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					Simplified Quote Form (group size 2-50)
  Broker Name                                                                                                  Broker number                                            Date submitted                                     Requested effective date



  Type                                                     Current carrier                                     Association                                              Type of industry                                   Rates

        New         Change             Reinstatement                                                                                                                                                                            Composite
                                                                                                                                                                                                                                Composite         Age/Sex
                                                                                                                                                                                                                                                  Age/Sex

  Broker fax no.                                           Broker phone no.                                    Broker e-mail                                            Group name                                         Group no.



  Group contact name                                       Group phone no.                                     Group address                                            City, State, ZIP code                              SIC code




 Please select            Plan Yr
 Benefit period:          Calendar Yr


  Blue Access® PPO Cost Share Options
                                                                                               Network                                                                                                                  Non-Network

             MHP                                                                                                                                 Out of       Out of                 Emergency                         Covered      Out of       Out of
                     Office Visit           Office Visit   Deductible   Deductible    Inpatient     Outpatient       Outpatient      IP/OP                                                     Deductible Deductible
   Options Compliant                                                                                                                           Pocket Limit Pocket Limit Urgent Care   Room                            Services   Pocket Limit Pocket Limit
                         PCP                    SCP          Single      Family        Facility      Surgery           Other      Professional                                                   Single    Family
            Option                                                                                                                               Single       Family                  Services                       Co-Insurance   Single       Family

    1                           $10             $10            $0              $0       NCS              NCS           NCS           NCS          None         None           $75           $200     $300      $900       20%          $2,000         $4,000
    2                           $15             $15           $250           $750       10%              10%            10%          10%         $1,500       $3,000          $75          200/10%   $500     $1,500      30%          $3,000         $6,000
    3                           $30             $30            $0              $0       $250             $100           20%          NCS         $2,000       $4,000          $75           $200     $300      $900       30%          $4,000         $8,000
    4                           $20             $20            $0              $0       20%              20%            20%          20%         $1,500       $3,000          $75          200/20%   $500     $1,500      40%          $3,000         $6,000
    5                           $15             $15           $250           $750       20%              20%            20%          20%         $1,500       $3,000          $75          200/20%   $500     $1,500      40%          $3,000         $6,000
    6                           $20             $20           $500           $1,500     20%              20%            20%          20%         $1,000       $2,000          $75          200/20%   $1,000   $3,000      40%          $2,000         $4,000
    7                           $15             $15           $500           $1,500     10%              10%            10%          10%         $2,500       $5,000          $75          200/10%   $1,000   $3,000      30%          $5,000         $10,000
    8                           $20             $50           $500           $1,500     20%              20%            20%          20%         $1,000       $2,000          $75          200/20%   $1,000   $3,000      40%          $2,000         $4,000
    9                           $15             $45           $500           $1,500     10%              10%            10%          10%         $2,500       $5,000          $75          200/10%   $1,000   $3,000      30%          $5,000         $10,000
    10                          $25             $25          $1,000          $3,000      0%              0%             0%            0%         $1,000       $3,000          $75           $200     $2,000   $6,000      20%          $5,000        $10,000
    11                          $30             $30           $750           $2,250     20%              20%            20%          20%         $2,000       $4,000          $75          200/20%   $1,500   $4,500      40%          $4,000         $8,000
    12                          $25             $50          $1,000          $3,000      0%              0%             0%            0%         $1,000       $3,000          $75           $200     $2,000   $6,000      20%          $5,000        $10,000
    13                          $20             $20          $1,000          $3,000     20%              20%            20%          20%         $4,000       $8,000          $75          200/20%   $2,000   $6,000      40%          $8,000         $16,000
    14                          $25             $25          $2,000          $6,000      0%              0%             0%            0%         $2,000       $6,000          $75           $200     $4,000   $12,000     20%          $8,000        $16,000
    15                          $20             $50          $1,000          $3,000     20%              20%            20%          20%         $4,000       $8,000          $75          200/20%   $2,000   $6,000      40%          $8,000         $16,000
    16                          $25             $50          $2,000          $6,000      0%              0%             0%            0%         $2,000       $6,000          $75           $200     $4,000   $12,000     20%          $8,000        $16,000
    17                          $25             $25          $2,500          $7,500     20%              20%            20%          20%         $5,000      $10,000          $75           20%      $5,000   $15,000     50%          $10,000       $20,000
    18                          $30             $30          $2,500          $7,500     30%              30%            30%          30%         $5,000       $10,000         $75          200/30%   $5,000   $15,000     50%          $10,000        $20,000




OH SG - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                                                                                           Page 1 of 56
Simplified Quote Form (group size 2-50)
                                                                              The benefit description is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract.
                                                                                               In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail.

                                                                          Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association.
                                                         ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.




OH SG - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                                                                                                 Page 2 of 56
Simplified Quote Form (group size 2-50)
  Blue Access® PPO Cost Share Options (continued)
                                                                                                      Network                                                                                                                                        Non-Network

             MHP                                                                                                                                           Out of       Out of                 Emergency                         Covered      Out of       Out of
                     Office Visit           Office Visit      Deductible     Deductible      Inpatient       Outpatient      Outpatient        IP/OP                                                     Deductible Deductible
   Options Compliant                                                                                                                                     Pocket Limit Pocket Limit Urgent Care   Room                            Services   Pocket Limit Pocket Limit
                         PCP                    SCP             Single        Family          Facility        Surgery          Other        Professional                                                   Single    Family
            Option                                                                                                                                         Single       Family                  Services                       Co-Insurance   Single       Family

    D1                          $20             $20              $250           $500            20%             20%             20%              20%            $2,000          $4,000            $75         200/20%         $500         $1,000      40%         $4,000         $8,000
    D2                          $15             $15              $500          $1,000           20%             20%             20%              20%            $2,000          $4,000            $75         200/20%        $1,000        $2,000      40%         $4,000         $8,000
    D3                          $20             $20              $500          $1,000           20%             20%             20%              20%            $3,000          $6,000            $75         200/20%        $1,000        $2,000      40%         $6,000         $12,000
    D4                          $30             $30              $750          $1,500           20%             20%             20%              20%            $2,000          $4,000            $75         200/20%        $1,500        $3,000      40%         $4,000         $8,000
    D5                          $20             $20             $1,000         $2,000           20%             20%             20%              20%            $4,000          $8,000            $75         200/20%        $2,000        $4,000      40%         $8,000         $16,000
    D6                          $30             $50             $2,500         $5,000            0%              0%              0%              0%             $2,500          $5,000            $75           $200         $5,000        $10,000     40%         $10,000        $20,000
    D7                          $25             $25             $2,500         $5,000           20%             20%             20%              20%            $5,000         $10,000            $75           20%          $5,000        $10,000     50%         $10,000        $20,000
    D8                          $30             $50             $3,000         $6,000            0%              0%              0%              0%             $3,000          $6,000            $75           $200         $6,000        $12,000     40%         $12,000        $24,000
    D9                          $30             $50             $4,000         $8,000            0%              0%              0%              0%             $4,000          $8,000            $75           $200         $8,000        $16,000     40%         $16,000        $32,000
    D10                         $30             $50             $5,000        $10,000            0%              0%              0%              0%             $5,000         $10,000            $75           $200        $10,000        $20,000     40%         $20,000        $40,000
    D11                         $30             $50             $5,000        $10,000           20%             20%             20%              20%           $10,000         $20,000            $75         200/20%       $10,000        $20,000     40%         $20,000        $40,000



  Anthem Essentialsm PPO Cost Share Options
                                                                                                      Network                                                                                                                                        Non-Network

             MHP                                                                                                                                           Out of       Out of                              Emergency                         Covered      Out of       Out of
                     Office Visit           Office Visit      Deductible     Deductible      Inpatient       Outpatient      Outpatient        IP/OP                                                                  Deductible Deductible
   Options Compliant                                                                                                                                     Pocket Limit Pocket Limit                            Room                            Services   Pocket Limit Pocket Limit
                         PCP                    SCP             Single        Family          Facility        Surgery          Other        Professional                                                                Single    Family
            Option                                                                                                                                         Single       Family                               Services                       Co-Insurance   Single       Family

  HS1                                 $20/50%                   $1,000         $3,000        $500/20%           20%             20%              20%            $5,000         $10,000                       $200/20%        $2,000        $6,000      50%         $10,000       $20,000
  HS2                                 $20/50%                   $2,000         $6,000        $750/20%           20%             20%              20%            $5,000         $10,000                       $200/20%        $4,000       $12,000      50%         $10,000       $20,000
  HS3                                 $20/50%                   $2,500         $7,500       $1000/20%           20%             20%              20%            $5,000         $10,000                       $200/20%        $5,000       $15,000      50%         $10,000       $20,000
  HS4                                 $20/50%                   $5,000        $15,000       $1000/20%           20%             20%              20%           $10,000         $20,000                       $200/20%        $10,000      $30,000      50%         $20,000       $40,000




                                                                                The benefit description is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract.
                                                                                                 In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail.

                                                                            Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association.
                                                           ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.



OH SG - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                                                                                                                       Page 3 of 56
Simplified Quote Form (group size 2-50)
  Blue Prioritysm Plus POS Cost Share Options -Cincinnati and Dayton
                                                                                                      Network                                                                                                                                       Non-Network

                                                                                                                                                           Out of       Out of                 Emergency                         Covered      Out of       Out of
                            Office Visit    Office Visit      Deductible     Deductible      Inpatient       Outpatient      Outpatient        IP/OP                                                     Deductible Deductible
   Options                                                                                                                                               Pocket Limit Pocket Limit Urgent Care   Room                            Services   Pocket Limit Pocket Limit
                                PCP             SCP             Single        Family          Facility        Surgery          Other        Professional                                                   Single    Family
                                                                                                                                                           Single       Family                  Services                       Co-Insurance   Single       Family

    1                           $20             $50             $1,000         $3,000           20%             20%             20%              20%           $4,000            8,000            $75        $200/20%        $2,000        $6,000     40%         $8,000        $16,000
    2                           $20             $50              $500          $1,500           20%             20%             20%              20%           $1,000            2,000            $75        $200/20%        $1,000        $3,000     40%         $2,000        $4,000
    3                           $15             $15              $500          $1,500           10%             10%             10%              10%           $2,500            5,000            $75        $200/10%        $1,000        $3,000     30%         $5,000        $10,000
    4                           $20             $20              $150           $450           $500             $300            20%              NCS           $1,500            3,000            $75           $200          $500         $1,500     40%         $3,000        $6,000
    5                           $15             $15              $200           $600            10%             10%             10%              10%           $1,000            2,000            $75        $200/10%         $400         $1,200     30%         $2,000        $4,000



  Prescription Drug Plans
   Option                              Network/Participating Retail Pharmacy                                                            Anthem Mail Service                                               Non-Network/Non-Participating Pharmacy                            Out of Pocket Limit

    B                                                 $10/$25/$40                                                                           $10/$65/$120                                                                 50% (min $40)
    C                                       $10/$25/$40/25% w $150 max                                                             $10/$65/$120/25% w $150 max                                                           50% (min $40)                                         $2,500 - 4th tier
    F                                                 $10/$30/$60                                                                           $10/$75/$180                                                                 50% (min $60)
    G                                       $10/$30/$60/25% w $150 max                                                             $10/$75/$180/25% w $150 max                                                           50% (min $60)                                         $2,500 - 4th tier
    K                                         $15/$30/25% - w $150 max                                                                $15/$75/25% w $150 max                                                             50% (min $60)                                         $2,500 - 3rd tier
    M                                                    $10/100%                                                                             $10/100%                                                              50% generic/100% brand


                          Medicare Rx Options
                              Wrap




                                                                                The benefit description is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract.
                                                                                                 In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail.

                                                                            Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association.
                                                           ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

OH SG - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                                                                                                                     Page 4 of 56
Simplified Quote Form (group size 2-50)




                                                         Prescription Drug
                                                             Options


                                                            C, G, K, M
                                                            C, G, K, M
                                                            C, G, K, M
                                                            C, G, K, M
                                                            C, G, K, M
                                                            C, G, K, M
                                                            C, G, K, M
                                                            C, G, K, M
                                                            C, G, K, M
                                                            C, G, K, M
                                                            C, G, K, M
                                                            C, G, K, M
                                                            C, G, K, M
                                                            C, G, K, M
                                                            C, G, K, M
                                                            C, G, K, M
                                                            C, G, K, M
                                                            C, G, K, M




OH SG - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                       Page 5 of 56
                       Simplified Quote Form (group size 2-50)
of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract.
Group Contract and this description, the terms of the Group Contract will prevail.

Community Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association.
 he Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.




                       OH SG - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                          Page 6 of 56
                       Simplified Quote Form (group size 2-50)


                                                                                                                       Prescription Drug
                                                                                                                           Options


                                                                                                                          C, G, K, M
                                                                                                                          C, G, K, M
                                                                                                                          C, G, K, M
                                                                                                                          C, G, K, M
                                                                                                                          C, G, K, M
                                                                                                                          C, G, K, M
                                                                                                                          C, G, K, M
                                                                                                                          C, G, K, M
                                                                                                                          C, G, K, M
                                                                                                                          C, G, K, M
                                                                                                                          C, G, K, M




                                                                                                                       Prescription Drug
                                                                                                                           Options


                                                                                                                              M
                                                                                                                              M
                                                                                                                              M
                                                                                                                              M




of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract.
Group Contract and this description, the terms of the Group Contract will prevail.

Community Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association.
 he Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.



                       OH SG - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                              Page 7 of 56
                       Simplified Quote Form (group size 2-50)


                                                                                                                                       Prescription Drug
                                                                                                                                           Options


                                                                                                                                             B, F
                                                                                                                                             B, F
                                                                                                                                             B, F
                                                                                                                                             B, F
                                                                                                                                             B, F




                                                                                                                       Out of Pocket Limit



                                                                                                                         $2,500 - 4th tier


                                                                                                                         $2,500 - 4th tier
                                                                                                                        $2,500 - 3rd tier




of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract.
Group Contract and this description, the terms of the Group Contract will prevail.

Community Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association.
 he Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

                       OH SG - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                              Page 8 of 56
Simplified Quote Form (group size 51+)
   Broker Name                                                                                               Broker number                                     Date submitted                                    Requested effective date



   Type                                                        Current carrier                               Association                                       Type of industry                                  Rates

         New         Change            Reinstatement                                                                                                                                                                Composite        Age/Sex
                                                                                                                                                                                                                                     Age/Sex


   Broker fax no.                                              Broker phone no.                              Broker e-mail                                     Group name                                        Group no.



   Group contact name                                          Group phone no.                               Group address                                     City, State, ZIP code                             SIC code




  Please select                Plan Yr
  Benefit period:              Calendar Yr

   Blue Access® PPO Cost Share Options
                                                                                   Network                                                                                                              Non-Network

                                                                                        Outpatient
                                                                                                                                   Out of       Out of                 Emergency                         Covered    Out of       Out of
                Office Visit    Office Visit    Deductible   Deductible   Inpatient   Surgery: Hosp/   Outpatient      IP/OP                                                     Deductible Deductible
    Options                                                                              Alt. Care
                                                                                                                                 Pocket Limit Pocket Limit Urgent Care   Room                            Services Pocket Limit Pocket Limit
                   PCP             SCP            Single      Family       Facility                      Other      Professional                                                   Single    Family
                                                                                          Faciltiy                                 Single       Family                  Services                       Co-Insurance Single       Family

     1              $15             $15              $0         $0          NCS              NCS         NCS           NCS          None        None         $75        $200           $300    $900        30%           $1,000       $2,000
     2              $10             $30              $0         $0          NCS              NCS         NCS           NCS          None        None         $75        $200           $300    $900        20%           $2,000       $4,000
     3              $15             $15              $0         $0          $500             $200        NCS           NCS          None        None         $75        $200           $300    $900        30%           $2,000       $4,000
     4              $10             $10              $0         $0          10%              10%          10%          10%         $1,000       $2,000       $75      $200/10%         $300    $900        30%           $2,000       $4,000
     5              $15             $15            $200        $600         10%              10%          10%          10%         $1,000       $2,000       $75      $200/10%         $400   $1,200       30%           $2,000       $4,000
     6              $20             $20              $0         $0          $250             $75          20%          NCS         $2,000       $4,000       $75      $200/20%         $300    $900        30%           $4,000       $8,000
     7              $15             $15            $250        $750         10%              10%          10%          10%         $1,500       $3,000       $75      $200/10%         $500   $1,500       30%           $3,000       $6,000
     8              $15             $15            $250        $750         $750             $300         20%          NCS         $1,500       $3,000       $75      $200/20%         $500   $1,500       20%           $3,000       $6,000
     9              $20             $20              $0         $0          20%              20%          20%          20%         $1,500       $3,000       $75      $200/20%         $500   $1,500       40%           $3,000       $6,000
     10             $30             $50              $0         $0          $250             $100         20%          NCS         $2,000       $4,000       $75        $200           $300    $900        30%           $4,000       $8,000
     11             $15             $15            $250        $750         20%              20%          20%          20%         $1,500       $3,000       $75      $200/20%         $500   $1,500       40%           $3,000       $6,000
     12             $15             $15            $200        $600         20%              20%          20%          20%         $2,000       $4,000       $75      $200/20%         $400   $1,200       40%           $4,000       $8,000
     13             $20             $20             $250       $750         20%              20%          20%          20%         $2,000       $4,000       $75      $200/20%         $500   $1,500       40%           $4,000       $8,000
     14             $20             $50            $500        $1,500       20%              20%          20%          20%         $1,000       $2,000       $75      $200/20%     $1,000     $3,000       40%           $2,000       $4,000
     15             $15             $15            $500        $1,500       20%              20%          20%          20%         $2,000       $4,000       $75      $200/20%     $1,000     $3,000       40%           $4,000       $8,000
     16             $25             $25            $1,000      $3,000       0%               0%           0%            0%         $1,000       $3,000       $75        $200       $2,000     $6,000       20%           $5,000       $10,000
     17             $20             $20            $500        $1,500       20%              20%          20%          20%         $3,000       $6,000       $75      $200/20%     $1,000     $3,000       40%           $6,000       $12,000
     18             $25             $25            $500        $1,500       20%              20%          20%          20%         $3,000       $6,000       $75      $200/20%     $1,000     $3,000       40%           $6,000       $12,000
     19             $25             $50            $1,000      $3,000        0%              0%           0%            0%         $1,000       $3,000       $75        $200       $2,000     $6,000       20%           $5,000       $10,000
     20             $30             $30            $750        $2,250       20%              20%          20%          20%         $2,000       $4,000       $75      $200/20%     $1,500     $4,500       40%           $4,000       $8,000




OH LG - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                                                                            Page 9 of 56
Simplified Quote Form (group size 51+)
                                                                              The benefit description is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract.
                                                                                               In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail.

                                                                         Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association.
                                                         ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.




OH LG - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                                                                                                 Page 10 of 56
Simplified Quote Form (group size 51+)
                                ®
   Blue Access PPO Cost Share Options (continued)
                                                                                         Network                                                                                                                                                                    Non-Network

                                                                                                 Outpatient
                                                                                                                                                         Out of       Out of                 Emergency                         Covered    Out of       Out of
                Office Visit    Office Visit    Deductible   Deductible        Inpatient       Surgery: Hosp/         Outpatient             IP/OP                                                     Deductible Deductible
    Options                                                                                       Alt. Care
                                                                                                                                                       Pocket Limit Pocket Limit Urgent Care   Room                            Services Pocket Limit Pocket Limit
                   PCP             SCP            Single      Family            Facility                                Other             Professional                                                   Single    Family
                                                                                                   Faciltiy                                              Single       Family                  Services                       Co-Insurance Single       Family

     21             $25             $25            $2,000      $6,000              0%                  0%                   0%                   0%                $2,000               $6,000               $75               $200              $4,000   $12,000     20%         $8,000         $16,000
     22             $25             $50            $2,000      $6,000              0%                  0%                   0%                   0%                $2,000               $6,000               $75               $200              $4,000   $12,000     20%         $8,000         $16,000
     23             $25             $25            $2,500      $7,500              20%                20%                  20%                  20%                $5,000              $10,000               $75                20%              $5,000   $15,000     50%         $10,000        $20,000
     24             $30             $30            $2,500      $7,500             30%                 30%                  30%                  30%                $5,000              $10,000               $75            $200/30%            $5,000    $15,000     50%         $10,000        $20,000
     D1             $10             $10              $0         $0                10%                 10%                  10%                  10%                $1,000               $2,000               $75            $200/10%              $300     $600       30%         $2,000          $4,000
     D2             $20             $20            $500        $1,000             20%                 20%                  20%                  20%                $1,000               $2,000               $75            $200/20%            $1,000    $2,000      40%         $2,000          $4,000
     D3             $20             $20            $250        $500               20%                 20%                  20%                  20%                $2,000               $4,000               $75            $200/20%              $500    $1,000      40%         $4,000          $8,000
     D4             $20             $20            $500        $1,000             20%                 20%                  20%                  20%                $3,000               $6,000               $75            $200/20%            $1,000    $2,000      40%         $6,000         $12,000
     D5             $20             $20            $1,500      $3,000             20%                 20%                  20%                  20%                $3,000               $6,000               $75                20%             $3,000    $6,000      40%         $6,000         $12,000
     D6             $20             $20            $1,000      $2,000             20%                 20%                  20%                  20%                $4,000               $8,000               $75            $200/20%            $2,000    $4,000      40%         $8,000         $16,000
     D7             $30             $50            $2,500      $5,000              0%                  0%                   0%                  0%                 $2,500               $5,000               $75               $200             $5,000    $10,000     40%         $10,000        $20,000
     D8             $30             $50            $3,000      $6,000              0%                  0%                   0%                  0%                 $3,000               $6,000               $75               $200             $6,000    $12,000     40%         $12,000        $24,000
     D9             $30             $50            $4,000      $8,000              0%                  0%                   0%                  0%                 $4,000               $8,000               $75               $200             $8,000    $16,000     40%         $16,000        $32,000
     D10            $30             $50            $5,000     $10,000              0%                  0%                   0%                  0%                 $5,000              $10,000               $75               $200             $10,000   $20,000     40%         $20,000        $40,000
     D11            $30             $50            $5,000     $10,000             20%                 20%                  20%                  20%               $10,000              $20,000               $75            $200/20%            $10,000   $20,000     40%         $20,000        $40,000



   Anthem Essentialsm PPO Cost Share Options
                                                                                         Network                                                                                                                                                                    Non-Network

                                                                                                 Outpatient
                                                                                                                                                         Out of       Out of                                               Emergency                         Covered    Out of       Out of
                Office Visit    Office Visit    Deductible   Deductible        Inpatient       Surgery: Hosp/         Outpatient             IP/OP                                                                                   Deductible Deductible
    Options                                                                                       Alt. Care
                                                                                                                                                       Pocket Limit Pocket Limit                                             Room                            Services Pocket Limit Pocket Limit
                   PCP             SCP            Single      Family            Facility                                Other             Professional                                                                                 Single    Family
                                                                                                   Faciltiy                                              Single       Family                                                Services                       Co-Insurance Single       Family

   HS1                    $20/50%                  $1,000      $3,000          $500/20%               20%                  20%                  20%                $5,000             $10,000                               $200/20%            $2,000    $6,000      50%         $10,000        $20,000
   HS2                    $20/50%                  $2,000      $6,000          $750/20%               20%                  20%                  20%                $5,000             $10,000                               $200/20%            $4,000    $12,000     50%         $10,000        $20,000
   HS3                    $20/50%                  $2,500      $7,500         $1000/20%               20%                  20%                  20%                $5,000             $10,000                               $200/20%            $5,000    $15,000     50%         $10,000        $20,000
   HS4                    $20/50%                  $5,000     $15,000         $1000/20%               20%                  20%                  20%               $10,000             $20,000                               $200/20%           $10,000    $30,000     50%         $20,000        $40,000




                                                                                          The benefit description is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract.
                                                                                                           In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail.

                                                                                     Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association.
                                                                     ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
OH LG - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                                                                                                                                      Page 11 of 56
Simplified Quote Form (group size 51+)
                                sm
   Blue Priority                       Plus POS Cost Share Options-Cincinnati and Dayton
                                                                                   Network                                                                                                           Non-Network

                                                                                        Outpatient
                                                                                                                                   Out of       Out of             Emergency                         Covered    Out of       Out of
                Office Visit    Office Visit    Deductible   Deductible   Inpatient   Surgery: Hosp/   Outpatient      IP/OP                                                 Deductible Deductible
    Options                                                                              Alt. Care
                                                                                                                                 Pocket Limit Pocket Limit           Room                            Services Pocket Limit Pocket Limit
                   PCP             SCP            Single      Family       Facility                      Other      Professional                                               Single    Family
                                                                                          Faciltiy                                 Single       Family              Services                       Co-Insurance Single       Family

     1              $20             $50           $1,000       $3,000       20%              20%          20%          20%         $4,000         8,000      $75   $200/20%     $2,000     $6,000      40%         $8,000        $16,000
     2              $20             $50            $500        $1,500       20%              20%          20%          20%         $1,000         2,000      $75   $200/20%     $1,000     $3,000      40%         $2,000         $4,000
     3              $15             $15            $500        $1,500       10%              10%          10%          10%         $2,500         5,000      $75   $200/10%     $1,000     $3,000      30%         $5,000        $10,000
     4              $20             $20            $150        $450        $500              $300         20%          NCS         $1,500         3,000      $75     $200        $500      $1,500      40%         $3,000         $6,000
     5              $15             $15            $200        $600         10%              10%          10%          10%         $1,000         2,000      $75   $200/10%      $400      $1,200      30%         $2,000         $4,000
  Please select                Plan Yr
  Benefit period:              Calendar Yr

                                     ®
   Blue Preferred HMO Cost Share Options
                                                                                   Network                                                                                                           Non-Network

                                                                                        Outpatient
                                                                                                                                   Out of       Out of             Emergency                         Covered    Out of       Out of
                Office Visit    Office Visit    Deductible   Deductible   Inpatient   Surgery: Hosp/   Outpatient      IP/OP                                                 Deductible Deductible
    Options                                                                              Alt. Care
                                                                                                                                 Pocket Limit Pocket Limit           Room                            Services Pocket Limit Pocket Limit
                   PCP             SCP            Single      Family       Facility                      Other      Professional                                               Single    Family
                                                                                          Faciltiy                                 Single       Family              Services                       Co-Insurance Single       Family

     1              $15             $15            $100        $300         $250             $75          10%          10%          $1,000       $2,000      $75   $200/10%      N/A        N/A         N/A         N/A            N/A
     2              $15             $15            $250        $750         20%              20%          20%          20%          $2,000       $4,000      $75   $200/20%      N/A        N/A         N/A         N/A            N/A




OH LG - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                                                                      Page 12 of 56
Simplified Quote Form (group size 51+)
                                                                              The benefit description is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract.
                                                                                               In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail.

                                                                         Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association.
                                                         ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.




OH LG - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                                                                                                 Page 13 of 56
Simplified Quote Form (group size 51+)
  Prescription Drug Plans
    Option                       Network/Participating Retail Pharmacy                                                               Anthem Mail Service                                                                 Non-Network/Non-Participating Pharmacy      Out of Pocket Limit

     B                                          $10/$25/$40                                                                                $10/$65/$120                                                                                      50% (min $40)
     C                                   $10/$25/$40/25% w $150 max                                                            $10/$65/$120/25% w $150 max                                                                                   50% (min $40)              $2,500 - 4th tier
     F                                          $10/$30/$60                                                                                $10/$75/$180                                                                                      50% (min $60)
     G                                   $10/$30/$60/25% w $150 max                                                            $10/$75/$180/25% w $150 max                                                                                   50% (min $60)              $2,500 - 4th tier
     K                                    $15/$30/25% - w $150 max                                                                 $15/$75/25% w $150 max                                                                                    50% (min $60)              $2,500 - 3rd tier
     M                                           $10/100%                                                                                    $10/100%                                                                                 50% generic/100% brand


                     Medicare Rx Options                                                                                            Dependent Eligibility
                              Wrap                                                                    End of                To
                                                                                 End of
                                                                                                      Month              Birthday
                              Subsidy*                                         Calendar Yr

                              Waiver                                                                                                         Age 18; 23, federal tax exemption (ASO only)
  * Subsidy is only available to 100+ size groups.                                                                                           Age 19
                                                                                                                                             Age 19; 21 full-time student
  100+ Group Size Only                                                                                                                       Age 19; 23 full-time student
                              Refill by mail                                                                                                 Age 19; 24 full-time student
                              Customer request applies                                                                                       Age 19; 25 full-time student
                                                                             Note: Bold text is the standard Dependent Eligibility




                                                                                           The benefit description is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract.
                                                                                                            In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail.

                                                                                      Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association.
                                                                      ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
OH LG - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                                                                                                              Page 14 of 56
Simplified Quote Form (group size 51+)




                                                         Prescription Drug
                                                             Options


                                                          B, C, F, G, K, M
                                                          B, C, F, G, K, M
                                                          B, C, F, G, K, M
                                                          B, C, F, G, K, M
                                                          B, C, F, G, K, M
                                                          B, C, F, G, K, M
                                                          B, C, F, G, K, M
                                                          B, C, F, G, K, M
                                                          B, C, F, G, K, M
                                                          B, C, F, G, K, M
                                                          B, C, F, G, K, M
                                                          B, C, F, G, K, M
                                                          B, C, F, G, K, M
                                                          B, C, F, G, K, M
                                                          B, C, F, G, K, M
                                                          B, C, F, G, K, M
                                                          B, C, F, G, K, M
                                                          B, C, F, G, K, M
                                                          B, C, F, G, K, M
                                                          B, C, F, G, K, M




OH LG - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                       Page 15 of 56
                            Simplified Quote Form (group size 51+)
ge. The entire provisions of benefits and exclusions are contained in the Group Contract.
ontract and this description, the terms of the Group Contract will prevail.

y Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association.
Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.




                            OH LG - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                            Page 16 of 56
                            Simplified Quote Form (group size 51+)


                                                                                                              Prescription Drug
                                                                                                                  Options


                                                                                                               B, C, F, G, K, M
                                                                                                               B, C, F, G, K, M
                                                                                                               B, C, F, G, K, M
                                                                                                               B, C, F, G, K, M
                                                                                                               B, C, F, G, K, M
                                                                                                               B, C, F, G, K, M
                                                                                                               B, C, F, G, K, M
                                                                                                               B, C, F, G, K, M
                                                                                                               B, C, F, G, K, M
                                                                                                               B, C, F, G, K, M
                                                                                                               B, C, F, G, K, M
                                                                                                               B, C, F, G, K, M
                                                                                                               B, C, F, G, K, M
                                                                                                               B, C, F, G, K, M
                                                                                                               B, C, F, G, K, M




                                                                                                              Prescription Drug
                                                                                                                  Options


                                                                                                                     M
                                                                                                                     M
                                                                                                                     M
                                                                                                                     M




ge. The entire provisions of benefits and exclusions are contained in the Group Contract.
ontract and this description, the terms of the Group Contract will prevail.

y Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association.
Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
                            OH LG - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                Page 17 of 56
Simplified Quote Form (group size 51+)


                                                         Prescription Drug
                                                             Options


                                                               B, F
                                                               B, F
                                                               B, F
                                                               B, F
                                                               B, F




                                                         Prescription Drug
                                                             Options


                                                                F
                                                                F




OH LG - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                       Page 18 of 56
                            Simplified Quote Form (group size 51+)
ge. The entire provisions of benefits and exclusions are contained in the Group Contract.
ontract and this description, the terms of the Group Contract will prevail.

y Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association.
Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.




                            OH LG - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                            Page 19 of 56
                            Simplified Quote Form (group size 51+)
                                                                                                              Out of Pocket Limit



                                                                                                                $2,500 - 4th tier


                                                                                                                $2,500 - 4th tier
                                                                                                               $2,500 - 3rd tier




ge. The entire provisions of benefits and exclusions are contained in the Group Contract.
ontract and this description, the terms of the Group Contract will prevail.

y Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association.
Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
                            OH LG - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                  Page 20 of 56
Simplified Quote Form (group size 100+)
    Broker Name                                                                                                 Broker number                                                     Date submitted                                            Requested effective date



    Type                                                 Current carrier                                        Association                                                       Type of industry                                          Rates

         New       Change         Reinstatement                                                                                                                                                                                                Composite
                                                                                                                                                                                                                                               Composite        Age/Sex
                                                                                                                                                                                                                                                                Age/Sex
                                                                                                                                                                                                                                                                Age/Sex

    Broker fax no.                                       Broker phone no.                                       Broker e-mail                                                     Group name                                                Group no.



    Group contact name                                   Group phone no.                                        Group address                                                     City, State, ZIP code                                     SIC code



    Please select              Plan Yr
    Benefit period:            Calendar Yr



    Blue Access® PPO Cost Share Options
                                                       Deductible                                                                             Out-of-Pocket Maximum                                                                                        Outpatient Therapy Visit Limits
                                                                                                                                                                                                          Emergency Room
             Network                 Non-Network                        Network                   Non-Network                           Network                   Non-Network                                                                                    Physical/Occupational: 20/20
                       Single/Family                                               Single/Family                                                   Single/Family                                        $50 @ ER/$35 @ Urgent                                    Manipulation Therapy: 12
               None                    $300/$600                          $300/$600                $600/$1,200                         None                       $1,000/$2,000                         $75 @ ER/$35 @ Urgent                                    Speech: 20
               None                    $500/$1,000                        $300/$900                $600/$1,800                         $500/$1,000                $1,000/$2,000                         $75 @ ER/$50 @ Urgent                                    Physical/Occupational: 30/30
               $0/$0                   $300/$600                          $400/$800                $800/$1,600                         $750/$1,500                $1,500/$3,000                         $75/20% @ ER/$35 @ Urgent                                Manipulation Therapy: 12
               $0/$0                   $300/$900                          $500/$1,000             $1,000/$2,000                        $1,000/$2,000              $2,000/$4,000                         $100 @ ER/$35 @ Urgent                                   Speech: 20
               $0/$0                   $500/$1,500                        $500/$1,500             $1,000/$3,000                        $1,000/$2,000              $3,000/$6,000                         $100 @ ER/$50 @ Urgent                                   Physical/Occupational: 45/45
               $100/$200               $200/$400                          $750/$1,500             $1,500/$3,000                        $1,000/$3,000             $5,000/$10,000                         $100/10% @ ER/$50 @ Urgent                               Manipulation Therapy: 24
               $100/$200               $300/$600                          $750/$2,250             $1,500/$4,500                        $1,500/$3,000              $3,000/$6,000                         $150 @ ER/$35 @ Urgent                                   Speech: 40
               $100/$300               $300/$900                          $1,000/$2,000           $2,000/$4,000                        $1,500/$3,000              $4,500/$9,000                         $150 @ ER/$50 @ Urgent
               $150/$300               $300/$600                          $1,000/$3,000           $2,000/$6,000                        $2,000/$4,000              $4,000/$8,000                         $150/10% @ ER/$50 @ Urgent
               $200/$400               $400/$800                          $1,500/$3,000           $3,000/$6,000                        $2,000/$6,000             $8,000/$16,000                         $150/20% @ ER/$50 @ Urgent
               $200/$600               $400/$1,200                        $2,000/$6,000          $4,000/$12,000                        $2,500/$5,000             $5,000/$10,000                         $150/30% @ ER/$50 @ Urgent
               $250/$500               $500/$1,000                        $2,500/$5,000          $5,000/$10,000                        $3,000/$6,000             $6,000/$12,000                         $200 @ ER / $75 @ Urgent
               $250/$750               $500/$1,500                        $2,500/$7,500          $5,000/$15,000                        $4,000/$8,000             $8,000/$16,000                         $200/10% @ ER / $75 @ Urgent

    Note: Coinsurance on Physician Home and Office Services, Emergency Care and Urgent Care requires a minimum                         $5,000/$10,000           $10,000/$20,000                         $200/20% @ ER / $75 @ Urgent
    Network deductible of $1,000.                                                                                                                                                                       $200/30% @ ER / $75 @ Urgent
                                                                                                                                                                                                        0% @ ER/0% @ Urgent*
                                                                                 Lifetime Maximum                                                                                                       10% @ ER/10% @ Urgent
                                                                                 $1 million combined                                                                                                    20% @ ER/20% @ Urgent
                                                                                 $2 million combined                                                                                                    20% @ ER/$50 @ Urgent
                                                                                 $5 million combined                                                                                                    30% @ ER/30% @ Urgent
                                                                                                                                                                                                        40% @ ER/40% @ Urgent

                                                               The benefit description is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions     *Network and network coinsurance must match
                                                               are contained in the Group Contract. In the event of a conflict between the Group Contract and this description, the         other medical "covered services" coinsurance.
                                                               terms of the Group Contract will prevail.
OH PPO 100+ - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                                                                                                Page 21 of 56
Simplified Quote Form (group size 100+)                        The benefit description is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions
                                                               are contained in the Group Contract. In the event of a conflict between the Group Contract and this description, the
                                                               terms of the Group Contract will prevail.

                                                                                       Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association.
                                                                       ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.




OH PPO 100+ - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                                                                                                         Page 22 of 56
Simplified Quote Form (group size 100+)
                                                        Copayment/coinsurance for Covered Services

                                                                 Outpatient Surgery:
      Physician Home and                                                                    Other Outpatient    Inpatient/Outpatient
                                   Inpatient Facility          Hospital/Alternative Care
        Office Services                                                                        Services        Professional Services
                                                                        Facility

       Network PCP/SCP/               Network/                        Network/                 Network/
                                                                                                               Network/Non-network
         Non-network                 Non-network                     Non-network              Non-network

              $5/$5/30%                NCS/30%                         NCS/30%                  NCS/30%              NCS/30%
              $5/$5/30%                $100/30%                        $50/30%                  20%/30%              NCS/30%
              $5/$5/30%                $250/30%                        $75/30%                  20%/30%              NCS/30%
              $5/$5/40%                20%/40%                         20%/40%                  20%/40%              20%/40%
              $10/$10/20%              NCS/20%                         NCS/20%                  NCS/20%              NCS/20%
              $10/$30/20%              NCS/20%                         NCS/20%                  NCS/20%              NCS/20%
              $10/$10/30%              NCS/30%                         NCS/30%                  NCS/30%              NCS/30%
              $10/$10/30%              $100/30%                        $50/30%                  20%/30%              NCS/30%
              $10/$10/30%              $250/30%                        $75/30%                  20%/30%              NCS/30%
              $10/$10/30%              $250/30%                       $100/30%                  NCS/30%              NCS/30%
              $10/$10/30%              10%/30%                         10%/30%                  10%/30%              10%/30%
              $10/$10/40%              NCS/40%                         NCS/40%                  NCS/40%              NCS/40%
              $10/$10/40%              10%/40%                         10%/40%                  10%/40%              10%/40%
              $10/$10/40%              20%/40%                         20%/40%                  20%/40%              20%/40%
              $15/$15/20%              NCS/20%                         NCS/20%                  NCS/20%              NCS/20%
              $15/$15/20%              $750/20%                       $300/20%                  20%/20%              NCS/20%
              $15/$15/30%              NCS/30%                         NCS/30%                  NCS/30%              NCS/30%
              $15/$15/30%              $100/30%                        $50/30%                  20%/30%              NCS/30%
              $15/$15/30%              $250/30%                       $100/30%                  20%/30%              NCS/30%
              $15/$15/30%              $500/30%                       $200/30%                  NCS/30%              NCS/30%
              $15/$15/30%              $500/30%                       $200/30%                  20%/30%              NCS/30%
              $15/$15/30%              10%/30%                         10%/30%                  10%/30%              10%/30%
              $15/$15/40%              NCS/40%                         NCS/40%                  NCS/40%              NCS/40%
              $15/$15/40%              10%/40%                         10%/40%                  10%/40%              10%/40%
              $15/$15/40%              20%/40%                         20%/40%                  20%/40%              20%/40%
              $15/$45/30%              10%/30%                         10%/30%                  10%/30%              10%/30%           The benefit description is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract. In the event of a con
                                                                                                                                       between the Group Contract and this description, the terms of the Group Contract will prevail.
              $15/$45/40%              20%/40%                         20%/40%                  20%/40%              20%/40%
                                                                                                                                       Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association. ® ANTHEM
              $20/$20/20%              NCS/20%                         NCS/20%                  NCS/20%              NCS/20%
                                                                                                                                       registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield
                                                                       NCS/30%                                       NCS/30%           Association.
              $20/$20/30%              NCS/30%                                                  NCS/30%
              $20/$20/30%              $100/30%                        $50/30%                  20%/30%              NCS/30%




OH PPO 100+ - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                                                                                                              Page 23 of 56
Simplified Quote Form (group size 100+)
                                                        Copayment/coinsurance for Covered Services

                                                                 Outpatient Surgery:
      Physician Home and                                                                    Other Outpatient    Inpatient/Outpatient
                                   Inpatient Facility          Hospital/Alternative Care
        Office Services                                                                        Services        Professional Services
                                                                        Facility

       Network PCP/SCP/               Network/                        Network/                 Network/
                                                                                                               Network/Non-network
         Non-network                 Non-network                     Non-network              Non-network

              $20/$20/30%              $250/30%                        $75/30%                  20%/30%              NCS/30%
              $20/$20/30%              $500/30%                       $300/30%                  20%/30%              NCS/30%
              $20/$20/30%              10%/30%                         10%/30%                  10%/30%              10%/30%
              $20/$20/40%              NCS/40%                         NCS/40%                  NCS/40%              NCS/40%
              $20/$20/40%              10%/40%                         10%/40%                  10%/40%              10%/40%
              $20/$20/40%              20%/40%                         20%/40%                  20%/40%              20%/40%
              $20/$50/40%              20%/40%                         20%/40%                  20%/40%              20%/40%
              $25/$25/20%               0%/20%                         0%/20%                    0%/20%              0%/20%
              $25/$25/30%              NCS/30%                         NCS/30%                  NCS/30%              NCS/30%
              $25/$25/30%              $100/30%                        $50/30%                  20%/30%              NCS/30%
              $25/$25/30%              10%/30%                         10%/30%                  10%/30%              10%/30%
              $25/$25/40%              NCS/40%                         NCS/40%                  NCS/40%              NCS/40%
              $25/$25/40%              10%/40%                         10%/40%                  10%/40%              10%/40%
              $25/$25/40%              20%/40%                         20%/40%                  20%/40%              20%/40%
              $25/$25/50%              20%/50%                         20%/50%                  20%/50%              20%/50%
              $25/$25/50%              40%/50%                         40%/50%                  40%/50%              40%/50%
              $25/$50/20%               0%/20%                         0%/20%                    0%/20%              0%/20%
              $25/$50/40%              20%/40%                         20%/40%                  20%/40%              20%/40%
              $30/$30/30%              $250/30%                       $100/30%                  20%/30%              NCS/30%           The benefit description is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract. In the event of a con
                                                                                                                                       between the Group Contract and this description, the terms of the Group Contract will prevail.
              $30/$30/40%              20%/40%                         20%/40%                  20%/40%              20%/40%
                                                                                                                                       Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association. ® ANTHEM
              $30/$30/50%              30%/50%                         30%/50%                  30%/50%              30%/50%
                                                                                                                                       registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield
                                                                       40%/50%                                       40%/50%           Association.
              $30/$30/50%              40%/50%                                                  40%/50%
              $30/$50/30%              $250/30%                       $100/30%                  20%/30%              NCS/30%




OH PPO 100+ - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                                                                                                              Page 24 of 56
Simplified Quote Form (group size 100+)
    Prescription Drug Plans
                                                                                                                                                                                                         Non-Network/Non-
             Option                       Network/Participating Retail Pharmacy                                           Anthem Mail Service                                                                                                                   Deductible       Out of Pocket Limit
                                                                                                                                                                                                       Participating Pharmacy

                A                                        $10/$20/$30                                                            $10/$50/$90                                                                   50% (min $30)
                B                                        $10/$25/$40                                                           $10/$65/$120                                                                   50% (min $40)
                C                               $10/$25/$40/25% w $150 max                                          $10/$65/$120/25% w $150 max                                                               50% (min $40)                                                         $2,500 - 4th tier
                D                               $10/$25/$45/25% w $150 max                                          $10/$65/$135/25% w $150 max                                                               50% (min $45)                                                         $2,500 - 4th tier
                E                               $10/$25/$50/25% w $150 max                                          $10/$65/$150/25% w $150 max                                                               50% (min $50)                                                         $2,500 - 4th tier
                F                                        $10/$30/$60                                                           $10/$75/$180                                                                   50% (min $60)
                G                               $10/$30/$60/25% w $150 max                                          $10/$75/$180/25% w $150 max                                                               50% (min $60)                                                         $2,500 - 4th tier
                H                               $10/$40/$60/25% w $150 max                                         $10/$100/$180/25% w $150 max                                                               50% (min $60)                                                         $2,500 - 4th tier
                 I                                       $15/$40/$60                                                           $15/$100/$180                                                                  50% (min $60)                                         $200
                 J                              $15/$40/$60/25% w $150 max                                         $15/$100/$180/25% w $150 max                                                               50% (min $60)                                         $200            $2,500 - 4th tier
                K                                $15/$30/25% - w $150 max                                              $15/$75/25% w $150 max                                                                 50% (min $60)                                                        $2,500 - 3rd tier
                L                    $15/$50/50% ($75 min-$150max)/25% w $150 max                    $15/$125/50% ($225 min-$450max)/25% w $150 max                                                           50% (min $75)                                                         $2,500 - 4th tier
                M                                         $10/100%                                                                $10/100%                                                             50% generic/100% brand
                N                               $10/$35/$60/25% w $150 max                                          $10/$90/$180/25% w $150 max                                                               50% (min $60)                                                         $2,500 - 4th tier
                O                               $10/$35/$75/25% w $150 max                                          $10/$90/$225/25% w $150 max                                                               50% (min $75)                                                         $2,500 - 4th tier
                P                                      $10/50%/50%/50%                                                      $10/50%/50%/50%                                                                   50% (min $50)                                                         NO OOP MAX
                Q                               $10/$20/$30/25% w $150 max                                           $10/$50/$90/25% w $150 max                                                               50% (min $30)                                                         $2,500 - 4th tier
                3                                         $8/$15/$25                                                            $16/$30/$50                                                                   50% (min $30)


                     Medicare Rx Options                                                                                                       Dependent Eligibility
                               Wrap                                                                           End of                                   To
                                                                           End of
                                                                                                              Month                                 Birthday
                               Subsidy*                                  Calendar Yr

                               Waiver                                                                                                                                                Age 18; 23, federal tax exemption (ASO only)
    * Subsidy is only available to 100+ size groups.                                                                                                                                 Age 19
                                                                                                                                                                                     Age 19; 21 full-time student
                                                                                                                                                                                     Age 19; 23 full-time student
    100+ Group Size Only                                                                                                                                                             Age 19; 24 full-time student
                               Customer request applies                                                                                                                              Age 19; 25 full-time student
                               Refill by mail                     Note: Bold text is the standard Dependent Eligibility




                                                                                               The benefit description is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract.
                                                                                                                In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail.

                                                                                          Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association.
                                                                          ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.



OH PPO 100+ - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                                                                                                                 Page 25 of 56
Simplified Quote Form (group size 100+)


                                                               Composite
                                                               Composite        Age/Sex
                                                                                Age/Sex
                                                                                Age/Sex




                                                                           Outpatient Therapy Visit Limits
                                                                                 Physical/Occupational: 20/20
                                                                                 Manipulation Therapy: 12
                                                                                 Speech: 20
                                                                                 Physical/Occupational: 30/30
                                                                                 Manipulation Therapy: 12
                                                                                 Speech: 20
                                                                                 Physical/Occupational: 45/45
                                                                                 Manipulation Therapy: 24
                                                                                 Speech: 40




OH PPO 100+ - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                    Page 26 of 56
                            Simplified Quote Form (group size 100+)
ame of Community Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association.
 s, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.




                            OH PPO 100+ - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                        Page 27 of 56
Simplified Quote Form (group size 100+)




      The benefit description is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract. In the event of a conflict
      between the Group Contract and this description, the terms of the Group Contract will prevail.

      Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association. ® ANTHEM is a
      registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield
      Association.




OH PPO 100+ - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                                    Page 28 of 56
Simplified Quote Form (group size 100+)




      The benefit description is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract. In the event of a conflict
      between the Group Contract and this description, the terms of the Group Contract will prevail.

      Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association. ® ANTHEM is a
      registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield
      Association.




OH PPO 100+ - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                                    Page 29 of 56
                            Simplified Quote Form (group size 100+)
                                                                                                                                Out of Pocket Limit




                                                                                                                                  $2,500 - 4th tier
                                                                                                                                  $2,500 - 4th tier
                                                                                                                                  $2,500 - 4th tier


                                                                                                                                  $2,500 - 4th tier
                                                                                                                                  $2,500 - 4th tier


                                                                                                                                  $2,500 - 4th tier
                                                                                                                                 $2,500 - 3rd tier
                                                                                                                                  $2,500 - 4th tier


                                                                                                                                  $2,500 - 4th tier
                                                                                                                                  $2,500 - 4th tier
                                                                                                                                  NO OOP MAX
                                                                                                                                  $2,500 - 4th tier




 outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract.
een the Group Contract and this description, the terms of the Group Contract will prevail.

ame of Community Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association.
 s, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.



                            OH PPO 100+ - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                              Page 30 of 56
         Simplified Quote Form (group size 100+)
Broker Name                                                                                                   Broker number                                           Date submitted                                     Requested effective date



Type                                                      Current carrier                                     Association                                             Type of industry                                   Rates

     New         Change         Reinstatement                                                                                                                                                                                   Composite
                                                                                                                                                                                                                                Composite        Age/Sex
                                                                                                                                                                                                                                                 Age/Sex

Broker fax no.                                            Broker phone no.                                    Broker e-mail                                           Group name                                         Group no.



Group contact name                                        Group phone no.                                     Group address                                           City, State, ZIP code                              SIC code



Please select                                Plan Yr
Benefit period:                              Calendar Yr

                                    ®
Blue Preferred Plus POS Cost Share Options
                                                                                             Network                                                                                                                   Non-Network

                         Physician                                                        Outpatient                              Inpatient/                                                                         Covered Services
                                                                                                                Other                                Out-of-Pocket                 Emergency Room                                           Out-of-Pocket       Prescription
                       Home and Office          Deductible             Inpatient       Surgery: Hospital/                         Outpatient                                                         Deductible       Co-insurance
      Options                                                                                                 Outpatient                               Maximum       Urgent Care     Services @                                               Maximum              Drug
                          Services             Single/Family            Facility          Alternative                            Professional                                                       Single/Family    unless otherwise
                                                                                                              Services*                              Single/Family                    Hospital                                              Single/Family         Options
                         PCP/SCP                                                         Care Facility                             Services                                                                               stated

     1                        $10                  None                  NCS                   NCS                NCS                NCS                   None         $75                $200      $200/$600              20%             $2,000/$4,000              A, B, F
     2                        $10                $100/$300               $100                   $50               20%                NCS             $1,000/$2,000      $75              $200/20%    $200/$600              40%             $2,000/$4,000              A, B, F
     3                        $15                $100/$300               $250                   $75               10%                10%             $1,000/$2,000      $75              $200/10%    $200/$600              30%             $2,000/$4,000              A, B, F
     4                        $15                $150/$450               10%                   10%                10%                10%             $1,500/$3,000      $75              $200/10%    $300/$900              30%             $3,000/$6,000              A, B, F
     5                        $15                $250/$750               20%                   20%                20%                20%             $2,000/$4,000      $75              $200/20%   $500/$1,500             40%             $4,000/$8,000              A, B, F

Prescription Drug Plans
      Option                                 Network/Participating Retail Pharmacy                                                       Anthem Mail Service                                             Non-Network/Non-Participating Pharmacy

          A                                                $10/$20/$30                                                                       $10/$50/$90                                                               50% (min $30)
          B                                                $10/$25/$40                                                                      $10/$65/$120                                                               50% (min $40)
          F                                                $10/$30/$60                                                                     $10/$75/$180                                                               50% (min $60)


                     Medicare Rx Options                                               100+ Group Size Only                                                                                               Dependent Eligibility
                                  Wrap                                                                        Refill by mail                                                              End of         To
                                                                                                                                                                       End of
                                                                                                                                                                                          Month       Birthday
                                  Subsidy*                                                                    Customer request applies                               Calendar Yr

                                  Waiver                                                                                                                                                                               Age 18; 23, federal tax exemption (ASO only)
* Subsidy is only available to 100+ size groups.                                                                                                                                                                       Age 19
                                                                                                                                                                                                                       Age 19; 21 full-time student
                                                                                                                                                                                                                       Age 19; 23 full-time student
The benefit description is intended to be a brief outline of coverage. The entire provisions of benefits
and exclusions are contained in the Group Contract. In the event of a conflict between the Group                                                                                                                       Age 19; 24 full-time student
Contract and this description, the terms of the Group Contract will prevail.
                                                                                                                                                                                                                       Age 19; 25 full-time student
         OH POS 100+ - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                                                                                  Page 31 of 56
Simplified Quote Form (group size 100+)
                                                                                                                                                                                      Note: Bold text is the standard Dependent Eligibility

                                                                               Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association.
                                                               ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.




OH POS 100+ - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                                                                                                 Page 32 of 56
Simplified Quote Form (group size 100+)




OH POS 100+ - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls   Page 33 of 56
       Simplified Quote Form (group size 100+)
Broker Name                                                                                    Broker number                                    Date submitted                                                  Requested effective date



Type                                                Current carrier                            Association                                      Type of industry                                                Rates

    New        Change         Reinstatement                                                                                                                                                                           Composite
                                                                                                                                                                                                                     Composite
                                                                                                                                                                                                                     Composite         Age/Sex
                                                                                                                                                                                                                                       Age/Sex

Broker fax no.                                      Broker phone no.                           Broker e-mail                                    Group name                                                      Group no.



Group contact name                                  Group phone no.                            Group address                                    City, State, ZIP code                                           SIC code



Please select                        Plan Yr
Benefit period:                      Calendar Yr

Blue Preferred® HMO Cost Share Options
                      Deductible                                                Copayments/coinsurance for Covered Services                                Outpatient Therapy Visit Limits                                          Emergency Room
                     Single/Family                                                                                                                             Physical/Occupational: 20/20                                      and Urgent Care Facility
                                                                PCP/SCP                                                           Inpatient/
             $0/$0                                                                           Outpatient Surgery:      Other                                    Manipulation Therapy: 12                                       $50 @ ER/$25 @ Urgent
                                                               Physician         Inpatient                                        Outpatient
                                                                                             Hospital/Alternative   Outpatient
             $100/$200                                       Home and Office      Facility                                       Professional                  Speech: 20                                                     $75 @ ER/$25 @ Urgent
                                                                                                Care Facility        Services
                                                                Services                                                           Services
             $100/$300                                                                                                                                         Physical/Occupational: 30/30                                   $150 @ ER/$50 @ Urgent
             $150/$450                                                $5/$5        NCS              NCS                NCS           NCS                       Manipulation Therapy: 12                                       $150/10% @ ER/$50 @ Urgent
             $250/$500                                                $5/$5       $100              $50                20%           NCS                       Speech: 20                                                     $150/20% @ ER/$50 @ Urgent
             $250/$750                                                $5/$5       $250              $75                20%           NCS                       Physical/Occupational: 45/45                                   $200 @ ER / $75 @ Urgent
                                                                      $5/$5        20%              20%                20%           20%                       Manipulation Therapy: 24                                       $200/10% @ ER / $75 @ Urgent
             Out-of-Pocket Maximum                                    $10/$10      NCS              NCS                NCS           NCS                       Speech: 40                                                     $200/20% @ ER / $75 @ Urgent
                     Single/Family                                    $10/$10     $100              $50                20%           NCS                                                                                      $200/30% @ ER / $75 @ Urgent
             $1,000/$2,000                                            $10/$10     $250              $75                20%           NCS                                                                        * Coinsurance must match other medical "covered
             $1,500/$3,000                                            $10/$10      20%              20%                20%           20%                                                                        services" coinsurance
             $2,000/$4,000                                            $15/$15      NCS              NCS                NCS           NCS
             $3,000/$6,000                                            $15/$15     $100              $50                20%           NCS
                                                                      $15/$15     $250              $75                10%           10%
                                                                      $15/$15     $250              $75                20%           NCS
                                                                      $15/$15      10%              10%                10%           10%
                                                                      $15/$15      20%              20%                20%           20%
                                                                      $20/$20      NCS              NCS                NCS           NCS
                                                                      $20/$20     $100              $50                20%           NCS
                                                                      $20/$20     $250              $75                20%           NCS
                                                                      $20/$20      20%              20%                20%           20%
                                                                      $25/$25      NCS              NCS                NCS           NCS
                                                                      $25/$25     $100              $50                20%           NCS         The benefit description is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are
                                                                      $25/$25     $250              $75                20%           NCS         contained in the Group Contract. In the event of a conflict between the Group Contract and this description, the terms of
                                                                                                                                                 the Group Contract will prevail.
                                                                      $25/$25      20%              20%                20%           20%
       OH HMO 100+ - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                                                                               Page 34 of 56
Simplified Quote Form (group size 100+)
                                                                                Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association.
                                                               ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.




OH HMO 100+ - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                                                                                                 Page 35 of 56
       Simplified Quote Form (group size 100+)
Prescription Drug Plans
     Option                               Network/Participating Retail Pharmacy                                                                            Anthem Mail Service

        A                                             $10/$20/$30                                                                                                 $10/$50/$90
        B                                             $10/$25/$40                                                                                                $10/$65/$120
        F                                             $10/$30/$60                                                                                                $10/$75/$180
        1                                              $8/$15/$25                                                                                                 $16/$30/$50


                 Medicare Rx Options                                                                                             Dependent Eligibility
                         Wrap                                                                  End of                          To
                                                                      End of
                                                                                               Month                        Birthday
                         Subsidy*                                   Calendar Yr

                         Waiver                                                                                                                         Age 18; 23, federal tax exemption (ASO only)
* Subsidy is only available to 100+ size groups.                                                                                                        Age 19
                                                                                                                                                        Age 19; 21 full-time student
100+ Group Size Only                                                                                                                                    Age 19; 23 full-time student
                         Refill by mail                                                                                                                 Age 19; 24 full-time student
                         Customer request applies                                                                                                       Age 19; 25 full-time student
                                                              Note: Bold text is the standard Dependent Eligibility




                                                                                            The benefit description is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract.
                                                                                                             In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail.

                                                                                        Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association.
                                                                       ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.


       OH HMO 100+ - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                                                                                                  Page 36 of 56
Simplified Quote Form (group size 100+)
      Broker Name                                                                              Broker number                                       Date submitted                                Requested effective date



      Type                                                 Current carrier                     Association                                         Type of industry                              Rates

          New        Change         Reinstatement                                                                                                                                                   Composite
                                                                                                                                                                                                    Composite
                                                                                                                                                                                                    Composite          Age/Sex
                                                                                                                                                                                                                       Age/Sex
                                                                                                                                                                                                                       Age/Sex

      Broker fax no.                                       Broker phone no.                    Broker e-mail                                       Group name                                    Group no.



      Group contact name                                   Group phone no.                     Group address                                       City, State, ZIP code                         SIC code




     Please select                Plan Yr
     Benefit period:              Calendar Yr




     Blue Traditional® Cost Share Options
                                                                                                         Outpatient Surgery:                                                     Out-of-Pocket
                                        Physician                    Deductible    Inpatient                                           Other              Inpatient/Outpatient                       Routine/Preventive
                Options                                                                                  Hospital/Alternative                                                      Maximum
                                  Home and Office Services          Singe/Family    Facility                                    Outpatient Services*     Professional Services                         Single/Family
                                                                                                            Care Facility                                                        Single/Family

                1                             20%                       $0/$0        20%                        20%                     20%                      20%             $1,000/$2,000               Covered
                2                             20%                     $250/$750      20%                        20%                     20%                      20%              $500/$1,000                Covered
                3                             20%                     $250/$750      20%                        20%                     20%                      20%              $500/$1,000            Not covered
                4                             20%                     $250/$750      20%                        20%                     20%                      20%              $750/$1,500                Covered
                5                             20%                     $200/$600      20%                        20%                     20%                      20%             $1,000/$2,000               Covered
                6                             20%                     $250/$750      20%                        20%                     20%                      20%              $750/$1,500            Not covered
                7                             20%                     $150/$450      20%                        20%                     20%                      20%             $1,500/$3,000               Covered
                8                             20%                     $200/$600      20%                        20%                     20%                      20%             $1,000/$2,000           Not covered
                9                             20%                     $150/$450      20%                        20%                     20%                      20%             $1,500/$3,000           Not covered
                10                            20%                     $250/$750      20%                        20%                     20%                      20%             $1,250/$2,500               Covered
                11                            20%                     $250/$750      20%                        20%                     20%                      20%             $1,250/$2,500           Not covered
                12                            20%                     $250/$750      20%                        20%                     20%                      20%             $1,500/$3,000               Covered
                13                            20%                     $250/$750      20%                        20%                     20%                      20%             $1,500/$3,000           Not covered
                14                            20%                    $500/$1,500     20%                        20%                     20%                      20%             $3,000/$6,000               Covered
                15                            20%                    $500/$1,500     20%                        20%                     20%                      20%             $3,000/$6,000           Not covered




OH TRAD 100+ - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                                                    Page 37 of 56
Simplified Quote Form (group size 100+)
                                                                                              The benefit description is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract.
                                                                                                               In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail.

                                                                                         Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association.
                                                                         ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.



     Prescription Drug Plans
               Option                    Network/Participating Retail Pharmacy                                         Anthem Mail Service                                                             Non-Network/Non-Participating Pharmacy                           Out of Pocket Limit

                  A                                        $10/$20/$30                                                        $10/$50/$90                                                                                     50% (min $30)
                  C                              $10/$25/$40/25% w $150 max                                       $10/$65/$120/25% w $150 max                                                                                 50% (min $40)                                $2,500 - 4th tier


                       Medicare Rx Options                                                                                                                                        Dependent Eligibility
                                Wrap                                                                                                                 End of                                   To
                                                                                                             End of
                                                                                                                                                     Month                                 Birthday
                                Subsidy*                                                                   Calendar Yr

                                Waiver                                                                                                                                                                                  Age 18; 23, federal tax exemption (ASO only)
     * Subsidy is only available to 100+ size groups.                                                                                                                                                                   Age 19
                                                                                                                                                                                                                        Age 19; 21 full-time student
                                                                                                                                                                                                                        Age 19; 23 full-time student
     100+ Group Size Only                                                                                                                                                                                               Age 19; 24 full-time student
                                Refill by mail                                                                                                                                                                          Age 19; 25 full-time student
                                Customer request applies                                        Note: Bold text is the standard Dependent Eligibility




OH TRAD 100+ - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                                                                                                          Page 38 of 56
Simplified Quote Form (group size 100+)
                                                                                     The benefit description is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract.
                                                                                                      In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail.

                                                                                Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association.
                                                                ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.




OH TRAD 100+ - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                                                                                                 Page 39 of 56
Simplified Quote Form (group size 100+)
                                                                Requested effective date




                                                                   Composite
                                                                   Composite
                                                                   Composite     Age/Sex
                                                                                 Age/Sex
                                                                                 Age/Sex




                                                                                           Rx Plans



                                                                                             A, C
                                                                                             A, C
                                                                                             A, C
                                                                                             A, C
                                                                                             A, C
                                                                                             A, C
                                                                                             A, C
                                                                                             A, C
                                                                                             A, C
                                                                                             A, C
                                                                                             A, C
                                                                                             A, C
                                                                                             A, C
                                                                                             A, C
                                                                                             A, C




OH TRAD 100+ - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                         Page 40 of 56
                             Simplified Quote Form (group size 100+)
ef outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract.
ween the Group Contract and this description, the terms of the Group Contract will prevail.

ame of Community Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association.
es, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.




                                                                                                                                Out of Pocket Limit



                                                                                                                                   $2,500 - 4th tier




                             OH TRAD 100+ - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                             Page 41 of 56
                             Simplified Quote Form (group size 100+)
ef outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract.
ween the Group Contract and this description, the terms of the Group Contract will prevail.

ame of Community Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association.
es, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.




                             OH TRAD 100+ - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                      Page 42 of 56
OH Prescription Drug Notes

                                                              Prescription Drug Definitions, Provisions, Covered Services and Limitations
                                                              Cost share structure equals tier 1/tier 2/tier 3 (and tier 4, if applicable)
                                                              Deductible applies to all prescription drug expenses except tier I. Once the deductible is met the appropriate copayment/ coinsurance applie
                                                              Benefit period = Calendar year or Plan year benefits
                                                              HMO - Rx Plans coupled with HMO products have no Non-Network benefit




                                                              Network out-of-pocket (if applicable) includes both Retail and Mail Service 4th tier drugs
                                                              N/A means Not Applicable
                                                              Diabetic test strips paid same as any other drug (Network and Non-network)
                                                              Certain diabetic and asthmatic supplies, excluding test strips, have no deductible/copayment/coinsurance up to the maximum allowable am
                                                              RX Option K - Generic Premium uses a condensed preferred drug list. Non preferred drugs are not covered. Requires mail service after 3rd
                                                              Rx Option M
                                                              • Brand prescription drugs are 100% member cost share
                                                              • Prescription Drug Card program includes chemotherapeutic agents and immunosuppressant at the appropriate generic copayment
                                                              • Certain diabetic and asthmatic supplies including test strips are covered subject to applicable Prescription Drug Copayments/Coinsurance

                                                              Day Limits
                                                              Retail: Up to a 30 day supply unless otherwise indicated at Network and Non-Network pharmacies
                                                              Mail Service: Up to a 90 day supply. No Non-Network coverage
                                                              Specialty: Drugs are available at both retail and mail service except as noted for Option K. Up to a 30 day supply will be dispensed for most

                                                              100+ Refill by Mail
                                                              Included with Rx Option K (Generic Premium) and is available as an option with other Rx plans for 100+ groups. (HMO, POS, PPO, exclud

                                                              Refill by mail
                                                              Requires the use of our mail service pharmacy after 3 retail fills of the same prescription




OH RxNotes - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                Page 43 of 56
OH Prescription Drug Notes




OH RxNotes - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls   Page 44 of 56
          OH Prescription Drug Notes

Prescription Drug Definitions, Provisions, Covered Services and Limitations
Cost share structure equals tier 1/tier 2/tier 3 (and tier 4, if applicable)
Deductible applies to all prescription drug expenses except tier I. Once the deductible is met the appropriate copayment/ coinsurance applies, only applies to options I and J
Benefit period = Calendar year or Plan year benefits
HMO - Rx Plans coupled with HMO products have no Non-Network benefit

Mandatory Generic substitution (DAW) applies except for Option K & M. When the member selects a brand drug when a generic equivalent is available the member is responsible for the generic copay plus (+) the cost difference between the generic and the brand
drug. If the physician indicates no substitutions, the member is only responsible for the appropriate cost share.

Network out-of-pocket (if applicable) includes both Retail and Mail Service 4th tier drugs
N/A means Not Applicable
Diabetic test strips paid same as any other drug (Network and Non-network)
Certain diabetic and asthmatic supplies, excluding test strips, have no deductible/copayment/coinsurance up to the maximum allowable amount at Network pharmacies. (Not covered at Non-network pharmacies.)
RX Option K - Generic Premium uses a condensed preferred drug list. Non preferred drugs are not covered. Requires mail service after 3rd fill at retail
Rx Option M
• Brand prescription drugs are 100% member cost share
• Prescription Drug Card program includes chemotherapeutic agents and immunosuppressant at the appropriate generic copayment
• Certain diabetic and asthmatic supplies including test strips are covered subject to applicable Prescription Drug Copayments/Coinsurance when obtained from a Network Pharmacy

Day Limits
Retail: Up to a 30 day supply unless otherwise indicated at Network and Non-Network pharmacies
Mail Service: Up to a 90 day supply. No Non-Network coverage
Specialty: Drugs are available at both retail and mail service except as noted for Option K. Up to a 30 day supply will be dispensed for most specialty drugs, at mail services and retail pharmacies

100+ Refill by Mail
Included with Rx Option K (Generic Premium) and is available as an option with other Rx plans for 100+ groups. (HMO, POS, PPO, excludes CDHP)

Refill by mail
Requires the use of our mail service pharmacy after 3 retail fills of the same prescription




          OH RxNotes - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                                                                        Page 45 of 56
OH Prescription Drug Notes
                                                                               The benefit description is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract.
                                                                                                In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail.

                                                                          Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association.
                                                          ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.




OH RxNotes - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                                                                                             Page 46 of 56
OH Medical Notes for All Plans

                                                                    Ohio Blue Product notes - product specific exceptions to these are noted separa
                                                                    Definitions and Provisions
                                                                    • 0% means no coinsurance up to the maximum allowable amount
                                                                    • Additional copayments, coinsurance and limits apply and may vary by option selected. Refer to the benefit summary for detailed information
                                                                    • All medical deductibles and percentage (%) coinsurance apply toward the out-of-pocket maximum (excluding flat dollar, Prescription Drug cost shares and
                                                                    • Allergy injections -- $5 Network copayment when office visit or Urgent care design is a copayment
                                                                    Ambulance and Hospice paid at the Network level( except HMO which is no deductible, copayment or coinsurance up to our maximum allowable amount)
                                                                    • Benefit period = Calendar year or Plan year benefits
                                                                    • Deductible does not apply to Emergency Room Services where a copayment and (%) coinsurance apply
                                                                    • Deductible(s) apply only to covered medical services listed with a percentage (%) coinsurance
                                                                    • Human Organ and Tissue Transplants:
                                                                         Network: No deductible/copayment/coinsurance up to the maximum allowable amount
                                                                         Non-network: 50% coinsurance. Does not apply to out-of-pocket maximums
                                                                         Kidney and cornea transplants are paid the same as any other medical covered benefit
                                                                    • Medical Nutritional Therapy is covered Non-Network
                                                                    • Medical option prefixes
                                                                     - D = Single/Family deductible ratio is 1:2
                                                                     - HS = Anthem Essential option
                                                                    • NCS (No Cost Share) means no deductible/copayment/coinsurance up to the maximum allowable amount
                                                                    • Network and Non-Network deductibles, copayments, coinsurance and out-of-pocket maximums are separate and do not accumulate toward each other




                                                                    • Physician Home and Office Services exclude certain diagnostic tests such as MRAs, MRIs, PETS, C-Scans, Nuclear Cardiology Imaging Studies, non-ma
                                                                    • Specialist (SCP) copayment is applicable to all Specialists (excludes: General Physicians, Internists, Pediatricians, OB/Gyns, Geriatrics or any other Netw
                                                                    • Urgent Care Facility copay excludes certain diagnostic tests such as MRAs, MRIs, PETS, C-Scans, Nuclear Cardiology Imaging Studies, non-maternity re




OH Medical Notes - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                           Page 47 of 56
OH Medical Notes for All Plans




OH Medical Notes - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls   Page 48 of 56
OH Medical Notes for All Plans




                                                                    • Preventive immunizations (Network) are not subject to the deductible/copayment if the option has a flat dollar Office Visit copayment and if rendered witho
                                                                    • Mammograms (routine and diagnostic) are subject to the PCP/OV cost share in office and outpatient facility settings.
                                                                    • Physical Medicine and Rehabilitation (Network and Non-network combined): Limited to 60 days, includes Day Rehabilitation programs
                                                                    • Durable Medical Equipment, Appliances and Orthotics:
                                                                         - DME subject to benefit max of $4,000 (excluding Prosthetic Devices, Limbs and Medical Supplies) Network and Non-Network combined
                                                                         - Prosthetic Devices $4,000 limit
                                                                         - Prosthetic limbs $10,000 limit
                                                                    • Skilled Nursing Facility (Network and Non-network combined): Limited to 90 days



                                                                    Limits are benefit period unless otherwise stated




OH Medical Notes - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                            Page 49 of 56
OH Medical Notes for All Plans
                                                                    Anthem By Design
                                                                    Grp Size 10-50
                                                                    • Only applies to Blue Access PPO
                                                                    • Select one Buy-up Option (mark a “B” in the box next to the option number)
                                                                    • Select one Core Option (mark a “C” in the box next to the option number)
                                                                    • Work with your Anthem Sales Representative or Underwriting to maintain at least a 10 percent and no more than 35 percent pricing spread between the C



                                                                    Grp Size 51+
                                                                    • Dual and Triple options available
                                                                    • For By-up Dental/Vision/Life selections refer to Anthem By Design Specialty Form
                                                                    • Only applies to Blue Access PPO
                                                                    • Select one Buy-up Option (mark a “B” in the box next to the option number)
                                                                    • Select one Core Option (mark a “C” in the box next to the option number)



                                                                    Anthem Essential
                                                                    Definitions and Provisions



                                                                    • Deductible(s) apply to covered medical services except for office visits, emergency room services, and Inpatient Care Services where a copayment and c
                                                                    • Network Office visit copay/coinsurance applies to the office visit charge and remaining services unless otherwise noted
                                                                    • Deductible and coinsurance apply to diagnostics, surgery and pharmaceutical injections and drugs dispensed/administered in the phys
                                                                    • Inpatient Care includes Inpatient admissions for Surgery, Maternity Care and Skilled Nursing Facility Care
                                                                    • Outpatient Surgery includes Surgery and related services associated with the surgery, chemotherapy, radiation therapy, infusion therapy and dialysis trea
                                                                    • Urgent Care - Not Covered



                                                                    Anthem Essential
                                                                    Covered Services and Limitations
                                                                    • Exclusion of services – some benefits are limited to dollar amounts, day limit, visit limit and actual service type as defined in the Certificate and Schedule
                                                                     services are preventive services that are not mandated by the department of insurance, Medical Nutritional Therapy, outpatient physical medicine therapie
                                                                     Allergy Testing and Treatment (allergy injections), Durable Medical Equipment, Appliances, and Orthotics




OH Medical Notes - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                               Page 50 of 56
OH Medical Notes for All Plans


                                                                    Grp Size 2-50:
                                                                      • Behavioral Health Services (Mental Health/Alcoholism) Biological based services covered based on place of services cost sharing
                                                                      • Outpatient non-biologically based services limited to $550
                                                                      • Alcoholism (network and non network combined) Limited up to $550
                                                                    When enrolling in Federal Mental Health Compliant product, the following applies:
                                                                      • Biologically-based mental illness and alcoholism-based services -- coverage provided to the same extent and degrees as for the treatment of physical i
                                                                      • Non-biologically-based outpatient services for mental and emotional disorders -- coverage provided to the same extent and degrees as for the treatmen
                                                                    For groups with 50+ Total employees, Behavioral Health Services:
                                                                      • Biologically-based mental illness and alcoholism-based services -- coverage provided to the same extent and degrees as for the treatment of physical i
                                                                      • Non-biologically-based outpatient services for mental and emotional disorders -- coverage provided to the same extent and degrees as for the treatmen
                                                                      • Home Care Services (Network and Non-network combined): Limited to 60 visits




                                                                    Age 19; 24, full time student
                                                                    Age 19; 25 full time student **
                                                                    Age 25 **
                                                                    Age 18; 23, federal tax exemption
                                                                    end of calendar year, end of month, to birthday




OH Medical Notes - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                          Page 51 of 56
             OH Medical Notes for All Plans

Ohio Blue Product notes - product specific exceptions to these are noted separately
Definitions and Provisions
• 0% means no coinsurance up to the maximum allowable amount
• Additional copayments, coinsurance and limits apply and may vary by option selected. Refer to the benefit summary for detailed information
• All medical deductibles and percentage (%) coinsurance apply toward the out-of-pocket maximum (excluding flat dollar, Prescription Drug cost shares and Non-Network Human Organ and Tissue Transplant (HOTT) Services)
• Allergy injections -- $5 Network copayment when office visit or Urgent care design is a copayment
Ambulance and Hospice paid at the Network level( except HMO which is no deductible, copayment or coinsurance up to our maximum allowable amount)
• Benefit period = Calendar year or Plan year benefits
• Deductible does not apply to Emergency Room Services where a copayment and (%) coinsurance apply
• Deductible(s) apply only to covered medical services listed with a percentage (%) coinsurance
• Human Organ and Tissue Transplants:
     Network: No deductible/copayment/coinsurance up to the maximum allowable amount
     Non-network: 50% coinsurance. Does not apply to out-of-pocket maximums
     Kidney and cornea transplants are paid the same as any other medical covered benefit
• Medical Nutritional Therapy is covered Non-Network
• Medical option prefixes
 - D = Single/Family deductible ratio is 1:2
 - HS = Anthem Essential option
• NCS (No Cost Share) means no deductible/copayment/coinsurance up to the maximum allowable amount
• Network and Non-Network deductibles, copayments, coinsurance and out-of-pocket maximums are separate and do not accumulate toward each other
• Other Outpatient Services include, but are not limited to, Allergy Testing, Physical Medicine Therapy through Day Rehabilitation programs, Ambulance Service, DME, Home Care Services (including Private Duty Nursing), Hospice Care, MRAs, MRIs, PETS,
C-Scans, Nuclear Cardiology Imaging Studies, Ultrasounds and pharmaceutical injections and drugs
• Physician Home and Office Services exclude certain diagnostic tests such as MRAs, MRIs, PETS, C-Scans, Nuclear Cardiology Imaging Studies, non-maternity related Ultrasounds, Allergy Testing, and pharmaceutical injections and drugs
• Specialist (SCP) copayment is applicable to all Specialists (excludes: General Physicians, Internists, Pediatricians, OB/Gyns, Geriatrics or any other Network provider as allowed by the plan)
• Urgent Care Facility copay excludes certain diagnostic tests such as MRAs, MRIs, PETS, C-Scans, Nuclear Cardiology Imaging Studies, non-maternity related Ultrasounds, Allergy Testing, and pharmaceutical injections and drugs




             OH Medical Notes - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                                                                              Page 52 of 56
OH Medical Notes for All Plans
                                                                              The benefit description is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract.
                                                                                               In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail.

                                                                         Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association.
                                                         ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.




OH Medical Notes - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                                                                                      Page 53 of 56
             OH Medical Notes for All Plans
Covered Services and Limitations
  • Accidental Dental Coverage $3000 Limit
  • Behavioral Health Services
     Group Size 2-50:
        • Biologically Based Mental Illnesses are paid the same as any other illness
        • Non-Biologically Based Mental Illnesses and Substance Abuse (Network):
        • (Inpatient): Limited to 30 days (Includes Non-Network)
        • (Outpatient): Limited to 30 visits
        • Non-Biologically Based Mental Illnesses and Substance Abuse (Non-Network):
        • Inpatient mental health combined with Network day limits
        • Outpatient mental health is limited to 10 visits
        • Alcoholism Limited up to $550 (Non-Network Only)
        • Inpatient and outpatient substance abuse rehabilitation programs are limited to two per lifetime (Network and Non-network combined)
         When enrolling in a Federal Mental Health Compliant product, the following applies:
          Behavioral Health Services: Coverage for Inpatient and Outpatient treatment of Behavioral Health conditions is provided to the same extent and degree as for the treatment of physical illness. Copayments / Coinsurance based on setting where covered services are received.
     Group Size 51+:
          Behavioral Health Services: Coverage for Inpatient and Outpatient treatment of Behavioral Health conditions is provided to the same extent and degree as for the treatment of physical illness. Copayments / Coinsurance based on setting where covered services are received.
        • Physical Medicine Therapy Limits, Outpatient Therapy (Network and Non-network combined):
           - Cardiac Rehab: 36 visits
           - Manipulation Therapy: 12 visits
           - Occupational Therapy: 20 visits
           - Physical Therapy: 20 visits
           - Pulmonary Rehab: 20 visits
           - Speech Therapy: 20 visits
• Home Care Services (Network and Non-network combined): Limited to 90 visits (excludes Private Duty Nursing)
     -Private Duty Nursing – limited to $50,000 per benefit period with a lifetime maximum of $100,000
• Preventive immunizations (Network) are not subject to the deductible/copayment if the option has a flat dollar Office Visit copayment and if rendered without an office visit charge.
• Mammograms (routine and diagnostic) are subject to the PCP/OV cost share in office and outpatient facility settings.
• Physical Medicine and Rehabilitation (Network and Non-network combined): Limited to 60 days, includes Day Rehabilitation programs
• Durable Medical Equipment, Appliances and Orthotics:
     - DME subject to benefit max of $4,000 (excluding Prosthetic Devices, Limbs and Medical Supplies) Network and Non-Network combined
     - Prosthetic Devices $4,000 limit
     - Prosthetic limbs $10,000 limit
• Skilled Nursing Facility (Network and Non-network combined): Limited to 90 days
Lifetime maximum of $5 million for all covered medical services (Network and Non-Network combined, except for HMO, which is unlimited and 100+ PPO which offers $1million, $2million and $5million options). However, once the medical lifetime maximum is met, no additional prescription drug
claims will be paid
Limits are benefit period unless otherwise stated


                                                                                              The benefit description is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract.
                                                                                                               In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail.

                                                                                         Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association.
                                                                         ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
             OH Medical Notes - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                                                                                             Page 54 of 56
             OH Medical Notes for All Plans
Anthem By Design
Grp Size 10-50
• Only applies to Blue Access PPO
• Select one Buy-up Option (mark a “B” in the box next to the option number)
• Select one Core Option (mark a “C” in the box next to the option number)
• Work with your Anthem Sales Representative or Underwriting to maintain at least a 10 percent and no more than 35 percent pricing spread between the Core and the Buy-up option



Grp Size 51+
• Dual and Triple options available
• For By-up Dental/Vision/Life selections refer to Anthem By Design Specialty Form
• Only applies to Blue Access PPO
• Select one Buy-up Option (mark a “B” in the box next to the option number)
• Select one Core Option (mark a “C” in the box next to the option number)



Anthem Essential
Definitions and Provisions
• Outpatient Other covered services includes Outpatient Diagnostic Services and Physical, Medicine and Rehabilitation, Physical Medicine Therapy through Day Rehabilitation programs, Ambulance Service, Home Care Services (excluding Private Duty Nursing), Hospice Care, MRAs, MRIs, PETS,
C-Scans, Nuclear Cardiology Imaging Studies, Ultrasounds and pharmaceutical injections and drugs
• Deductible(s) apply to covered medical services except for office visits, emergency room services, and Inpatient Care Services where a copayment and coinsurance applies
• Network Office visit copay/coinsurance applies to the office visit charge and remaining services unless otherwise noted
• Deductible and coinsurance apply to diagnostics, surgery and pharmaceutical injections and drugs dispensed/administered in the physicians office
• Inpatient Care includes Inpatient admissions for Surgery, Maternity Care and Skilled Nursing Facility Care
• Outpatient Surgery includes Surgery and related services associated with the surgery, chemotherapy, radiation therapy, infusion therapy and dialysis treatment (excluding preventive services) in the office and outpatient setting
• Urgent Care - Not Covered



Anthem Essential
Covered Services and Limitations
• Exclusion of services – some benefits are limited to dollar amounts, day limit, visit limit and actual service type as defined in the Certificate and Schedule of Benefits. Some of the excluded
 services are preventive services that are not mandated by the department of insurance, Medical Nutritional Therapy, outpatient physical medicine therapies unless otherwise noted, Urgent Care Services,
 Allergy Testing and Treatment (allergy injections), Durable Medical Equipment, Appliances, and Orthotics




                                                                                              The benefit description is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract.
                                                                                                               In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail.

                                                                                         Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association.
                                                                         ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.




             OH Medical Notes - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                                                                                         Page 55 of 56
             OH Medical Notes for All Plans


Grp Size 2-50:
  • Behavioral Health Services (Mental Health/Alcoholism) Biological based services covered based on place of services cost sharing
  • Outpatient non-biologically based services limited to $550
  • Alcoholism (network and non network combined) Limited up to $550
When enrolling in Federal Mental Health Compliant product, the following applies:
  • Biologically-based mental illness and alcoholism-based services -- coverage provided to the same extent and degrees as for the treatment of physical illness.
  • Non-biologically-based outpatient services for mental and emotional disorders -- coverage provided to the same extent and degrees as for the treatment of physical illness.
For groups with 50+ Total employees, Behavioral Health Services:
  • Biologically-based mental illness and alcoholism-based services -- coverage provided to the same extent and degrees as for the treatment of physical illness.
  • Non-biologically-based outpatient services for mental and emotional disorders -- coverage provided to the same extent and degrees as for the treatment of physical illness.
  • Home Care Services (Network and Non-network combined): Limited to 60 visits
  • Human Organ and Tissue Transplants:
     Network/Non-network: Subject to Cost Share based on place of service up to the maximum allowable amount
     Non-network: Does not apply to out-of-pocket limits
     Kidney and cornea transplants are paid the same as any other medical covered benefit
• Lifetime maximum of $2 million for all covered medical services (Network and Non-network combined). Once the medical lifetime maximum is met, no additional prescription drug claims will be paid
• Outpatient Diagnostic Services (Network and Non-network combined): $300 limit office and outpatient combined (excludes state mandated services and inpatient care)
• Preventive Care Services - not covered except state mandated well-baby birth to age one-$500 limit, Age 1-8 $150 limit-includes immunizations, Routine newborn hearing screening, Mammograms, Pap, and Pelvic Exam
• State mandates covered subject to place of service cost share unless otherwise stated
Anthem By Design 2+:
• Work with your Anthem Sales Representative or Underwriting to maintain at least a 10 percent and no more than 60 percent pricing spread between the Core and the Buy-up option. (Only applies when one option is an Anthem Essential PPO Plan.)

Grp Size 100+ Case Exception Applies

Dependent Age Options
Grp Size 2+ standard: Dependent Age: Age 19; 24, full-time student, end of calendar year
Grp Size 51+: Age 19 only
Age 19; 21, full-time student
Age 19; 23, full-time student
Age 19; 24, full time student
Age 19; 25 full time student **
Age 25 **
Age 18; 23, federal tax exemption
end of calendar year, end of month, to birthday
**Purchasers of health benefit plans providing coverage to eligible dependents up to age 25 may have state and/or federal tax implications to either or both the employer groups and/or the employee. Because Anthem is licensed as a health plan and is not licensed to dispense tax or legal advise,
groups must consult their own legal and tax advisors for more information on whether tax implications may exist in your particular situation


                                                                                            The benefit description is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract.
                                                                                                             In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail.

                                                                                       Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association.
                                                                       ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
             OH Medical Notes - SQF - 8f9d1dd0-511a-41f3-b691-bdc756099608.xls                                                                                                                                                                                                  Page 56 of 56

				
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