Common use of THIS CONTRACT IS NOT A MEDICARE SUPPLEMENT POLICY Clause in Contracts

THIS CONTRACT IS NOT A MEDICARE SUPPLEMENT POLICY. If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare available from us. IMPORTANT CONTACT INFORMATION AND WEB SITES • Our Customer Service numbers are: (000) 000-0000 or 0-000-000-0000 or Voice TDD 711 (711 is a national relay service for the deaf and hearing impaired). • Our normal business hours: Monday - Friday from 8:00 a.m. - 8:00 p.m. Please see Section 1.5 for more details. • Our Website: xxx.XXXXXX.xxx. • Blue Stores/Walk-in Service Centers – visit our website for specific locations and business hours. • Recommended Preauthorization Services for which preauthorization is recommended are marked with an asterisk (*) in the Summary of Medical Benefits. To obtain preauthorization for a covered health care service: o BCBSRI providers will obtain preauthorization on your behalf for covered health care services they provide to you o For mental health and substance abuse disorder services we recommend that your BCBSRI provider call our Behavioral Health Administrator at 0-000-000-0000 before you receive inpatient, residential substance abuse program, partial hospital or intermediate care services. Lines are open 24 hours a day, 7 days per week • Required Preauthorization: See the Pharmacy Benefits section and the Summary of Pharmacy Benefits for information about required prescription drug preauthorization. BlueCard Access - 1-800-810-BLUE (2583) or visit the BlueCard Doctor and Hospital finder web page at xxx.xxxx.xxx. HealthSource RI – 0-000-000-0000 EyeMed Vision Care – 0-000-000-0000 HELPFUL TIPS • Read all information provided, especially this Subscriber Agreement. Become familiar with services excluded from coverage (See Section 4.0– Health Services Not Covered Under This Agreement.)

THIS CONTRACT IS NOT A MEDICARE SUPPLEMENT POLICY. If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare available from us. IMPORTANT CONTACT INFORMATION AND WEB SITES •  Our Customer Service numbers are: (000) 000-0000 or 0-000-000-0000 or Voice TDD 711 (711 is a national relay service for the deaf and hearing impaired). •  Our normal business hours: Monday - Friday from 8:00 a.m. - 8:00 p.m. Please see Section 1.5 for more details. •  Our Website: xxx.XXXXXX.xxx. •  Blue Stores/Walk-in Service Centers – visit our website for specific locations and business hours. •  Recommended Preauthorization Services for which preauthorization is recommended are marked with an asterisk (*) in the Summary of Medical Benefits. To obtain preauthorization for a covered health care service: o BCBSRI providers will obtain preauthorization on your behalf for covered health care services they provide to you o For mental health and substance abuse disorder services we recommend that your BCBSRI provider call our Behavioral Health Administrator at 0-000-000-0000 before you receive inpatient, residential substance abuse program, partial hospital or intermediate care services. Lines are open 24 hours a day, 7 days per week •  Required Preauthorization: See the Pharmacy Benefits section and the Summary of Pharmacy Benefits for information about required prescription drug preauthorization. BlueCard Access - 1-800-810-BLUE (2583) or visit the BlueCard Doctor and Hospital finder web page at xxx.xxxx.xxx. HealthSource RI – 0-000-000-0000 EyeMed Vision Care – 0-000-000-0000 HELPFUL TIPS •  Read all information provided, especially this Subscriber Agreement. Become familiar with services excluded from coverage (See Section 4.0– Health Services Not Covered Under This Agreement.))  In Section 8.0 – Glossary, there is a list of definitions of words used throughout this agreement. It is very helpful to become familiar with these words and their definitions.  Identification Cards (ID) are provided to all members. The ID card must be shown when obtaining health care services. Your ID card should be kept in a safe location, just like money, credit cards or other important documents. BCBSRI should be notified immediately if your ID card is lost or stolen.  Our list of network providers changes from time to time. You may want to call our Customer Service Department in advance to make sure that a provider is a network provider.  You are encouraged to choose a primary care physician. Although no referral from a primary care physician is needed to receive covered health care services from a specialist physician, primary care physicians can help manage health care services.  You are encouraged to become involved in your health care treatment by asking providers about all treatment plans available and their costs. You also are encouraged to take advantage of the preventive health services offered under this agreement to help you stay healthy and find problems before they become serious.

THIS CONTRACT IS NOT A MEDICARE SUPPLEMENT POLICY. If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare available from us. IMPORTANT CONTACT INFORMATION AND WEB SITES • Our Customer Service numbers are: (000) 000-0000 or 0-000-000-0000 or Voice TDD 711 (711 is a national relay service for the deaf and hearing impaired). • Our normal business hours: Monday - Friday from 8:00 a.m. - 8:00 p.m. Please see Section 1.5 for more details. • Our Website: xxx.XXXXXX.xxx. • Blue Stores/Walk-in Service Centers – visit our website for specific locations and business hours. • Recommended Preauthorization Services for which preauthorization is recommended are marked with an asterisk (*) in the Summary of Medical Benefits. To obtain preauthorization for a covered health care service: o BCBSRI providers will obtain preauthorization on your behalf for covered health care services they provide to you o For mental health and substance abuse disorder services we recommend that your BCBSRI provider call our Behavioral Health Administrator at 0-000-000-0000 before you receive inpatient, residential substance abuse program, partial hospital or intermediate care services. Lines are open 24 hours a day, 7 days per week • Required Preauthorization: See the Pharmacy Benefits section and the Summary of Pharmacy Benefits for information about required prescription drug preauthorization. BlueCard Access - 1-800-810-BLUE (2583) or visit the BlueCard Doctor and Hospital finder web page at xxx.xxxx.xxx. HealthSource RI – 0-000-000-0000 EyeMed Vision Care – 0-000-000-0000 HELPFUL TIPS • Read all information provided, especially this Subscriber Agreement. Become familiar with services excluded from coverage (See Section 4.0– Health Services Not Covered Under This Agreement.)