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. 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. IMPORTANT TELEPHONE NUMBERS 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. HealthSource RI – 0-000-000-0000 EyeMed Vision Care – 0-000-000-0000 BlueCard Access- 1-800-810-BLUE (2583) or visit the BlueCard Doctor and Hospital finder web page at xxx.xxxx.xxx.

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. HELPFUL TIPS  • Read all information provided, especially this Subscriber Agreement. Become familiar with services excluded from coverage (See Section 4.04.0 – Health Services Not Covered Under This Agreement.)  • In Section 8.0 8 – 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 card 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 personal physician. Although no referral from a primary care personal physician is needed to receive covered health care services from a specialist physician, primary care personal 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. IMPORTANT TELEPHONE NUMBERS AND WEB SITES  Our WEBSITES 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)0-000-000-0000.  Our normal business hours: hours are Monday - Friday from 8:00 a.m. - 8:00 p.m. Please see Section 1.5 for more details.  Our Website: Website - xxx.XXXXXX.xxx. HealthSource RI – Recommended Preauthorization Services for which preauthorization is recommended are marked with an asterisk (*) in the Summary of Medical Benefits. Rhode Island network providers are responsible to obtain recommended preauthorization. Please see Section 1.6 for more information. o Medical/Surgical - call our Customer Service Department. Please see Section 1.6 for details. o Mental Health and Chemical Dependency - call 0-000-000-0000 EyeMed Vision Care – 0-000-000-0000 before having care. Lines are open 24 hours a day, 7 days per week. Please see Section 1.6 for details. Required Preauthorization Prescription drugs for which preauthorization is required are marked with the symbol (+) in the Summary of Pharmacy Benefits. Please see Section 1.6 and Section 3.27 for more information. o Prescription drugs - ask your prescribing physician to call the number listed for the “Pharmacist” on the back of your ID card. To see if prescription drug requires preauthorization, call our Customer Service Department or visit our Web site. BlueCard Access- 1-800-810-BLUE (2583) or visit the BlueCard PPO Doctor and Hospital finder web page at xxx.xxxx.xxx.

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. HELPFUL TIPS  • Read all information provided, especially this Subscriber Agreement. Become familiar with services excluded from coverage (See Section 4.04.0 – Health Services Not Covered Under This Agreement.)  • In Section 8.0 8 – 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 card 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 personal physician. Although no referral from a primary care personal physician is needed to receive covered health care services from a specialist physician, primary care personal 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. IMPORTANT TELEPHONE NUMBERS AND WEB SITES  Our WEBSITES 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)0-000-000-0000.  Our normal business hours: hours are Monday - Friday from 8:00 a.m. - 8:00 p.m. Please see Section 1.5 for more details.  Our Website: Website - xxx.XXXXXX.xxx. HealthSource RI – Recommended Preauthorization Services for which preauthorization is recommended are marked with an asterisk (*) in the Summary of Medical Benefits. Rhode Island network providers are responsible to obtain recommended preauthorization. Please see Section 1.6 for more information. o Medical/Surgical - call our Customer Service Department. Please see Section 1.6 for details. o Mental Health and Chemical Dependency - call 0-000-000-0000 EyeMed Vision Care – 0-000-000-0000 before having care. Lines are open 24 hours a day, 7 days per week. Please see Section 1.6 for details. Required Preauthorization Prescription drugs for which preauthorization is required are marked with the symbol (+) in the Summary of Pharmacy Benefits. Please see Section 1.6 and Section 3.27 for more information. o Prescription drugs - ask your prescribing physician to call the number listed for the “Pharmacist” on the back of your ID card. To see if prescription drug requires preauthorization, call our Customer Service Department or visit our Web site. BlueCard Access- 1-800-810-BLUE (2583) or visit the BlueCard PPO Doctor and Hospital finder web page at xxx.xxxx.xxx. ELIGIBILITY Subscriber/Dependents See Section 2.1 – Who is Eligible for Coverage Subscriber Eligible for coverage. See Section 2.1 Spouse Not eligible for coverage. Children Not eligible for coverage.