Common use of HOW TO USE THIS BOOKLET Clause in Contracts

HOW TO USE THIS BOOKLET. We realize that using a health care plan can seem complicated, so we’ve prepared this contract to help you understand how to get the most out of your benefits. Please contact Customer Service if you have any questions about this plan. We are happy to answer your questions and hear any of your comments. On our website at xxxxxxx.xxx you can also:  Learn more about your plan  Find a healthcare provider near you  Look for information about many health topics Every section in this booklet contains important information, but the following sections may be particularly useful to you:  How to Contact Us – Our website, phone numbers, mailing addresses and other contact information are on the back cover.  Summary of Your Costs – Lists your costs for covered services.  Important Plan Information – Describes deductibles, copayments, coinsurance, out-of-pocket maximums and allowed amounts  How Providers Affect Your Costs – How using an in-network provider affects your benefits and lowers your out-of-pocket costs  Prior Authorization – Describes our prior authorization and emergency admission notifications provision  Clinical Review – Describes our clinical review provision  Personal Health Support Programs – Describes our personal health support programs  Continuity of Care – Describes how to continue care at the in-network level of benefits when a provider is no longer in the network  Covered Services –A detailed description of what is covered  Exclusions – Describes services that are not covered  Other Coverage – Describes how benefits are paid when you have other coverage or what you must do when a third party is responsible for an injury or illness  Sending Us a Claim –Instructions on how to send in a claim  Complaints and Appeals – What to do if you want to share ideas, ask questions, file a complaint, or submit an appeal  Eligibility and Enrollment – Describes who can be covered.  Termination of Coverage – Describes when coverage ends  Other Plan Information – Lists general information about how this plan is administered and required state and federal notices  Definitions – Meanings of words and terms used TABLE OF CONTENTS HOW TO CONTACT US (SEE BACK COVER OF THIS BOOKLET) SUMMARY OF YOUR COSTS 1 IMPORTANT PLAN INFORMATION 7 Calendar Year Deductible 7 Copayments 8 Coinsurance 8 Out-Of-Pocket Maximum 8 Allowed Amount 8 HOW PROVIDERS AFFECT YOUR COSTS 9 Medical Services 9 CARE MANAGEMENT 10 Prior Authorization 11 Clinical Review 12 Personal Health Support Programs 12 Continuity Of Care 12 COVERED SERVICES 13 Common Medical Services 14 Other Covered Services 29 EXCLUSIONS 32 OTHER COVERAGE 37 Coordinating Benefits With Other Plans 37 Third Party Liability (Subrogation) 39 SENDING US A CLAIM 40 COMPLAINTS AND APPEALS 41 ELIGIBILITY AND ENROLLMENT 43 Open Enrollment Period 44 When Coverage Begins 45 TERMINATION 47 When Coverage Ends 47 Continuation of Coverage 47 OTHER PLAN INFORMATION 48 DEFINITIONS 52 MULTI-STATE PLAN BLUE CROSS BRONZE PPO 6350 This plan uses the following network:  Heritage Signature medical network SUMMARY OF YOUR COSTS This is a summary of your costs for covered services. Your costs are subject to the all of the following:  The allowed amount. This is the most this plan allows for a covered service. See Important Plan Information for details. Non-contracted providers may bill you for amounts over the allowed amount, even when the cost share says No charge.  The copays. These are set dollar amounts you pay at the time you get services. Only one office visit copay per provider per day will apply.  The deductible. The amount you pay before this plan covers healthcare costs. Network Providers Out-of-Network Providers Individual deductible $6,350 $12,700 Family deductible $12,700 Not Applicable  The out-of-pocket maximum. This is the most you pay each year for services from in-network providers. There is no out-of-pocket maximum for out-of-network providers. Network Providers Out-of-Network Providers Individual out-of-pocket maximum $6,850 $13,700 Family out-of-pocket maximum $13,700 Not applicable Prior authorization. Some services must be authorized by us in writing before you get them, in order to be eligible for benefits. See Prior Authorization for details. The conditions, time limits and maximum limits are described in this booklet. Some services have special rules. See Covered Services for these details.

HOW TO USE THIS BOOKLET. We realize that using a health care plan can seem complicated, so we’ve prepared this contract to help you understand how to get the most out of your benefits. Please contact Customer Service if you have any questions about this plan. We are happy to answer your questions and hear any of your comments. On our website at xxxxxxx.xxx you can also:  Learn more about your plan  Find a healthcare provider near you  Look for information about many health topics Every section in this booklet contains important information, but the following sections may be particularly useful to you:  How to Contact Us – Our website, phone numbers, mailing addresses and other contact information are on the back cover.  Summary of Your Costs – Lists your costs for covered services.  Important Plan Information – Describes deductibles, copayments, coinsurance, out-of-pocket maximums and allowed amounts  How Providers Affect Your Costs – How using an in-network provider affects your benefits and lowers your out-of-pocket costs  Prior Authorization – Describes our prior authorization and emergency admission notifications provision  Clinical Review – Describes our clinical review provision  Personal Health Support Programs – Describes our personal health support programs  Continuity of Care – Describes how to continue care at the in-network level of benefits when a provider is no longer in the network  Covered Services –A detailed description of what is covered  Exclusions – Describes services that are not covered  Other Coverage – Describes how benefits are paid when you have other coverage or what you must do when a third party is responsible for an injury or illness  Sending Us a Claim –Instructions on how to send in a claim  Complaints and Appeals – What to do if you want to share ideas, ask questions, file a complaint, or submit an appeal  Eligibility and Enrollment – Describes who can be covered.  Termination of Coverage – Describes when coverage ends  Other Plan Information – Lists general information about how this plan is administered and required state and federal notices  Definitions – Meanings of words and terms used TABLE OF CONTENTS HOW TO CONTACT US (SEE BACK COVER OF THIS BOOKLET) SUMMARY OF YOUR COSTS 1 IMPORTANT PLAN INFORMATION 7 6 Calendar Year Deductible 7 6 Copayments 8 6 Coinsurance 8 6 Out-Of-Pocket Maximum 8 6 Allowed Amount 8 7 HOW PROVIDERS AFFECT YOUR COSTS 9 8 Medical Services 9 8 CARE MANAGEMENT 10 9 Prior Authorization 11 9 Clinical Review 12 10 Personal Health Support Programs 12 10 Continuity Of Care 12 11 COVERED SERVICES 13 11 Common Medical Services 14 12 Other Covered Services 29 27 EXCLUSIONS 32 30 OTHER COVERAGE 37 35 Coordinating Benefits With Other Plans 37 35 Third Party Liability (Subrogation) 39 37 SENDING US A CLAIM 40 38 COMPLAINTS AND APPEALS 41 39 ELIGIBILITY AND ENROLLMENT 43 41 Open Enrollment Period 44 42 When Coverage Begins 43 TERMINATION 45 TERMINATION 47 When Coverage Ends 47 45 Continuation of Coverage 47 45 OTHER PLAN INFORMATION 48 46 DEFINITIONS 52 50 MULTI-STATE PLAN BLUE CROSS BRONZE PPO 6350 SILVER 3000 HSA CSR1 This plan uses the following network:  Heritage Signature medical network SUMMARY OF YOUR COSTS This is a summary of your costs for covered services. Your costs are subject to the all of the following:  The allowed amount. This is the most this plan allows for a covered service. See Important Plan Information for details. Non-contracted providers may bill you for amounts over the allowed amount, even when the cost share says No charge.  The copays. These are set dollar amounts you pay at the time you get services. Only one office visit copay per provider per day will apply.  The deductible. The amount you pay before this plan covers healthcare costs. Network Providers Out-of-Network Providers Individual deductible $6,350 2,600 $12,700 5,200 Family deductible $12,700 Not Applicable 5,200 $10,400  The out-of-pocket maximum. This is the most you pay each year for services from in-network providers. There is no out-of-pocket maximum for out-of-network providers. Network Providers Out-of-Network Providers Individual out-of-pocket maximum $6,850 $13,700 3,500 Not applicable Family out-of-pocket maximum $13,700 7,000 Not applicable Prior authorization. Some services must be authorized by us in writing before you get them, in order to be eligible for benefits. See Prior Authorization for details. The conditions, time limits and maximum limits are described in this booklet. Some services have special rules. See Covered Services for these details.

HOW TO USE THIS BOOKLET. We realize that using a health care plan can seem complicated, so we’ve prepared this contract to help you understand how to get the most out of your benefits. Please contact Customer Service if you have any questions about this plan. We are happy to answer your questions and hear any of your comments. On our website at xxxxxxx.xxx you can also:  Learn more about your plan  Find a healthcare provider near you  Look for information about many health topics Every section in this booklet contains important information, but the following sections may be particularly useful to you:  How to Contact Us – Our website, phone numbers, mailing addresses and other contact information are on the back cover.  Summary of Your Costs – Lists your costs for covered services.  Important Plan Information – Describes deductibles, copayments, coinsurance, out-of-pocket maximums and allowed amounts  How Providers Affect Your Costs – How using an in-network provider affects your benefits and lowers your out-of-pocket costs  Prior Authorization – Describes our prior authorization and emergency admission notifications provision  Clinical Review – Describes our clinical review provision  Personal Health Support Programs – Describes our personal health support programs  Continuity of Care – Describes how to continue care at the in-network level of benefits when a provider is no longer in the network  Covered Services –A detailed description of what is covered  Exclusions – Describes services that are not covered  Other Coverage – Describes how benefits are paid when you have other coverage or what you must do when a third party is responsible for an injury or illness  Sending Us a Claim –Instructions on how to send in a claim  Complaints and Appeals – What to do if you want to share ideas, ask questions, file a complaint, or submit an appeal  Eligibility and Enrollment – Describes who can be covered.  Termination of Coverage – Describes when coverage ends  Other Plan Information – Lists general information about how this plan is administered and required state and federal notices  Definitions – Meanings of words and terms used TABLE OF CONTENTS HOW TO CONTACT US (SEE BACK COVER OF THIS BOOKLET) SUMMARY OF YOUR COSTS 1 IMPORTANT PLAN INFORMATION 7 6 Calendar Year Deductible 7 6 Copayments 8 6 Coinsurance 8 6 Out-Of-Pocket Maximum 8 6 Allowed Amount 8 7 HOW PROVIDERS AFFECT YOUR COSTS 9 8 Medical Services 9 8 CARE MANAGEMENT 10 9 Prior Authorization 11 9 Clinical Review 12 10 Personal Health Support Programs 12 10 Continuity Of Care 12 11 COVERED SERVICES 13 11 Common Medical Services 14 12 Other Covered Services 29 27 EXCLUSIONS 32 30 OTHER COVERAGE 37 34 Coordinating Benefits With Other Plans 37 34 Third Party Liability (Subrogation) 39 37 SENDING US A CLAIM 40 38 COMPLAINTS AND APPEALS 41 38 ELIGIBILITY AND ENROLLMENT 43 42 Open Enrollment Period 44 42 When Coverage Begins 43 TERMINATION 45 TERMINATION 47 When Coverage Ends 47 45 Continuation of Coverage 47 45 OTHER PLAN INFORMATION 48 46 DEFINITIONS 52 MULTI-STATE PLAN 50 PREMERA BLUE CROSS BRONZE PPO 6350 PREFERRED SILVER 3000 HSA This plan uses the following network:  Heritage Signature medical network SUMMARY OF YOUR COSTS This is a summary of your costs for covered services. Your costs are subject to the all of the following:  The allowed amount. This is the most this plan allows for a covered service. See Important Plan Information for details. Non-contracted providers may bill you for amounts over the allowed amount, even when the cost share says No charge.  The copays. These are set dollar amounts you pay at the time you get services. Only one office visit copay per provider per day will apply.  The deductible. The amount you pay before this plan covers healthcare costs. Network Providers Out-of-Network Providers Individual deductible $6,350 3,000 $12,700 6,000 Family deductible $12,700 Not Applicable 6,000 $12,000  The out-of-pocket maximum. This is the most you pay each year for services from in-network providers. There is no out-of-pocket maximum for out-of-network providers. Network Providers Out-of-Network Providers Individual out-of-pocket maximum $6,850 $13,700 4,100 Not applicable Family out-of-pocket maximum $13,700 8,200 Not applicable Prior authorization. Some services must be authorized by us in writing before you get them, in order to be eligible for benefits. See Prior Authorization for details. The conditions, time limits and maximum limits are described in this booklet. Some services have special rules. See Covered Services for these details.

HOW TO USE THIS BOOKLET. We realize that using a health care plan can seem complicated, so we’ve prepared this contract to help you understand how to get the most out of your benefits. Please contact Customer Service if you have any questions about this plan. We are happy to answer your questions and hear any of your comments. On our website at xxxxxxx.xxx you can also:  Learn more about your plan  Find a healthcare provider near you  Look for information about many health topics Every section in this booklet contains important information, but the following sections may be particularly useful to you:  How to Contact Us – Our website, phone numbers, mailing addresses and other contact information are on the back cover.  Summary of Your Costs – Lists your costs for covered services.  Important Plan Information – Describes deductibles, copayments, coinsurance, out-of-pocket maximums and allowed amounts  How Providers Affect Your Costs – How using an in-network provider affects your benefits and lowers your out-of-pocket costs  Prior Authorization – Describes our prior authorization and emergency admission notifications provision  Clinical Review – Describes our clinical review provision  Personal Health Support Programs – Describes our personal health support programs  Continuity of Care – Describes how to continue care at the in-network level of benefits when a provider is no longer in the network  Covered Services –A detailed description of what is covered  Exclusions – Describes services that are not covered  Other Coverage – Describes how benefits are paid when you have other coverage or what you must do when a third party is responsible for an injury or illness  Sending Us a Claim –Instructions on how to send in a claim  Complaints and Appeals – What to do if you want to share ideas, ask questions, file a complaint, or submit an appeal  Eligibility and Enrollment – Describes who can be covered.  Termination of Coverage – Describes when coverage ends  Other Plan Information – Lists general information about how this plan is administered and required state and federal notices  Definitions – Meanings of words and terms used TABLE OF CONTENTS HOW TO CONTACT US (SEE BACK COVER OF THIS BOOKLET) SUMMARY OF YOUR COSTS 1 IMPORTANT PLAN INFORMATION 7 Calendar Year Deductible 7 Copayments 8 Coinsurance 8 Out-Of-Pocket Maximum 8 Allowed Amount 8 HOW PROVIDERS AFFECT YOUR COSTS 9 Medical Services 9 CARE MANAGEMENT 10 Prior Authorization 11 Clinical Review 12 Personal Health Support Programs 12 Continuity Of Care 12 COVERED SERVICES 13 Common Medical Services 14 Other Covered Services 29 EXCLUSIONS 32 OTHER COVERAGE 37 Coordinating Benefits With Other Plans 37 Third Party Liability (Subrogation) 39 SENDING US A CLAIM 40 COMPLAINTS AND APPEALS 41 ELIGIBILITY AND ENROLLMENT 43 Open Enrollment Period 44 When Coverage Begins 45 TERMINATION 47 When Coverage Ends 47 Continuation of Coverage 47 OTHER PLAN INFORMATION 48 DEFINITIONS 52 MULTI-STATE PLAN BLUE CROSS BRONZE PPO 6350 GOLD 1000 This plan uses the following network:  Heritage Signature medical network SUMMARY OF YOUR COSTS This is a summary of your costs for covered services. Your costs are subject to the all of the following:  The allowed amount. This is the most this plan allows for a covered service. See Important Plan Information for details. Non-contracted providers may bill you for amounts over the allowed amount, even when the cost share says No charge.  The copays. These are set dollar amounts you pay at the time you get services. Only one office visit copay per provider per day will apply.  The deductible. The amount you pay before this plan covers healthcare costs. Network Providers Out-of-Network Providers Individual deductible $6,350 1,000 $12,700 2,000 Family deductible $12,700 2,000 Not Applicable  The out-of-pocket maximum. This is the most you pay each year for services from in-network providers. There is no out-of-pocket maximum for out-of-network providers. Network Providers Out-of-Network Providers Individual out-of-pocket maximum $6,850 $13,700 4,500 Not applicable Family out-of-pocket maximum $13,700 9,000 Not applicable Prior authorization. Some services must be authorized by us in writing before you get them, in order to be eligible for benefits. See Prior Authorization for details. The conditions, time limits and maximum limits are described in this booklet. Some services have special rules. See Covered Services for these details.

HOW TO USE THIS BOOKLET. We realize that using a health care plan can seem complicated, so we’ve prepared this contract to help you understand how to get the most out of your benefits. Please contact Customer Service if you have any questions about this plan. We are happy to answer your questions and hear any of your comments. On our website at xxxxxxx.xxx you can also:  Learn more about your plan  Find a healthcare provider near you  Look for information about many health topics Every section in this booklet contains important information, but the following sections may be particularly useful to you:  How to Contact Us – Our website, phone numbers, mailing addresses and other contact information are on the back cover.  Summary of Your Costs – Lists your costs for covered services.  Important Plan Information – Describes deductibles, copayments, coinsurance, out-of-pocket maximums and allowed amounts  How Providers Affect Your Costs – How using an in-network provider affects your benefits and lowers your out-of-pocket costs  Prior Authorization – Describes our prior authorization and emergency admission notifications provision  Clinical Review – Describes our clinical review provision  Personal Health Support Programs – Describes our personal health support programs  Continuity of Care – Describes how to continue care at the in-network level of benefits when a provider is no longer in the network  Covered Services –A detailed description of what is covered  Exclusions – Describes services that are not covered  Other Coverage – Describes how benefits are paid when you have other coverage or what you must do when a third party is responsible for an injury or illness  Sending Us a Claim –Instructions on how to send in a claim  Complaints and Appeals – What to do if you want to share ideas, ask questions, file a complaint, or submit an appeal  Eligibility and Enrollment – Describes who can be covered.  Termination of Coverage – Describes when coverage ends  Other Plan Information – Lists general information about how this plan is administered and required state and federal notices  Definitions – Meanings of words and terms used TABLE OF CONTENTS HOW TO CONTACT US (SEE BACK COVER OF THIS BOOKLET) SUMMARY OF YOUR COSTS 1 IMPORTANT PLAN INFORMATION 7 6 Calendar Year Deductible 7 6 Copayments 8 6 Coinsurance 8 6 Out-Of-Pocket Maximum 8 6 Allowed Amount 8 7 HOW PROVIDERS AFFECT YOUR COSTS 9 8 Medical Services 9 8 CARE MANAGEMENT 10 9 Prior Authorization 11 9 Clinical Review 12 10 Personal Health Support Programs 12 10 Continuity Of Care 12 11 COVERED SERVICES 13 11 Common Medical Services 14 12 Other Covered Services 29 27 EXCLUSIONS 32 30 OTHER COVERAGE 37 34 Coordinating Benefits With Other Plans 37 34 Third Party Liability (Subrogation) 39 37 SENDING US A CLAIM 40 38 COMPLAINTS AND APPEALS 41 38 ELIGIBILITY AND ENROLLMENT 43 42 Open Enrollment Period 44 42 When Coverage Begins 43 TERMINATION 45 TERMINATION 47 When Coverage Ends 47 45 Continuation of Coverage 47 45 OTHER PLAN INFORMATION 48 46 DEFINITIONS 52 MULTI-STATE PLAN 50 PREMERA BLUE CROSS PREFERRED BRONZE PPO 6350 HSA 5250 This plan uses the following network:  Heritage Signature medical network SUMMARY OF YOUR COSTS This is a summary of your costs for covered services. Your costs are subject to the all of the following:  The allowed amount. This is the most this plan allows for a covered service. See Important Plan Information for details. Non-contracted providers may bill you for amounts over the allowed amount, even when the cost share says No charge.  The copays. These are set dollar amounts you pay at the time you get services. Only one office visit copay per provider per day will apply.  The deductible. The amount you pay before this plan covers healthcare costs. Network Providers Out-of-Network Providers Individual deductible $6,350 5,250 $12,700 10,500 Family deductible $12,700 Not Applicable 10,500 $21,000  The out-of-pocket maximum. This is the most you pay each year for services from in-network providers. There is no out-of-pocket maximum for out-of-network providers. Network Providers Out-of-Network Providers Individual out-of-pocket maximum $6,850 $13,700 6,100 Not applicable Family out-of-pocket maximum $13,700 12,200 Not applicable Prior authorization. Some services must be authorized by us in writing before you get them, in order to be eligible for benefits. See Prior Authorization for details. The conditions, time limits and maximum limits are described in this booklet. Some services have special rules. See Covered Services for these details.