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PRODUCT OPTIONS

the network but must pay a higher percentage of their health care costs. SuperBlue Plus 2004 Superited Benefits Lim Blue Plus 2004 SuperBlue Plus 2004 isis a product with a $25,000 annual maximum and is designed to provide a cost effective SuperBlue Plus 2004 a PPO product that is designed to be compatible with a Health Reimbursement SuperBlue Plus 2004 who cannot afford traditional coverage. This product is not designed to be a Account (HRA). However, it works just as well without the HRA for groups looking for catastrophic coverage. alternative for is a PPO product that is designed to be compatible with a Health Reimbursement Super Blue Plus 2004those Super product is 2004used PPOthe West that is designed to be compatible with a Health Reimbursement This Blue Plus also is a for policy. Virginia Small Business Plan. comprehensive medical product as well without the HRA for groups looking for catastrophic coverage. Account (HRA). However, it it worksjust as well without the HRA for groups looking for catastrophic coverage. Account (HRA). However, works just This SuperBluealso used for the West Virginia Small Business Plan. product is Plus used This product is also2008 for the West Virginia Small Business Plan. Super Blue Plus 2008 is a PPO product designed with prevention in mind. The product was developed in an SuperBlue Plus 2008 but also to apply emphasis on preventive benefits to coincide with our wellness effort to Plus 2008 reduce 2008 SuperBlue Plus costs Super Blue Plus 2008 is is a PPO productdesigned with prevention in mind. The product was developed in an an initiatives. Plus 2008 a PPO product designed with prevention in mind. The product was developed in Super Blue effort to reduce costs but also to apply emphasis on preventive benefits to coincide with our wellness effort to reduce costs but also to apply emphasis on preventive benefits to coincide with our wellness Qualified initiatives. initiatives. High Deductible Health Plan (HDHP) is designed for individuals who wish to enroll in a qualified high deductible health plan for use with a Health Savings Account as defined by the Internal Revenue Service. QualifiedHowever, it is not a requirement of this product to open for individuals who wish to to enroll a ais Plan (HDHP) Qualified High Deductible HealthPlan (HDHP) designed for individuals Account. enroll in in Qualified High Deductible Health Plan (HDHP) is designed a Health Savingswho wish The decision determined deductible health of the use with a qualified highby each subscriber planforpolicy.with a Health Savings Account as defined byby the Internal Revenue for use qualified high deductible health plan Savings Account as defined the Internal Revenue Service. However, is is not a requirementof this product to open a Health Savings Account. The decision is is it not a requirement of this product to open a Health Savings Account. The decision Service. However, it Limited Benefits is a product determined each subscriber of with a $25,000 annual maximum and is designed to provide a cost effective determined by by each subscriber of thepolicy. the policy. alternative for those who cannot afford traditional coverage. This product is not designed to be a comprehensive medical policy. Limited Benefits is a product with a $25,000 annual maximum and is designed to provide a cost effective

The BlueCard PPO Program allows members traveling outside the MSBCBS in mind. The product high developed in an service area Super when utilizing the services product designed Blue Cross Blue Shield Preferred to receive was level of benefits Blue Plus 2008 is a PPOof morethan 385,000with prevention Shield Preferred Providers than 385,000 Blue Cross Blue benefits when utilizing the services of more traveling outside the MSBCBS service area to Providers The BlueCard PPO Programbut also to apply emphasis on preventive benefits to coincide with our wellness receive high level of effort to reduce costs allows members nationwide. nationwide.when utilizing the services of more than 385,000 Blue Cross Blue Shield Preferred Providers benefits initiatives. nationwide. drug coverage is offered through our extensive preferred pharmacy network of more than 40,000 Prescription Prescription drug coverage is offered through our extensive preferred pharmacy network of more than 40,000 pharmacies nationwide. Qualified High Deductible Health P lan (HDHP ) is designed for individuals who wish to enroll in a pharmacies nationwide. Prescription drug coverage is offered through our extensive preferred pharmacy network of more than 40,000 qualified high deductible health plan for use with a Health Savings Account as defined by the Internal Revenue pharmacies nationwide. SuperBlue Plus 2000 Service. However, it is not a requirement of this product to open a Health Savings Account. The decision is SuperBlue Plus 2000 is a PPO managed care health plan. Participants receive maximum benefits when their Plus 2000 Super Blue Plus 2000 determined by the SuperBlue Plus 2000 many hospitals care policy. plan. of physicians and other professional providers in their Super Blue provided byis a PPO managed and the thousands Participants receive maximum benefits when the care is Plus 2000 each subscriber of the health (With this product is a PPO managed care health plan. of physicians and maximum only apply for a Super Blue Plus Blue many Blue Shieldand the and Individual Out-of-Pocket other professional providersin the care Mountain State2000 the Individual Deductiblethousands Participants receivecan elect to benefits when not subscriber with is provided by the Cross hospitals Super Blue Plus Network. Participants Maximums use providers theirin individual but the Blue Shield Super Blue their health care Family other elect to be providers or care is provided byCrossFora higher percentage thousands of physicians andDeductible must use met by onethe more members the network Bluemust many subscriber with family coverage, thecosts. Mountain Statecoverage. pay a hospitals and the of Plus Network. Participants canprofessional providers in not in of the but must Cross Blue will be paid.) Mountainfamily before benefits Shield Super Blue their Network. Participants can elect to use providers not in the network State Blue pay a higher percentage of Plus health care costs.

reliable health insurer ­ Mountain State Blue Cross Blue Shield your needs. relationships, financial resources and service expertise to meet (MSBCBS). So go with an experienced, reliable health insurer 2004 ­ Mountain State Blue Cross Blue (MSBCBS). SuperBlue Preferred Provider Organization (PPO) with all product options. Your relationship your MSBCBS utilizes a P a Preferred Provider Organization (PPO)Shieldall product options. Your relationship withwith your MSBCBS utilizes lus with local local doctors, hospitals and other providersisisan important part of getting well and staying a Health Reimbursement doctors, hospitals and is a providers Super Blue Plus 2004otherPPO product an important part of getting well and with that way. That's that is designed to be compatible staying that way. That's MSBCBS utilizes a Preferred Provider (PPO) with all product relationship why why we've (HRA). However, it to Organizationyou receive quality care. options. Your includes 95%with your we've credentialed providers toworks ensureyou receive quality care.Our network looking for95%the the coverage. Our network help just as of of Account credentialed providers help ensure well without the HRA for groups includes catastrophic local doctors, hospitals and other providers is an important part of getting well and staying that way. That's hospitals 75% is thethe physicians in West Virginia. To find out if your provider is is in our network, you can hospitals and and 75%alsophysicianstheWest Virginia. To find Business Plan. of of used for in West Virginia Small out if your provider in our network, you can This product why we've credentialed providers to help ensure you receive quality care. Our network includes 95% of the call 1-800-533-3627. call 1-800-533-3627. hospitals and 75% of the physicians in West Virginia. To find out if your provider is in our network, you can SuperBlue P lus call 1-800-533-3627. 2008 allows members traveling outside the MSBCBS service area to receive high level of The BlueCard PPO Program

SuperBlue P lus 2000 Super Blue a health care Preferred Provider Organization (PPO) receive as your partner in PPO managed care health plan. Participants When you choosePlus 2000 is acoverage program, you also choose the insurer behind itmaximum benefits when their When iscoverage.a by the care coverage program, the thousandsyour insurer behind it other professional provider in the care you choose You want to choose carefully,you you choose of physicians and as your partner in provided health many hospitals and so also know the insurer has the experience, provider health care health care coverage. You want to choose carefully, Blue Plus Network. Participants can elect to use Moutnain State resources Blue Shield Super so you choose needs. has the experience, provider When you financial health care coverage program, you also know your insurerSo go with an experienced, relationships, choose a Blue Crossand service expertise to meet yourthe insurer behind it as your partner in provider not in relationships, financialYou pay ato choose carefully, soto meet your needs. So haswith an experienced, the care insurer must want higher percentage Shield health care health network but ­ resources and service expertise you know your insurer go the reliable health coverage. Mountain State Blue Cross Blue of their(MSBCBS). costs. experience, provider

Limited Benefits is a product with a $25,000 annual maximum and is designed to provide a cost effective Benefits alternative for those who cannot afford traditional coverage. This product is not designed to be a alternative for those who cannot afford traditional coverage. This product is not designed to be a comprehensive medical policy. comprehensive medical policy.

WEBSITE ACCESS 24/7 ­ www.mybenefitshome.com

As a MSBCBS member, you will have a wealth of health information at your fingertips via our innovative internet web site, www.mybenefitshome.com. You'll find a wide range of24/7 to help you take greater control of your health. From the Personal WEBSITE ACCESS tools ­ www.mybenefitshome.com Wellness Profile that provides a comprehensive health assessment to online access to 24-hour-a-day health decision support, your As a MSBCBS member, you provides in-depth health information. Through My Benefits via our you will have access to physician and MSBCBS member web site will have a wealth of health information at your fingertips Home innovative internet web site, As a MSBCBS directories,youyou can look wealth of rangein information locatetake greater control of your health. FromwebID card, al www.mybenefitshome.com. You'll a upaawide health your planhelp you your nearestvia our innovative internet the Person pharmacy member, so will have find physician of tools to or at your fingertips pharmacy. You can request an site, Wellness claim form, send a You'll find a wide range of tools to help online access signcontrol of your health. of EOB the Person www.mybenefitshome.com. secure message to customer service, checkyoua claim or to 24-hour-a-day health decision support, your al order a Profile that provides a comprehensive health assessment to on take greater up to receive edelivery From MSBCBS member web site a comprehensive health assessment to online Benefits Home you will have access to physician and (Explanation of Benefits) statements - all online. Wellness Profile that provides provides in-depth health information. Through My access to 24-hour-a-day health decision support, your pharmacy directories, so provides in-depth health information. or locate your nearest pharmacy. You can access to ID card, MSBCBS member web site you can look up a physician in your planThrough My Benefits Home you will have request an physician and order a claim form, so you can look up a physician in service, or locate claim or sign pharmacy. edelivery of EOB pharmacy directories, send a secure message to customeryour plancheck on ayour nearest up to receiveYou can request an ID card, (Explanation of send a statements - all online. order a claim form,Benefits)secure message to customer service, check on a claim or sign up to receive edelivery of EOB

WEBSITE ACCESS 24/7 ­ www.mybenefitshome.com

(Explanation of Benefits) statements - all online.

Yearly Deductible Preventive

In-network Coverage

Network Annual Out-ofPocket Maximum, Out-of-network Excluding Deductible Indiv/Family Coverage

Office Visit Copay In Network

ER Copay/Coins.

Prescription Drug Coverage (You Pay)

Super Blue Plus 2000

60% 100% up to $500 100% up to $500 100% up to $500 100% up to $500 100% up to $500 60% 60% 60% 60% $2,500/$5,000 $25

Routine Gynecological, Mammograms, Prostate Screenings

$100 $1,000/$2,000 $1,000/$2,000 $1,000/$2,000 $10 $10

Routine Gynecological, Mammograms, Prostate Screenings Routine Gynecological, Mammograms, Prostate Screenings

80% $10

Routine Gynecological, Mammograms, Prostate Screenings

$1,000/$2,000

$10

Routine Gynecological, Mammograms, Prostate Screenings

R: 30% $10 Min M: 30% $30 Min R: 30% $10 Min M: 30% $30 Min R: 30% $10 Min M: 30% $30 Min R: 30% $10 Min M: 30% $30 Min R: 30% $25 Min M: 30% $75 Min

$250

80%

$500

80%

$1,000

80%

$2,500

80%

Super Blue Plus 2004

60% $1,000/$2,000 N/A

$1,000

80%

R: 50% $25 Min M: 50% $75 Min R: 50% $25 Min M: 50% $75 Min R: 50% $25 Min M: 50% $75 Min

$3,000 60% $1,000/$2,000 N/A

80%

60%

$1,000/$2,000

N/A

$5,000

80%

First $300 100%, then paid at 80% thereafter -subject 80% after deductible to deductible First $300 100%, then paid at 80% thereafter -subject 80% after deductible to deductible First $300 100%, then paid at 80% thereafter -subject 80% after deductible to deductible

HDHP

80%

High Deductible Health Plans, compatible with Health Savings Accounts

Single $3,000 Family $6,000

100%

$0 - Medical

N/A

Single $5,000 Family $10,000 80%

100%

$0 - Medical

N/A

50% after deductible First $300 100%, then paid with add'l coinsurance at 80% thereafter -subject 100% after deductible limit ($2,500/$5,000) to deductible First $300 100%, then paid 50% after deductible at 80% thereafter -subject with add'l coinsurance to deductible 100% after deductible limit ($500/$1,000) (Copay Waived if Admitted)

Annual Routine Physical Adult Immunizations Routine Diagnostics N/A $15/$30 $100 ER copay, then 100% thereafter Generic: 50% Brand: No Benefit 9/25/2007

The individual deductible and out of pocket maximums only apply for a subscriber with individual coverage. The family deductible must be met by one or more members of the family.

LBP

60%

Limited Benefit Plan $25,000 Annual Maximum

$250

80%

Yearly Deductible Preventive

In/Out-of Network Coverage %

Network Annual Out-ofPocket Maximum, Excluding Deductible Indiv/Family

Office Visit Copay In Network

ER Copay/Coins. (Copay Waived if Admitted)

(You Pay)

Prescription Drug Coverage

Super Blue Plus 2008

$3,000/$6,000 or $4,500/$9,000 $3,000/$6,000 or $4,500/$9,000 $3,000/$6,000 or $4,500/$9,000 $3,000/$6,000 or $4,500/$9,000 $3,000/$6,000 or $4,500/$9,000 $100 Copay, then subject to Deductible & Coinsurance

$500

80 / 60

R: 50% $10 Min M: 50% $30 Min or R: 30% $10 Min M: 30% $30 Min R: 50% $10 Min M: 50% $30 Min

$500

70 / 50

$1,000

80 / 60

$100 Copay, then subject to Deductible & Coinsurance

$1,000

70 / 50

or R: 30% $10 Min M: 30% $30 Min $100 Copay, then subject to Deductible & Coinsurance R: 50% $10 Min M: 50% $30 Min or R: 30% $10 Min M: 30% $30 Min $100 Copay, then subject to Deductible & Coinsurance R: 50% $10 Min M: 50% $30 Min or R: 30% $10 Min M: 30% $30 Min $100 Copay, then subject to Deductible & Coinsurance R: 50% $10 Min M: 50% $30 Min or R: 30% $10 Min M: 30% $30 Min

$1,500

80 / 60

$1,500

70 / 50

$2,500

80 / 60

$2,500

70 / 50

$5,000

80 / 60

$5,000

70 / 50

Annual Routine Physical $25 Office Visit Copay, Routine Diagnostics and $25,then 100% Adult Immunizations subject to Deductible & Coinsurance Annual Routine Physical $25 Office Visit Copay, Routine Diagnostics and Adult Immunizations subject $25,then 100% to Deductible & Coinsurance Annual Routine Physical $25 Office Visit Copay, Routine Diagnostics and $25,then 100% Adult Immunizations subject to Deductible & Coinsurance Annual Routine Physical $25 Office Visit Copay, Routine Diagnostics and $25,then 100% Adult Immunizations subject to Deductible & Coinsurance Annual Routine Physical $25 Office Visit Copay, Routine Diagnostics and Adult Immunizations subject $25, then 100% to Deductible & Coinsurance

Influe Medical Surgical Supplies Varic Durable Medical Equipment & Oxygen COVER ED ED SERCES Hepa COVER SER VI VI CES Orthotic Devices & Prosthetic Appliances COVERED COVER ED SER VI CES SERVICES Hepa Home Health Care Services Meni Outpatient Services Outpatient Services Ambulance Outpatient Services Office Visits Office Visits Hospice Care Surgery Office Visits Surgery Human Organ Transplants & BoneBone Marrow Human Organ Transplants & Marrow Surgery Diagnostic, X-ray, Lab Testing Human Organ Transplants & Bone Marrow Diagnostic, X-ray, Lab Testing *For more detailed information, please request a Summary of Benefits Diagnostic, X-ray, Lab Testing Occupational & Physical Therapy (first (first 20 Occupational & Physical Therapy 20 Prescription P rescription Drug Coverage P rescription Drug Coverage Occupational & Physical Therapy (first 20 treatments) P rescription treatments) MailM ail order Drugs Coverage M ail Order Drugs Drug order Drugs treatments) Rehabilitation Services M ail order Drugs Rehabilitation Services OTHER IMPORTANT INFORM Rehabilitation Services Radiation & Chemotherapy Radiation & Chemotherapy W ellW ell Baby Care Well Baby Care Radiation & Chemotherapy Respiratory/Hyperbaric/Pulmonary/Speech Therapy Respiratory/Hyperbaric/Pulmonary/Speech Therapy W ellW ell Child Care Iunizations Imm Well W ell Baby Care m m unizations Child Care Immunizations Respiratory/Hyperbaric/Pulmonary/Speech Therapy Coverage stops a Pre-Admission Testing W ell Child Care I m m unizations Pre-Admission Testing Pre-Admission Testing who is an Eligible Allergy Testing & Treatment Allergy Testing & Treatment Allergy Testing & Treatment P Eligible Dependent Age Limitation reventive Preventive Services month the individu TMD/CMD PP reventive Services reventive Services TMD/CMD TMD/CMD Age Routine Gynecological Exam (one (one per calendar year) 18 and older is e unmarried Mental Health Care Care Services Services Routine Gynecological Exam per calendar year) 18 yrs & older and Routine Gynecological Exam (one per calendar year) Mental Health Care Services Mental Health Routine Pap Smear (one (one per calendar year) 18& older Qualified Child Age 18 yrs and older for DrugDrug Abuse Services Abuse Services Routine Pap Smear per calendar year)year) Routine Pap Smear (one per calendar Drug Abuse Services Routine Mammogram (per schedule) Alcoholism Services Routine Mammogram (per schedule) Routine Mammogram (per Alcoholism Services Alcoholism Services (Males age 50) 50) Annual Prostate Screening (Males over50 and older) Penalty for no Pre Annual Prostate Screening (Males over 50) Annual Prostate Precertification Screening Diabetes Education &Requirement Control Inpatient admissio Diabetes Education & Control I npatient Hospital Services Diabetes Education & Control I npatient Hospital Services Inpatient Hospital Services I npatient Colorectal Screening (Age 50 and older) Physician Visits Visits Physician Visits Physician Preexisting Condi Unlimited Day Semi-Private Room & Board Board Unlimited Day Semi-Private Room Board Unlimited Day Semi-Private Room && another health ins Additional Preventive Services - SB+ 2008 Ancillaries, Drugs, Therapy Services, X-ray, X-ray, Lab Ancillaries, Drugs, Therapy Services, Lab Ancillaries, Drugs, Therapy Services, X-ray, Lab coverage under th Routine AnnualCondition Limitation Diagnostics Physical & Associated Routine Annual Physical Preexisting Routine Annual Physical & Associated Diagnostics Diagnostics General General Nursing Care & Surgical Services Nursing Care & Surgical Services General Nursing Care & Surgical Services covered under the LipidLipid Panel PanelPanel Lipid Mental Health Care Care Services Mental Health Care Services Mental Health Services Preexisting Condi Urinalysis Urinalysis Urinalysis DrugDrug Abuse Services Abuse Services Drug Abuse Services in coverage, the 3 Complete Blood Count (CBC) Complete Blood Complete Blood Count (CBC) Alcoholism Services Alcoholism Services Alcoholism Services BloodBloodGlucose Screening Glucose Screening Blood Glucose Screening Rubella Titer Titer Test Rubella Test Test Rubella Titer Other Covered Services Other Covered Services Other Covered Services Adult AdultImmunizations Immunizations Immunizations Adult Private DutyDuty Nursing Private Duty Private NursingNursing MMRMMRPneumococcal Polysaccaride Vaccine Pneumococcal Polysaccaride Vaccine MMR Pneumococcal Polysaccaride Vaccine Skilled NursingNursing Facility Skilled Facility Skilled Nursing Facility Influenza Vaccine Influenza Vaccine Influenza Vaccine MedicalMedical Surgical Supplies Surgical Supplies Medical Surgical Supplies Varicella Vaccine Varicella Vaccine Varicella Vaccine Durable Durable Medical Equipment & Oxygen Medical Equipment & Oxygen Durable Medical Equipment & Oxygen Hepatitis B Series Hepatitis B Series Hepatitis B Series OrthoticOrthotic Devices Prosthetic Appliances Devices & Prosthetic Appliances Orthotic Devices & & Prosthetic Appliances Hepatitis A Series Hepatitis A Series Home Health Care Services Hepatitis A Series Home Health Care Care Services Home Health Services Meningococcal Vaccine Meningococcal Vaccine Ambulance Meningococcal Vaccine Ambulance Ambulance HospiceHospice Care Care Hospice Care

*For more detailed information, please request of Benefits Insert. *For*For more detailed information, please request a a Summaryof Benefits Insert. more detailed information, please request a Summary of Benefits Insert. Summary

OTHER IMPORTANT INFORMATION OTHER IMPORTANT INFORMATION OTHER IMPORTANT INFORMATION

Eligible Dependent Age Limitation Eligible Dependent Age Age Limitation Eligible Dependent Limitation Coverage at the the end of the month of at 19 for Coverage stopsstopsatend of the month of age agefor afora child childchild Coverage stops Dependent,the month of 19 to the end of the age a who is an Eligible the end of but will continue 19 who who is an Eligible Dependent,will continue to the end of the the is an Eligible Dependent, but but will continue to the end of month the individual reaches the age of 25 if the adult child is month the individual reaches the age of 25 if 25 ifadultadult child is child is month the individual reaches the age of the meets the criteria unmarried and is either a full-time student or the unmarried and is either a full-time student or meets the criteria unmarried and is either a full-time student or meets the criteria for Qualified Child or Qualified Relative under IRS rules. for Qualified Child or Qualified Relative under IRS rules. for Qualified Child or Qualified Relative under IRS rules. Penalty for no Precertification is $500 reduction of benefits per Penalty for no Precertification is $500 reduction of benefits per per Penalty for no Precertification is $500 reduction of benefits Inpatient admission. Inpatient admission. Inpatient admission. Preexisting Condition Waiting Period: "If you were enrolled in Preexisting Condition Waiting Period: "If youthe Hire Date ofin in another health insurance policy prior "If you enrolled your Preexisting Condition Waiting Period:to werewere enrolled another health insurance Contract, the length of time you your your coverage under this policy prior to the the Date of were another health insurance policy prior toHire Hire Date of coverage under this the previous policy length of time werewere covered under this Contract, the will time you to the coverage under Contract, the length ofbe applied you covered under the previous policy will be applied to the the lapse Preexisting Condition Waiting Period. If there is a 63 covered under the previous policy will be applied to day Preexisting Condition 365 day Period. period will apply." 63 lapse in coverage, the Waiting waiting If there is a is day day lapse Preexisting Condition Waiting Period. If there 63 a in coverage, the 365 day waiting period will apply." in coverage, the 365 day waiting period will apply."

Precertification Requirement Precertification Requirement Precertification Requirement

Preexisting Condition Limitation Preexisting Condition Limitation Preexisting Condition Limitation

This document does not constitute an insurance contract and is intended only to provide a brief overview of our products. The actual terms, conditions and limitations of coverage are contained in the Group Contract. They may vary and are subject to change without notice. ALL SERVICES ARE SUBJECT TO A DETERMINATION OF MEDICAL NECESSITY BY MOUNTAIN STATE BLUE CROSS BLUE SHIELD. PAYMENT IS BASED ON THE ACTUAL CHARGES, PROFESSIONAL ALLOWANCE OR PROVIDERS REASONABLE CHARGE. IN ADDITION, YOU WILL BE RESPONSIBLE FOR THE NON-NETWORK LIABILITY.

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