The Maximum Access Package

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The Maximum Access Package With this package, every plan provides your employees the freedom to choose with open access to our largest network of providers. This rich package is ideal if many of your employees live outside of the CareFirst BlueCross BlueShield service area (Maryland, D.C. and rthern Virginia) they can receive in-network benefits across the country and worldwide through the BlueCross BlueShield PPO network. 00/80 Coinsurance (Option 6) Deductible Coinsurance ne $,500/$3,000 charge $20 n-integrated ( or ) 00/80 Coinsurance (Option 9) $500/$,000 $,500/$3,000 charge $0 n-integrated 80/60 Coinsurance (Option 23) $500/$,000 $,500/$3,000 20% $20 n-integrated 90/70 Coinsurance (Option 22) $500/$,000 $,500/$3,000 0% $20 n-integrated 80/60 Coinsurance (Option 6) $,000/$2,000 $3,500/$7,000 20% $20 n-integrated 90/70 Coinsurance (Option 5) $,000/$2,000 $3,500/$7,000 0% $20 n-integrated 00/80 Coinsurance (Option 4) $,000/$2,000 $3,500/$7,000 charge $20 n-integrated For this package, products are underwritten by CareFirst of Maryland, Inc. or Group Hospitalization and Medical Services, Inc., depending on a group s location. (continued)

90/70 Coinsurance (Option 9) 00/80 Coinsurance (Option 8) 90/70 Coinsurance (Option 2) 80/60 Coinsurance (Option ) 00/80 Coinsurance (Option 0) Deductible Coinsurance $,500/$3,000 $3,000/$6,550 0% 0% Integrated Deductible $0/$25/$45/50% to $75 $,500/$3,000 $3,000/$6,550 charge charge Integrated Deductible $0/$25/$45/50% to $75 $2,500/$5,000 $3,500/$6,550 0% 0% Integrated Deductible $0/$25/$45/50% to $75 $,500/$3,000 $3,000/$6,550 20% 20% Integrated Deductible $0/$25/$45/50% to $75 $2,500/$5,000 $3,500/$6,550 charge charge Integrated Deductible $0/$25/$45/50% to $75 ( or ) SUM397-E (6/6) 206 CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc.

The High Value Package with Advantage Products Cost savings are the highlight of this high value package. Every plan provides your employees open access to the extensive CareFirst BlueChoice provider network throughout Maryland, D.C. and rthern Virginia, plus some plans also provide out-of-network benefits. The package also contains Advantage plans that accommodate employees receiving care outside our service area by providing in-network benefits through BlueCard PPO providers. (Option 4) (Option B) (Option K) BlueChoice Opt Out (Option 4) BlueChoice Opt Out (Option H) BlueChoice Opt Out (Option M) BlueChoice Advantage (Option 3) (Option C-S) Deductible Coinsurance ne $,300/$2,600 N/A $20/$30 n-integrated $500/$,000 $2,500/$5,000 N/A $20/$30 n-integrated $,000/$2,000 $2,500/$5,000 N/A $20/$30 n-integrated ne $,300/$2,600 N/A $20/$30 n-integrated $500/$,000 $2,500/$5,000 20% for Hospital Facility $20/$30 n-integrated $,000/$2,000 $2,500/$5,000 20% for Hospital Facility $20/$30 n-integrated ne $,500/$3,000 20% $20 $500/$,000 $4,500/$6,550 N/A $0/$30 $,000/$2,000 $4,500/$6,550 N/A $0/$30 n-integrated n-integrated n-integrated ( or ) For this package, BlueChoice and HealthyBlue products are underwritten by CareFirst BlueChoice, Inc. (continued)

(Option 4) (Option 2) Deductible Coinsurance $,500/$3,000 $3,000/$6,550 N/A $0/$20 Integrated Deductible $0/$25/$45/50% to $75 $2,500/$5,000 $3,500/$6,550 N/A Charge Integrated Deductible $0/$25/$45/50% to $75 ( or ) SUM393-E (6/6) 206 CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc.

The High Value Package without Advantage Products This is the most economical and flexible option if most of your employees live in the Maryland, D.C. and rthern Virginia area. This package features high value plans that allow open access to providers in the CareFirst BlueChoice network, as well as plans that permit employees to receive out-of-network benefits when seeing non-bluechoice providers. (Option 4) (Option B) (Option K) BlueChoice Opt Out (Option 4) BlueChoice Opt Out (Option H) BlueChoice Opt Out (Option M) (Option 4) (Option 2) Deductible Coinsurance ne $,300/$2,600 N/A $20/$30 n-integrated $500/$,000 $2,500/$5,000 N/A $20/$30 n-integrated $,000/$2,000 $2,500/$5,000 N/A $20/$30 n-integrated ne $,300/$2,600 N/A $20/$30 n-integrated $500/$,000 $2,500/$5,000 20% for Hospital Facility $20/$30 n-integrated $,000/$2,000 $2,500/$5,000 20% for Hospital Facility $20/$30 n-integrated $,500/$3,000 $3,000/$6,550 N/A $0/$20 Integrated Deductible $0/$25/$45/50% to $75 $2,500/$5,000 $3,500/$6,550 N/A Charge Integrated Deductible $0/$25/$45/50% to $75 ( or ) For this package, BlueChoice and HealthyBlue products are underwritten by CareFirst BlueChoice, Inc. (continued)

Deductible Coinsurance ( or ) SUM392-E (6/6) 206 CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc.

The Maximum Choice Package This package is an excellent choice if you have employees who live in our service area (Maryland, D.C. and rthern Virginia) and employees who live outside our service area. This package offers the most choices of plan types and premiums to meet your employees needs, from economical HMOs to PPOs offering the most provider choice. All plans are open access and no referrals are needed for specialty care. (Option -S) (Option 2-S) (Option 3-S) BlueChoice Advantage (Option -S) BlueChoice Advantage (Option 2-S) BlueChoice Advantage (Option 3-S) Deductible Coinsurance ne $4,500/$9,000 N/A $0/$20 $500/$,000 $4,500/$9,000 N/A $0/$20 $,000/$2,000 $6,850/$3,700 N/A $20/$40 n-integrated $5/$45/$70/50% to $50 n-integrated $5/$45/$70/50% to $50 n-integrated $5/$45/$70/50% to $50 ne $4,500/$9,000 N/A $0/$20 $500/$,000 $4,500/$9,000 N/A $0/$20 $,000/$2,000 $6,850/$3,700 N/A $20/$40 n-integrated $5/$45/$70/50% to $50 n-integrated $5/$45/$70/50% to $50 n-integrated $5/$45/$70/50% to $50 ( or ) For this package, BlueChoice, and products are underwritten by CareFirst BlueChoice, Inc. and products are underwritten by CareFirst of Maryland, Inc. or Group Hospitalization and Medical Services, Inc., depending on a group s location. (continued)

HealthyBlue Advantage HealthyBlue Advantage (Option -S) (Option 2-S) (Option 3-S) Deductible Coinsurance ne $4,500/$9,000 N/A $0/$20 $500/$,000 $4,500/$9,000 N/A $0/$20 $,000/$2,000 $6,850/$3,700 N/A $20/$40 n-integrated $5/$45/$70/50% to $50 n-integrated $5/$45/$70/50% to $50 n-integrated $5/$45/$70/50% to $50 ( or ) SUM396-E (6/6) 206 CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc.

The Healthy Behaviors Package with Advantage Products This package features health care plans specially designed to encourage employees to get and stay healthy. All plans reward employees for taking action to improve their health and some plans provide all office visits to the primary care provider with no copay. Cost-savings are greatest with in-network providers, and there are care options for employees living in or outside of Maryland, D.C. and rthern Virginia. Deductible Coinsurance $500/$,000 $4,500/$6,550 N/A $0/$30 n-integrated ( or ) $500/$,000 $4,500/$6,550 N/A $0/$30 n-integrated $500/$,000 $4,500/$6,550 N/A $0/$30 n-integrated $500/$,000 $4,500/$6,550 N/A $0/$30 n-integrated (Option C-S) $,000/$2,000 $4,500/$6,550 N/A $0/$30 n-integrated (Option C-S) $,000/$2,000 $4,500/$6,550 N/A $0/$30 n-integrated (Option C-S) $,000/$2,000 $4,500/$6,550 N/A $0/$30 n-integrated (Option G-S) $,000/$2,000 $4,500/$6,550 N/A $0/$30 n-integrated For this package,, and products are underwritten by CareFirst BlueChoice, Inc. products are underwritten by CareFirst of Maryland, Inc. or Group Hospitalization and Medical Services, Inc., depending on a group s location. (continued)

Deductible Coinsurance ( or ) SUM395-E (6/6) 206 CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc.

The Healthy Behaviors Package without Advantage Products Build a healthier workforce with this package that rewards employees for being proactive about their health a move that can save you money over time. All plans reward employees for taking action to improve their health and some plans provide all office visits to the primary care provider with no copay. This package is optimal if most of your employees live in the Maryland, D.C. and rthern Virginia area, as their costs will be lowest when using in-network providers. This package also includes plans, such as, that provide benefits for employees who receive care outside the CareFirst BlueCross BlueShield service area. (Option C-S) (Option C-S) (Option G-S) Deductible Coinsurance $500/$,000 $4,500/$6,550 N/A $0/$30 $500/$,000 $4,500/$6,550 N/A $0/$30 $500/$,000 $4,500/$6,550 N/A $0/$30 $,000/$2,000 $4,500/$6,550 N/A $0/$30 $,000/$2,000 $4,500/$6,550 N/A $0/$30 $,000/$2,000 $4,500/$6,550 N/A $0/$30 n-integrated n-integrated n-integrated n-integrated n-integrated n-integrated ( or ) For this package, and products are underwritten by CareFirst BlueChoice, Inc. products are underwritten by CareFirst of Maryland, Inc. or Group Hospitalization and Medical Services, Inc., depending on a group s location. (continued)

Deductible Coinsurance ( or ) SUM394-E (6/6) 206 CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc.

Dental and Vision Options BlueDental Plus By choosing BlueDental Plus, your employees will have access to the largest provider network available at CareFirst BlueCross BlueShield (CareFirst), deepest discounts and richest benefits including orthodontia coverage for both children and adults. When visiting a participating provider, preventive and diagnostic services are covered in full and there are no claim forms to file. Our participating providers have also agreed to pre-determined fees for their services, so your employees will only be responsible for their coinsurance and deductible for covered services. BlueDental Plus Employer-sponsored, sold with orthodontics, no age limit ($,500 orthodontic lifetime max) Standard Deductible (Does not apply to Preventive & Diagnostic and Orthodontic Services) Standard Maximum (Does not apply to Preventive & Diagnostic and Orthodontic Services) Preferred and Participating Network (Preventive & Diagnostic/ Basic/Major Restorative) Out-of-Network (Preventive & Diagnostic/ Basic/Major Restorative) In: $25/$75; Out: $50/$50 $,500 00/80/50 00/80/50 This plan is underwritten by CareFirst of Maryland, Inc. or Group Hospitalization and Medical Services, Inc. depending on a group s location. : Major Surgical Services have the same coinsurance as Basic Services. BlueDental Plus: Product has deductible credit and deductible carryover as a CORE benefit. BlueDental Basic Employees looking for a low-cost, routine care only option should select BlueDental Basic. They will have access to the largest network available, plus there are no referrals or claim forms needed with participating providers. Since our participating providers have also agreed to pre-determined fees for their services, your employees will only be responsible for their coinsurance and deductible for covered services. BlueDental Basic Employer-sponsored, provides coverage for Preventive & Diagnostic and Basic Services only 2 Standard Deductible (Does not apply to Preventive & Diagnostic Services) Standard Maximum (Does not apply to Preventive & Diagnostic Services) Preferred and Participating Network (Preventive & Diagnostic/ Basic/Major Restorative) Out-of-Network (Preventive & Diagnostic/ Basic/Major Restorative) In: $25/$75; Out: $50/$50 $,000 00/80/0 80/60/0 This plan is underwritten by CareFirst of Maryland, Inc. or Group Hospitalization and Medical Services, Inc. depending on a group s location. Employer-sponsored requires an employer contribution of at least 50% of Individual premium. 2 BlueDental Basic: Product has deductible credit and deductible carryover as a CORE benefit; freestanding load for 2 50 groups. (continued) SUM3098-E (4/6)

BlueDHMO BlueDHMO $0 coverage keeps dental insurance simple. Your employees can receive in-network preventive care, X-rays, dental surgery and more for a set copay with no deductible to meet. BlueDHMO Description BlueDHMO $0 Basic Dental Services $0 per office visit This plan is underwritten by The Dental Network in Maryland or CareFirst BlueChoice, Inc. in DC and Virginia. BlueVision Plus With BlueVision Plus, employees can receive a routine eye examination (including dilation) at any Davis Vision 3 participating location and one pair of eye glasses or a supply of contact lenses during each benefit period. This plan also provides complete coverage for lenses and frames when employees choose from Davis Vision s Exclusive Collection of frames. BlueVision Plus Option Exam Copay Benefit Period Option B $0 2/2/24 month 3 CareFirst partners with Davis Vision to offer an extensive national network of optometrists, ophthalmologists and opticians. Davis Vision is an independent company that provides administrative services for vision care to CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. members. Davis Vision is solely responsible for the services it provides. SUM3098-E (4/6) CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc. and The Dental Network are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc.

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