Common use of Important Information Regarding HSAs Clause in Contracts

Important Information Regarding HSAs. The PPO Savings Plan is not a “Health Savings Account” or an “HSA”. It is designed as a “high deductible health plan” that may allow Employers, if they are eligible, to take advantage of the income tax benefits available when they establish an HSA for their employees. The money put into the HSA is used to pay for qualified medical expenses subject to the deductibles under this Plan. NOTICE: Blue Shield does not provide tax advice. If Employers intend to purchase this Plan to use with an HSA for tax purposes, they should consult with their tax advisor about whether they are eligible and whether their HSA meets all legal requirements. The HSA is a governmental pilot program that is continued year to year at the discretion of Congress. Blue Shield has designed this Plan to meet government requirements for a high deductible health plan to be used in conjunction with establishing eligibility for HSA tax benefits. Although Blue Shield believes that this Plan meets these requirements, the Internal Revenue Service has not ruled on whether the Plan is qualified as a high deductible health plan. Should an Employer purchase this Plan in order to obtain the income tax benefits associated with an HSA and the Internal Revenue Service were to rule that this Plan does not qualify as a high deductible health plan, the Employer and employees may not be eligible for the income tax benefits associated with an HSA. In this instance, they may have adverse income tax consequences with respect to their HSA for all years in which they were not eligible. However, if there were such a ruling, or if government requirements for a high deductible health plan change, Blue Shield intends to amend the PPO Savings Plan prospectively, if necessary, to meet the requirements of a qualified plan. A change in the Plan's Dues may also be required as a result of a change in the Plan. To learn more about Health Savings Accounts, eligibility and the law's current provisions, the Subscriber can consult with a financial advisor. (GPHSA) PART I. INTRODUCTION 4 PART II. DEFINITIONS 4 PART III. ELIGIBILITY 5

Important Information Regarding HSAs. The PPO Savings This Plan is not a “Health Savings Account” or an “HSA”. It , but is designed as a “high deductible health plan” that may allow Employersyou, if they you are eligible, to take advantage of the income tax benefits available to you when they you establish an HSA for their employees. The and use the money you put into the HSA is used to pay for qualified medical expenses ex- penses subject to the deductibles under this Plan. NOTICE: Blue Shield does not provide tax advice. If Employers intend to purchase this Plan to use with an HSA for tax purposes, they should consult with their tax advisor about whether they are eligible and whether their HSA meets all legal requirements. The HSA is a governmental pilot program that is continued year to year at the discretion of Congress. Blue Shield has designed this Plan to meet government requirements for a high deductible health plan to be used in conjunction with establishing eligibility for HSA tax benefits. Although Blue Shield believes that this Plan meets these requirements, the Internal Revenue Service has not ruled on whether the Plan is qualified as a high deductible health plan. Should an Employer purchase this Plan was selected in order to obtain the income tax benefits associated with an HSA and the Internal Revenue Service were to rule that this Plan does not qualify as a high deductible health plan, the Employer and employees you may not be eligible for the income tax benefits associated with an HSA. In this instance, they you may have adverse income tax consequences with respect to their your HSA for all years in which they you were not eligible. HoweverNOTICE: Blue Shield does not provide tax advice. If you intend to purchase this Plan to use with an HSA for tax purposes, if there were such you should consult with your tax advisor about whether you are eligible and whether your HSA meets all legal requirements. This Evidence of Coverage and Disclosure Form (EOC) constitutes only a ruling, or if government requirements for a high deductible summary of the Health Plan. The health plan changecontract must be consulted to determine the exact terms and conditions of coverage. Please read this EOC carefully and completely to understand which services are Covered Services, Blue Shield intends and the limitations and exclusions that apply to amend the PPO Savings Plan prospectively, if necessary, to meet the requirements of a qualified plan. A change in the Plan's Dues may also be required as a result of a change in the Plan. To learn more Pay particular attention to those sections of the EOC that apply to any special health care needs. For questions about Health Savings Accountsthis Plan, eligibility and please contact Blue Shield Customer Service at the law's current provisions, address or telephone number provided on the Subscriber can consult with a financial advisor. (GPHSA) PART I. INTRODUCTION 4 PART II. DEFINITIONS 4 PART III. ELIGIBILITY 5back page of this EOC.

Important Information Regarding HSAs. The Full PPO Savings HSA Plan is not a “Health Savings Account” or an “HSA”. It is designed as a “high deductible health plan” that may allow Small Employers, if they are eligible, to take advantage of the income tax benefits available when they establish an HSA for their employees. The money put into the HSA is used to pay for qualified medical expenses subject to the deductibles under this Plan. NOTICE: Blue Shield does not provide tax advice. If Small Employers intend to purchase this Plan to use with an HSA for tax purposes, they should consult with their tax advisor about whether they are eligible and whether their HSA meets all legal requirements. The HSA is a governmental pilot program that is continued year to year at the discretion of Congress. Blue Shield has designed this Plan to meet government requirements for a high deductible health plan to be used in conjunction with establishing eligibility for HSA tax benefits. Although Blue Shield believes that this Plan meets these requirements, the Internal Revenue Service has not ruled on whether the Plan is qualified as a high deductible health plan. Should an a Small Employer purchase this Plan in order to obtain the income tax benefits associated with an HSA and the Internal Revenue Service were to rule that this Plan does not qualify as a high deductible health plan, the Employer and employees may not be eligible for the income tax benefits associated with an HSA. In this instance, they may have adverse income tax consequences with respect to their HSA for all years in which they were not eligible. However, if there were such a ruling, or if government requirements for a high deductible health plan change, Blue Shield intends to amend the Full PPO Savings HSA Plan prospectively, if necessary, to meet the requirements of a qualified plan. A change in the Plan's Dues may also be required as a result of a change in the Plan. To learn more about Health Savings Accounts, eligibility and the law's current provisions, the Subscriber can consult with a financial advisor. (GPHSA) PART I. INTRODUCTION 4 PART II. DEFINITIONS 4 PART III. ELIGIBILITY 5

Important Information Regarding HSAs. The Shield PPO Savings Plan is not a “Health Savings Account” or an “HSA”. It is designed as a “high deductible health plan” that may allow Small Employers, if they are eligible, to take advantage of the income tax benefits available when they establish an HSA for their employees. The money put into the HSA is used to pay for qualified medical expenses subject to the deductibles under this Plan. NOTICE: Blue Shield does not provide tax advice. If Small Employers intend to purchase this Plan to use with an HSA for tax purposes, they should consult with their tax advisor about whether they are eligible and whether their HSA meets all legal requirements. The HSA is a governmental pilot program that is continued year to year at the discretion of Congress. Blue Shield has designed this Plan to meet government requirements for a high deductible health plan to be used in conjunction with establishing eligibility for HSA tax benefits. Although Blue Shield believes that this Plan meets these requirements, the Internal Revenue Service has not ruled on whether the Plan is qualified as a high deductible health plan. Should an a Small Employer purchase this Plan in order to obtain the income tax benefits associated with an HSA and the Internal Revenue Service were to rule that this Plan does not qualify as a high deductible health plan, the Employer and employees may not be eligible for the income tax benefits associated with an HSA. In this instance, they may have adverse income tax consequences with respect to their HSA for all years in which they were not eligible. However, if there were such a ruling, or if government requirements for a high deductible health plan change, Blue Shield intends to amend the Shield PPO Savings Plan prospectively, if necessary, to meet the requirements of a qualified plan. A change in the Planplan's Dues dues may also be required as a result of a change in the Planplan. To learn more about Health Savings Accounts, eligibility and the law's current provisions, the Subscriber can consult with a financial advisor. (GPHSA) PART I. INTRODUCTION 4 C-4 PART II. DEFINITIONS 4 DEFINITIONS........................................................................................................................................................ C-4 PART III. ELIGIBILITY 5ELIGIBILITY........................................................................................................................................................ C-5 PART V. DUES...................................................................................................................................................................... C-8 PART VI. INTER-PLAN PROGRAMS (BLUECARD PROGRAM AND OTHERS) ....................................................... C-9 X. Xxxxx Period ............................................................................................................................................................ C-11 E. Payment or Refund of Dues Upon Cancellation...................................................................................................... C-11 F. Termination of Benefits........................................................................................................................................... C-11 B. Use of Masculine Pronoun ...................................................................................................................................... C-12 C. Workers' Compensation........................................................................................................................................... C-12 D. Changes: Entire Contract........................................................................................................................................ C-12 E. Statutory Requirements ........................................................................................................................................... C-13 F. Legal Process........................................................................................................................................................... C-13 G. Time of Commencement or Termination ................................................................................................................ C-13 H. Records and Information to be Furnished ............................................................................................................... C-13 I. Inquiries and Complaints......................................................................................................................................... C-13 J. Confidentiality......................................................................................................................................................... C-13 K. ERISA Plan Administrator ...................................................................................................................................... C-13 PART IX. CONTRACTHOLDER RESPONSIBILITY FOR DISTRIBUTION AND NOTIFICATION REQUIREMENTSC-14 Refer to the Table of Contents in the Evidence of Coverage and Disclosure Form The Evidence of Coverage and Disclosure Form includes the following optional Benefits/riders: Substance Abuse Condition Benefits