Empire BCBS 2014 Individual Products Pathway Network Key

Empire BCBS 2014 Individual Products

Pathway Network Key Facts: § 75% the size of the larger HMO Provider network § 75+ hospitals in the Pathway Network § The network can be accessed through Provider Finder at www. empireblue. com § 28 county New York Service Area for HMO products § 28 county New York Service Area for EPO products § Under the EPO, members who reside outside of the 28 county NY service area can use Blue Card. 2

Consolidation of rating regions Empire’s operating area is dividing into five rating regions for all medical products Rates are based on the following locations: § Albany (region 1): Albany, Columbia, Fulton, Green, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Warren and Washington § Long Island (region 8): Nassau and Suffolk § Mid-Hudson (region 3): Delaware, Dutchess, Orange, Putnam, Sullivan and Ulster § New York City (region 4): Bronx, Kings, New York, Queens, Richmond, Rockland Westchester § Upstate (region 7): Clinton and Essex 3

Empire’s Individual OFF Marketplace portfolio (non-child only plans) Plan Name Deductible Single/ Family Office Visit PCP Specialist Annual Out of Pocket Network Max Coins Single/ Family Pharmacy Inpatient Hospital Emergency Room (Facility) Urgent Care $200 Copay then Ded/ Coins $50 Copay then Ded/ Coins BRONZE Empire Core Guided Access caat $5, 800/ $11, 600 Empire Core Guided Access cabs $4, 000/ $8, 000 $45 2 OV with copay; 3+ OV Ded/Coins $35 3 OV with copay; 4+ OV Ded/Coins Ded/ Coins 20% $6, 350/ $12, 700 Ded/ Coins $1000 Copay then Ded/ Coins 40% $6, 350/ $12, 700 Ded/ Coins $1, 000 Copay then Ded/ Coins SILVER Empire Essential Guided Access w/HSA - cbib Empire Essential Guided Access - cbjw Ded then $200 Ded then $50 $1, 000 Copay & Coins $1, 000 Copay $200 Copay $50 Copay then Ded/ Coins $2, 450/ $4, 900 Deductible/ Coinsurance 10% $6, 350/ $12, 700 Ded/ Coins $2, 250/ $4, 500 $30 Copay (No Ded) 25% $5800/ $11, 600 Ded/ Coins $1, 000/ $2, 000 $30 Copay (No Ded) 10% $6, 250/ $12, 500 Tier 1 - $15 Tier 2 - $40 Tier 3 Ded/Coins $1, 000 Copay then Ded/ Coins $200/ $400 $25 Copay (No Ded) 5% $3, 400/ $6, 800 Tier 1 - $15 Tier 2 - $40 Tier 3 Ded/Coins $500 Copay then Ded/ Coins GOLD Empire Preferred Guided Access - cecb Ded/ Coins $200 Copay $50 Copay then Ded/ Coins PLATINUM Empire Premier Guided Access - cazd Ded/ Coins $200 Copay then Ded/ Coins $50 Copay then Ded/ Coins The above is a summary. See the Certificate of Coverage with the Schedule of Benefits and any riders associated with the plan for complete coverage details and related terms and conditions. 4

Individual Enrollment To be eligible, an individual must live in one of the 28 counties where Empire is licensed to sell Open Enrollment: ▪ Plans can be purchased once a year through an open enrollment period • 1/1/14 effective date – open enrollment from 10/1 to 12/15 • Post 1/1/14 effective date – open enrollment from 12/16/13 to 3/31/14 Effective date assignment rules will be the same for ON and OFF the Individual Marketplace ▪ If application received 1 st – 15 th, effective 1 st of next month ▪ If application received 16 th – EOM, effective 1 st of following month Exception: Newborns and adopted children can be added or enrolled in a plan as of the date of birth or placement as long as we are advised within 60 days. 5

Empire BCBS 2014 Individual Rates Plan Name NYC Single Rate Bronze Core Guided Access (caat) $359. 87 Core Guided Access (cabs) $367. 44 Silver Essential Guided Access (cbjw) $427. 33 Essential Guided Access w/ HSA (cdib) $417. 57 Gold Preferred Guided Access (cecb) $518. 56 Platinum Premier Guided Access (cazd) $615. 61 66