Small Group 2018 SimplyBlue Plans. Plan Features for all Plans. Plan

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1 Small Group 2018 SimplyBlue Plans Plan Features for all Plans Preventive Adult and Child Wellness Services for all plans: In-network, Out-of-network not covered. Prescription Generic oral contraceptives are covered at no cost to the member. Oral Chemotherapy drugs are available at a $10 member cost share for all SimplyBlue plans. Out-of-network services are not covered (except for emergency services). Out-of-Pocket Maximum includes: Deductible, Copayments, Coinsurance and Rx. Point of Service Rider for coverage for Out-of-network services is not available with SimplyBlue plans. All plans come with Pediatric Vision Care and Pediatric Dental Care Benefits (see last page). Benefit Maximums for all Plans Home Health Care Inpatient Rehabilitation Therapy Inpatient Habilitation Therapy Skilled Nursing Facility Outpatient Rehabilitation Therapy Outpatient Habilitation Therapy Spinal Manipulations PBP=Per Benefit Period 30 Visits PBP 30 Days PBP 30 Days PBP 60 Days PBP 35 Visits PBP 35 Visits PBP 26 Visits PBP Florida Blue HMO is a trade name of Health Options, Inc., an HMO affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of the Blue Cross and Blue Shield Association. Florida Blue HMO does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations. This matrix is only a partial description of the many benefits and services provided or authorized by Florida Blue HMO. This matrix does not constitute a Contract. Small Group 2018 SimplyBlue Plans listed in order of cost Metal Plan Family In-Network CYD / Coins / OOP In-Network PCP / Spec SimplyBlue BlueOptions Gold Essential $1,500 / 90% / $3,000 DED + Coins Silver All Copay $2,500 / 100% / $7,350 $35 / $ Silver Predictable Cost $3,500 / 50% / $7,350 $40 / $ NA Silver Predictable Cost $3,500 / 100% / $7,350 $35 / $ NA Silver Predictable Cost $4,000 / 100% / $7,000 $35 / $ NA Silver Predictable Cost $5,500 / 100% / $7,350 $25 / $ NA Silver Predictable Cost $4,500 / 80% / $7,350 $45 / $ NA Silver Everyday Health $2,750 / 70% / $7,350 $40 / $ Bronze Essential $6,700 / 50% / $7,350 $40 / DED Silver Predictable Cost $2,000 / 50% / $7,350 $45 / DED + Coins Bronze Everyday Health $5,500 / 50% / $7,000 $40 / $ NA Silver Essential $6,750 / 50% / $7,350 $50 / $ Bronze Essential $6,700 / 50% / $7,350 $45 / DED + Coins Bronze Essential $7,350 / 100% / $7,350 DED + Coins NA Small Group 2018 SimplyBlue Plans HRA Employer Contribution Levels Employer contributions to an HRA impacts Actuarial Value (AV). Employer plan contributions must be within the defined dollar ranges listed to the right in order to comply with ACA Actuarial Value and metal level requirements. Plan Contribution Levels Bronze Silver Gold Platinum Essential (Gold) NA NA - $174 $526 - $1, All Copay NA - $47 $368 - $1,127 $1,914 - $2, Predictable Cost NA - $161 $520 - $1,331 $2,140 - $3, Predictable Cost NA - $49 $373 - $1,140 $1,940 - $3, Predictable Cost NA - $53 $373 - $1,104 $1,841 - $3, Predictable Cost NA - $65 $392 - $1,154 $1,934 - $3, Predictable Cost NA - $248 $623 - $1,431 $2,202 - $3, Everyday Health NA - $213 $569 - $1,323 $2,028 - $2, Essential - $103 $168 - $647 $1,080 - $1,969 $2,790 - $4, Predictable Cost NA - $280 $666 - $1,495 NA Everyday Health (Bonze) - $69 $133 - $595 $1,014 - $1,868 $2,656 - $4, Essential NA - $445 $875 - $1,780 $2,627 - $4, Essential - $194 $264 - $772 $1,224 - $2,135 $2,962 - $4, Essential - $245 $319 - $863 $1,357 - $2,369 $3,313 - $5,179

2 Small Group 2018 SimplyBlue Plans in order of Cost Page 2 of (Gold) All Copay Plan Deductible (Per Person / Family Aggregate) In-Network $1,500 / $3,000 $2,500 / $5,000 $3,500 / $7,000 $3,500 / $7,000 $4,000 / $8,000 Not Covered Not Covered Not Covered Not Covered Not Covered Coinsurance (Amount member pays) In-Network 10% 0% 50% 0% 0% Provider Not Covered Not Covered Not Covered Not Covered Not Covered Out-of-Pocket Maximum In-Network $3,000 / $6,000 $7,350 / $14,700 $7,350 / $14,700 $7,350 / $14,700 $7,000 / $14,000 (Per Person / Family Aggregate) Not Covered Not Covered Not Covered Not Covered Not Covered Physician Family Physician DED + Coins $35 Copay $40 Copay $35 Copay $35 Copay Office Services Specialist DED + Coins $75 Copay $80 Copay $65 Copay $70 Copay DED + Coins $75 Copay $80 Copay $65 Copay $70 Copay In-Network Provider ($200 Monthly Member OOP Max) 20% Coinsurance 20% Coinsurance 20% Coinsurance 20% Coinsurance 20% Coinsurance INN DED + Coins $600 Copay $500 Copay $550 Copay $500 Copay Urgent Care Centers DED + Coins $80 Copay $85 Copay $70 Copay $75 Copay (Fac. / Phy. Charges Diagnostic Services (other than AIS) DED + Coins $200 Copay $85 Copay $200 Copay $200 Copay DED + Coins $350 Copay DED + Coins $350 Copay $300 Copay Independent Clinical Lab $25 Copay $50 Copay $50 Copay $50 Copay $50 Copay Provider Services at ER INN DED + Coins Provider Services at Hospital and Ambulatory Surgical Center DED + Coins $50 Copay DED + Coins $55 Copay Provider Services at Locations Family Physician DED + Coins $35 Copay $40 Copay $35 Copay $35 Copay other than Office, Hospital and ER Specialist DED + Coins $75 Copay $80 Copay $65 Copay $70 Copay Ambulatory Surgical Center DED + Coins $500 Copay $400 Copay $600 Copay $500 Copay Inpatient Hospital Facility Services (per admission) DED + Coins $750 per day ($2,250 Max) $1,500 per day ($4,500 Max) DED + $750 per day ($2,250 Max) DED + $2,250 Copay Outpatient Hospital Therapy Services DED + Coins $1,000 Copay $500 Copay DED + $1,000 Copay DED + $1,000 Copay Facility Services (per visit) All Other Services DED + Coins $1,000 Copay $500 Copay DED + $1,000 Copay DED + $1,000 Copay Prescription Preventive Medications* Drugs Condition Care Rx*: Generic / Brand $4 / $15 $4 / $30 $4 / $35 $4 / $40 $4 / $30 Low Cost Generic / High Cost Generic and Brand $10** / $30** $25 / $60 $20 / $70 $30 / $50 $25 / ** Non-Preferred and Specialty $150** 50%** $500** 50%** ** Mail-Order (Specialty not Available) 2.5x retail cost-share 2.5x retail cost-share 2.5x retail cost-share 2.5x retail cost-share 2.5x retail cost-share *Preventive Medication and Condition Care Rx Lists are available in the Medication Guide. **Applies after INN DED is met

3 Small Group 2018 SimplyBlue Plans in order of Cost Page 3 of Everyday Health Plan Deductible (Per Person / Family Aggregate) In-Network $5,500 / $11,000 $4,500 / $9,000 $2,750 / $5,500 $6,700 / $13,400 $2,000 / $4,000 Not Covered Not Covered Not Covered Not Covered Not Covered Coinsurance (Amount member pays) In-Network 0% 20% 30% 50% 50% Provider Not Covered Not Covered Not Covered Not Covered Not Covered Out-of-Pocket Maximum In-Network $7,350 / $14,700 $7,350 / $14,700 $7,350 / $14,700 $7,350 / $14,700 $7,350 / $14,700 (Per Person / Family Aggregate) Not Covered Not Covered Not Covered Not Covered Not Covered Physician Family Physician $25 Copay $45 Copay $40 Copay $40 Copay $45 Copay Office Services Specialist $50 Copay $85 Copay $80 Copay DED DED + Coins $50 Copay $85 Copay $80 Copay DED DED + Coins In-Network Provider ($200 Monthly Member OOP Max) 20% Coinsurance 20% Coinsurance 20% Coinsurance 20% Coinsurance 20% Coinsurance $500 Copay $600 Copay INN DED + Coins INN DED INN DED + Coins Urgent Care Centers $55 Copay $90 Copay $85 Copay DED DED + Coins (Fac. / Phy. Charges Diagnostic Services (other than AIS) $200 Copay DED + Coins DED + Coins DED $150 Copay $600 Copay DED + Coins DED + Coins DED $250 Copay Independent Clinical Lab $40 Copay $50 Copay $25 Copay $35 Copay Provider Services at ER INN DED INN DED + Coins Provider Services at Hospital and Ambulatory Surgical Center DED DED + Coins DED DED + Coins DED + Coins Provider Services at Locations Family Physician $25 Copay $45 Copay $40 Copay $40 Copay $45 Copay other than Office, Hospital and ER Specialist $50 Copay $85 Copay $80 Copay DED DED + Coins Ambulatory Surgical Center $500 Copay DED + Coins DED + $700 Copay $400 Copay DED + Coins Inpatient Hospital Facility Services (per admission) DED + $450 per day ($1,350 Max) DED + Coins DED + Coins $1,000 per day ($3,000 Max) DED + Coins Outpatient Hospital Therapy Services DED + $900 Copay DED + Coins DED + Coins $500 Copay DED + Coins Facility Services (per visit) All Other Services DED + $900 Copay DED + Coins DED + Coins $500 Copay DED + Coins Prescription Preventive Medications* Drugs Condition Care Rx*: Generic / Brand $4 / $25 $4 / $20 $4 / $30 $4 / $30 $4 / $30 Low Cost Generic / High Cost Generic and Brand $15 / $50 $10 / $40** $20 / 50%** $20 / ** $10 / 50%*** Non-Preferred and Specialty 50%** $200** 50%** 50%** 50%*** Mail-Order (Specialty not Available) 2.5x retail cost-share 2.5x retail cost-share 2.5x retail cost-share 2.5x retail cost-share 2.5x retail cost-share *Preventive Medication and Condition Care Rx Lists are available in the Medication Guide. **Applies after INN DED is met ***Applies after $5,000 Rx DED is met

4 Small Group 2018 SimplyBlue Plans in order of Cost Page 4 of Everyday Health Plan Deductible (Per Person / Family Aggregate) In-Network $5,500 / $11,000 $6,750 / $13,500 $6,700 / $13,400 $7,350 / $14,700 Not Covered Not Covered Not Covered Not Covered Coinsurance (Amount member pays) In-Network 50% 50% 50% 0% Provider Not Covered Not Covered Not Covered Not Covered Out-of-Pocket Maximum In-Network $7,000 / $14,000 $7,350 / $14,700 $7,350 / $14,700 $7,350 / $14,700 (Per Person / Family Aggregate) Not Covered Not Covered Not Covered Not Covered Physician Family Physician $40 Copay $50 Copay $45 Copay DED Office Services Specialist $100 Copay $150 Copay DED + Coins DED $100 Copay $150 Copay DED + Coins DED In-Network Provider ($200 Monthly Member OOP Max) 20% Coinsurance 20% Coinsurance 20% Coinsurance 20% Coinsurance INN DED + Coins INN DED + Coins INN DED + Coins INN DED Urgent Care Centers $105 Copay $155 Copay DED + Coins DED (Fac. / Phy. Charges Diagnostic Services (other than AIS) DED + Coins DED + Coins DED + Coins DED DED + Coins DED + Coins DED + Coins DED Independent Clinical Lab $50 Copay $50 Copay Provider Services at ER INN DED + Coins INN DED + Coins INN DED + Coins INN DED Provider Services at Hospital and Ambulatory Surgical Center DED + Coins DED + Coins DED + Coins DED Provider Services at Locations Family Physician $40 Copay $50 Copay $45 Copay DED other than Office, Hospital and ER Specialist $100 Copay $150 Copay DED + Coins DED Ambulatory Surgical Center 50% Coinsurance DED + Coins DED + Coins DED Inpatient Hospital Facility Services (per admission) DED + Coins DED + Coins DED + Coins DED Outpatient Hospital Therapy Services DED + Coins DED + Coins DED + Coins DED Facility Services (per visit) All Other Services DED + Coins DED + Coins DED + Coins DED Prescription Preventive Medications* Drugs Condition Care Rx*: Generic / Brand $4 / $75 $4 / $40 $4 / $40 $4 / $30 Low Cost Generic / High Cost Generic and Brand $25 / $150** $25 / $80 $32 / 50%** ** / ** Non-Preferred and Specialty $250** 50% ** 50%** ** Mail-Order (Specialty not Available) 2.5x retail cost-share 2.5x retail cost-share 2.5x retail cost-share 2.5x retail cost-share *Preventive Medication and Condition Care Rx Lists are available in the Medication Guide. **Applies after INN DED is met

5 Small Group 2018 SimplyBlue Plans Pediatric Vision and Dental (In-Network Services Only) Page 5 of 5 Pediatric Vision Care Costs shown below are for covered individuals Amount Member Pays who are under age 19. Exclusive In-Network Provider Services Eye Examination Eye Glass Lenses Eyeglasses Frame Benefit Pediatric Frame Selection Included Non-Selection Frame Allowance Amount over standard $150 allowance, minus a 20% discount Eyeglass Benefit - Spectacle Lenses Clear plastic single-vision, lined bifocal, trifocal or lenticular lenses (any prescription) Oversize Lenses Tinting of Plastic Lenses Scratch-Resistant Coating Polycarbonate Lenses Standard Progressive Lenses Plastic Photosensitive Lenses Ultraviolet Coating One-Year Breakage Warranty Contact Lens Benefit (in lieu of eyeglasses) Pediatric Contact Lens Selection Included Non-Selection Contact Lenses (Instead of eyeglasses) Materials Allowance, Evaluation, Fitting, and Follow-up Care Medically Necessary Contact Lenses (with prior approval) Materials, Evaluation, Fitting & Follow-Up Care Additional Discounts Available Up to $150 plus a 15% discount on any overage Pediatric Dental Care Costs shown below are for covered individuals Amount Member Pays who are under age 19. Exclusive In-Network Provider Services Preventive Services Oral exams, cleaning and fluoride treatments X-rays (bitewing) Space Maintainers Sealants Basic Services Anesthesia Emergency Treatment (Palliative Care) Fillings Extractions Minor Endodontics Minor Periodontics Minor Prosthodontics Major Services Major Endodontics Major Periodontics Major Prosthodontics Medically Necessary Implants (Prior Authorization is required) Medically Necessary Orthodontics Prior authorization is required