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State of Illinois CIP BA HMO: Blue Cross and Blue Shield of IllinoisSummary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage Period: 07/01/2014 – 06/30/2015Coverage for: ALL Plan Type: HMOThis is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plandocument at www.bcbsil.com or by calling 1-800-868-9520.Important QuestionsAnswersWhy this Matters:What is the overalldeductible? 0See the chart starting on page 2 for your costs for services this plan covers.Are there otherdeductibles for specificservices?No.You don’t have to meet deductibles for specific services, but see the chart starting on page2 for other costs for services this plan covers.Is there an out–of–pocket limit on myexpenses?Yes. 3,000 Individual/ 6,000Family.The out-of-pocket limit is the most you could pay during a coverage period (usually oneyear) for your share of the cost of covered services. This limit helps you plan for healthcare expenses.What is not included inthe out–of–pocketlimit?Premiums, balanced-billedcharges, and health care thisplan doesn’t cover.Even though you pay these expenses, they don’t count toward the out–of–pocket limit.Does this plan use anetwork of providers?Yes. Visit www.bcbsil.com orcall 1-800-868-9520 for a list ofparticipating providers.If you use an in-network doctor or other health care provider, this plan will pay some or allof the costs of covered services. Be aware, your in-network doctor or hospital may use anout-of-network provider for some services. Plans use the term in-network, preferred, orparticipating for providers in their network. See the chart starting on page 2 for how thisplan pays different kinds of providers.Do I need a referral tosee a specialist?Yes.This plan will pay some or all of the costs to see a specialist for covered services but onlyif you have the plan’s permission before you see the specialist.Are there services thisplan doesn’t cover?Yes.Some of the services this plan doesn’t cover are listed on page 5. See your policy or plandocument for additional information about excluded services.Questions: Call 1-800-868-9520 or visit us at www.bcbsil.com.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat http://www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-855-756-4448 to request a copy.Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association1 of 8

State of Illinois CIP BA HMO: Blue Cross and Blue Shield of IllinoisSummary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage Period: 07/01/2014 – 06/30/2015Coverage for: ALL Plan Type: HMO Copayments are fixed dollar amounts (for example, 15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, ifthe plan’s allowed amount for an overnight hospital stay is 1,000, your coinsurance payment of 20% would be 200. This may change ifyou haven’t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than theallowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges 1,500 for an overnight stay andthe allowed amount is 1,000, you may have to pay the 500 difference. (This is called balance billing.) This plan may encourage you to use participating providers by charging you lower deductibles, copayments and coinsurance amounts.CommonMedical EventIf you visit a healthcare provider’s officeor clinicIf you have a testServices You May NeedYour Cost IfYou Use aParticipatingProviderPrimary care visit to treat an injury or illness 30 copay/visitSpecialist visitOther practitioner office visitPreventive care/screening/immunizationDiagnostic test (x-ray, blood work)Imaging (CT/PET scans, MRIs) 30 copay/visit 30 copay/visitNo ChargeNo ChargeNo ChargeYour Cost If YouUse aLimitations & ExceptionsNon-ParticipatingProviderServices or supplies that are notordered by your Primary CarePhysician or Women’s PrincipalNot CoveredHealth Care Provider, exceptemergency and routine vision exams,are not covered.Not CoveredReferral required.Not CoveredReferral required.Not Covered---none--Not CoveredReferral required.Not CoveredQuestions: Call 1-800-868-9520 or visit us at www.bcbsil.com.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat http://www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-855-756-4448 to request a copy.2 of 8

State of Illinois CIP BA HMO: Blue Cross and Blue Shield of IllinoisSummary of Benefits and Coverage: What this Plan Covers & What it CostsCommonMedical EventServices You May NeedGeneric drugsIf you need drugs totreat your illness orconditionFormulary brand drugsMore informationabout prescriptiondrug coverage isavailable atwww.bcbsil.com.Non-Formulary brand drugsIf you haveoutpatient surgeryIf you needimmediate medicalattentionYour Cost IfYou Use aParticipatingProvider 12 copay /prescription for upto 34 day supply. 24 copay /prescription for upto 90 day supply. 24 copay /prescription for upto 34 day supply. 48 copay /prescription for upto a 90 day supply. 48 copay /prescription for upto 34 day supply. 96 copay /prescription for upto a 90 day supply.Coverage Period: 07/01/2014 – 06/30/2015Coverage for: ALL Plan Type: HMOYour Cost If YouUse aLimitations & ExceptionsNon-ParticipatingProviderNot CoveredDispensing limit may apply to certaindrugs.Not CoveredCertain women’s preventive serviceswill be covered with no cost to themember. For a full list of theseprescriptions and/or services, pleasecontact Customer Service.Not CoveredSpecialty drugs 96 copayNot CoveredFacility fee (e.g., ambulatory surgery center)Physician/surgeon feesEmergency room servicesEmergency medical transportation 200 copay/visitNo Charge 200 copay/visitNo ChargeNot CoveredNot Covered 200 copay/visitNo ChargeUrgent care 30 copay/visitNot CoveredCoverage based on group policy.Prior authorization may be required.Referral required.Copay waived if admitted.Ground transportation only.Must be affiliated with member’schosen medical group or referralrequired. Applicable copay mayapply.Facility fee (e.g., hospital room) 250 copayNot CoveredReferral required.Physician/surgeon feeNo ChargeNot CoveredQuestions: Call 1-800-868-9520 or visit us at www.bcbsil.com.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat http://www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-855-756-4448 to request a copy.If you have ahospital stay3 of 8

State of Illinois CIP BA HMO: Blue Cross and Blue Shield of IllinoisSummary of Benefits and Coverage: What this Plan Covers & What it CostsCommonMedical EventIf you have mentalhealth, behavioralhealth, or substanceabuse needsIf you are pregnantIf you need helprecovering or haveother special healthneedsIf your child needsdental or eye careServices You May NeedMental/Behavioral health outpatientservicesMental/Behavioral health inpatient servicesYour Cost IfYou Use aParticipatingProviderCoverage Period: 07/01/2014 – 06/30/2015Coverage for: ALL Plan Type: HMOYour Cost If YouUse aLimitations & ExceptionsNon-ParticipatingProvider 30 copay/visitNot CoveredUnlimited visits. Referral required. 250 copayNot CoveredSubstance use disorder outpatient services 30 copay/visitNot CoveredSubstance use disorder inpatient services 250 copayNot CoveredPrenatal and postnatal care 30 copayNot CoveredDelivery and all inpatient servicesHome health careRehabilitation servicesHabilitation services 250 copay 30 copay/visitNo ChargeNo ChargeNot CoveredNot CoveredNot CoveredNot CoveredUnlimited days. Referral required.Use a plan provider only.Referral required. Unlimited visits.Unlimited visits. Referral required.Copay applies for the 1st prenatalvisit only.---none--Referral required.60 treatments combined for alltherapies. Referral required.Skilled nursing care 250 copayNot CoveredDurable medical equipment20% coinsuranceNot CoveredHospice serviceNo ChargeNot CoveredEye examNo ChargeNot CoveredGlassesDental check-upNot CoveredNot CoveredNot CoveredNot CoveredQuestions: Call 1-800-868-9520 or visit us at www.bcbsil.com.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat http://www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-855-756-4448 to request a copy.Excludes custodial care. Referralrequired.Referral required.Inpatient copay may apply.Referral required.Limited to one exam every 12months at participating providers.---none-----none---4 of 8

State of Illinois CIP BA HMO: Blue Cross and Blue Shield of IllinoisCoverage Period: 07/01/2014 – 06/30/2015Coverage for: ALL Plan Type: HMOSummary of Benefits and Coverage: What this Plan Covers & What it CostsExcluded Services & Other Covered Services:Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.) Cosmetic Surgery Long-term care Custodial care services Private-duty Nursing Dental careNon-emergency care when traveling outsidethe U.S Routine foot careOther Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for theseservices.) Acupuncture Hearing aids Routine eye care (Adult) Bariatric surgery Infertility treatment Chiropractic care Most coverage provided outside the UnitedStates. See www.bcbsil.com.Weight Loss (except when non-medicallysupervised)Your Rights to Continue Coverage:If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep healthcoverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you paywhile covered under the plan. Other limitations on your rights to continue coverage may also apply.For more information on your rights to continue coverage, contact the plan at 1-800-868-9520. You may also contact your state insurance department, theU.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health andHuman Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.Questions: Call 1-800-868-9520 or visit us at www.bcbsil.com.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat http://www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-855-756-4448 to request a copy.5 of 8