1 2 Blue Choice Advantage Plan Overview Selection

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Blue. Choice Advantage Plan Overview • Selection of Primary Care Physician (PCP) recommended • Referrals not required • In-Network Providers are: § Blue. Choice HMO and Blue. Preferred PPO providers (in Northern Virginia, Maryland, and the District of Columbia) § Blue. Card PPO providers • (nationwide provider network) Labs § Blue. Choice providers must use Lab. Corp® for lab services to be covered innetwork § Blue. Preferred PPO and Blue. Card PPO providers may use other participating PPO labs 3

Benefits Annual medical deductible (individual / family) In-network You Pay Out-of-network You Pay $250 / $500 / $1, 000 Annual medical out-of-pocket maximum (individual / family) $2, 000 / $4, 000 combined in/out-of-network Preventive care (Well Child, Adult Routine Physicals) $0 PCP copay Deductible, then 40% AB Primary Care Physician (PCP) office visit Deductible, then $20 copay Deductible, then 40% AB Specialist office visit Deductible, then $40 copay Deductible, then 40% AB Labs (at approved locations) Deductible, then No charge Deductible, then 40% AB X-rays (at approved locations) Deductible, then No charge Deductible, then 40% AB Outpatient Physical, Speech, Occupational Therapy (limited to 90 days combined/illness/benefit period and combined between in and out-of-network) Deductible, then $40 copay Deductible, then 40% AB AB = Allowed Benefit (member could be subject to Balance Billing when utilizing out-of-network providers) 4

Benefits In-network You Pay Out-of-network You Pay Convenience care (retail health clinic) Deductible, then $20 copay Deductible, then 40% of AB Urgent Care Deductible, then $40 copay In-network Deductible, then $40 copay Deductible, then $150 copay per visit, then 10% of AB In-network Deductible, then $150 copay per visit, then 10% of AB Deductible, then 10% of AB In-network Deductible, then 10% of AB Deductible, then $150 per admission copay, then $100 copay per day (maximum 5 daily copays) Deductible, then $150 per admission copay, then 40% of AB Deductible, then $20 PCP/$40 Specialist copay Deductible, then 40% of AB Emergency room – Facility Services (copay waived if admitted) Emergency room – Physician Services Inpatient hospital - Facility Services Inpatient hospital - Physician Services AB = Allowed Benefit (member could be subject to Balance Billing when utilizing out-of-network providers) 5

Vision

Importance of vision Vision is important to your overall health – can be a key indicator of other health concerns. Care. First Vision gives you: § Preventive vision services, eye exams on a regular basis § Access to a network of nearly 90, 000 provider access points through our partnership with Davis Vision § Participating providers include major retailers like: Visionworks, Walmart, Sam’s Club, Sears, JCPenney and Target

Vision benefit chart In-Network You Pay Eye Examinations (Once Per Calendar Year) Routine Eye Examination with dilation $20 copay Frames (Once Per Every Other Calendar Year) Davis Vision Frame Collection § Fashion level § Designer level § Premier level Non-Collection Frame No copay $25 copay Plan pays up to $130, you pay balance minus 20% discount Visit www. carefirst. com/fcps for more information 8

Vision benefit chart In-Network You Pay Spectacle Lenses (Once Per Calendar Year) Clear plastic single-vision, lined bifocal, trifocal or lenticular lenses (any Rx) No copay Contact Lenses (Initial Supply) (Once Per Calendar Year, In Lieu of Spectacle Lenses) Davis Vision Contact Lenses Collection No copay Medically Necessary Contact Lenses No copay with prior approval Other (Non-Collection) Contact Lenses Plan pays up to $125, you pay balance minus 15% discount Visit www. carefirst. com/fcps for more information 9

Vision benefit chart Out-of-Network Plan Pays Routine Eye Examination with dilation (per calendar year) Plan pays $40, you pay balance Frames Plan pays $45, you pay balance Single Lenses Bifocal Lenses Trifocal Lenses Plan pays $40, you pay balance Plan pays $60, you pay balance Plan pays $80, you pay balance Elective Contact Lenses Plan pays $125, you pay balance Medically Necessary Contacts Plan pays $225, you pay balance Visit www. carefirst. com/fcps for more information 10

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Care. First Video Visit Required Information Once Registered 1. Credit Card information for any applicable copays. 2. Location where you are being treated. 3. Wait for a doctor to become available on your device (e. g. smartphone, tablet or computer). 4. When doctor is available, they will chime in to hold face-to-face consultation. 5. Provider can call in prescriptions if needed. *Pharmacy information will be required (e. g. name and address). 20

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For more information § Visit www. carefirst. com/fcps for more information § 2020 Medical and Vision benefits and FAQs § Step-by-Step Guide Provider Search 34