaching and educational materials. We automatically enroll eligible members at no charge. The program emphasizes the importance of having a personal physician to guide your kidney health management. This doctor can help you identify the best medications and dosing to enhance your kidney function and improve your quality of life.

Chronic Obstructive Pulmonary Disease (COPD)

Great Expectations COPD is a program that helps members with chronic obstructive pulmonary disease learn how to manage their disease. Our goal is to support members in practicing recommended self-care behaviors and following their physicians’ plan of care. Members may receive access to a personal health coach, educational materials, newsletters, and case management services, when needed.

tel:855-838-5897

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Depression

The Depression Program is a coaching program that assists members in developing a personalized plan for strategies to better manage their depression. The program educates and empowers members using evidence-based interventions for symptom monitoring. Members are able to set their own goals and may also receive educational mailings, access to online resources and newsletters, as appropriate.

Diabetes

The Great Expectations Diabetes program helps members learn how to manage their diabetes and reduce the risk of developing complications from their disease. Members may receive access to a personal health coach, educational materials, free preferred glucose monitors and a free yearly diabetes office visit. We also help members take advantage of their benefits for eye exams and diabetes education, both at no additional charge to the member.

Healthy and Active Kids and Teens

The Great Expectations Healthy and Active Kids and Teens program identifies children who are overweight or obese and offers their families education and interactive tools for adopting healthy habits.

Heart Disease

Great Expectations Heart Disease is a program for members with coronary artery or ischemic heart disease. The program educates members about lifestyle modifications and evidence-based guidelines for the monitoring and control of cardiac risk factors, such as hyperlipidemia and hypertension. Members may receive access to a personal health coach, educational materials, newsletters, and case management services, as appropriate.

Heart Failure

The Great Expectations Heart Failure program educates members with heart failure about appropriate self-care strategies to minimize exacerbation of their condition. Members receive access to a personal health coach, educational materials, newsletters, and case management services, as appropriate.

High Blood Pressure

Great Expectations High Blood Pressure is an educational program for members who want to learn more about managing their blood pressure. The program educates members about lifestyle modifications and evidence-based guidelines for the monitoring and control of cardiac risk factors, such as hypertension. Members may receive access to a personal health coach, access to online resources and newsletter, as appropriate.

High Cholesterol

The Great Expectations High Cholesterol program is an educational program for members who want to learn more about managing their cholesterol. The program educates members about lifestyle modifications and evidence-based guidelines for the monitoring and control of cardiac risk factors, such as high cholesterol. Members may receive access to a personal health coach, educational mailings, access to online resources and newsletters.

MaternityThe Great Expectations Maternity program educates members about taking steps toward having a healthy baby. We provide educational materials, support, and monitoring throughout a member’s pregnancy and postpartum period. The program is open to all eligible, expectant mothers.

Metabolic Health

The Great Expectations Metabolic Health program helps members learn how to manage pre-diabetes and/or metabolic syndrome, reducing the risk of developing complications such as type 2 diabetes and heart disease. Metabolic syndrome is the name of a group of conditions linked to being overweight or obese. Members may receive access to a personal health coach, educational materials to encourage lifestyle changes, free preferred glucose monitors for members with pre-diabetes, and information to help members take advantage of their benefits for free diabetes education.

Migraine

The Great Expectations Migraine program is for adults who suffer from severe, recurrent headaches. We provide information about the importance of having a personal physician to guide headache management. Members may receive access to a personal health coach, educational materials about pertinent migraine-related topics, access to online resources and newsletters, as appropriate.

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Moms Support Program

The Moms Support Program is a coaching program that helps moms across the child-bearing spectrum. Members develop strategies to better manage their depression and anxiety at any stage, pre or post-pregnancy. The program empowers and educates members, which allows them to identify and self-monitor their symptoms. Members are able to set their own goals. They may also receive educational mailings, access to online resources and newsletters, as appropriate.

NICU Case Management

We offer the Great Expectations NICU Case Management program to infants who have certain conditions. These conditions include, but aren’t limited to, complications associated with premature birth, congenital birth defects, hydrocephalus, seizures, cystic fibrosis and genetic disorders. Clinically experienced certified nurse case managers work closely with the caregiver and the member’s providers to ensure ongoing communication and coordination of care.

Recovery Support for Substance Use Disorder

The Recovery Support program helps members through recovery, one day at a time. Members set personal sobriety goals to stay off alcohol, opiates and other substances. Coaches help members develop a personalized action plan to help overcome the challenges of addiction and better manage their recovery. The program educates members about evidence-based coping strategies to deal with cravings and relapse triggers. Members may receive educational mailings, access to online resources and newsletters, as appropriate.

Stress Management

The Stress Management Program is a coaching program that helps members develop a personalized plan for strategies to better manage their stress. The program educates and empowers members, providing them with tools to improve functioning for an overall healthier life and lifestyle. Members are able to set their own goals and may also receive educational mailings, access to online resources and newsletters, as appropriate.

Tobacco Cessation

The Great Expectations Tobacco Cessation program is for members ages 18 and above and provides support and resources to help members become tobacco free. This program guides members through deciding to quit, identifying triggers and overcoming the challenges of giving up tobacco.

Weight Management

The Great Expectations Weight Management program educates members about healthy eating and exercise, as well as behavior modification strategies to maximize weight loss and maintenance. Members who enroll in the program receive unlimited telephone access to a weight-loss coach and a wide variety of digital tools designed to help members learn more about the key principles of implementing a successful weight-loss plan.


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Blue DentalFor Groups With 5 – 50 Employees

If you would like to offer a comprehensive dental plan to your employees, you can purchase one of our Blue

Dental plans. Blue Dental can offer your employees a whole-health approach to their dental care. By choosing

BlueChoice for both your medical and dental coverage, your covered employees get an integrated approach that

provides a complete picture of their overall health. Proper dental care can help your employees spot issues early,

like diabetes, heart disease, osteoporosis, oral cancer and kidney disease.

Our comprehensive dental offerings allow you to choose a dental benefit design that fits the needs of you and

your employees. Plus, by offering your medical and dental through BlueChoice, administering your dental benefits

becomes easier.

Why Choose Blue Dental?Flexible plan designsChoose from our comprehensive dental plan options: Open Access or Select.

OrthodontiaFor employers with preferred pricing, orthodontia is available for children and adults up to age 19. Preferred

pricing is for employers that contribute at least 50 percent or more of the single premium and have a minimum

10 or more contracts or 50 percent participation, whichever is greater.

Easy to administerSingle-source placement consolidates billing, eligibility and enrollment through a single account team.

Comprehensive dental networksBlue Dental gives your covered employees access to one of the industry’s largest national dental PPO networks.

Your covered employees can choose from more than 2,400 access points in South Carolina and more than 263,000

nationally. Referrals are not required before your covered employee sees a specialist. Visit www.BlueChoiceSC.com

for a comprehensive list of dental providers.

Let your BlueChoice representative help you find the best dental plan for your employees.


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Companion LifeCompanion Life offers a complete portfolio of innovative and competitive employee benefit plans. Because

Companion Life is a separate company from BlueChoice, Companion Life will be responsible for all services

related to these products. Companion Life specializes in comprehensive and affordable group life and disability

income programs with a variety of features and flexible plan design options. Products can be offered on a

voluntary or group basis.

LifeGroup term life insurance can be offered as a flat amount or multiple of salaries up to $500,000, with accidental

death and dismemberment included. Guaranteed issue amounts are available.

Short- and Long-Term DisabilityShort-term disability protection offers a wide selection of benefit percentages, waiting periods, benefit maximums

and payment durations up to one year. Partial disability is also available. Companion Life offers small group short-term

disability benefits down to two lives, with no pre-existing limitations on employer-paid plans.

Long-term disability protection provides choices for benefit payment maximums, elimination periods and benefit

duration periods. New enhancements include a less restrictive definition of a disability and a less restrictive

definition of own occupation.

Voluntary VisionYour BusinessADVANTAGE plan includes a routine vision program. If you prefer, you can also offer your employees

vision through Companion Life. To offer this service, two participants are required. Your employees will have access to

a national network of providers. You have the choice of three plans: exam-only, materials-only or exam and materials.

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Options That Make Your Life Easier It’s the little extras that make a big difference. Time and money savings can add up with these optional services.

QuickBillSM

QuickBill is an electronic benefit service that allows you to view and pay your invoices online, 24 hours a day,

seven days a week.

Bill PresentationView your invoices directly via the internet, 24 hours a day, seven days a week. New invoice notifications are sent

to you via email. Simply log in to QuickBill to view, print, export or create detailed reports.

Bill PaymentPay invoices via a one-time electronic funds transfer (EFT), establish a recurring credit card payment, or establish a

recurring bank draft from one of your corporate bank accounts. QuickBill offers a quick, easy and secure online payment

experience. Reduce the number of lost checks and invoices and decrease postage and check production costs.

Bill AdjustmentRequest and receive immediate invoice corrections. QuickBill Adjustment offers invoice approval and workflow

management capabilities designed to make your life easier. Adjustments are integrated with your health insurance

carrier’s membership system.

Online Eligibility Systems – QuickEnroll and ChoiceEnrollQuickEnroll is the group online enrollment and benefits administration platform, while ChoiceEnroll is the

platform agent’s use to manage all their BlueChoice small groups.

QuickEnroll replaces time-consuming, expensive and paper-based benefit enrollment with a comprehensive

electronic benefit administration and enrollment solution. It’s secure, online and paper free! Call your agent or

marketing representative to get started.

ChoiceEnroll eliminates paper by allowing enrollments, changes and terminations to be processed securely

online. There’s no software to download and best of all, this service is FREE. Agents can manage transactions and

requests, such as annual enrollments, terminations, qualifying life events, and more! All transactions are processed

in five minutes or less per event!

HRA/HSA/FSA/COBRAWe have health reimbursement accounts (HRAs), health savings accounts (HSAs), flexible spending accounts

(FSAs) and COBRA administration solutions. With BlueChoice, you have the flexibility of choosing the vendor to

meet your needs. We can discuss which of our partners can help you accomplish your goals.

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Access to Health Information AnytimeMy Health Toolkit

To get answers specific to their plan, your employees can create a free account and log in to My Health Toolkit.

My Health Toolkit is a protected, secure and convenient way for members to access their personal information.

With My Health Toolkit, your employees can:

• View their digital ID card.

• See if their claim has been paid.

• Ask Member Services a question.

• Access the FOCUSfwd Wellness Incentive Program.

• Find a doctor or hospital.

• Find out how much a prescription drug costs.

• Take a personal health assessment.

• Find out how much they have paid toward their deductible.

• View their Schedule of Benefits (SOB), which includes their copay and coinsurance amounts.

• Request a new member ID card.

My Health Toolkit AppYour employees can take My Health Toolkit with them when they’re on the go with our FREE mobile app! They can:

• View and share their digital ID card.

• Check the status of their claims.

• Confirm coverage.

• Find a doctor or hospital in network.

• Update their contact information.

• Access the FOCUSfwd Wellness Incentive Program.

Get the AppSearch for My Health Toolkit in the App Store or Google Play

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BENEFIT FEATURE & DESCRIPTION GOLD 1000 GOLD 1001 GOLD 1003 GOLD 1100 GOLD 1502 GOLD 1750 GOLD 2000 NEW – GOLD 2001Coinsurance 20% 30% 25% 30% 30% 25% 50% 40%

Deductible (Single/Family) $1,000/$2,000 $1,000/$2,000 $1,000/$2,000 $1,100/$2,200 $1,500/$3,000 $1,750/$3,500 $2,000/$4,000 $2,000/$4,000Maximum Out of Pocket (MOOP) (Single/Family) $7,000/$14,000 $5,500/$11,000 $6,000/$12,000 $5,000/$10,000 $5,000/$10,000 $4,250/$8,500 $4,000/$8,000 $7,000/$14,000

Annual Dollar Limits Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited UnlimitedLifetime Maximum Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited UnlimitedPrimary Care Physician (PCP) Office Visits $30 $20 $25 $20 $15 $25 $20 $25Doctors Care Office Visits/Blue CareOnDemand $30 $20 $25 $20 $15 $25 $20 $25Specialist Office Visits $60 $45 $50 $50 $45 $50 $45 $50

Inpatient Physician and Surgical Services 20% after deductible 30% after deductible 25% after deductible 30% after deductible 30% after deductible 25% after deductible 50% after deductible 40% after deductible

Outpatient Surgery Physician and Surgical Services 20% after deductible 30% after deductible 25% after deductible 30% after deductible 30% after deductible 25% after deductible 50% after deductible 40% after deductible

Urgent Care $75 $75 $75 $75 $75 $75 $75 $75

Freestanding Ambulatory Surgical Center* $200 per visit $200 per visit $200 per visit $200 per visit $200 per visit $200 per visit $200 per visit $200 per visit

Emergency Room 20% after deductible$250 copayment, then deductible,

then 30%25% after deductible 30% after deductible 30% after deductible 25% after deductible

$250 copayment, then deductible, then 50%

40% after deductible

Chiropractic Care** 20% after deductible 30% after deductible 25% after deductible 30% after deductible 30% after deductible 25% after deductible 50% after deductible 40% after deductible

Preventive Care/Screenings/Immunizations, including lactation support*** $0 $0 $0 $0 $0 $0 $0 $0

Pediatric Vision One exam per benefit period. Eyeglass frames every two years. Eyeglass lenses once per benefit period. In network only.

Exam — $25 Eyeglasses — $50








Inpatient Hospital Services**** Including mental health and substance use disorder, habilitation and rehabilitation

20% after deductible 30% after deductible 25% after deductible 30% after deductible 30% after deductible 25% after deductible 50% after deductible 40% after deductible

Outpatient Facility Fee (e.g., ambulatory surgical center) Including mental health and substance use disorder

20% after deductible 30% after deductible 25% after deductible 30% after deductible 30% after deductible 25% after deductible 50% after deductible 40% after deductible

Prescription DrugsSeparate Drug Deductible No No No No No No No No

Pharmacy Retail Copays reflect a 31-day supply. Can purchase a 90-day supply for three times the cost.

Tier 1: $20Tier 2: $20Tier 3: $40Tier 4: 20%Tier 5: 20%Tier 6: 20%

Tier 1: $15Tier 2: $15Tier 3: $35Tier 4: $70Tier 5: $250Tier 6: $250



Tier 1: $15 Tier 2: $15 Tier 3: $35 Tier 4: $70 Tier 5: $250 Tier 6: $250




Mail Order Generic and brand drugs are available for a 90-day supply through the mail-order program. Specialty drugs are available for a 30-day supply through the mail-order program.









2020 Gold Level Plans

Important Notes for 2020: • These products provide out-of-network coverage at 50 percent with no deductible or maximum out-of-pocket cost, except where noted otherwise. • Emergency room services received out of network are covered at the same level as in network if emergency room criteria is met. Non-contracting providers may

balance bill for services provided out of network.• Pharmacy benefits and preventive services are only covered at a participating provider. • All plans include: routine vision care, preventive dental, FOCUSfwd, EAP, personal health assessment and Blue CareOnDemand. • The MOOP for out-of-network services is unlimited. • All plans include an embedded deductible and MOOP.

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BENEFIT FEATURE & DESCRIPTION GOLD 1000 GOLD 1001 GOLD 1003 GOLD 1100 GOLD 1502 GOLD 1750 GOLD 2000 NEW – GOLD 200130% 30% 25% 50% 40%

$1,100/$2,200 $1,500/$3,000 $1,750/$3,500 $2,000/$4,000 $2,000/$4,000

$5,000/$10,000 $5,000/$10,000 $4,250/$8,500 $4,000/$8,000 $7,000/$14,000

Unlimited Unlimited Unlimited Unlimited UnlimitedUnlimited Unlimited Unlimited Unlimited Unlimited

$20 $15 $25 $20 $25$20 $15 $25 $20 $25$50 $45 $50 $45 $50

30% after deductible 30% after deductible 25% after deductible 50% after deductible 40% after deductible


$75 $75 $75 $75 $75

$200 per visit $200 per visit $200 per visit $200 per visit $200 per visit

30% after deductible 30% after deductible 25% after deductible$250 copayment, then deductible, then 50%



$0 $0 $0 $0 $0








No No No No No











Coinsurance 20% 30% 25%

Deductible (Single/Family) $1,000/$2,000 $1,000/$2,000 $1,000/$2,000Maximum Out of Pocket (MOOP) (Single/Family) $7,000/$14,000 $5,500/$11,000 $6,000/$12,000

Annual Dollar Limits Unlimited Unlimited UnlimitedLifetime Maximum Unlimited Unlimited UnlimitedPrimary Care Physician (PCP) Office Visits $30 $20 $25 Doctors Care Office Visits/Blue CareOnDemand $30 $20 $25 Specialist Office Visits $60 $45 $50

Inpatient Physician and Surgical Services 20% after deductible 30% after deductible 25% after deductible

Outpatient Surgery Physician and Surgical Services 20% after deductible 30% after deductible 25% after deductible

Urgent Care $75 $75 $75

Freestanding Ambulatory Surgical Center* $200 per visit $200 per visit $200 per visit

Emergency Room 20% after deductible$250 copayment, then deductible,

then 30%25% after deductible

Chiropractic Care** 20% after deductible 30% after deductible 25% after deductible

Preventive Care/Screenings/Immunizations, including lactation support*** $0 $0 $0






20% after deductible 30% after deductible 25% after deductible



Prescription DrugsSeparate Drug Deductible No No No









* Facility charges only. Providers may bill separately for their services.**Limited to 5 visits per benefit period for subluxation under chiropractic care.*** Covered according to the United States Preventive Services Task Force (USPSTF), the Centers for Disease Control and Prevention (CDC) and the Health

Resources and Services Administration (HRSA). It includes prostate screening (PSA). These are independent organizations that offer health information on behalf of BlueChoice.

****30 visits for rehabilitative therapy and 30 visits for habilitative therapy per benefit year.

16

BENEFIT FEATURE & DESCRIPTION GOLD 2400 GOLD 2503 NEW – GOLD 2700 GOLD 3000 NEW – GOLD 3001 NEW – GOLD 4500 NEW – GOLD 5225Coinsurance 0% 30% 25% 30% 15% 10% 0%

Deductible (Single/Family) $2,400/$4,800 $2,500/$5,000 $2,700/$5,400 $3,000/$6,000 $3,000/$6,000 $4,500/$9,000 $5,225/$10,450

Maximum Out of Pocket (MOOP) (Single/Family) $2,400/$4,800 $3,750/$7,500 $7,125/$14,250 $7,350/$14,700 $7,500/$15,000 $8,150/$16,300 $5,225/$10,450

Annual Dollar Limits Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited

Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited

Primary Care Physician (PCP) Office Visits Deductible $25 $20 30% $0 $0 $0

Doctors Care Office Visits/Blue CareOnDemand Deductible $25 $20 30% $0 $0 $0

Specialist Office Visits Deductible $50 $50 30% $50 $25 $50

Inpatient Physician and Surgical Services Deductible 30% after deductible 25% after deductible 30% after deductible 15% after deductible 10% after deductible Deductible

Outpatient Surgery Physician and Surgical Services Deductible 30% after deductible 25% after deductible 30% after deductible 15% after deductible 10% after deductible Deductible

Urgent Care Deductible $75 $75 30% $75 $75 $75

Freestanding Ambulatory Surgical Center* $200 per visit $200 per visit $200 per visit $200 per visit $200 per visit $200 per visit $200 per visit

Emergency Room Deductible 30% after deductible 25% after deductible 30% after deductible 15% after deductible 10% after deductible Deductible

Chiropractic Care** Deductible 30% after deductible 25% after deductible 30% after deductible 15% after deductible 10% after deductible Deductible

Preventive Care/Screenings/Immunizations, including lactation support*** $0 $0 $0 $0 $0 $0 $0










Deductible 30% after deductible 25% after deductible 30% after deductible 15% after deductible 10% after deductible Deductible


Deductible 30% after deductible 25% after deductible 30% after deductible 15% after deductible 10% after deductible Deductible

PRESCRIPTION DRUGSSeparate Drug Deductible No No No No No No No


All Tiers — Deductible



All Tiers — 30%








All Tiers — 30%




2020 Gold Level Plans



17

BENEFIT FEATURE & DESCRIPTION GOLD 2400 GOLD 2503 NEW – GOLD 2700 GOLD 3000 NEW – GOLD 3001 NEW – GOLD 4500 NEW – GOLD 522530% 15% 10% 0%

$3,000/$6,000 $3,000/$6,000 $4,500/$9,000 $5,225/$10,450

$7,350/$14,700 $7,500/$15,000 $8,150/$16,300 $5,225/$10,450

Unlimited Unlimited Unlimited Unlimited


30% $0 $0 $0

30% $0 $0 $0

30% $50 $25 $50

30% after deductible 15% after deductible 10% after deductible Deductible


30% $75 $75 $75

$200 per visit $200 per visit $200 per visit $200 per visit



$0 $0 $0 $0







No No No No

All Tiers — 30%




All Tiers — 30%





Deductible (Single/Family) $2,400/$4,800 $2,500/$5,000 $2,700/$5,400

Maximum Out of Pocket (MOOP) (Single/Family) $2,400/$4,800 $3,750/$7,500 $7,125/$14,250

Annual Dollar Limits Unlimited Unlimited Unlimited

Lifetime Maximum Unlimited Unlimited Unlimited

Primary Care Physician (PCP) Office Visits Deductible $25 $20

Doctors Care Office Visits/Blue CareOnDemand Deductible $25 $20

Specialist Office Visits Deductible $50 $50

Inpatient Physician and Surgical Services Deductible 30% after deductible 25% after deductible

Outpatient Surgery Physician and Surgical Services Deductible 30% after deductible 25% after deductible

Urgent Care Deductible $75 $75


Emergency Room Deductible 30% after deductible 25% after deductible

Chiropractic Care** Deductible 30% after deductible 25% after deductible







Deductible 30% after deductible 25% after deductible


Deductible 30% after deductible 25% after deductible

PRESCRIPTION DRUGSSeparate Drug Deductible No No No












18

2020 Silver Level PlansBENEFIT FEATURE & DESCRIPTION SILVER 2000 SILVER 2375 SILVER 2850 SILVER 3200 SILVER 3500 SILVER 4500

Coinsurance 50% 50% 45% 50% 40% 50%

Deductible (Single/Family) $2,000/$4,000 $2,375/$4,750 $2,850/$5,700 $3,200/$6,400 $3,500/$7,000 $4,500/$9,000

Maximum Out of Pocket (MOOP) (Single/Family) $7,500/$15,000 $8,150/$16,300 $8,000/$16,000 $7,500/$15,000 $8,000/$16,000 $8,150/$16,300

Annual Dollar Limits Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited

Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited

Primary Care Office (PCP) Visits $35 $40 $35 $35 $40 $40

Doctors Care Office Visits/Blue CareOnDemand $35 $40 $35 $35 $40 $40

Specialist Office Visits $75 $80 $65 $75 $80 $80

Inpatient Physician and Surgical Services 50% after deductible 50% after deductible 45% after deductible 50% after deductible 40% after deductible 50% after deductible

Outpatient Surgery Physician and Surgical Services 50% after deductible 50% after deductible 45% after deductible 50% after deductible 40% after deductible 50% after deductible

Urgent Care $75 $75 $75 $75 $75 $75

Freestanding Ambulatory Surgical Center* $200 per visit $200 per visit $200 per visit $200 per visit $200 per visit $200 per visit

Emergency Room $400 copayment,

then deductible, then 50% $350 copayment,

then deductible, then 50%$250 copayment,



then deductible, then 40%50% after deductible

Chiropractic Care** 50% after deductible 50% after deductible 45% after deductible 50% after deductible 40% after deductible 50% after deductible

Preventive Care/Screenings/Immunizations, including lactation support*** $0 $0 $0 $0 $0 $0













40% after deductible 50% after deductible


50% after deductible 50% after deductible 45% after deductible 50% after deductible 40% after deductible 50% after deductible

PRESCRIPTION DRUGSSeparate Drug Deductible No No No No No No


Tier 1: $20Tier 2: $20Tier 3: 50% after deductibleTier 4: 50% after deductibleTier 5: 50% after deductibleTier 6: 50% after deductible















19

BENEFIT FEATURE & DESCRIPTION SILVER 2000 SILVER 2375 SILVER 2850 SILVER 3200 SILVER 3500 SILVER 450045% 50% 40% 50%

$2,850/$5,700 $3,200/$6,400 $3,500/$7,000 $4,500/$9,000

$8,000/$16,000 $7,500/$15,000 $8,000/$16,000 $8,150/$16,300



$35 $35 $40 $40

$35 $35 $40 $40

$65 $75 $80 $80

45% after deductible 50% after deductible 40% after deductible 50% after deductible


$75 $75 $75 $75







$0 $0 $0 $0









No No No No









Coinsurance 50% 50%

Deductible (Single/Family) $2,000/$4,000 $2,375/$4,750

Maximum Out of Pocket (MOOP) (Single/Family) $7,500/$15,000 $8,150/$16,300

Annual Dollar Limits Unlimited Unlimited

Lifetime Maximum Unlimited Unlimited

Primary Care Office (PCP) Visits $35 $40

Doctors Care Office Visits/Blue CareOnDemand $35 $40

Specialist Office Visits $75 $80

Inpatient Physician and Surgical Services 50% after deductible 50% after deductible

Outpatient Surgery Physician and Surgical Services 50% after deductible 50% after deductible

Urgent Care $75 $75

Freestanding Ambulatory Surgical Center* $200 per visit $200 per visit


then deductible, then 50% $350 copayment,

then deductible, then 50%

Chiropractic Care** 50% after deductible 50% after deductible

Preventive Care/Screenings/Immunizations, including lactation support*** $0 $0









PRESCRIPTION DRUGSSeparate Drug Deductible No No










20

BENEFIT FEATURE & DESCRIPTION NEW – SILVER 4800 NEW – SILVER 5000 SILVER 5001 NEW – SILVER 5550 SILVER 5800 SILVER 6750Coinsurance 20% 30% 30% 20% 0% 0%

Deductible (Single/Family) $4,800/$9,600 $5,000/$10,000 $5,000/$10,000 $5,550/$11,100 $5,800/$11,600 $6,750/$13,500

Maximum Out of Pocket (MOOP) (Single/Family) $6,000/$12,000 $7,900/$15,800 $7,900/$15,800 $7,350/$14,700 $5,800/$11,600 $6,750/$13,500

Annual Dollar Limits Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited

Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited

Primary Care Office (PCP) Visits $25 $20 $30 $45 $45 $0

Doctors Care Office Visits/Blue CareOnDemand $25 $20 $30 $45 $45 $0

Specialist Office Visits $50 $45 $60 $100 $90 $55

Inpatient Physician and Surgical Services 20% after deductible 30% after deductible 30% after deductible 20% after deductible Deductible Deductible

Outpatient Surgery Physician and Surgical Services 20% after deductible 30% after deductible 30% after deductible 20% after deductible Deductible Deductible

Urgent Care $75 $75 $75 $75 $75 $75

Freestanding Ambulatory Surgical Center* $200 per visit $200 per visit $200 per visit $200 per visit $200 per visit $200 per visit





then deductible, then 20%$300 copayment, then deductible

$150 copayment, then deductible

Chiropractic Care** 20% after deductible 30% after deductible 30% after deductible 20% after deductible Deductible Deductible

Preventive Care/Screenings/Immunizations, including lactation support*** $0 $0 $0 $0 $0 $0











30% after deductible$500 copayment,




20% after deductible 30% after deductible 30% after deductible 20% after deductible Deductible Deductible

PRESCRIPTION DRUGSSeparate Drug Deductible No $450 Deductible No No No No


All Tiers — 20% after deductible

Tier 1: $15Tier 2: $15Tier 3: $35Tier 4: Rx deductible, then 30%Tier 5: Rx deductible, then 30%Tier 6: Rx deductible, then 30%


Tier 1: $15Tier 2: $15Tier 3: $35Tier 4: 20% after deductibleTier 5: 20% after deductibleTier 6: 20% after deductible










2020 Silver Level Plans



21

BENEFIT FEATURE & DESCRIPTION NEW – SILVER 4800 NEW – SILVER 5000 SILVER 5001 NEW – SILVER 5550 SILVER 5800 SILVER 675030% 20% 0% 0%

$5,000/$10,000 $5,550/$11,100 $5,800/$11,600 $6,750/$13,500

$7,900/$15,800 $7,350/$14,700 $5,800/$11,600 $6,750/$13,500



$30 $45 $45 $0

$30 $45 $45 $0

$60 $100 $90 $55

30% after deductible 20% after deductible Deductible Deductible


$75 $75 $75 $75







$0 $0 $0 $0





30% after deductible$500 copayment,




No No No No









Coinsurance 20% 30%








Inpatient Physician and Surgical Services 20% after deductible 30% after deductible

Outpatient Surgery Physician and Surgical Services 20% after deductible 30% after deductible

Urgent Care $75 $75




then deductible, then 30%

Chiropractic Care** 20% after deductible 30% after deductible










PRESCRIPTION DRUGSSeparate Drug Deductible No $450 Deductible










22

BENEFIT FEATURE & DESCRIPTION SILVER 6850 NEW – SILVER 7001 NEW – SILVER 7100 SILVER 7350 NEW – SILVER 8150Coinsurance 40% 0% 20% 0% 0%

Deductible (Single/Family) $6,850/$13,700 $7,000/$14,000 $7,100/$14,200 $7,350/$14,700 $8,150/$16,300

Maximum Out of Pocket (MOOP) (Single/Family) $7,800/$15,600 $7,000/$14,000 $8,150/$16,300 $7,350/$14,700 $8,150/$16,300

Annual Dollar Limits Unlimited Unlimited Unlimited Unlimited Unlimited

Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Unlimited

Primary Care Office (PCP) Visits $25 $0 $15 $40 $0

Doctors Care Office Visits/Blue CareOnDemand $25 $0 $15 $40 $0

Specialist Office Visits $60 $50 $50 $80 $50

Inpatient Physician and Surgical Services 40% after deductible Deductible 20% after deductible Deductible Deductible

Outpatient Surgery Physician and Surgical Services 40% after deductible Deductible 20% after deductible Deductible Deductible

Urgent Care $75 $75 $75 $75 $75

Freestanding Ambulatory Surgical Center* $200 per visit $200 per visit $200 per visit $200 per visit $200 per visit

Emergency Room 40% after deductible $500 copayment, then deductible $500 copayment, then deductible, then 20% Deductible $500 copayment, then deductible

Chiropractic Care** 40% after deductible Deductible 20% after deductible Deductible Deductible

Preventive Care/Screenings/Immunizations, including lactation support*** $0 $0 $0 $0 $0








40% after deductible $500 copayment, then deductible $500 copayment, then deductible, then 20% Deductible $500 copayment, then deductible


40% after deductible Deductible 20% after deductible Deductible Deductible

PRESCRIPTION DRUGSSeparate Drug Deductible No No No No No



Tier 1: $25Tier 2: $25Tier 3: $45Tier 4: DeductibleTier 5: DeductibleTier 6: Deductible


Tier 1 - $35 Tier 2 - $35 Tier 3 - $60 Tier 4 - $75 Tier 5 - $300 Tier 6 - $300








2020 Silver Level Plans



23

BENEFIT FEATURE & DESCRIPTION SILVER 6850 NEW – SILVER 7001 NEW – SILVER 7100 SILVER 7350 NEW – SILVER 815020% 0% 0%

$7,100/$14,200 $7,350/$14,700 $8,150/$16,300

$8,150/$16,300 $7,350/$14,700 $8,150/$16,300

Unlimited Unlimited Unlimited

Unlimited Unlimited Unlimited

$15 $40 $0

$15 $40 $0

$50 $80 $50

20% after deductible Deductible Deductible


$75 $75 $75

$200 per visit $200 per visit $200 per visit

$500 copayment, then deductible, then 20% Deductible $500 copayment, then deductible


$0 $0 $0




$500 copayment, then deductible, then 20% Deductible $500 copayment, then deductible


No No No







Coinsurance 40% 0%








Inpatient Physician and Surgical Services 40% after deductible Deductible

Outpatient Surgery Physician and Surgical Services 40% after deductible Deductible

Urgent Care $75 $75


Emergency Room 40% after deductible $500 copayment, then deductible

Chiropractic Care** 40% after deductible Deductible






40% after deductible $500 copayment, then deductible


40% after deductible Deductible

PRESCRIPTION DRUGSSeparate Drug Deductible No No










24

2020 Bronze Level PlansBENEFIT FEATURE & DESCRIPTION NEW – BRONZE 5550 NEW – BRONZE 5800 BRONZE 6000 NEW – BRONZE 6500 BRONZE 7300 BRONZE 7901 NEW – BRONZE 8150

Coinsurance 20% 20% 20% 20% 50% 0% 0%

Deductible (Single/Family) $5,550/$11,100 $5,800/$11,600 $6,000/$12,000 $6,500/$13,000 $7,300/$14,600 $7,900/$15,800 $8,150/$16,300

Maximum Out of Pocket (MOOP) (Single/Family) $7,900/$15,800 $8,150/$16,300 $7,900/$15,800 $8,150/$16,300 $8,150/$16,300 $7,900/$15,800 $8,150/$16,300

Annual Dollar Limits Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited UnlimitedLifetime Maximum Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited

Primary Care Office Visits 20% after deductible $45 20% after deductible $40 $40 $45 Deductible

Doctors Care Office Visits/Blue CareOnDemand 20% after deductible $45 20% after deductible $40 $40 $45 Deductible

Specialist Office Visits 20% after deductible $90 20% after deductible $90 $90 $90 Deductible

Inpatient Physician and Surgical Services 20% after deductible 20% after deductible 20% after deductible 20% after deductible 50% after deductible Deductible Deductible

Outpatient Surgery Physician and Surgical Services 20% after deductible 20% after deductible 20% after deductible 20% after deductible 50% after deductible Deductible Deductible

Urgent Care 20% after deductible $75 20% after deductible $75 $75 $75 Deductible

Freestanding Ambulatory Surgical Center* $200 per visit $200 per visit $200 per visit $200 per visit $200 per visit $200 per visit $200 per visit

Emergency Room $500 copayment, then deductible,

then 20%

$500 copayment, then deductible,

then 20%


then 20%





Chiropractic Care** 20% after deductible 20% after deductible 20% after deductible 20% after deductible 50% after deductible Deductible Deductible

Preventive Care/Screenings/Immunizations, including lactation support*** $0 $0 $0 $0 $0 $0 $0











then 20%


then 20%


then 20%






20% after deductible 20% after deductible 20% after deductible 20% after deductible 50% after deductible Deductible Deductible

PRESCRIPTION DRUGSSeparate Drug Deductible/Coinsurance No No No No No No No


All Tiers —20% after deductible





Tier 1: $35Tier 2: $35Tier 3: DeductibleTier 4: DeductibleTier 5: DeductibleTier 6: Deductible












25

BENEFIT FEATURE & DESCRIPTION NEW – BRONZE 5550 NEW – BRONZE 5800 BRONZE 6000 NEW – BRONZE 6500 BRONZE 7300 BRONZE 7901 NEW – BRONZE 815020% 50% 0% 0%

$6,500/$13,000 $7,300/$14,600 $7,900/$15,800 $8,150/$16,300

$8,150/$16,300 $8,150/$16,300 $7,900/$15,800 $8,150/$16,300

Unlimited Unlimited Unlimited UnlimitedUnlimited Unlimited Unlimited Unlimited

$40 $40 $45 Deductible












$0 $0 $0 $0










No No No No












Annual Dollar Limits Unlimited Unlimited UnlimitedLifetime Maximum Unlimited Unlimited Unlimited

Primary Care Office Visits 20% after deductible $45 20% after deductible

Doctors Care Office Visits/Blue CareOnDemand 20% after deductible $45 20% after deductible

Specialist Office Visits 20% after deductible $90 20% after deductible

Inpatient Physician and Surgical Services 20% after deductible 20% after deductible 20% after deductible

Outpatient Surgery Physician and Surgical Services 20% after deductible 20% after deductible 20% after deductible

Urgent Care 20% after deductible $75 20% after deductible


Emergency Room $500 copayment, then deductible,

then 20%


then 20%


then 20%Chiropractic Care** 20% after deductible 20% after deductible 20% after deductible








then 20%


then 20%


then 20%



PRESCRIPTION DRUGSSeparate Drug Deductible/Coinsurance No No No










Resources and Services Administration (HRSA). It includes prostate screening (PSA). These are independent organizations that offer health information on behof BlueChoice.


alf

26

BENEFIT FEATURE & DESCRIPTION GOLD 2850 HD NEW – GOLD 3225 HD SILVER 4200 HDCoinsurance 0% 0% 0%



Annual Dollar Limits Unlimited Unlimited Unlimited

Lifetime Maximum Unlimited Unlimited Unlimited

Primary Care Physician (PCP) Office Visits Deductible Deductible Deductible

Doctors Care Office Visits/Blue CareOnDemand Deductible Deductible Deductible

Specialist Office Visits Deductible Deductible Deductible

Inpatient Physician and Surgical Services Deductible Deductible Deductible

Outpatient Surgery Physician and Surgical Services Deductible Deductible Deductible

Urgent Care Deductible Deductible Deductible

Freestanding Ambulatory Surgical Center* Deductible Deductible Deductible

Emergency Room Deductible Deductible Deductible

Chiropractic Care** Deductible Deductible Deductible


Pediatric Vision One exam per benefit period. Eyeglass frames every two years. Eyeglass lenses once per benefit period.In network only.





Deductible Deductible Deductible


Deductible Deductible Deductible

PRESCRIPTION DRUGSSeparate Drug Deductible No No No


All Tiers — Deductible All Tiers — Deductible All Tiers — Deductible


All Tiers — Deductible All Tiers — Deductible All Tiers — Deductible

2020 HDHP Plans



27

SILVER 4600 HD SILVER 5004 HD BRONZE 6200 HD BRONZE 6900 HD0% 0% 0% 0%

$4,600/$9,200 $5,000/$10,000 $6,200/$12,400 $6,900/$13,800

$4,600/$9,200 $5,000/$10,000 $6,200/$12,400 $6,900/$13,800



Deductible Deductible Deductible Deductible







Deductible Deductible Deductible DeductibleDeductible Deductible Deductible Deductible

$0 $0 $0 $0







No No No No

All Tiers — Deductible All Tiers — Deductible All Tiers — Deductible All Tiers — Deductible

All Tiers — Deductible All Tiers — Deductible All Tiers — Deductible All Tiers — Deductible




28

2020 BusinessADVANTAGESM Plan ChangesThis grid illustrates benefit changes that will become effective Jan. 1, 2020, for existing BusinessADVANTAGE plans that were offered during 2019. Please refer to your Schedule of Benefits for complete details of your 2020 plan benefits.

GOLD PLANSGOLD 1000 2019 - Gold 1000 2020 - Gold 1000

Coinsurance 15% 20%

GOLD 1001 2019 - Gold 1001 2020 - Gold 1001Coinsurance 25% 30%

Individual MOOP $4,500 $5,500

Family MOOP $9,000 $11,000

Primary Care Visit $15 $20

Specialist Office Visit $35 $45

GOLD 1002 2019 - Gold 1002 2020 - Gold 1001Plan is no longer available. Members will move to Gold 1001.Coinsurance 20% 30%


Family MOOP $10,000 $11,000


GOLD 1003 2019 - Gold 1003 2020 - Gold 1003Individual MOOP $5,000 $6,000

Family MOOP $10,000 $12,000

GOLD 1012 2019 - Gold 1012 2020 - Gold 1750Plan is no longer available. Name changes to Gold 1750.Coinsurance 30% 25%

Individual Deductible $1,000 $1,750

Family Deductible $2,000 $3,500


Family MOOP $8,000 $8,500


GOLD 1250 2019 - Gold 1250 2020 - Gold 1750Plan is no longer available. Members will move to Gold 1750.Coinsurance 20% 25%



29

GOLD PLANS (continued)GOLD 1502 2019 - Gold 1502 2020 - Gold 1502

Coinsurance 20% 30%


Family MOOP $8,000 $10,000






2019 GOLD 2001 2019 - Gold 2001 2020 - Gold 2400Members who were in the Gold 2001 plan in 2019 will be moved to new Gold 2400 in 2020.Individual Deductible $2,000 $2,400




GOLD 2200 2019 - Gold 2200 2020 - Gold 2400Plan is no longer available. Members will move to Gold 2400.Individual Deductible $2,200 $2,400




GOLD 2700 HD 2019 - Gold 2700 HD 2020 - Gold 2850 HDPlan is no longer available. Name changes to Gold 2850 HD.Individual Deductible $2,700 $2,850




30

SILVER PLANSSILVER 1500 2019 - Silver 1500 2020 - Silver 2375

Plan is no longer available. Members will move to Silver 2375.Individual Deductible $1,500 $2,375



Family MOOP $15,800 $16,300



SILVER 2000 2019 - Silver 2000 2020 - Silver 2000Coinsurance 30% 50%


Family MOOP $13,200 $15,000


Specialist Office Visit $25, then deductible, then 30% $75

SILVER 2001 2019 - Silver 2001 2020 - Silver 2375Plan is no longer available. Members will move to Silver 2375.Individual Deductible $2,000 $2,375



Family MOOP $15,800 $16,300



SILVER 2400 2019 - Silver 2400 2020 - Silver 2850Plan is no longer available. Members will move to Silver 2850.Coinsurance 50% 45%




Family MOOP $14,000 $16,000






Family MOOP $15,800 $16,000



31

SILVER PLANS (continued)SILVER 2502 2019 - Silver 2502 2020 - Silver 2000

Plan is no longer available. Members will move to Silver 2000.Individual Deductible $2,500 $2,000



Family MOOP $14,700 $15,000

Primary Care Visit$0 for the first two visits,

then 50% after deductible$35

Specialist Office Visit 50% after deductible $75

SILVER 2750 2019 - Silver 2750 2020 - Silver 2850Plan is no longer available. Name changes to Silver 2850.Individual Deductible $2,750 $2,850



Family MOOP $15,500 $16,000







Family MOOP $14,700 $16,000


SILVER 3000 2019 - Silver 3000 2020 - Silver 3200Plan is no longer available. Name changes to Silver 3200.Coinsurance 40% 50%








Family MOOP $15,800 $16,000



32



Family MOOP $14,000 $16,000







Family MOOP $13,700 $15,000



SILVER 3850 HD 2019 - Silver 3850 HD 2020 - Silver 4200 HDPlan is no longer available. Name changes to Silver 4200 HD. Individual Deductible $3,850 $4,200




SILVER 4400 HD 2019 - Silver 4400 HD 2020 - Silver 4600 HDPlan is no longer available. Name changes to Silver 4600 HD. Individual Deductible $4,400 $4,600




SILVER 4500 2019 - Silver 4500 2020 - Silver 4500Individual MOOP $7,000 $8,150

Family MOOP $14,000 $16,300



SILVER 5001 2019 - Silver 5001 2020 - Silver 5001Coinsurance 20% 30%


Family MOOP $15,100 $15,800



33


Plan is no longer available. Name changes to Silver 5800.Individual Deductible $5,250 $5,800



Family MOOP $10,500 $11,600




Family MOOP $13,100 $13,500


SILVER 6750 2019 - Silver 6750 2020 - Silver 6750Specialist Office Visit $45 $55

SILVER 6850 2019 - Silver 6850 2020 - Silver 6850Individual MOOP $7,350 $7,800

Family MOOP $14,700 $15,600






Family MOOP $14,500 $16,300





Family MOOP $15,800 $16,300


34

BRONZE PLANSBRONZE 4400 2019 - Bronze 4400 2020 - Bronze 5550

Plan is no longer available. Members will move to Bronze 5550.Coinsurance 50% 20%




Family MOOP $14,700 $15,800

Primary Care Visit $45 20% after deductible

Specialist Office Visit $45, then deductible, then 50% 20% after deductible

BRONZE 5501 HD 2019 - Bronze 5501 HD 2020 - Bronze 6200 HDPlan is no longer available. Name changes to Bronze 6200 HD.Individual Deductible $5,500 $6,200



Family MOOP $11,000 $12,400

BRONZE 5550 2019 - Bronze 5550 2020 - Silver 5550Members who were in the Bronze 5550 plan in 2019 will be moved to new Silver 5550 in 2020.Coinsurance 50% 20%



BRONZE 5750 2019 - Bronze 5750 2020 - Silver 5000Plan is no longer available. Members will move to Silver 5000.Coinsurance 50% 30%





BRONZE 6000 2019 - Bronze 6000 2020 - Bronze 6000Coinsurance 50% 20%

Primary Care Visit$0 for the first two visits,

then 50% after deductible20% after deductible

Specialist Office Visit 50% after deductible 20% after deductible

BRONZE 6550 HD 2019 - Bronze 6550 HD 2020 - Bronze 6900 HDPlan is no longer available. Name changes to Bronze 6900 HD.Individual Deductible $6,550 $6,900



Family MOOP $13,100 $13,800

35

BRONZE PLANS (continued)BRONZE 7000 2019 - Bronze 7000 2020 - Silver 7001

Plan is no longer available. Members will move to Silver 7001.Primary Care Visit $45 $0


BRONZE 7100 2019 - Bronze 7100 2020 - Silver 7100Plan is no longer available. Members will move to Silver 7100.Coinsurance 0% 20%


Family MOOP $14,200 $16,300



BRONZE 7300 2019 - Bronze 7300 2020 - Bronze 7300Coinsurance 0% 50%


Family MOOP $14,600 $16,300

Primary Care Visit Deductible $40

Specialist Office Visit Deductible $90

BRONZE 7900 2019 - Bronze 7900 2020 - Silver 8150Plan is no longer available. Members will move to Silver 8150.Individual Deductible $7,900 $8,150



Family MOOP $15,800 $16,300



36

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Statement of ConfidentialityBlueChoice knows how important it is to protect the privacy of each member’s confidential medical information.

Here are the efforts we make to protect your privacy.

Protection of PrivacyBlueChoice keeps all medical information about a member strictly confidential. BlueChoice has administrative,

technical and physical safeguards in place to protect the privacy of members’ personal health information. Our

information systems have advanced security that limits access to personal health information to authorized

personnel only. We require all staff to keep confidential any personal health information they learn in performing

their jobs. Additionally, staff is required to limit requests to external entities for a member’s personal health

information to the minimum necessary for their intended purpose.

BlueChoice requires all physicians and other health care professionals in our provider network to maintain the

confidentiality of their patients’ health information, and they must guard against unauthorized or inadvertent

disclosure of this confidential information. Through on-site visits, BlueChoice reviews each provider’s privacy

policies and methods for storing and protecting patients’ medical records.

BlueChoice requires all business associates, consultants and other entities with whom we contract for clinical or

administrative services to maintain such confidentiality and to have a privacy policy in place that protects against

unauthorized use or disclosure of confidential information. All such entities must sign an agreement attesting to

the fact that they are compliant with federal privacy regulations.

Collection, Use and Disclosure of Medical InformationBlueChoice may use and disclose medical information about your employee for the purposes of treatment, payment

and health care operations. Examples of these routine activities that involve the collection, use and disclosure

of health information include getting information from health care providers to determine medical necessity,

processing claims, issuing Explanations of Benefits to policyholders and conducting quality improvement activities.

If there is a need to release member-identifiable information for purposes other than those approved by law for

treatment, payment and health care operations, BlueChoice must first get a written authorization form signed by

the member. The authorization form allows the member to specify what information BlueChoice is authorized to

release, to whom it may be released and for what purpose.

BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association.

BlueChoiceSC.com


210863-BCS-2005-8-2019

Our Commitment to Keeping Your Employees HealthyBlueChoice has a commitment to offer quality comprehensive health care coverage. We participate in these

quality-focused programs:

• Health Employer Data and Information Set (HEDIS®) — a set of measures health plans use to uniformly collect

data and report on their performance.

• Consumer Assessment of Healthcare Providers and Systems (CAHPS) — standardized surveys of patients’ experiences.

• Touchpoints — a quality assurance (QA) program that measures performance of all Blue Plans on established

criteria the Blue Cross and Blue Shield Association sets.

In each of these programs, we consistently meet or exceed national averages on measures that most other

carriers don’t even track. From our 98 percent score on timeliness of prenatal care to an average claim processing

time of less than two days, BlueChoice is focused on providing exceptional quality and superior service.

Your representative can provide you with the most updated operational performance statistics.

Documents

Blue Option 6-Tier Business ADVANTAGE Sales Book...We are giving members the knowledge and . control needed to take control of their health. ... News Blue Option Blues Flash. Producers