The Manufacturer Business Association Insurance by btt20058

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									The Manufacturer & Business Association Insurance
Committee has worked closely with Highmark Blue
Cross Blue Shield in an effort to continue providing
the most cost-effective and comprehensive health care
plans available. We will pursue every possible way
to control and reduce your health care costs while
enhancing the quality of care provided to you.


We encourage you to carefully review this bulletin.
It contains detailed information including plan
options that will be effective January 1, 2010.
—Manufacturer & Business Association Insurance Committee
About the
Manufacturer
& Business
Association
In 1905, 61 manufacturers joined together as a
group to accomplish the challenges they could not
meet alone. From that alliance, the Manufacturer &
Business Association emerged. Today, more than
6,000 companies in western Pennsylvania maximize
their effectiveness by utilizing the numerous services
provided by the Association.


If you are not a member and are interested in
becoming a member of the Manufacturer & Business
Association, please complete one of the membership
applications found at the back of this bulletin.




 Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs
     Contents



Blue Cross Blue Shield coverage offers employers                                      Out-of-Area PPO
important advantages: ....................................................... 4       (HDHP 100/80 $2,600 Deductible) .............................. 67
Coverage your employees will value ................................. 7                HDHP 90/70 $2,600 Deductible .................................. 69
Health Plan Options......................................................... 10       HDHP 90/70 $3,500 Deductible .................................. 71
   ClassicBlue
            ®
              Traditional....................................................11       HDHP 80/60 Value Option ........................................... 73
                     .................................................... 13
   PPOBlue High Option I                                                              EPOBlue Essential ...................................................... 75
                      ................................................... 15
   PPOBlue High Option II                                                             KeystoneBlue .............................................................. 77
   Out-of-Area PPO High Option II .................................. 17               Signature 65SM Plan ..................................................... 79
   PPOBlue Enhanced..................................................... 19           BlueRx Prescription Drug Plan .................................... 81
   PPOBlue Standard ...................................................... 21         FreedomBlue ............................................................... 82
   Out-of-Area PPO Standard.......................................... 23              SecurityBlueSM Program .............................................. 84
   PPOBlue $500 Deductible........................................... 25              Vision Plan Options ..................................................... 86
   Out-of-Area PPO $500 Deductible .............................. 27                  Fashion Advantage Option I ........................................ 89
   PPOBlue $750 Deductible Value ................................. 29                 Fashion Advantage Option V ....................................... 91
   PPOBlue $1,250 High-Deductible Value ..................... 31                      Fashion Advantage Gold Option I................................ 93
   Out-of-Area $1,250 High-Deductible Value ................. 33                      Fashion Advantage Gold Option V .............................. 95
   PPOBlue $1,000 High-Deductible Value ..................... 35                   Underwriting Regulations ................................................ 97
   PPOBlue $1,500 High-Deductible Value ..................... 37                   Rating and Billing Procedures............... .........................101
   Out-of-Area PPO $1,500 High Deductible Value ......... 39                       Demographic Rating .......................................................102
   PPOBlue $2,500 High-Deductible Value ..................... 41                   Demographic Factors .....................................................102
   PPOBlue Split Copayment 100/80 .............................. 43                How rates are calculated at renewal ..............................102
   PPOBlue Split Copayment 90/70 ................................ 45               Important Insurance Reference Guide ...........................102
   PPOBlue 90/70 ............................................................ 47   Billing System Procedures..............................................103
   PPOBlue 80/60 ............................................................ 49   Billing Date .....................................................................103
   PPOBlue 70/50 ............................................................ 51   Checks............................................................................103
   PPOBlue Value Plus 250 ............................................. 53         Auto Pay Option .............................................................103
   PPOBlue Value Plus 500 ............................................. 55         Additions, Terminations, and Changes ...........................103
   Out-of-Area PPO Value Plus 500 ................................ 57              Previous Month Transactions .........................................104
   HDHP 100/80 $1,250 Deductible Value ...................... 59                   Billing, Administrative Fees and Procedures ..................105
   HDHP 100/80 $1,500 Deductible Value ...................... 61                   Optional Enhanced COBRA Administration ....................106
   HDHP 100/80 $2,000 Deductible Value ...................... 63                   Membership Application .................................................107
   HDHP 100/80 $2,600 Deductible ................................ 65



                                  Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs
Blue Cross Blue Shield coverage offers employers all of these
important advantages:
• Close to home convenience and service                               • Coverage your employees can take
  Highmark Blue Cross Blue Shield is a leading                          with them
  health care insurer in this area. One reason is that                  Your employees have access to health care
  we’re located right here in western Pennsylvania.                     coverage now through you. But what happens
  That means, when you or your employees                                if they retire or turn 65 and become eligible for
  have questions, they have a place to turn. Your                       Medicare? Highmark offers a variety of health
  employees can simply call us toll-free or visit a                     care benefit programs for individuals who aren’t
  conveniently located Highmark Servicenter.                            eligible for group benefits. And that includes an
                                                                        excellent choice of popular Medicare supplemental
• More than 70 years of dependability                                   programs. If they lose their group coverage for
  Since 1937 Highmark has been a pioneer in the                         any reason, they can “convert” their benefits to
  development and delivery of health care benefit                       an appropriate individual program so they can
  programs that meet the diverse needs of customers                     continue to enjoy the dependability, convenience
  in western Pennsylvania. Highmark is one of the                       and outstanding protection of Blue Cross Blue
  region’s largest employers. We are committed to                       Shield benefits.
  serving our community and supporting local health
  and human services organizations.                                   • Online Enrollment through the EBDSWEB
                                                                        You can make additions, terminations or changes
• Financial stability                                                   online! All activity entered on the Web site will be
  When you’re choosing health care coverage, it’s                       automatically downloaded into the Billing System
  important to know all you can about the company                       within 24 hours. It will then be electronically
  that backs your benefits. Highmark Blue Cross                         reported to Highmark once it is posted in the
  Blue Shield’s financial stability has earned a                        billing system. EBDSWEB will provide you
  “strong” rating from the nationally recognized                        with online enrollment, administration, and
  Standard & Poor’s Insurance Rating Services.                          other service capabilities. This will speed up the
  Our secure financial position means you can count                     enrollment and ID card process, give you control
  on us now and in the future.                                          of your own updates and give you access to those
                                                                        changes and information at your fingertips…
• An identification card that’s recognized across                       http://www.ebdsbenefits.com/gbomaint/
  the country
  Your employees will carry a health insurance
  identification card with the Cross and Shield
  symbols – recognized throughout the country.
  That’s a real comfort if they live outside
  Pennsylvania or are outside Pennsylvania on
  business or vacation and need medical attention,
  or if they have children away at school.

                        Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                -4-
• Health care programs and a combined health reimbursement account (HRA)—all from one source
  BlueAccountSM HRA is flexible and can be tailored to your specifications.

YOU specify…
Which product        BlueAccount HRA can be added to these PPOBlue Programs at no additional cost:
                     • PPOBlue $500
                     • OOA PPO $500
                     • PPOBlue Value Plus $500
                     • OOA PPO Value Plus $500
                     • PPOBlue $750 Value
                     • PPOBlue $1,250 High-Deductible Value
                     • OOA PPO $1,250 High-Deductible
                     • PPOBlue $1,000 High-Deductible Value
                     • PPOBlue $1,500 High-Deductible Value
                     • OOA PPO $1,500 High-Deductible Value
                     • PPOBlue $2,500 High-Deductible Value
How much of the      • 25%
deductible to fund   • 50%
                     • 75%
                     • 100%
The order of         • Employee first
reimbursement        • Employer first
                     • 50/50 split employee/employer
Who to reimburse     • Employee (via check or direct deposit)
                     • Provider
The bank             • BlueAccount will interface with any bank
                     • Separate pre-funded account not necessary

We provide:
• Template illustrations of plan documents and summary plan descriptions
• A secure Web site for your employees to monitor activity and for you to monitor claims payment
• Convenient administration by providing both your health care program and a combined HRA—all from one
  source. Employees use www.highmarkbcbs.com to manage their HRA AND access all of their health and
  benefit coverage information.

Note: Self-employed individuals (sole proprietors, partners, LLC and more than 2% shareholders of a
subchapter S Corporation) can participate in the Highmark Medical Plan but cannot participate and receive tax-
free contributions to an HRA. Please consult your tax professional regarding your specific situation.



                       Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

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                                                                        Increase Consumer Engagement
• Increase your employees’ role with
                                                                        Qualified and non-qualified high-deductible
    BlueAccount health savings account (HSA)
                                                                        health plans offer a number of advantages. Some
    BlueAccount HSA is a “health savings account”
                                                                        employers, however, may be reluctant to move to
    that increases your employees’ role in their health
                                                                        a plan that provides very little coverage until the
    coverage and care decisions. BlueAccount HSA is
                                                                        deductible is met. They may think that the high
    an employee option that couples a tax-advantaged
                                                                        upfront deductible could discourage employees
    health care savings account with a federally
                                                                        from getting medical care they really need. A
    qualified high-deductible health program. (To be
                                                                        coinsurance-based plan without a high upfront
    “qualified,” high-deductible health programs must
                                                                        deductible helps you ease the transition from a
    follow specified rules for coverage set by the IRS.)
                                                                        richer benefit program because costs are truly
  Health savings accounts let employees use pre-tax                     “shared” between the employee and the health plan,
  dollars to pay for medical expenses not reimbursed                    starting with the first medical services employees
  by their high-deductible health program. Because                      receive each year.
  HSAs are individual savings accounts managed by
                                                                        If you already offer a qualified high-deductible
  the employee, not the employer, they require the
                                                                        program – or you’re ready to move to a plan with
  highest level of employee involvement of all the
                                                                        a higher upfront deductible – adding coinsurance
  BlueAccount products.
                                                                        can be a smart move for you too. That’s because
  Highmark offers a choice of benefit designs that                      coinsurance-based plans encourage members to
  meet the federal guidelines for qualified high-                       act as “educated consumers” on an ongoing basis.
  deductible health programs. To make it easy for                       Members have an ongoing incentive to be aware of
  your employees, BlueAccount HSA allows them to                        the cost of their care and to be involved in health
  manage their health care benefits and health savings                  care decisions.
  account through www.highmarkbcbs.com.




                        Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                -6-
Coverage your employees will value
Highmark offers:

The largest provider network – more choice of                        • Personal Nutrition CoachingSM is individual
physicians and hospitals.                                              nutrition coaching by a registered dietitian/licensed
                                                                       nutritionist to address weight management, heart
                                                                       health, diabetes and other health issues.
Lifestyle improvement programs right in your
neighborhood.                                                        • Diabetes Awareness and PreventionSM is
Highmark has partnered with local community and                        a 4-week program for the prevention and
healthcare organizations to create the Preventive                      management of diabetes for those with or at risk
Health Alliance and provide wellness programs                          for diabetes.
in the communities we serve. We offer programs
on everything from smoking cessation, to stress                      • The Spectrum is a six-week program to help
management, nutrition and weight loss.                                 prevent heart disease and improve overall health.

Your employees/members can sign up for the
                                                                     • Drop 10 in 10SM is an exciting weight management
following free programs:
                                                                       program designed to help participants lose 10
                                                                       pounds or 10 percent of their weight through a
• Clear the AirSM is a group-based tobacco cessation                   program of balanced nutrition, sensible activity
  preparation program.                                                 and meaningful lifestyle changes.

• Discover Relaxation WithinSM I and II are                          • Health on the MenuSM is a series of one-hour
  group-based stress management programs that                          wellness workshops on a variety of health
  are practical, educational and experiential to                       promotion topics.
  help participants identify and cope with personal
  stressors.                                                         • KidShape® builds healthy families through fun,
                                                                       interactive exercise and nutrition activities to help
• Eat Well for LifeSM I and II are group-based                         promote wellness and self-esteem.
  programs that promote healthy choices and
  long-term weight management through balanced                       Online Programs
  nutrition, smart shopping, healthy cooking and
  physical activity.                                                 • The Succeed quick and easy Wellness Profile
                                                                       will evaluate members’ current health,
• HOPESM (Highmark Osteoporosis Prevention                             wellness and lifestyle behaviors, as well as
  and Education Program) focuses on making                             provide a customized report with prioritized
  healthy choices to improve bone health and                           recommendations.
  prevent or manage osteoporosis.




                       Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                               -7-
                                                                                         Coverage your employees will value | continued...




• If your employees want to manage weight or                         And your company will benefit from participation
  stress, improve their eating habits, manage chronic                as well. Over the short run, Baby BluePrints can
  conditions or back pain, quit smoking or make                      enhance your employees’ morale and provide added
  overall healthier choices, Highmark offers online                  value to their health benefit program. In the long run,
  programs that can help them meet their wellness                    Baby BluePrints is a tool to help reduce maternity-
  goals. It only takes a few minutes to get started at               driven costs due to turnover, absenteeism and loss of
  www.highmarkbcbs.com.                                              productivity.

Telephonic Programs                                                  Blues On Call – Your employees can contact a Blues
• Smokeless® offers two telephonic options for                       On Call Health Coach 24 hours a day, seven days a
  smoking cessation: the self-directed Guided                        week with questions or concerns about their health,
  Self-Help Smokeless and the year-long                              care, treatment plans. The list is endless.
  Telephonic Smokeless. Both programs work
  with a professional tobacco cessation specialist.                  Condition Management – If your employees have a
  Discounted nicotine replacement products are                       chronic condition, such as asthma, chronic obstructive
  available to enrolled participants.                                pulmonary disease, coronary artery disease or
                                                                     diabetes, our condition management programs can
                                                                     help them manage all of the different aspects of their
Baby BluePrints - To help expectant families better                  disease. Health Coaches are available 24 hours a
understand every stage of pregnancy and make more                    day/ 7 days a week to give personalized support with
informed care and lifestyle-related decisions, we                    medication management, discussion of treatment
introduced the Baby BluePrints Maternity Education                   options, knowing what to ask at doctor appointments,
and Support Program.                                                 watching diet requirements and whatever else they
                                                                     may need.
The program offers members educational information
on all aspects of pregnancy through multiple printed                 Wellness Discount Program – Your employees can
and online resources. Baby BluePrints also provides                  receive discounts up to 30% on non-covered services
program participants access to individualized support                through a complementary wellness discount program
throughout their pregnancy from a nurse Health                       provided by American WholeHealth. The program
Coach. The nurse Health Coach will make outreach                     includes over 35,000 providers nationwide. It is
calls to all enrolled participants; the number of                    accessible through the Highmark Web site.
calls will depend on the individualized needs of the
expectant mother.




                       Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                               -8-
                                                                                           Coverage your employees will value | continued...




Highmark’s Web site                                                  Choose Providers
Highmark gives your employees everything they                        • Do your employees need to locate a doctor, hospital,
need in one convenient location, www.highmarkbcbs.                     or other health care provider? No problem – they can
com. Whether they need to find benefits information,                   do as simple or detailed of a search as they want right
the status of a claim, a doctor or hospital, the cost of a             here.
procedure, or open a health savings account – it’s all
here, neatly organized under five easy-to-use tabs, ready               And clicking on the “find a pharmacy” link generates
whenever they are – 24 hours a day, 7 days a week.                      a handy list of participating pharmacies located in the
                                                                        zip code or city and state they specify.
Your Coverage
• Under the “Your Coverage” tab, they can update                     Health Topics
  their e-mail address, check the formulary, and request             • A wealth of wellness information awaits on this
  a replacement ID card. And, they’ll get access to                    page. Search the Health Encyclopedia to learn
  Highmark’s new Plan Cost Advisor. This handy tool                    about diseases and conditions; go Inside the Human
  uses the information we have in our system to help                   Body, get the latest information on surgeries and
  them compare health insurance plans, including the                   procedures, and find articles on special family topics.
  amounts they’ll need to pay for each option and their                Your employees will also find Chronic Condition
  anticipated out-of-pocket expenses.                                  Guides here, along with step-by-step instructions to
                                                                       help them understand and manage their condition.
Your Spending
• Here’s the place to manage their BlueAccount health
  savings account (HSA), health reimbursement
  account (HRA), or flexible spending account
  (FSA). They can also track their claims, access their
  Explanations of Benefits (EOBs), and monitor their
  health care spending.

Your Health
• The “Your Health” tab is the place to get 24-hour-
  a-day health care decision support and explore
  treatment options with Blues On Call. Our
  Wellness Profile inventories wellness and makes
  recommendations in just about 30 minutes.

  If you have Highmark’s drug benefit, your employees
  can order a prescription, check on its status, and view
  their prescription history.


                         Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                 -9-
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ClassicBlue Traditional
ClassicBlue Traditional is our traditional health insurance plan offering the highest level of benefits and choice. The program is not a managed care
program and patients can choose providers both in- and out-of-network. Health care benefits are separated into hospital, medical/surgical and Major
Medical. Most Major Medical benefits are subject to deductible and coinsurance provisions which require you to share a portion of the medical costs.
This chart is not intended as a contract of benefits. It is designed purely as a reference to help you compare the programs available through the Manufacturer & Business Association.

 Benefit                                                                                     Hospital                                  Medical/Surgical                                   Major Medical
 Benefit Period(1)                                                                                                                          Calendar Year
 Deductible (per benefit period)
    Individual                                                                                    None                                               None                                         $200
    Family                                                                                        None                                               None                                         $400
 Plan Payment Level – Based on the                                                                100%                                               100%                                  80% after deductible
 provider’s reasonable charge (PRC)
 Out-of-Pocket Maximums (Once met, plan
 payment level becomes 100%)
    Individual                                                                                 None                                                None                                           $400
    Family                                                                                     None                                                None                                           $800
 Lifetime Maximum (per person)                                                               Unlimited                                           Unlimited                                    $1,000,000
 Primary Care Physician Office Visits                                                       Not Covered                                         Not Covered                                80% after deductible
 Specialist Office Visits                                                                   Not Covered                                         Not Covered                                80% after deductible
 Preventive Care
    Adult
        Routine physical exams                                                              Not Covered                                         Not Covered                                   Not Covered
        Adult Immunizations                                                                 Not Covered                                         Not Covered                                   Not Covered
        Mammograms, annual routine and                                                         100%                                                100%                                    80% after deductible
        medically necessary
     Pediatric
        Routine physical exams                                                              Not Covered                                         Not Covered                                 Not Covered
        Pediatric immunizations                                                                100%                                                100%                               80% (deductible does not
                                                                                                                                                                                                apply)
 Emergency Room Services                                                                       100%                                                100%                                 80% after deductible
 Spinal Manipulations                                                                       Not Covered                                         Not Covered                             80% after deductible
                                                                                                                                                                                    Limit: 20 visits/benefit period
 Physical Medicine                                                                         100%                                                 Not Covered                             80% after deductible
                                                                               Limit: 21 visits/benefit period                                                                      Limit: 20 visits/benefit period
 Speech Therapy                                                                            100%                                                 Not Covered                             80% after deductible
                                                                               Limit: 21 visits/benefit period                                                                      Limit: 20 visits/benefit period
 Occupational Therapy                                                                      100%                                                 Not Covered                             80% after deductible
                                                                               Limit: 21 visits/benefit period                                                                      Limit: 20 visits/benefit period
 Allergy Extracts and Injections                                                       Not Covered                                              Not Covered                             80% after deductible
 Ambulance                                                                             Not Covered                                              Not Covered                             80% after deductible
 Assisted Fertilization Procedures                                                     Not Covered                                              Not Covered                                 Not Covered
 Dental Services Related to Accidental                                                     100%                                                 Not Covered                             80% after deductible
 Injury
 Diabetes Treatment                                                                               100%                                          Not Covered                                80% after deductible
 Diagnostic Services (including routine)                                                          100%                                             100%                                    80% after deductible
  Advanced Imaging (MRI, CAT Scan, PET
  scan, etc.)
  Basic Diagnostic Services (standard                                                             100%                                               100%                                  80% after deductible
  imaging, diagnostic medical, lab/pathology,
  allergy testing)
 Durable Medical Equipment, Orthotics                                                       Not Covered                                         Not Covered                                80% after deductible
 and Prosthetics
 Enteral Formulae                                                                                 100%                                          Not Covered                              80% (deductible does not
                                                                                                                                                                                                 apply)
 Home Infusion Therapy                                                                 Not Covered                                              Not Covered                                80% after deductible
 Home Health Care                                                                         100%                                                  Not Covered                                80% after deductible
                                                                              Limit: 100 visits/benefit period
 Hospice                                                                               Not Covered                                              Not Covered                                80% after deductible

                                                 Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

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  Benefit                                                               Hospital                         Medical/Surgical                       Major Medical
  Hospital Services – Inpatient                                             100%                               Not Covered                      80% after deductible
  Hospital Services – Outpatient                                            100%                               Not Covered                      80% after deductible
  Infertility Counseling, Testing and                                       100%                                  100%                          80% after deductible
  Treatment(2)
  Maternity (facility & professional services)                             100%                                     100%                        80% after deductible
  Medical/Surgical Expenses (except office                              Not Covered                                 100%                        80% after deductible
  visits)
  Mental Health – Inpatient(3)                                             100%                                   100%                          80% after deductible
  Mental Health – Outpatient(3)                                         Not Covered                            Not Covered                      80% after deductible
  Private Duty Nursing                                                  Not Covered                            Not Covered                      80% after deductible
  Respiratory Therapy                                                      100%                                Not Covered                      80% after deductible
  Skilled Nursing Facility Care                                            100%                                   100%                          80% after deductible
  Substance Abuse – Inpatient                                              100%                                   100%                          80% after deductible
  Detoxification
  Substance Abuse – Inpatient                                               100%                                    100%                        80% after deductible
  Rehabilitation
  Substance Abuse – Outpatient                                           100%                                  Not Covered                      80% after deductible
  Therapy Services (Cardiac Rehab, Infusion                              100%                                     100%                          80% after deductible
  Therapy, Chemotherapy, Radiation Therapy                    (Cardiac Rehab: Not Covered)                  (Cardiac Rehab &
  and Dialysis)                                                                                           Infusion Therapy: Not
                                                                                                                 Covered)
  Transplant Services                                                       100%                                  100%                          80% after deductible
  Precertification Requirements(4)                                           Yes                                   No                                   No
  Major Medical Acute Prescription Drug                                                                         Retail
  Program                                                                                                80% after deductible
  Member must pay for prescription at point-
  of-sale and submit a Major Medical claim to
  Highmark for reimbursement.
  Premier Prescription Drug Program                                                     Retail or Mail Order (30-day to 60-day supply)
  Defined by Premier Pharmacy Network - Not                                                     100% after $6 generic copayment
  Physician Network. Prescriptions filled at a                                                  100% after $12 brand copayment
  non-network pharmacy are not covered.
(1) Your group's benefit period is based on a Calendar Year which runs from January 1 to December 31.
(2) Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered
    depending on your group’s prescription drug program.
(3) State mandated minimum benefits may apply to a diagnosis of serious mental illness. (If the above grid does not show a limit, your mental health benefit days and
    visits are unlimited.)
(4) Highmark Healthcare Management Services (HMS) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-related
    inpatient admission. Some facility providers will contact HMS and obtain precertification of the inpatient admission on your behalf. Be sure to verify that your
    provider is contacting HMS for precertification. If not, you are responsible for contacting HMS. If this does not occur and it is later determined that all or part of the
    inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered.




                                       Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

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PPOBlue High Option I
A PPO, or Preferred Provider Organization, offers two levels of benefits. If you receive services from a provider who is in the PPO network, you’ll
receive the highest level of benefits. If you receive services from a provider who is not in the PPO network, you’ll receive the lower level of benefits.
In either case, you coordinate your own care. There is no requirement to select a Primary Care Physician (PCP) to coordinate your care. Below are
specific benefit levels.
This chart is not intended as a contract of benefits. It is designed purely as a reference to help you compare the programs available through the Manufacturer & Business Association.

Benefit                                                                                                  Network                                                            Out-of-Network
Benefit Period(1)                                                                                                                             Contract Year
Deductible (per benefit period)
   Individual                                                                                                 None                                                                  $250
   Family                                                                                                     None                                                                  $500
Plan Payment Level – Based on the provider’s                                                                  100%                                                           80% after deductible
reasonable charge (PRC)
Out-of-Pocket Maximums (Once met, plan
payment level becomes 100%)
   Individual                                                                                           None                                                                       $2,000
   Family                                                                                               None                                                                       $4,000
Lifetime Maximum (per person)                                                                        Unlimited                                                                  $1,000,000
Primary Care Physician Office Visits                                                          100% after $10 copayment                                                       80% after deductible
Specialist Office Visits                                                                      100% after $10 copayment                                                       80% after deductible
Preventive Care
   Adult
       Routine physical exams                                                                 100% after $10 copayment                                                          Not Covered
       Adult Immunizations                                                                             100%                                                                  80% after deductible
       Colorectal Cancer Screening
           Diagnostic Services                                                                         100%                                                              80% after deductible
           Medical Surgical                                                                            100%                                                              80% after deductible
       Routine gynecological exams, including a                                               100% after $10 copayment                                              80% (deductible does not apply)
       Pap Test
       Mammograms, annual routine and                                                                         100%                                                           80% after deductible
       medically necessary
    Pediatric
       Routine physical exams                                                                 100% after $10 copayment                              Not Covered
       Pediatric immunizations                                                                         100%                                80% (deductible does not apply)
Emergency Room Services                                                                                    100% after $35 copayment (waived if admitted)
Spinal Manipulations                                                                          100% after $10 copayment                           80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Physical Medicine                                                                             100% after $10 copayment                           80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Speech Therapy                                                                                100% after $10 copayment                           80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Occupational Therapy                                                                          100% after $10 copayment                           80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Allergy Extracts and Injections                                                                        100%                                      80% after deductible
Ambulance                                                                                                                      100%
Assisted Fertilization Procedures                                                                                          Not Covered
Dental Services Related to Accidental Injury                                                           100%                                      80% after deductible
Diabetes Treatment                                                                                     100%                                      80% after deductible
Diagnostic Services (including routine)
 Advanced Imaging (MRI, CAT Scan, PET                                                                         100%                                                           80% after deductible
 scan, etc.)
 Basic Diagnostic Services (standard imaging,                                                                 100%                                                           80% after deductible
 diagnostic medical, lab/pathology, allergy
 testing)
Durable Medical Equipment, Orthotics and                                                                      100%                                                           80% after deductible
Prosthetics
Enteral Formulae                                                                                              100%                                                  80% (deductible does not apply)
Home Infusion Therapy                                                                                                                               100%
                                               Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                                             -1-
 Benefit                                                                          Network                                           Out-of-Network
 Home Health Care                                                                                                 100%
 Hospice                                                                                                          100%
 Hospital Services – Inpatient                                                       100%                                            80% after deductible
 Hospital Services – Outpatient                                                      100%                                            80% after deductible
 Infertility Counseling, Testing and                                                 100%                                            80% after deductible
 Treatment(2)
 Maternity (facility & professional services)                                        100%                                            80% after deductible
 Medical/Surgical Expenses                                                           100%                                            80% after deductible
 (Except Office Visits)
 Mental Health – Inpatient(3)                                                     100%                                               80% after deductible
 Mental Health – Outpatient(3)                                           100% after $10 copayment                                    80% after deductible
 Private Duty Nursing                                                                                             100%
 Respiratory Therapy                                                                                              100%
 Skilled Nursing Facility Care                                                       100%                                           80% after deductible
                                                                                                                                Limit: 100 days/benefit period
 Substance Abuse – Inpatient Detoxification                                       100%                                              80% after deductible
 Substance Abuse – Inpatient Rehabilitation                                       100%                                              80% after deductible
 Substance Abuse – Outpatient                                            100% after $10 copayment                                   80% after deductible
 Therapy Services (Cardiac Rehab, Infusion                                        100%                                              80% after deductible
 Therapy, Chemotherapy, Radiation Therapy and
 Dialysis)
 Transplant Services                                                                 100%                                            80% after deductible
 Precertification Requirements(4)                                                                                  Yes
 Prescription Drug Deductible
    Individual                                                                                                  None
    Family                                                                                                      None
 Premier Prescription Drug Program                                                                 Retail Drugs (31-day Supply)
 Mandatory Generic(5)                                                                                   $8 generic copayment
 Defined by Premier Pharmacy Network - Not                                                         $30 formulary brand copayment
 Physician Network. Prescriptions filled at a non-                                               $55 non-formulary brand copayment
 network pharmacy are not covered.
                                                                                   Maintenance Drugs through Mail Order (90-day Supply)
                                                                                                   $16 generic copayment
                                                                                               $60 formulary brand copayment
                                                                                            $110 non-formulary brand copayment
(1) Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's renewal date. Contact
    your employer to determine the renewal date applicable to your program.
(2) Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered
    depending on your group’s prescription drug program.
(3) State mandated minimum benefits may apply to a diagnosis of serious mental illness. (If the above grid does not show a limit, your mental health benefit days and
    visits are unlimited.)
(4) Highmark Healthcare Management Services (HMS) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-related
    inpatient admission. Some facility providers will contact HMS and obtain precertification of the inpatient admission on your behalf. Be sure to verify that your
    provider is contacting HMS for precertification. If not, you are responsible for contacting HMS. If this does not occur and it is later determined that all or part of the
    inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered.
(5) The formulary is an extensive list of Food and Drug Administration (FDA) approved prescription drugs selected for their quality, safety and effectiveness. It includes
    products in every major therapeutic category. The formulary was developed by the Highmark Pharmacy and Therapeutics Committee made up of clinical pharmacists
    and physicians. Your program includes coverage for both formulary and non-formulary drugs at the specific copayment or coinsurance amounts listed above. You are
    responsible for the payment differential when a generic drug is authorized by your doctor and you purchase a brand name drug. Your payment is the price difference
    between the brand name drug and generic drug in addition to the brand name drug copayment or coinsurance amounts, which may apply.




                                     Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                     -1-
PPOBlue High Option II
This chart is not intended as a contract of benefits. It is designed purely as a reference to help you compare the programs available through the Manufacturer & Business Association.

Benefit                                                                                                  Network                                                             Out-of-Network
Benefit Period(1)                                                                                                                              Contract Year
Deductible (per benefit period)
   Individual                                                                                                 None                                                                   $250
   Family                                                                                                     None                                                                   $500
Plan Payment Level – Based on the provider’s                                                                  100%                                                            80% after deductible
reasonable charge (PRC)
Out-of-Pocket Maximums (Once met, plan
payment level becomes 100%)
   Individual                                                                                           None                                                                        $2,000
   Family                                                                                               None                                                                        $4,000
Lifetime Maximum (per person)                                                                        Unlimited                                                                   $1,000,000
Primary Care Physician Office Visits                                                          100% after $10 copayment                                                        80% after deductible
Specialist Office Visits                                                                      100% after $10 copayment                                                        80% after deductible
Preventive Care
   Adult
       Routine physical exams                                                                 100% after $10 copayment                                                           Not Covered
       Adult Immunizations                                                                             100%                                                                   80% after deductible
       Colorectal Cancer Screening
           Diagnostic Services                                                                         100%                                                               80% after deductible
           Medical Surgical                                                                            100%                                                               80% after deductible
       Routine gynecological exams, including a                                               100% after $10 copayment                                               80% (deductible does not apply)
       Pap Test
       Mammograms, annual routine and                                                                         100%                                                            80% after deductible
       medically necessary
    Pediatric
       Routine physical exams                                                                 100% after $10 copayment                               Not Covered
       Pediatric immunizations                                                                         100%                                 80% (deductible does not apply)
Emergency Room Services                                                                                     100% after $35 copayment (waived if admitted)
Spinal Manipulations                                                                          100% after $10 copayment                            80% after deductible
                                                                                                                    Limit: 20 visits/benefit period
Physical Medicine                                                                             100% after $10 copayment                            80% after deductible
                                                                                                                    Limit: 20 visits/benefit period
Speech Therapy                                                                                100% after $10 copayment                            80% after deductible
                                                                                                                    Limit: 20 visits/benefit period
Occupational Therapy                                                                          100% after $10 copayment                            80% after deductible
                                                                                                                    Limit: 20 visits/benefit period
Allergy Extracts and Injections                                                                        100%                                       80% after deductible
Ambulance                                                                                                                       100%
Assisted Fertilization Procedures                                                                                           Not Covered
Dental Services Related to Accidental Injury                                                           100%                                       80% after deductible
Diabetes Treatment                                                                                     100%                                       80% after deductible
Diagnostic Services (including routine)
 Advanced Imaging (MRI, CAT Scan, PET                                                                         100%                                                            80% after deductible
 scan, etc.)
 Basic Diagnostic Services (standard imaging,                                                                 100%                                                            80% after deductible
 diagnostic medical, lab/pathology, allergy
 testing)
Durable Medical Equipment, Orthotics and                                                                      100%                                                            80% after deductible
Prosthetics
Enteral Formulae                                                                                              100%                                                   80% (deductible does not apply)
Home Infusion Therapy                                                                                                                                100%
Home Health Care                                                                                                                                     100%
Hospice                                                                                                                                              100%
Hospital Services – Inpatient                                                                                 100%                                                            80% after deductible
Hospital Services – Outpatient                                                                                100%                                                            80% after deductible
                                               Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                                             -1-
 Benefit                                                                          Network                                             Out-of-Network
 Infertility Counseling, Testing and                                                  100%                                             80% after deductible
 Treatment(2)
 Maternity (facility & professional services)                                         100%                                             80% after deductible
 Medical/Surgical Expenses                                                            100%                                             80% after deductible
 (Except Office Visits)
 Mental Health – Inpatient(3)                                                      100%                                                80% after deductible
 Mental Health – Outpatient(3)                                            100% after $10 copayment                                     80% after deductible
 Private Duty Nursing                                                                                               100%
 Respiratory Therapy                                                                                                100%
 Skilled Nursing Facility Care                                                        100%                                            80% after deductible
                                                                                                                                  Limit: 100 days/benefit period
 Substance Abuse – Inpatient Detoxification                                        100%                                               80% after deductible
 Substance Abuse – Inpatient Rehabilitation                                        100%                                               80% after deductible
 Substance Abuse – Outpatient                                             100% after $10 copayment                                    80% after deductible
 Therapy Services (Cardiac Rehab, Infusion                                         100%                                               80% after deductible
 Therapy, Chemotherapy, Radiation Therapy and
 Dialysis)
 Transplant Services                                                                  100%                                             80% after deductible
 Precertification Requirements(4)                                                                                    Yes
 Prescription Drug Deductible
    Individual                                                                                          None per Contract year
    Family                                                                                              None per Contract year
 Premier Prescription Drug Program                                                                   Retail Drugs (31-day Supply)
 Mandatory Generic(5)                                                                                    $8 generic copayment
 Defined by Premier Pharmacy Network - Not                                                               $30 brand copayment
 Physician Network. Prescriptions filled at a non-
 network pharmacy are not covered.                                                  Maintenance Drugs through Mail Order (90-day Supply)
                                                                                                   $16 generic copayment
                                                                                                    $60 brand copayment
(1)   Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's renewal date. Contact
      your employer to determine the renewal date applicable to your program.
(2)   Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered
      depending on your group’s prescription drug program.
(3)   State mandated minimum benefits may apply to a diagnosis of serious mental illness. (If the above grid does not show a limit, your mental health benefit days and
      visits are unlimited.)
(4)   Highmark Healthcare Management Services (HMS) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-related
      inpatient admission. Some facility providers will contact HMS and obtain precertification of the inpatient admission on your behalf. Be sure to verify that your
      provider is contacting HMS for precertification. If not, you are responsible for contacting HMS. If this does not occur and it is later determined that all or part of the
      inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered.
(5)   Prescriptions are covered as long as they are listed on the prescription drug formulary applicable to your plan. To obtain a prescription medication that is not included
      on this formulary, your doctor must complete the 'Prescription Drug Medication Request Form' and return it to the Pharmacy Affairs Department for clinical review.
      Under the mandatory generic provision, you are responsible for the payment differential when a generic drug is available and you or your doctor specifies a brand
      name drug. Your payment is the price difference between the brand name drug and the generic drug in addition to the brand name drug copayment or coinsurance
      amounts, which may apply.




                                      Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                     -1-
Out-of-Area PPO High Option II
This chart is not intended as a contract of benefits. It is designed purely as a reference to help you compare the programs available through the Manufacturer & Business Association.

Benefit                                                                                                  Network                                                             Out-of-Network
Benefit Period(1)                                                                                                                              Contract Year
Deductible (per benefit period)
   Individual                                                                                                 None                                                                   $250
   Family                                                                                                     None                                                                   $500
Plan Payment Level – Based on the provider’s                                                                  100%                                                            80% after deductible
reasonable charge (PRC)
Out-of-Pocket Maximums (Once met, plan
payment level becomes 100%)
   Individual                                                                                           None                                                                        $2,000
   Family                                                                                               None                                                                        $4,000
Lifetime Maximum (per person)                                                                        Unlimited                                                                   $1,000,000
Primary Care Physician Office Visits                                                          100% after $10 copayment                                                        80% after deductible
Specialist Office Visits                                                                      100% after $10 copayment                                                        80% after deductible
Preventive Care
   Adult
       Routine physical exams                                                                 100% after $10 copayment                                                           Not Covered
       Adult Immunizations                                                                             100%                                                                   80% after deductible
       Colorectal Cancer Screening
           Diagnostic Services                                                                         100%                                                               80% after deductible
           Medical Surgical                                                                            100%                                                               80% after deductible
       Routine gynecological exams, including a                                               100% after $10 copayment                                               80% (deductible does not apply)
       Pap Test
       Mammograms, annual routine and                                                                         100%                                                            80% after deductible
       medically necessary
    Pediatric
       Routine physical exams                                                                 100% after $10 copayment                               Not Covered
       Pediatric immunizations                                                                         100%                                 80% (deductible does not apply)
Emergency Room Services                                                                                     100% after $35 copayment (waived if admitted)
Spinal Manipulations                                                                          100% after $10 copayment                            80% after deductible
                                                                                                                    Limit: 20 visits/benefit period
Physical Medicine                                                                             100% after $10 copayment                            80% after deductible
                                                                                                                    Limit: 20 visits/benefit period
Speech Therapy                                                                                100% after $10 copayment                            80% after deductible
                                                                                                                    Limit: 20 visits/benefit period
Occupational Therapy                                                                          100% after $10 copayment                            80% after deductible
                                                                                                                    Limit: 20 visits/benefit period
Allergy Extracts and Injections                                                                        100%                                       80% after deductible
Ambulance                                                                                                                       100%
Assisted Fertilization Procedures                                                                                           Not Covered
Dental Services Related to Accidental Injury                                                           100%                                       80% after deductible
Diabetes Treatment                                                                                     100%                                       80% after deductible
Diagnostic Services (including routine)
  Advanced Imaging (MRI, CAT Scan, PET                                                                        100%                                                            80% after deductible
  scan, etc.)
  Basic Diagnostic Services (standard imaging,                                                                100%                                                            80% after deductible
  diagnostic medical, lab/pathology, allergy
  testing)
Durable Medical Equipment, Orthotics and                                                                      100%                                                            80% after deductible
Prosthetics
Enteral Formulae                                                                                              100%                                                   80% (deductible does not apply)
Home Infusion Therapy                                                                                                                                100%
Home Health Care                                                                                                                                     100%
Hospice                                                                                                                                              100%
Hospital Services – Inpatient                                                                                 100%                                                            80% after deductible
Hospital Services – Outpatient                                                                                100%                                                            80% after deductible
                                               Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                                             -1-
 Benefit                                                                          Network                                             Out-of-Network
 Infertility Counseling, Testing and                                                  100%                                             80% after deductible
 Treatment(2)
 Maternity (facility & professional services)                                         100%                                             80% after deductible
 Medical/Surgical Expenses                                                            100%                                             80% after deductible
 (Except Office Visits)
 Mental Health – Inpatient(3)                                                      100%                                                80% after deductible
 Mental Health – Outpatient(3)                                            100% after $10 copayment                                     80% after deductible
 Private Duty Nursing                                                                                               100%
 Respiratory Therapy                                                                                                100%
 Skilled Nursing Facility Care                                                        100%                                            80% after deductible
                                                                                                                                  Limit: 100 days/benefit period
 Substance Abuse – Inpatient Detoxification                                        100%                                               80% after deductible
 Substance Abuse – Inpatient Rehabilitation                                        100%                                               80% after deductible
 Substance Abuse – Outpatient                                             100% after $10 copayment                                    80% after deductible
 Therapy Services (Cardiac Rehab, Infusion                                         100%                                               80% after deductible
 Therapy, Chemotherapy, Radiation Therapy and
 Dialysis)
 Transplant Services                                                                  100%                                             80% after deductible
 Precertification Requirements(4)                                                                                    Yes
 Prescription Drug Deductible
    Individual                                                                                          None per Contract year
    Family                                                                                              None per Contract year
 Premier Prescription Drug Program                                                                   Retail Drugs (31-day Supply)
 Mandatory Generic(5)                                                                                    $8 generic copayment
 Defined by Premier Pharmacy Network - Not                                                               $30 brand copayment
 Physician Network. Prescriptions filled at a non-
 network pharmacy are not covered.                                                  Maintenance Drugs through Mail Order (90-day Supply)
                                                                                                   $16 generic copayment
                                                                                                    $60 brand copayment
(1)   Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's renewal date. Contact
      your employer to determine the renewal date applicable to your program.
(2)   Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered
      depending on your group’s prescription drug program.
(3)   State mandated minimum benefits may apply to a diagnosis of serious mental illness. (If the above grid does not show a limit, your mental health benefit days and
      visits are unlimited.)
(4)   Highmark Healthcare Management Services (HMS) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-related
      inpatient admission. Some facility providers will contact HMS and obtain precertification of the inpatient admission on your behalf. Be sure to verify that your
      provider is contacting HMS for precertification. If not, you are responsible for contacting HMS. If this does not occur and it is later determined that all or part of the
      inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered.
(5)   Prescriptions are covered as long as they are listed on the prescription drug formulary applicable to your plan. To obtain a prescription medication that is not included
      on this formulary, your doctor must complete the 'Prescription Drug Medication Request Form' and return it to the Pharmacy Affairs Department for clinical review.
      Under the mandatory generic provision, you are responsible for the payment differential when a generic drug is available and you or your doctor specifies a brand
      name drug. Your payment is the price difference between the brand name drug and the generic drug in addition to the brand name drug copayment or coinsurance
      amounts, which may apply.




                                      Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                     -1-
PPOBlue Enhanced
This chart is not intended as a contract of benefits. It is designed purely as a reference to help you compare the programs available through the Manufacturer & Business Association.

Benefit                                                                                                  Network                                                             Out-of-Network
Benefit Period(1)                                                                                                                              Contract Year
Deductible (per benefit period)
   Individual                                                                                                 None                                                                   $500
   Family                                                                                                     None                                                                  $1,000
Plan Payment Level – Based on the provider’s                                                                  100%                                                            80% after deductible
reasonable charge (PRC)
Out-of-Pocket Maximums (Once met, plan
payment level becomes 100%)
   Individual                                                                                           None                                                                        $3,000
   Family                                                                                               None                                                                        $6,000
Lifetime Maximum (per person)                                                                        Unlimited                                                                   $1,000,000
Primary Care Physician Office Visits                                                          100% after $20 copayment                                                        80% after deductible
Specialist Office Visits                                                                      100% after $20 copayment                                                        80% after deductible
Preventive Care
   Adult
       Routine physical exams                                                                 100% after $20 copayment                                                           Not Covered
       Adult Immunizations                                                                             100%                                                                   80% after deductible
       Colorectal Cancer Screening
           Diagnostic Services                                                                         100%                                                               80% after deductible
           Medical Surgical                                                                            100%                                                               80% after deductible
       Routine gynecological exams, including a                                               100% after $20 copayment                                               80% (deductible does not apply)
       Pap Test
       Mammograms, annual routine and                                                                         100%                                                            80% after deductible
       medically necessary
    Pediatric
       Routine physical exams                                                                 100% after $20 copayment                               Not Covered
       Pediatric immunizations                                                                         100%                                 80% (deductible does not apply)
Emergency Room Services                                                                                     100% after $50 copayment (waived if admitted)
Spinal Manipulations                                                                          100% after $20 copayment                            80% after deductible
                                                                                                                    Limit: 20 visits/benefit period
Physical Medicine                                                                             100% after $20 copayment                            80% after deductible
                                                                                                                    Limit: 20 visits/benefit period
Speech Therapy                                                                                100% after $20 copayment                            80% after deductible
                                                                                                                    Limit: 20 visits/benefit period
Occupational Therapy                                                                          100% after $20 copayment                            80% after deductible
                                                                                                                    Limit: 20 visits/benefit period
Allergy Extracts and Injections                                                                        100%                                       80% after deductible
Ambulance                                                                                                                       100%
Assisted Fertilization Procedures                                                                                           Not Covered
Dental Services Related to Accidental Injury                                                           100%                                       80% after deductible
Diabetes Treatment                                                                                     100%                                       80% after deductible
Diagnostic Services (including routine)
 Advanced Imaging (MRI, CAT Scan, PET                                                                         100%                                                            80% after deductible
 scan, etc.)
 Basic Diagnostic Services (standard imaging,                                                                 100%                                                            80% after deductible
 diagnostic medical, lab/pathology, allergy
 testing)
Durable Medical Equipment, Orthotics and                                                                      100%                                                            80% after deductible
Prosthetics
Enteral Formulae                                                                                              100%                                                   80% (deductible does not apply)
Home Infusion Therapy                                                                                                                                100%
Home Health Care                                                                                              100%                                                            80% after deductible
Hospice                                                                                                       100%                                                            80% after deductible
Hospital Services – Inpatient                                                                                 100%                                                            80% after deductible
Hospital Services – Outpatient                                                                                100%                                                            80% after deductible
                                               Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                                             -1-
 Benefit                                                                          Network                                            Out-of-Network
 Infertility Counseling, Testing and                                                  100%                                            80% after deductible
 Treatment(2)
 Maternity (facility & professional services)                                         100%                                            80% after deductible
 Medical/Surgical Expenses                                                            100%                                            80% after deductible
 (Except Office Visits)
 Mental Health – Inpatient(3)                                                      100%                                               80% after deductible
 Mental Health – Outpatient(3)                                            100% after $20 copayment                                    80% after deductible
 Private Duty Nursing                                                                                              100%
 Respiratory Therapy                                                                                               100%
 Skilled Nursing Facility Care                                                        100%                                           80% after deductible
                                                                                                                                 Limit: 100 days/benefit period
 Substance Abuse – Inpatient Detoxification                                        100%                                              80% after deductible
 Substance Abuse – Inpatient Rehabilitation                                        100%                                              80% after deductible
 Substance Abuse – Outpatient                                             100% after $20 copayment                                   80% after deductible
 Therapy Services (Cardiac Rehab, Infusion                                         100%                                              80% after deductible
 Therapy, Chemotherapy, Radiation Therapy and
 Dialysis)
 Transplant Services                                                                  100%                                            80% after deductible
 Precertification Requirements(4)                                                                                   Yes
 Prescription Drug Deductible
    Individual                                                                                                  None
    Family                                                                                                      None
 Premier Prescription Drug Program                                                                  Retail Drugs (31-day Supply)
 Mandatory Generic(5)                                                                                   $8 generic copayment
 Defined by Premier Pharmacy Network - Not                                                              $40 brand copayment
 Physician Network. Prescriptions filled at a non-
 network pharmacy are not covered.                                                  Maintenance Drugs through Mail Order (90-day Supply)
                                                                                                   $16 generic copayment
                                                                                                    $80 brand copayment
(1)   Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's renewal date. Contact
      your employer to determine the renewal date applicable to your program.
(2)   Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered
      depending on your group’s prescription drug program.
(3)   State mandated minimum benefits may apply to a diagnosis of serious mental illness. (If the above grid does not show a limit, your mental health benefit days and
      visits are unlimited.)
(4)   Highmark Healthcare Management Services (HMS) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-related
      inpatient admission. Some facility providers will contact HMS and obtain precertification of the inpatient admission on your behalf. Be sure to verify that your
      provider is contacting HMS for precertification. If not, you are responsible for contacting HMS. If this does not occur and it is later determined that all or part of the
      inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered.
(5)   Prescriptions are covered as long as they are listed on the prescription drug formulary applicable to your plan. To obtain a prescription medication that is not included
      on this formulary, the physician must complete the 'Prescription Drug Medication Request Form' and return it to the Pharmacy Affairs Department for clinical review.
      Under the mandatory generic provision, you are responsible for the payment differential when a generic drug is available and you or your doctor specifies a brand
      name drug. Your payment is the price difference between the brand drug and the generic drug in addition to the brand drug copayment or coinsurance amounts, which
      may apply.




                                     Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                     -1-
PPOBlue Standard
This chart is not intended as a contract of benefits. It is designed purely as a reference to help you compare the programs available through the Manufacturer & Business Association.

Benefit                                                                                                  Network                                                            Out-of-Network
Benefit Period(1)                                                                                                                             Contract Year
Deductible (per benefit period)
   Individual                                                                                            $250                                                                       $500
   Family                                                                                                $500                                                                      $1,000
Plan Payment Level – Based on the provider’s                                                      100% after deductible                                                      80% after deductible
reasonable charge (PRC)
Out-of-Pocket Maximums (Once met, plan
payment level becomes 100%)
   Individual                                                                                                  None                                                                      $2,000
   Family                                                                                                      None                                                                      $4,000
Lifetime Maximum (per person)                                                                                                           $2,000,000 Combined
Primary Care Physician Office Visits                                                          100% after $20 copayment                                                       80% after deductible
Specialist Office Visits                                                                      100% after $20 copayment                                                       80% after deductible
Preventive Care
   Adult
       Routine physical exams                                                                 100% after $20 copayment                                                          Not Covered
       Adult Immunizations                                                                      100% after deductible                                                        80% after deductible
       Colorectal Cancer Screening
           Diagnostic Services                                                                  100% after deductible                                                    80% after deductible
           Medical Surgical                                                                     100% after deductible                                                    80% after deductible
       Routine gynecological exams, including a                                               100% after $20 copayment                                              80% (deductible does not apply)
       Pap Test
       Mammograms, annual routine and                                                    100% (deductible does not apply)                                                    80% after deductible
       medically necessary
    Pediatric
       Routine physical exams                                                               100% after $20 copayment                                Not Covered
       Pediatric immunizations                                                           100% (deductible does not apply)                  80% (deductible does not apply)
Emergency Room Services                                                                                   100% after $50 copayment (waived if admitted)
Spinal Manipulations                                                                        100% after $20 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Physical Medicine                                                                           100% after $20 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Speech Therapy                                                                              100% after $20 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Occupational Therapy                                                                        100% after $20 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Allergy Extracts and Injections                                                               100% after deductible                              80% after deductible
Ambulance                                                                                                         100% after network deductible
Assisted Fertilization Procedures                                                                                          Not Covered
Dental Services Related to Accidental Injury                                                  100% after deductible                              80% after deductible
Diabetes Treatment                                                                            100% after deductible                              80% after deductible
Diagnostic Services (including routine)
 Advanced Imaging (MRI, CAT Scan, PET                                                             100% after deductible                                                      80% after deductible
 scan, etc.)
 Basic Diagnostic Services (standard imaging,                                                     100% after deductible                                                      80% after deductible
 diagnostic medical, lab/pathology, allergy
 testing)
Durable Medical Equipment, Orthotics and                                                          100% after deductible                                                      80% after deductible
Prosthetics
Enteral Formulae                                                                         100% (deductible does not apply)              80% (deductible does not apply)
Home Infusion Therapy                                                                                             100% after network deductible
Home Health Care                                                                             100% after deductible                           80% after deductible
Hospice                                                                                      100% after deductible                           80% after deductible
Hospital Services – Inpatient                                                                100% after deductible                           80% after deductible
Hospital Services – Outpatient                                                               100% after deductible                           80% after deductible
                                               Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                                             -1-
Benefit                                                                        Network                                           Out-of-Network
Infertility Counseling, Testing and                                       100% after deductible                                   80% after deductible
Treatment(2)
Maternity (facility & professional services)                              100% after deductible                                   80% after deductible
Medical/Surgical Expenses                                                 100% after deductible                                   80% after deductible
(Except Office Visits)
Mental Health – Inpatient(3)                                             100% after deductible                          80% after deductible
Mental Health – Outpatient(3)                                          100% after $20 copayment                         80% after deductible
Private Duty Nursing                                                                         100% after network deductible
Respiratory Therapy                                                                          100% after network deductible
Skilled Nursing Facility Care                                            100% after deductible                          80% after deductible
                                                                                                                   Limit: 100 days/benefit period
Substance Abuse – Inpatient Detoxification                               100% after deductible                          80% after deductible
Substance Abuse – Inpatient Rehabilitation                               100% after deductible                          80% after deductible
Substance Abuse – Outpatient                                           100% after $20 copayment                         80% after deductible
Therapy Services (Cardiac Rehab, Infusion                                100% after deductible                          80% after deductible
Therapy, Chemotherapy, Radiation Therapy and
Dialysis)
Transplant Services                                                       100% after deductible                                   80% after deductible
Precertification Requirements(4)                                                                                Yes
Prescription Drug Deductible
   Individual                                                                                       None per Contract year
   Family                                                                                           None per Contract year
Premier Prescription Drug Program                                                                Retail Drugs (31-day Supply)
Mandatory Generic(5)                                                                                 $8 generic copayment
Defined by Premier Pharmacy Network - Not                                                            $40 brand copayment
Physician Network. Prescriptions filled at a non-
network pharmacy are not covered.                                               Maintenance Drugs through Mail Order (90-day Supply)
                                                                                               $16 generic copayment
                                                                                                $80 brand copayment
(1)   Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's renewal date. Contact
      your employer to determine the renewal date applicable to your program.
(2)   Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered
      depending on your group’s prescription drug program.
(3)   State mandated minimum benefits may apply to a diagnosis of serious mental illness. (If the above grid does not show a limit, your mental health benefit days and
      visits are unlimited.)
(4)   Highmark Healthcare Management Services (HMS) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-
      related inpatient admission. Some facility providers will contact HMS and obtain precertification of the inpatient admission on your behalf. Be sure to verify that
      your provider is contacting HMS for precertification. If not, you are responsible for contacting HMS. If this does not occur and it is later determined that all or
      part of the inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered.
(5)   Prescriptions are covered as long as they are listed on the prescription drug formulary applicable to your plan. To obtain a prescription medication that is not
      included on this formulary, your doctor must complete the 'Prescription Drug Medication Request Form' and return it to the Pharmacy Affairs Department for
      clinical review. Under the mandatory generic provision, you are responsible for the payment differential when a generic drug is available and you or your doctor
      specifies a brand name drug. Your payment is the price difference between the brand name drug and the generic drug in addition to the brand name drug
      copayment or coinsurance amounts, which may apply.




                                   Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs
.
                                                                                  -1-
 Out-of-Area PPO Standard
This chart is not intended as a contract of benefits. It is designed purely as a reference to help you compare the programs available through the Manufacturer & Business Association.

Benefit                                                                                                  Network                                                             Out-of-Network
Benefit Period(1)                                                                                                                              Contract Year
Deductible (per benefit period)
   Individual                                                                                            $250                                                                        $500
   Family                                                                                                $500                                                                       $1,000
Plan Payment Level – Based on the provider’s                                                      100% after deductible                                                       80% after deductible
reasonable charge (PRC)
Out-of-Pocket Maximums (Once met, plan
payment level becomes 100%)
   Individual                                                                                                  None                                                                      $2,000
   Family                                                                                                      None                                                                      $4,000
Lifetime Maximum (per person)                                                                                                            $2,000,000 Combined
Primary Care Physician Office Visits                                                          100% after $20 copayment                                                        80% after deductible
Specialist Office Visits                                                                      100% after $20 copayment                                                        80% after deductible
Preventive Care
   Adult
       Routine physical exams                                                                 100% after $20 copayment                                                           Not Covered
       Adult Immunizations                                                                      100% after deductible                                                         80% after deductible
       Colorectal Cancer Screening
           Diagnostic Services                                                                  100% after deductible                                                     80% after deductible
           Medical Surgical                                                                     100% after deductible                                                     80% after deductible
       Routine gynecological exams, including a                                               100% after $20 copayment                                               80% (deductible does not apply)
       Pap Test
       Mammograms, annual routine and                                                    100% (deductible does not apply)                                                     80% after deductible
       medically necessary
    Pediatric
       Routine physical exams                                                               100% after $20 copayment                                Not Covered
       Pediatric immunizations                                                           100% (deductible does not apply)                  80% (deductible does not apply)
Emergency Room Services                                                                                   100% after $50 copayment (waived if admitted)
Spinal Manipulations                                                                        100% after $20 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Physical Medicine                                                                           100% after $20 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Speech Therapy                                                                              100% after $20 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Occupational Therapy                                                                        100% after $20 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Allergy Extracts and Injections                                                               100% after deductible                              80% after deductible
Ambulance                                                                                                          100% after network deductible
Assisted Fertilization Procedures                                                                                          Not Covered
Dental Services Related to Accidental Injury                                                  100% after deductible                              80% after deductible
Diabetes Treatment                                                                            100% after deductible                              80% after deductible
Diagnostic Services (including routine)
  Advanced Imaging (MRI, CAT Scan, PET                                                            100% after deductible                                                       80% after deductible
  scan, etc.)
  Basic Diagnostic Services (standard imaging,                                                    100% after deductible                                                       80% after deductible
  diagnostic medical, lab/pathology, allergy
  testing)
Durable Medical Equipment, Orthotics and                                                          100% after deductible                                                       80% after deductible
Prosthetics
Enteral Formulae                                                                         100% (deductible does not apply)               80% (deductible does not apply)
Home Infusion Therapy                                                                                              100% after network deductible
Home Health Care                                                                             100% after deductible                            80% after deductible
Hospice                                                                                      100% after deductible                            80% after deductible
Hospital Services – Inpatient                                                                100% after deductible                            80% after deductible
Hospital Services – Outpatient                                                               100% after deductible                            80% after deductible
                                               Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                                             -1-
  Benefit                                                                          Network                                            Out-of-Network
  Infertility Counseling, Testing and                                        100% after deductible                                     80% after deductible
  Treatment(2)
  Maternity (facility & professional services)                               100% after deductible                                     80% after deductible
  Medical/Surgical Expenses                                                  100% after deductible                                     80% after deductible
  (Except Office Visits)
  Mental Health – Inpatient(3)                                              100% after deductible                          80% after deductible
  Mental Health – Outpatient(3)                                           100% after $20 copayment                         80% after deductible
  Private Duty Nursing                                                                          100% after network deductible
  Respiratory Therapy                                                                           100% after network deductible
  Skilled Nursing Facility Care                                             100% after deductible                          80% after deductible
                                                                                                                      Limit: 100 days/benefit period
  Substance Abuse – Inpatient Detoxification                                100% after deductible                          80% after deductible
  Substance Abuse – Inpatient Rehabilitation                                100% after deductible                          80% after deductible
  Substance Abuse – Outpatient                                            100% after $20 copayment                         80% after deductible
  Therapy Services (Cardiac Rehab, Infusion                                 100% after deductible                          80% after deductible
  Therapy, Chemotherapy, Radiation Therapy and
  Dialysis)
  Transplant Services                                                        100% after deductible                                     80% after deductible
  Precertification Requirements(4)                                                                                   Yes
  Prescription Drug Deductible
     Individual                                                                                         None per Contract year
     Family                                                                                             None per Contract year
  Premier Prescription Drug Program                                                                  Retail Drugs (31-day Supply)
  Mandatory Generic(5)                                                                                   $8 generic copayment
  Defined by Premier Pharmacy Network - Not                                                              $40 brand copayment
  Physician Network. Prescriptions filled at a non-
  network pharmacy are not covered.                                                  Maintenance Drugs through Mail Order (90-day Supply)
                                                                                                    $16 generic copayment
                                                                                                     $80 brand copayment
(1) Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's renewal date. Contact your
    employer to determine the renewal date applicable to your program.
(2) Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered
    depending on your group’s prescription drug program.
(3) State mandated minimum benefits may apply to a diagnosis of serious mental illness. (If the above grid does not show a limit, your mental health benefit days and visits
    are unlimited.)
(4) Highmark Healthcare Management Services (HMS) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-related
    inpatient admission. Some facility providers will contact HMS and obtain precertification of the inpatient admission on your behalf. Be sure to verify that your provider
    is contacting HMS for precertification. If not, you are responsible for contacting HMS. If this does not occur and it is later determined that all or part of the inpatient
    stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered.
(5) Prescriptions are covered as long as they are listed on the prescription drug formulary applicable to your plan. To obtain a prescription medication that is not included on
    this formulary, your doctor must complete the 'Prescription Drug Medication Request Form' and return it to the Pharmacy Affairs Department for clinical review.Under
    the mandatory generic provision, you are responsible for the payment differential when a generic drug is available and you or your doctor specifies a brand name drug.
    Your payment is the price difference between the brand name drug and the generic drug in addition to the brand name drug copayment or coinsurance amounts, which
    may apply.




                                      Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                      -1-
PPOBlue $500 Deductible
This chart is not intended as a contract of benefits. It is designed purely as a reference to help you compare the programs available through the Manufacturer & Business Association.

Benefit                                                                                                  Network                                                            Out-of-Network
Benefit Period(1)                                                                                                                             Contract Year
Deductible (per benefit period)
   Individual                                                                                            $500                                                                      $1,000
   Family                                                                                               $1,000                                                                     $2,000
Plan Payment Level – Based on the provider’s                                                      100% after deductible                                                      80% after deductible
reasonable charge (PRC)
Out-of-Pocket Maximums (Once met, plan
payment level becomes 100%)
   Individual                                                                                                  None                                                                      $3,000
   Family                                                                                                      None                                                                      $6,000
Lifetime Maximum (per person)                                                                                                           $2,000,000 Combined
Primary Care Physician Office Visits                                                          100% after $20 copayment                                                       80% after deductible
Specialist Office Visits                                                                      100% after $20 copayment                                                       80% after deductible
Preventive Care
   Adult
       Routine physical exams                                                                 100% after $20 copayment                                                          Not Covered
       Adult Immunizations                                                                      100% after deductible                                                        80% after deductible
       Colorectal Cancer Screening
           Diagnostic Services                                                                  100% after deductible                                                    80% after deductible
           Medical Surgical                                                                     100% after deductible                                                    80% after deductible
       Routine gynecological exams, including a                                               100% after $20 copayment                                              80% (deductible does not apply)
       Pap Test
       Mammograms, annual routine and                                                    100% (deductible does not apply)                                                    80% after deductible
       medically necessary
    Pediatric
       Routine physical exams                                                               100% after $20 copayment                                Not Covered
       Pediatric immunizations                                                           100% (deductible does not apply)                  80% (deductible does not apply)
Emergency Room Services                                                                                   100% after $75 copayment (waived if admitted)
Spinal Manipulations                                                                        100% after $20 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Physical Medicine                                                                           100% after $20 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Speech Therapy                                                                              100% after $20 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Occupational Therapy                                                                        100% after $20 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Allergy Extracts and Injections                                                               100% after deductible                              80% after deductible
Ambulance                                                                                                         100% after network deductible
Assisted Fertilization Procedures                                                                                          Not Covered
Dental Services Related to Accidental Injury                                                  100% after deductible                              80% after deductible
Diabetes Treatment                                                                            100% after deductible                              80% after deductible
Diagnostic Services (including routine)
  Advanced Imaging (MRI, CAT Scan, PET                                                            100% after deductible                                                      80% after deductible
  scan, etc.)
  Basic Diagnostic Services (standard imaging,                                                    100% after deductible                                                      80% after deductible
  diagnostic medical, lab/pathology, allergy
  testing)
Durable Medical Equipment, Orthotics and                                                          100% after deductible                                                      80% after deductible
Prosthetics
Enteral Formulae                                                                         100% (deductible does not apply)              80% (deductible does not apply)
Home Infusion Therapy                                                                                             100% after network deductible
Home Health Care                                                                             100% after deductible                           80% after deductible
Hospice                                                                                      100% after deductible                           80% after deductible
Hospital Services – Inpatient                                                                100% after deductible                           80% after deductible
Hospital Services – Outpatient                                                               100% after deductible                           80% after deductible
                                               Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                                             -1-
Benefit                                                                          Network                                           Out-of-Network
Infertility Counseling, Testing and                                        100% after deductible                                    80% after deductible
Treatment(2)
Maternity (facility & professional services)                               100% after deductible                                    80% after deductible
Medical/Surgical Expenses                                                  100% after deductible                                    80% after deductible
(Except Office Visits)
Mental Health – Inpatient(3)                                              100% after deductible                          80% after deductible
Mental Health – Outpatient(3)                                           100% after $20 copayment                         80% after deductible
Private Duty Nursing                                                                          100% after network deductible
Respiratory Therapy                                                                           100% after network deductible
Skilled Nursing Facility Care                                             100% after deductible                          80% after deductible
                                                                                                                    Limit: 100 days/benefit period
Substance Abuse – Inpatient Detoxification                                100% after deductible                          80% after deductible
Substance Abuse – Inpatient Rehabilitation                                100% after deductible                          80% after deductible
Substance Abuse – Outpatient                                            100% after $20 copayment                         80% after deductible
Therapy Services (Cardiac Rehab, Infusion                                 100% after deductible                          80% after deductible
Therapy, Chemotherapy, Radiation Therapy and
Dialysis)
Transplant Services                                                        100% after deductible                                    80% after deductible
Precertification Requirements(4)                                                                                  Yes
Prescription Drug Deductible
   Individual                                                                                                  None
   Family                                                                                                      None
Premier Prescription Drug Program                                                                  Retail Drugs (31-day Supply)
Mandatory Generic(5)                                                                                   $8 generic copayment
Defined by Premier Pharmacy Network - Not                                                              $40 brand copayment
Physician Network. Prescriptions filled at a non-
network pharmacy are not covered.                                                 Maintenance Drugs through Mail Order (90-day Supply)
                                                                                                 $16 generic copayment
                                                                                                  $80 brand copayment
(1)   Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's renewal
      date. Contact your employer to determine the renewal date applicable to your program.
(2)   Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be
      covered depending on your group’s prescription drug program.
(3)   State mandated minimum benefits may apply to a diagnosis of serious mental illness. (If the above grid does not show a limit, your mental health
      benefit days and visits are unlimited.)
(4)   Highmark Healthcare Management Services (HMS) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or
      maternity-related inpatient admission. Some facility providers will contact HMS and obtain precertification of the inpatient admission on your behalf.
      Be sure to verify that your provider is contacting HMS for precertification. If not, you are responsible for contacting HMS. If this does not occur and
      it is later determined that all or part of the inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs
      not covered.
(5)   Prescriptions are covered as long as they are listed on the prescription drug formulary applicable to your plan. To obtain a prescription medication that
      is not included on this formulary, your doctor must complete the 'Prescription Drug Medication Request Form' and return it to the Pharmacy Affairs
      Department for clinical review. Under the mandatory generic provision, you are responsible for the payment differential when a generic drug is
      available and you or your doctor specifies a brand name drug. Your payment is the price difference between the brand name drug and the generic drug
      in addition to the brand name drug copayment or coinsurance amounts, which may apply.




                                    Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                   -1-
Out-of-Area PPO $500 Deductible
This chart is not intended as a contract of benefits. It is designed purely as a reference to help you compare the programs available through the Manufacturer & Business Association.

Benefit                                                                                                  Network                                                            Out-of-Network
Benefit Period(1)                                                                                                                             Contract Year
Deductible (per benefit period)
   Individual                                                                                            $500                                                                      $1,000
   Family                                                                                               $1,000                                                                     $2,000
Plan Payment Level – Based on the provider’s                                                      100% after deductible                                                      80% after deductible
reasonable charge (PRC)
Out-of-Pocket Maximums (Once met, plan
payment level becomes 100%)
   Individual                                                                                                  None                                                                      $3,000
   Family                                                                                                      None                                                                      $6,000
Lifetime Maximum (per person)                                                                                                           $2,000,000 Combined
Primary Care Physician Office Visits                                                          100% after $20 copayment                                                       80% after deductible
Specialist Office Visits                                                                      100% after $20 copayment                                                       80% after deductible
Preventive Care
   Adult
       Routine physical exams                                                                 100% after $20 copayment                                                          Not Covered
       Adult Immunizations                                                                      100% after deductible                                                        80% after deductible
       Colorectal Cancer Screening
           Diagnostic Services                                                                  100% after deductible                                                     80% after deductible
           Medical Surgical                                                                     100% after deductible                                                     80% after deductible
       Routine gynecological exams, including a                                               100% after $20 copayment                                               80% (deductible does not apply)
       Pap Test
       Mammograms, annual routine and                                                    100% (deductible does not apply)                                                    80% after deductible
       medically necessary
    Pediatric
       Routine physical exams                                                               100% after $20 copayment                                Not Covered
       Pediatric immunizations                                                           100% (deductible does not apply)                  80% (deductible does not apply)
Emergency Room Services                                                                                   100% after $75 copayment (waived if admitted)
Spinal Manipulations                                                                        100% after $20 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Physical Medicine                                                                           100% after $20 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Speech Therapy                                                                              100% after $20 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Occupational Therapy                                                                        100% after $20 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Allergy Extracts and Injections                                                               100% after deductible                              80% after deductible
Ambulance                                                                                                         100% after network deductible
Assisted Fertilization Procedures                                                                                          Not Covered
Dental Services Related to Accidental Injury                                                  100% after deductible                              80% after deductible
Diabetes Treatment                                                                            100% after deductible                              80% after deductible
Diagnostic Services (including routine)
  Advanced Imaging (MRI, CAT Scan, PET                                                            100% after deductible                                                      80% after deductible
  scan, etc.)
  Basic Diagnostic Services (standard imaging,                                                    100% after deductible                                                      80% after deductible
  diagnostic medical, lab/pathology, allergy
  testing)
Durable Medical Equipment, Orthotics and                                                          100% after deductible                                                      80% after deductible
Prosthetics
Enteral Formulae                                                                         100% (deductible does not apply)              80% (deductible does not apply)
Home Infusion Therapy                                                                                             100% after network deductible
Home Health Care                                                                             100% after deductible                           80% after deductible
Hospice                                                                                      100% after deductible                           80% after deductible
Hospital Services – Inpatient                                                                100% after deductible                           80% after deductible
Hospital Services – Outpatient                                                               100% after deductible                           80% after deductible
                                               Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                                             -1-
Benefit                                                                        Network                                           Out-of-Network
Infertility Counseling, Testing and                                       100% after deductible                                   80% after deductible
Treatment(2)
Maternity (facility & professional services)                              100% after deductible                                   80% after deductible
Medical/Surgical Expenses                                                 100% after deductible                                   80% after deductible
(Except Office Visits)
Mental Health – Inpatient(3)                                             100% after deductible                          80% after deductible
Mental Health – Outpatient(3)                                          100% after $20 copayment                         80% after deductible
Private Duty Nursing                                                                         100% after network deductible
Respiratory Therapy                                                                          100% after network deductible
Skilled Nursing Facility Care                                            100% after deductible                          80% after deductible
                                                                                                                   Limit: 100 days/benefit period
Substance Abuse – Inpatient Detoxification                               100% after deductible                          80% after deductible
Substance Abuse – Inpatient Rehabilitation                               100% after deductible                          80% after deductible
Substance Abuse – Outpatient                                           100% after $20 copayment                         80% after deductible
Therapy Services (Cardiac Rehab, Infusion                                100% after deductible                          80% after deductible
Therapy, Chemotherapy, Radiation Therapy and
Dialysis)
Transplant Services                                                       100% after deductible                                   80% after deductible
Precertification Requirements(4)                                                                                Yes
Prescription Drug Deductible
   Individual                                                                                                None
   Family                                                                                                    None
Premier Prescription Drug Program                                                                Retail Drugs (31-day Supply)
Mandatory Generic(5)                                                                                 $8 generic copayment
Defined by Premier Pharmacy Network - Not                                                            $40 brand copayment
Physician Network. Prescriptions filled at a non-
network pharmacy are not covered.                                               Maintenance Drugs through Mail Order (90-day Supply)
                                                                                               $16 generic copayment
                                                                                                $80 brand copayment
(1)   Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's renewal date. Contact
      your employer to determine the renewal date applicable to your program.
(2)   Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered
      depending on your group’s prescription drug program.
(3)   State mandated minimum benefits may apply to a diagnosis of serious mental illness. (If the above grid does not show a limit, your mental health benefit days and
      visits are unlimited.)
(4)   Highmark Healthcare Management Services (HMS) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-
      related inpatient admission. Some facility providers will contact HMS and obtain precertification of the inpatient admission on your behalf. Be sure to verify that
      your provider is contacting HMS for precertification. If not, you are responsible for contacting HMS. If this does not occur and it is later determined that all or
      part of the inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered.
(5)   Prescriptions are covered as long as they are listed on the prescription drug formulary applicable to your plan. To obtain a prescription medication that is not
      included on this formulary, your doctor must complete the 'Prescription Drug Medication Request Form' and return it to the Pharmacy Affairs Department for
      clinical review. Under the mandatory generic provision, you are responsible for the payment differential when a generic drug is available and you or your doctor
      specifies a brand name drug. Your payment is the price difference between the brand name drug and the generic drug in addition to the brand name drug
      copayment or coinsurance amounts, which may apply.




                                   Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                  -1-
PPOBlue $750 Deductible Value
This chart is not intended as a contract of benefits. It is designed purely as a reference to help you compare the programs available through the Manufacturer & Business Association.

Benefit                                                                                                  Network                                                             Out-of-Network
Benefit Period(1)                                                                                                                              Contract Year
Deductible (per benefit period)
   Individual                                                                                            $750                                                                       $1,500
   Family                                                                                               $1,500                                                                      $3,000
Plan Payment Level – Based on the provider’s                                                      100% after deductible                                                       80% after deductible
reasonable charge (PRC)
Out-of-Pocket Maximums (Once met, plan
payment level becomes 100%)
   Individual                                                                                                  None                                                                       $5,000
   Family                                                                                                      None                                                                      $10,000
Lifetime Maximum (per person)                                                                                                            $5,000,000 Combined
Primary Care Physician Office Visits                                                          100% after $10 copayment                                                        80% after deductible
Specialist Office Visits                                                                      100% after $25 copayment                                                        80% after deductible
Preventive Care
   Adult
       Routine physical exams                                                                 100% after $10 copayment                                                           Not Covered
       Adult Immunizations                                                                      100% after deductible                                                         80% after deductible
       Colorectal Cancer Screening
           Diagnostic Services                                                                  100% after deductible                                                     80% after deductible
           Medical Surgical                                                                     100% after deductible                                                     80% after deductible
       Routine gynecological exams, including a                                               100% after $25 copayment                                               80% (deductible does not apply)
       Pap Test
       Mammograms, annual routine and                                                    100% (deductible does not apply)                                                     80% after deductible
       medically necessary
    Pediatric
       Routine physical exams                                                               100% after $10 copayment                                Not Covered
       Pediatric immunizations                                                           100% (deductible does not apply)                  80% (deductible does not apply)
Emergency Room Services                                                                                   100% after $100 copayment (waived if admitted)
Spinal Manipulations                                                                        100% after $25 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Physical Medicine                                                                           100% after $25 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Speech Therapy                                                                              100% after $25 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Occupational Therapy                                                                        100% after $25 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Allergy Extracts and Injections                                                               100% after deductible                              80% after deductible
Ambulance                                                                                                          100% after network deductible
Assisted Fertilization Procedures                                                                                          Not Covered
Dental Services Related to Accidental Injury                                                  100% after deductible                              80% after deductible
Diabetes Treatment                                                                            100% after deductible                              80% after deductible
Diagnostic Services (including routine)
  Advanced Imaging (MRI, CAT Scan, PET                                                            100% after deductible                                                       80% after deductible
  scan, etc.)
  Basic Diagnostic Services (standard imaging,                                                    100% after deductible                                                       80% after deductible
  diagnostic medical, lab/pathology, allergy
  testing)
Durable Medical Equipment, Orthotics and                                                          100% after deductible                                                       80% after deductible
Prosthetics
Enteral Formulae                                                                         100% (deductible does not apply)               80% (deductible does not apply)
Home Infusion Therapy                                                                                              100% after network deductible
Home Health Care                                                                             100% after deductible                            80% after deductible
Hospice                                                                                      100% after deductible                            80% after deductible
Hospital Services – Inpatient                                                                100% after deductible                            80% after deductible
Hospital Services – Outpatient                                                               100% after deductible                            80% after deductible
                                               Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                                             -1-
 Benefit                                                                          Network                                             Out-of-Network
 Infertility Counseling, Testing and                                         100% after deductible                                     80% after deductible
 Treatment(2)
 Maternity (facility & professional services)                                100% after deductible                                     80% after deductible
 Medical/Surgical Expenses                                                   100% after deductible                                     80% after deductible
 (Except Office Visits)
 Mental Health – Inpatient(3)                                               100% after deductible                          80% after deductible
 Mental Health – Outpatient(3)                                            100% after $25 copayment                         80% after deductible
 Private Duty Nursing                                                                           100% after network deductible
 Respiratory Therapy                                                                            100% after network deductible
 Skilled Nursing Facility Care                                              100% after deductible                          80% after deductible
                                                                                                                      Limit: 100 days/benefit period
 Substance Abuse – Inpatient Detoxification                                 100% after deductible                          80% after deductible
 Substance Abuse – Inpatient Rehabilitation                                 100% after deductible                          80% after deductible
 Substance Abuse – Outpatient                                             100% after $25 copayment                         80% after deductible
 Therapy Services (Cardiac Rehab, Infusion                                  100% after deductible                          80% after deductible
 Therapy, Chemotherapy, Radiation Therapy and
 Dialysis)
 Transplant Services                                                         100% after deductible                                     80% after deductible
 Precertification Requirements(4)                                                                                    Yes
 Prescription Drug Deductible
    Individual                                                                                                   None
    Family                                                                                                       None
 Premier Prescription Drug Program                                                                   Retail Drugs (31-day Supply)
 Mandatory Generic(5)                                                                                    $8 generic copayment
 Defined by Premier Pharmacy Network - Not                                                               $40 brand copayment
 Physician Network. Prescriptions filled at a non-
 network pharmacy are not covered.                                                  Maintenance Drugs through Mail Order (90-day Supply)
                                                                                                   $16 generic copayment
                                                                                                    $80 brand copayment
(1)   Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's renewal date. Contact
      your employer to determine the renewal date applicable to your program.
(2)   Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered
      depending on your group’s prescription drug program.
(3)   State mandated minimum benefits may apply to a diagnosis of serious mental illness. (If the above grid does not show a limit, your mental health
      benefit days and visits are unlimited.)
(4)   Highmark Healthcare Management Services (HMS) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-
      related inpatient admission. Some facility providers will contact HMS and obtain precertification of the inpatient admission on your behalf. Be sure to verify that
      your provider is contacting HMS for precertification. If not, you are responsible for contacting HMS. If this does not occur and it is later determined that all or part
      of the inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered.
(5)   Prescriptions are covered as long as they are listed on the prescription drug formulary applicable to your plan. To obtain a prescription medication that is not
      included on this formulary, your doctor must complete the 'Prescription Drug Medication Request Form' and return it to the Pharmacy Affairs Department for
      clinical review. Under the mandatory generic provision, you are responsible for the payment differential when a generic drug is available and you or your doctor
      specifies a brand name drug. Your payment is the price difference between the brand name drug and the generic drug in addition to the brand name drug
      copayment or coinsurance amounts, which may apply.




                                      Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                     -1-
PPOBlue $1,250 High-Deductible Value
This chart is not intended as a contract of benefits. It is designed purely as a reference to help you compare the programs available through the Manufacturer & Business Association.

Benefit                                                                                                  Network                                                             Out-of-Network
Benefit Period(1)                                                                                                                              Contract Year
Deductible (per benefit period)
   Individual                                                                                           $1,250                                                                      $2,500
   Family                                                                                               $2,500                                                                      $5,000
Plan Payment Level – Based on the provider’s                                                      100% after deductible                                                       80% after deductible
reasonable charge (PRC)
Out-of-Pocket Maximums (Once met, plan
payment level becomes 100%)
   Individual                                                                                                  None                                                                       $5,000
   Family                                                                                                      None                                                                      $10,000
Lifetime Maximum (per person)                                                                                                            $5,000,000 Combined
Primary Care Physician Office Visits                                                          100% after $10 copayment                                                        80% after deductible
Specialist Office Visits                                                                      100% after $25 copayment                                                        80% after deductible
Preventive Care
   Adult
       Routine physical exams                                                                 100% after $10 copayment                                                           Not Covered
       Adult Immunizations                                                                      100% after deductible                                                         80% after deductible
       Colorectal Cancer Screening
           Diagnostic Services                                                                  100% after deductible                                                     80% after deductible
           Medical Surgical                                                                     100% after deductible                                                     80% after deductible
       Routine gynecological exams, including a                                               100% after $25 copayment                                               80% (deductible does not apply)
       Pap Test
       Mammograms, annual routine and                                                    100% (deductible does not apply)                                                     80% after deductible
       medically necessary
    Pediatric
       Routine physical exams                                                               100% after $10 copayment                                Not Covered
       Pediatric immunizations                                                           100% (deductible does not apply)                  80% (deductible does not apply)
Emergency Room Services                                                                                   100% after $100 copayment (waived if admitted)
Spinal Manipulations                                                                        100% after $25 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Physical Medicine                                                                           100% after $25 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Speech Therapy                                                                              100% after $25 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Occupational Therapy                                                                        100% after $25 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Allergy Extracts and Injections                                                               100% after deductible                              80% after deductible
Ambulance                                                                                                          100% after network deductible
Assisted Fertilization Procedures                                                                                          Not Covered
Dental Services Related to Accidental Injury                                                  100% after deductible                              80% after deductible
Diabetes Treatment                                                                            100% after deductible                              80% after deductible
Diagnostic Services (including routine)
 Advanced Imaging (MRI, CAT Scan, PET                                                             100% after deductible                                                       80% after deductible
 scan, etc.)
 Basic Diagnostic Services (standard imaging,                                                     100% after deductible                                                       80% after deductible
 diagnostic medical, lab/pathology, allergy
 testing)
Durable Medical Equipment, Orthotics and                                                          100% after deductible                                                       80% after deductible
Prosthetics
Enteral Formulae                                                                         100% (deductible does not apply)               80% (deductible does not apply)
Home Infusion Therapy                                                                                              100% after network deductible
Home Health Care                                                                             100% after deductible                            80% after deductible
Hospice                                                                                      100% after deductible                            80% after deductible
Hospital Services – Inpatient                                                                100% after deductible                            80% after deductible
Hospital Services – Outpatient                                                               100% after deductible                            80% after deductible
                                               Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                                             -1-
 Benefit                                                                          Network                                             Out-of-Network
 Infertility Counseling, Testing and Treatment(2)                           100% after deductible                                      80% after deductible
 Maternity (facility & professional services)                               100% after deductible                                      80% after deductible
 Medical/Surgical Expenses                                                  100% after deductible                                      80% after deductible
 (Except Office Visits)
 Mental Health – Inpatient(3)                                               100% after deductible                          80% after deductible
 Mental Health – Outpatient(3)                                            100% after $25 copayment                         80% after deductible
 Private Duty Nursing                                                                           100% after network deductible
 Respiratory Therapy                                                                            100% after network deductible
 Skilled Nursing Facility Care                                              100% after deductible                          80% after deductible
                                                                                                                      Limit: 100 days/benefit period
 Substance Abuse – Inpatient Detoxification                                 100% after deductible                          80% after deductible
 Substance Abuse – Inpatient Rehabilitation                                 100% after deductible                          80% after deductible
 Substance Abuse – Outpatient                                             100% after $25 copayment                         80% after deductible
 Therapy Services (Cardiac Rehab, Infusion                                  100% after deductible                          80% after deductible
 Therapy, Chemotherapy, Radiation Therapy and
 Dialysis)
 Transplant Services                                                        100% after deductible                                      80% after deductible
 Precertification Requirements(4)                                                                                    Yes
 Prescription Drug Deductible
    Individual                                                                                                   None
    Family                                                                                                       None
 Premier Prescription Drug Program                                                                   Retail Drugs (31-day Supply)
 Mandatory Generic(5)                                                                                    $8 generic copayment
 Defined by Premier Pharmacy Network - Not                                                               $40 brand copayment
 Physician Network. Prescriptions filled at a non-
 network pharmacy are not covered.                                                  Maintenance Drugs through Mail Order (90-day Supply)
                                                                                                   $16 generic copayment
                                                                                                    $80 brand copayment
(1) Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's renewal date. Contact
    your employer to determine the renewal date applicable to your program.
(2) Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered
    depending on your group’s prescription drug program.
(3) State mandated minimum benefits may apply to a diagnosis of serious mental illness. (If the above grid does not show a limit, your mental health benefit
    days and visits are unlimited.)
(4) Highmark Healthcare Management Services (HMS) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-related
    inpatient admission. Some facility providers will contact HMS and obtain precertification of the inpatient admission on your behalf. Be sure to verify that your
    provider is contacting HMS for precertification. If not, you are responsible for contacting HMS. If this does not occur and it is later determined that all or part of the
    inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered.
(5) Prescriptions are covered as long as they are listed on the prescription drug formulary applicable to your plan. To obtain a prescription medication that is not included
    on this formulary, your doctor must complete the 'Prescription Drug Medication Request Form' and return it to the Pharmacy Affairs Department for clinical review.
    Under the mandatory generic provision, you are responsible for the payment differential when a generic drug is available and you or your doctor specifies a brand
    name drug. Your payment is the price difference between the brand name drug and the generic drug in addition to the brand name drug copayment or coinsurance
    amounts, which may apply.




                                     Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                     -1-
Out-of-Area $1,250 High-Deductible Value
This chart is not intended as a contract of benefits. It is designed purely as a reference to help you compare the programs available through the Manufacturer & Business Association.

Benefit                                                                                                  Network                                                             Out-of-Network
Benefit Period(1)                                                                                                                              Contract Year
Deductible (per benefit period)
   Individual                                                                                           $1,250                                                                      $2,500
   Family                                                                                               $2,500                                                                      $5,000
Plan Payment Level – Based on the provider’s                                                      100% after deductible                                                       80% after deductible
reasonable charge (PRC)
Out-of-Pocket Maximums (Once met, plan
payment level becomes 100%)
   Individual                                                                                                  None                                                                       $5,000
   Family                                                                                                      None                                                                      $10,000
Lifetime Maximum (per person)                                                                                                            $5,000,000 Combined
Primary Care Physician Office Visits                                                          100% after $10 copayment                                                        80% after deductible
Specialist Office Visits                                                                      100% after $25 copayment                                                        80% after deductible
Preventive Care
   Adult
       Routine physical exams                                                                 100% after $10 copayment                                                           Not Covered
       Adult Immunizations                                                                      100% after deductible                                                         80% after deductible
       Colorectal Cancer Screening
           Diagnostic Services                                                                  100% after deductible                                                     80% after deductible
           Medical Surgical                                                                     100% after deductible                                                     80% after deductible
       Routine gynecological exams, including a                                               100% after $25 copayment                                               80% (deductible does not apply)
       Pap Test
       Mammograms, annual routine and                                                    100% (deductible does not apply)                                                     80% after deductible
       medically necessary
    Pediatric
       Routine physical exams                                                               100% after $10 copayment                                Not Covered
       Pediatric immunizations                                                           100% (deductible does not apply)                  80% (deductible does not apply)
Emergency Room Services                                                                                   100% after $100 copayment (waived if admitted)
Spinal Manipulations                                                                        100% after $25 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Physical Medicine                                                                           100% after $25 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Speech Therapy                                                                              100% after $25 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Occupational Therapy                                                                        100% after $25 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Allergy Extracts and Injections                                                               100% after deductible                              80% after deductible
Ambulance                                                                                                          100%after network deductible
Assisted Fertilization Procedures                                                                                          Not Covered
Dental Services Related to Accidental Injury                                                  100% after deductible                              80% after deductible
Diabetes Treatment                                                                            100% after deductible                              80% after deductible
Diagnostic Services (including routine)
  Advanced Imaging (MRI, CAT Scan, PET                                                            100% after deductible                                                       80% after deductible
  scan, etc.)
  Basic Diagnostic Services (standard imaging,                                                    100% after deductible                                                       80% after deductible
  diagnostic medical, lab/pathology, allergy
  testing)
Durable Medical Equipment, Orthotics and                                                          100% after deductible                                                       80% after deductible
Prosthetics
Enteral Formulae                                                                         100% (deductible does not apply)               80% (deductible does not apply)
Home Infusion Therapy                                                                                              100%after network deductible
Home Health Care                                                                             100% after deductible                            80% after deductible
Hospice                                                                                      100% after deductible                            80% after deductible
Hospital Services – Inpatient                                                                100% after deductible                            80% after deductible

                                               Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                                             -1-
  Benefit                                                                          Network                                             Out-of-Network
  Hospital Services – Outpatient                                              100% after deductible                                     80% after deductible
  Infertility Counseling, Testing and Treatment(2)                            100% after deductible                                     80% after deductible
  Maternity (facility & professional services)                                100% after deductible                                     80% after deductible
  Medical/Surgical Expenses                                                   100% after deductible                                     80% after deductible
  (Except Office Visits)
  Mental Health – Inpatient(3)                                               100% after deductible                          80% after deductible
  Mental Health – Outpatient(3)                                            100% after $25 copayment                         80% after deductible
  Private Duty Nursing                                                                           100% after network deductible
  Respiratory Therapy                                                                            100% after network deductible
  Skilled Nursing Facility Care                                              100% after deductible                          80% after deductible
                                                                                                                       Limit: 100 days/benefit period
  Substance Abuse – Inpatient Detoxification                                 100% after deductible                          80% after deductible
  Substance Abuse – Inpatient Rehabilitation                                 100% after deductible                          80% after deductible
  Substance Abuse – Outpatient                                             100% after $25 copayment                         80% after deductible
  Therapy Services (Cardiac Rehab, Infusion                                  100% after deductible                          80% after deductible
  Therapy, Chemotherapy, Radiation Therapy and
  Dialysis)
  Transplant Services                                                         100% after deductible                                     80% after deductible
  Precertification Requirements(4)                                                                                    Yes
  Prescription Drug Deductible
     Individual                                                                                                   None
     Family                                                                                                       None
  Premier Prescription Drug Program                                                                   Retail Drugs (31-day Supply)
  Mandatory Generic(5)                                                                                    $8 generic copayment
  Defined by Premier Pharmacy Network - Not                                                               $40 brand copayment
  Physician Network. Prescriptions filled at a non-
  network pharmacy are not covered.                                                  Maintenance Drugs through Mail Order (90-day Supply)
                                                                                                    $16 generic copayment
                                                                                                     $80 brand copayment
(1) Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's effective date. Contact
    your employer to determine the effective date applicable to your program.
(2) Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered
    depending on your group’s prescription drug program.
(3) State mandated minimum benefits may apply to a diagnosis of serious mental illness. (If the above grid does not show a limit, your mental health benefit
    days and visits are unlimited.)
(4) Highmark Healthcare Management Services (HMS) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-related
    inpatient admission. Some facility providers will contact HMS and obtain precertification of the inpatient admission on your behalf. Be sure to verify that your
    provider is contacting HMS for precertification. If not, you are responsible for contacting HMS. If this does not occur and it is later determined that all or part of the
    inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered.
(5) Prescriptions are covered as long as they are listed on the prescription drug formulary applicable to your plan. To obtain a prescription medication that is not included
    on this formulary, your doctor must complete the 'Prescription Drug Medication Request Form' and return it to the Pharmacy Affairs Department for clinical review.
    Under the mandatory generic provision, you are responsible for the payment differential when a generic drug is available and you or your doctor specifies a brand
    name drug. Your payment is the price difference between the brand name drug and the generic drug in addition to the brand name drug copayment or coinsurance
    amounts, which may apply.




                                       Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                      -1-
PPOBlue $1,000 High-Deductible Value
This chart is not intended as a contract of benefits. It is designed purely as a reference to help you compare the programs available through the Manufacturer & Business Association.

Benefit                                                                                                  Network                                                            Out-of-Network
Benefit Period(1)                                                                                                                             Contract Year
Deductible (per benefit period)
   Individual                                                                                           $1,000                                                                     $2,000
   Family                                                                                               $2,000                                                                     $4,000
Plan Payment Level – Based on the provider’s                                                      100% after deductible                                                      80% after deductible
reasonable charge (PRC)
Out-of-Pocket Maximums (Once met, plan
payment level becomes 100%)
   Individual                                                                                                  None                                                                       $5,000
   Family                                                                                                      None                                                                      $10,000
Lifetime Maximum (per person)                                                                                                           $5,000,000 Combined
Primary Care Physician Office Visits                                                          100% after $10 copayment                                                       80% after deductible
Specialist Office Visits                                                                      100% after $25 copayment                                                       80% after deductible
Preventive Care
   Adult
       Routine physical exams                                                                 100% after $10 copayment                                                          Not Covered
       Adult Immunizations                                                                      100% after deductible                                                        80% after deductible
       Colorectal Cancer Screening
           Diagnostic Services                                                                  100% after deductible                                                     80% after deductible
           Medical Surgical                                                                     100% after deductible                                                     80% after deductible
       Routine gynecological exams, including a                                               100% after $25 copayment                                               80% (deductible does not apply)
       Pap Test
       Mammograms, annual routine and                                                    100% (deductible does not apply)                                                    80% after deductible
       medically necessary
    Pediatric
       Routine physical exams                                                               100% after $10 copayment                                Not Covered
       Pediatric immunizations                                                           100% (deductible does not apply)                  80% (deductible does not apply)
Emergency Room Services                                                                                  100% after $100 copayment (waived if admitted)
Spinal Manipulations                                                                        100% after $25 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Physical Medicine                                                                           100% after $25 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Speech Therapy                                                                              100% after $25 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Occupational Therapy                                                                        100% after $25 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Allergy Extracts and Injections                                                               100% after deductible                              80% after deductible
Ambulance                                                                                                         100% after network deductible
Assisted Fertilization Procedures                                                                                          Not Covered
Dental Services Related to Accidental Injury                                                  100% after deductible                              80% after deductible
Diabetes Treatment                                                                            100% after deductible                              80% after deductible
Diagnostic Services (including routine)
 Advanced Imaging (MRI, CAT Scan, PET                                                             100% after deductible                                                      80% after deductible
 scan, etc.)
 Basic Diagnostic Services (standard imaging,                                                     100% after deductible                                                      80% after deductible
 diagnostic medical, lab/pathology, allergy
 testing)
Durable Medical Equipment, Orthotics and                                                          100% after deductible                                                      80% after deductible
Prosthetics
Enteral Formulae                                                                         100% (deductible does not apply)              80% (deductible does not apply)
Home Infusion Therapy                                                                                             100% after network deductible
Home Health Care                                                                             100% after deductible                           80% after deductible
Hospice                                                                                      100% after deductible                           80% after deductible
Hospital Services – Inpatient                                                                100% after deductible                           80% after deductible
Hospital Services – Outpatient                                                               100% after deductible                           80% after deductible
                                               Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                                             -1-
 Benefit                                                                          Network                                            Out-of-Network
 Infertility Counseling, Testing and Treatment(2)                           100% after deductible                                     80% after deductible
 Maternity (facility & professional services)                               100% after deductible                                     80% after deductible
 Medical/Surgical Expenses                                                  100% after deductible                                     80% after deductible
 (Except Office Visits)
 Mental Health – Inpatient(3)                                               100% after deductible                          80% after deductible
 Mental Health – Outpatient(3)                                            100% after $25 copayment                         80% after deductible
 Private Duty Nursing                                                                           100% after network deductible
 Respiratory Therapy                                                                            100% after network deductible
 Skilled Nursing Facility Care                                              100% after deductible                          80% after deductible
                                                                                                                      Limit: 100 days/benefit period
 Substance Abuse – Inpatient Detoxification                                 100% after deductible                          80% after deductible
 Substance Abuse – Inpatient Rehabilitation                                 100% after deductible                          80% after deductible
 Substance Abuse – Outpatient                                             100% after $25 copayment                         80% after deductible
 Therapy Services (Cardiac Rehab, Infusion                                  100% after deductible                          80% after deductible
 Therapy, Chemotherapy, Radiation Therapy and
 Dialysis)
 Transplant Services                                                        100% after deductible                                     80% after deductible
 Precertification Requirements(4)                                                                                   Yes
 Prescription Drug Deductible
    Individual                                                                                         None per Contract year
    Family                                                                                             None per Contract year
 Premier Prescription Drug Program                                                                  Retail Drugs (31-day Supply)
 Mandatory Generic(5)                                                                                   $8 generic copayment
 Defined by Premier Pharmacy Network - Not                                                              $40 brand copayment
 Physician Network. Prescriptions filled at a non-
 network pharmacy are not covered.                                                 Maintenance Drugs through Mail Order (90-day Supply)
                                                                                                  $16 generic copayment
                                                                                                   $80 brand copayment
(1) Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's renewal date. Contact
    your employer to determine the renewal date applicable to your program.
(2) Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered
    depending on your group’s prescription drug program.
(3) State mandated minimum benefits may apply to a diagnosis of serious mental illness. (If the above grid does not show a limit, your mental health benefit days and
    visits are unlimited.)
(4) Highmark Healthcare Management Services (HMS) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-related
    inpatient admission. Some facility providers will contact HMS and obtain precertification of the inpatient admission on your behalf. Be sure to verify that your
    provider is contacting HMS for precertification. If not, you are responsible for contacting HMS. If this does not occur and it is later determined that all or part of the
    inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered.
(5) Prescriptions are covered as long as they are listed on the prescription drug formulary applicable to your plan. To obtain a prescription medication that is not included
    on this formulary, your doctor must complete the 'Prescription Drug Medication Request Form' and return it to the Pharmacy Affairs Department for clinical review.
    Under the mandatory generic provision, you are responsible for the payment differential when a generic drug is available and you or your doctor specifies a brand
    name drug. Your payment is the price difference between the brand name drug and the generic drug in addition to the brand name drug copayment or coinsurance
    amounts, which may apply.




                                     Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                     -1-
PPOBlue $1,500 High-Deductible Value
This chart is not intended as a contract of benefits. It is designed purely as a reference to help you compare the programs available through the Manufacturer & Business Association.

Benefit                                                                                                  Network                                                             Out-of-Network
Benefit Period(1)                                                                                                                              Contract Year
Deductible (per benefit period)
   Individual                                                                                           $1,500                                                                      $3,000
   Family                                                                                               $3,000                                                                      $6,000
Plan Payment Level – Based on the provider’s                                                      100% after deductible                                                       80% after deductible
reasonable charge (PRC)
Out-of-Pocket Maximums (Once met, plan
payment level becomes 100%)
   Individual                                                                                                  None                                                                       $5,000
   Family                                                                                                      None                                                                      $10,000
Lifetime Maximum (per person)                                                                                                            $5,000,000 Combined
Primary Care Physician Office Visits                                                          100% after $10 copayment                                                        80% after deductible
Specialist Office Visits                                                                      100% after $25 copayment                                                        80% after deductible
Preventive Care
   Adult
       Routine physical exams                                                                 100% after $10 copayment                                                           Not Covered
       Adult Immunizations                                                                      100% after deductible                                                         80% after deductible
       Colorectal Cancer Screening
           Diagnostic Services                                                                  100% after deductible                                                     80% after deductible
           Medical Surgical                                                                     100% after deductible                                                     80% after deductible
       Routine gynecological exams, including a                                               100% after $25 copayment                                               80% (deductible does not apply)
       Pap Test
       Mammograms, annual routine and                                                    100% (deductible does not apply)                                                     80% after deductible
       medically necessary
    Pediatric
       Routine physical exams                                                               100% after $10 copayment                                Not Covered
       Pediatric immunizations                                                           100% (deductible does not apply)                  80% (deductible does not apply)
Emergency Room Services                                                                                   100% after $100 copayment (waived if admitted)
Spinal Manipulations                                                                        100% after $25 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Physical Medicine                                                                           100% after $25 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Speech Therapy                                                                              100% after $25 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Occupational Therapy                                                                        100% after $25 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Allergy Extracts and Injections                                                               100% after deductible                              80% after deductible
Ambulance                                                                                                          100% after network deductible
Assisted Fertilization Procedures                                                                                          Not Covered
Dental Services Related to Accidental Injury                                                  100% after deductible                              80% after deductible
Diabetes Treatment                                                                            100% after deductible                              80% after deductible
Diagnostic Services (including routine)
 Advanced Imaging (MRI, CAT Scan, PET                                                             100% after deductible                                                       80% after deductible
 scan, etc.)
 Basic Diagnostic Services (standard imaging,                                                     100% after deductible                                                       80% after deductible
 diagnostic medical, lab/pathology, allergy
 testing)
Durable Medical Equipment, Orthotics and                                                          100% after deductible                                                       80% after deductible
Prosthetics
Enteral Formulae                                                                         100% (deductible does not apply)               80% (deductible does not apply)
Home Infusion Therapy                                                                                              100% after network deductible
Home Health Care                                                                             100% after deductible                            80% after deductible
Hospice                                                                                      100% after deductible                            80% after deductible
Hospital Services – Inpatient                                                                100% after deductible                            80% after deductible
Hospital Services – Outpatient                                                               100% after deductible                            80% after deductible
                                               Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                                             -1-
 Benefit                                                                          Network                                             Out-of-Network
 Infertility Counseling, Testing and Treatment(2)                           100% after deductible                                      80% after deductible
 Maternity (facility & professional services)                               100% after deductible                                      80% after deductible
 Medical/Surgical Expenses                                                  100% after deductible                                      80% after deductible
 (Except Office Visits)
 Mental Health – Inpatient(3)                                               100% after deductible                          80% after deductible
 Mental Health – Outpatient(3)                                            100% after $25 copayment                         80% after deductible
 Private Duty Nursing                                                                           100% after network deductible
 Respiratory Therapy                                                                            100% after network deductible
 Skilled Nursing Facility Care                                              100% after deductible                          80% after deductible
                                                                                                                      Limit: 100 days/benefit period
 Substance Abuse – Inpatient Detoxification                                 100% after deductible                          80% after deductible
 Substance Abuse – Inpatient Rehabilitation                                 100% after deductible                          80% after deductible
 Substance Abuse – Outpatient                                             100% after $25 copayment                         80% after deductible
 Therapy Services (Cardiac Rehab, Infusion                                  100% after deductible                          80% after deductible
 Therapy, Chemotherapy, Radiation Therapy and
 Dialysis)
 Transplant Services                                                        100% after deductible                                      80% after deductible
 Precertification Requirements(4)                                                                                    Yes
 Prescription Drug Deductible
    Individual                                                                                          None per Contract year
    Family                                                                                              None per Contract year
 Premier Prescription Drug Program                                                                   Retail Drugs (31-day Supply)
 Mandatory Generic(5)                                                                                    $8 generic copayment
 Defined by Premier Pharmacy Network - Not                                                               $40 brand copayment
 Physician Network. Prescriptions filled at a non-
 network pharmacy are not covered.                                                  Maintenance Drugs through Mail Order (90-day Supply)
                                                                                                   $16 generic copayment
                                                                                                    $80 brand copayment
(1) Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's renewal date. Contact
    your employer to determine the renewal date applicable to your program.
(2) Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered
    depending on your group’s prescription drug program.
(3) State mandated minimum benefits may apply to a diagnosis of serious mental illness. (If the above grid does not show a limit, your mental health benefit
    days and visits are unlimited.)
(4) Highmark Healthcare Management Services (HMS) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-related
    inpatient admission. Some facility providers will contact HMS and obtain precertification of the inpatient admission on your behalf. Be sure to verify that your
    provider is contacting HMS for precertification. If not, you are responsible for contacting HMS. If this does not occur and it is later determined that all or part of the
    inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered.
(5) Prescriptions are covered as long as they are listed on the prescription drug formulary applicable to your plan. To obtain a prescription medication that is not included
    on this formulary, your doctor must complete the 'Prescription Drug Medication Request Form' and return it to the Pharmacy Affairs Department for clinical review.
    Under the mandatory generic provision, you are responsible for the payment differential when a generic drug is available and you or your doctor specifies a brand
    name drug. Your payment is the price difference between the brand name drug and the generic drug in addition to the brand name drug copayment or coinsurance
    amounts, which may apply.




                                     Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                     -1-
Out-of-Area PPO $1,500 High-Deductible Value
This chart is not intended as a contract of benefits. It is designed purely as a reference to help you compare the programs available through the Manufacturer & Business Association.

Benefit                                                                                                  Network                                                            Out-of-Network
Benefit Period(1)                                                                                                                             Contract Year
Deductible (per benefit period)
   Individual                                                                                           $1,500                                                                     $3,000
   Family                                                                                               $3,000                                                                     $6,000
Plan Payment Level – Based on the provider’s                                                      100% after deductible                                                      80% after deductible
reasonable charge (PRC)
Out-of-Pocket Maximums (Once met, plan
payment level becomes 100%)
   Individual                                                                                                  None                                                                       $5,000
   Family                                                                                                      None                                                                      $10,000
Lifetime Maximum (per person)                                                                                                           $5,000,000 Combined
Primary Care Physician Office Visits                                                          100% after $10 copayment                                                       80% after deductible
Specialist Office Visits                                                                      100% after $25 copayment                                                       80% after deductible
Preventive Care
   Adult
       Routine physical exams                                                                 100% after $10 copayment                                                          Not Covered
       Adult Immunizations                                                                      100% after deductible                                                        80% after deductible
       Colorectal Cancer Screening
           Diagnostic Services                                                                  100% after deductible                                                    80% after deductible
           Medical Surgical                                                                     100% after deductible                                                    80% after deductible
       Routine gynecological exams, including a                                               100% after $25 copayment                                              80% (deductible does not apply)
       Pap Test
       Mammograms, annual routine and                                                    100% (deductible does not apply)                                                    80% after deductible
       medically necessary
    Pediatric
       Routine physical exams                                                               100% after $10 copayment                                Not Covered
       Pediatric immunizations                                                           100% (deductible does not apply)                  80% (deductible does not apply)
Emergency Room Services                                                                                  100% after $100 copayment (waived if admitted)
Spinal Manipulations                                                                        100% after $25 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Physical Medicine                                                                           100% after $25 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Speech Therapy                                                                              100% after $25 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Occupational Therapy                                                                        100% after $25 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Allergy Extracts and Injections                                                               100% after deductible                              80% after deductible
Ambulance                                                                                                         100%after network deductible
Assisted Fertilization Procedures                                                                                          Not Covered
Dental Services Related to Accidental Injury                                                  100% after deductible                              80% after deductible
Diabetes Treatment                                                                            100% after deductible                              80% after deductible
Diagnostic Services (including routine)
  Advanced Imaging (MRI, CAT Scan, PET                                                            100% after deductible                                                      80% after deductible
  scan, etc.)
  Basic Diagnostic Services (standard imaging,                                                    100% after deductible                                                      80% after deductible
  diagnostic medical, lab/pathology, allergy
  testing)
Durable Medical Equipment, Orthotics and                                                          100% after deductible                                                      80% after deductible
Prosthetics
Enteral Formulae                                                                         100% (deductible does not apply)              80% (deductible does not apply)
Home Infusion Therapy                                                                                             100%after network deductible
Home Health Care                                                                             100% after deductible                           80% after deductible
Hospice                                                                                      100% after deductible                           80% after deductible
Hospital Services – Inpatient                                                                100% after deductible                           80% after deductible

                                               Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                                             -1-
  Benefit                                                                          Network                                            Out-of-Network
  Hospital Services – Outpatient                                              100% after deductible                                    80% after deductible
  Infertility Counseling, Testing and Treatment(2)                            100% after deductible                                    80% after deductible
  Maternity (facility & professional services)                                100% after deductible                                    80% after deductible
  Medical/Surgical Expenses                                                   100% after deductible                                    80% after deductible
  (Except Office Visits)
  Mental Health – Inpatient(3)                                               100% after deductible                          80% after deductible
  Mental Health – Outpatient(3)                                            100% after $25 copayment                         80% after deductible
  Private Duty Nursing                                                                           100%after network deductible
  Respiratory Therapy                                                                            100%after network deductible
  Skilled Nursing Facility Care                                              100% after deductible                          80% after deductible
                                                                                                                      Limit: 100 days/benefit period
  Substance Abuse – Inpatient Detoxification                                 100% after deductible                          80% after deductible
  Substance Abuse – Inpatient Rehabilitation                                 100% after deductible                          80% after deductible
  Substance Abuse – Outpatient                                             100% after $25 copayment                         80% after deductible
  Therapy Services (Cardiac Rehab, Infusion                                  100% after deductible                          80% after deductible
  Therapy, Chemotherapy, Radiation Therapy and
  Dialysis)
  Transplant Services                                                         100% after deductible                                    80% after deductible
  Precertification Requirements(4)                                                                                   Yes
  Prescription Drug Deductible
     Individual                                                                                         None per Contract year
     Family                                                                                             None per Contract year
  Premier Prescription Drug Program                                                                  Retail Drugs (31-day Supply)
  Mandatory Generic(5)                                                                                   $8 generic copayment
  Defined by Premier Pharmacy Network - Not                                                              $40 brand copayment
  Physician Network. Prescriptions filled at a non-
  network pharmacy are not covered.                                                  Maintenance Drugs through Mail Order (90-day Supply)
                                                                                                    $16 generic copayment
                                                                                                     $80 brand copayment
(1) Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's effective date. Contact
    your employer to determine the effective date applicable to your program.
(2) Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered
    depending on your group’s prescription drug program.
(3) State mandated minimum benefits may apply to a diagnosis of serious mental illness. (If the above grid does not show a limit, your mental health benefit
    days and visits are unlimited.)
(4) Highmark Healthcare Management Services (HMS) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-related
    inpatient admission. Some facility providers will contact HMS and obtain precertification of the inpatient admission on your behalf. Be sure to verify that your
    provider is contacting HMS for precertification. If not, you are responsible for contacting HMS. If this does not occur and it is later determined that all or part of the
    inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered.
(5) Prescriptions are covered as long as they are listed on the prescription drug formulary applicable to your plan. To obtain a prescription medication that is not included
    on this formulary, your doctor must complete the 'Prescription Drug Medication Request Form' and return it to the Pharmacy Affairs Department for clinical review.
    Under the mandatory generic provision, you are responsible for the payment differential when a generic drug is available and you or your doctor specifies a brand
    name drug. Your payment is the price difference between the brand name drug and the generic drug in addition to the brand name drug copayment or coinsurance
    amounts, which may apply.




                                       Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                      -1-
PPOBlue $2,500 High-Deductible Value
This chart is not intended as a contract of benefits. It is designed purely as a reference to help you compare the programs available through the Manufacturer & Business Association.

Benefit                                                                                                  Network                                                             Out-of-Network
Benefit Period(1)                                                                                                                              Contract Year
Deductible (per benefit period)
   Individual                                                                                           $2,500                                                                      $5,000
   Family                                                                                               $5,000                                                                     $10,000
Plan Payment Level – Based on the provider’s                                                      100% after deductible                                                       80% after deductible
reasonable charge (PRC)
Out-of-Pocket Maximums (Once met, plan
payment level becomes 100%)
   Individual                                                                                                  None                                                                       $5,000
   Family                                                                                                      None                                                                      $10,000
Lifetime Maximum (per person)                                                                                                            $5,000,000 Combined
Primary Care Physician Office Visits                                                          100% after $10 copayment                                                        80% after deductible
Specialist Office Visits                                                                      100% after $25 copayment                                                        80% after deductible
Preventive Care
   Adult
       Routine physical exams                                                                 100% after $10 copayment                                                           Not Covered
       Adult Immunizations                                                                      100% after deductible                                                         80% after deductible
       Colorectal Cancer Screening
           Diagnostic Services                                                                  100% after deductible                                                     80% after deductible
           Medical Surgical                                                                     100% after deductible                                                     80% after deductible
       Routine gynecological exams, including a                                               100% after $25 copayment                                               80% (deductible does not apply)
       Pap Test
       Mammograms, annual routine and                                                    100% (deductible does not apply)                                                     80% after deductible
       medically necessary
    Pediatric
       Routine physical exams                                                               100% after $10 copayment                                Not Covered
       Pediatric immunizations                                                           100% (deductible does not apply)                  80% (deductible does not apply)
Emergency Room Services                                                                                   100% after $100 copayment (waived if admitted)
Spinal Manipulations                                                                        100% after $25 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Physical Medicine                                                                           100% after $25 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Speech Therapy                                                                              100% after $25 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Occupational Therapy                                                                        100% after $25 copayment                             80% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Allergy Extracts and Injections                                                               100% after deductible                              80% after deductible
Ambulance                                                                                                          100% after network deductible
Assisted Fertilization Procedures                                                                                          Not Covered
Dental Services Related to Accidental Injury                                                  100% after deductible                              80% after deductible
Diabetes Treatment                                                                            100% after deductible                              80% after deductible
Diagnostic Services (including routine)
 Advanced Imaging (MRI, CAT Scan, PET                                                             100% after deductible                                                       80% after deductible
 scan, etc.)
 Basic Diagnostic Services (standard imaging,                                                     100% after deductible                                                       80% after deductible
 diagnostic medical, lab/pathology, allergy
 testing)
Durable Medical Equipment, Orthotics and                                                          100% after deductible                                                       80% after deductible
Prosthetics
Enteral Formulae                                                                         100% (deductible does not apply)               80% (deductible does not apply)
Home Infusion Therapy                                                                                              100% after network deductible
Home Health Care                                                                             100% after deductible                            80% after deductible
Hospice                                                                                      100% after deductible                            80% after deductible
Hospital Services – Inpatient                                                                100% after deductible                            80% after deductible
Hospital Services – Outpatient                                                               100% after deductible                            80% after deductible
                                               Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                                             -1-
 Benefit                                                                          Network                                            Out-of-Network
 Infertility Counseling, Testing and Treatment(2)                           100% after deductible                                     80% after deductible
 Maternity (facility & professional services)                               100% after deductible                                     80% after deductible
 Medical/Surgical Expenses                                                  100% after deductible                                     80% after deductible
 (Except Office Visits)
 Mental Health – Inpatient(3)                                              100% after deductible                          80% after deductible
 Mental Health – Outpatient(3)                                           100% after $25 copayment                         80% after deductible
 Private Duty Nursing                                                                          100% after network deductible
 Respiratory Therapy                                                                           100% after network deductible
 Skilled Nursing Facility Care                                             100% after deductible                          80% after deductible
                                                                                                                     Limit: 100 days/benefit period
 Substance Abuse – Inpatient Detoxification                                100% after deductible                          80% after deductible
 Substance Abuse – Inpatient Rehabilitation                                100% after deductible                          80% after deductible
 Substance Abuse – Outpatient                                            100% after $25 copayment                         80% after deductible
 Therapy Services (Cardiac Rehab, Infusion                                 100% after deductible                          80% after deductible
 Therapy, Chemotherapy, Radiation Therapy and
 Dialysis)
 Transplant Services                                                        100% after deductible                                     80% after deductible
 Precertification Requirements(4)                                                                                   Yes
 Prescription Drug Deductible
    Individual                                                                                         None per Contract year
    Family                                                                                             None per Contract year
 Premier Prescription Drug Program                                                                  Retail Drugs (31-day Supply)
 Mandatory Generic(5)                                                                                   $8 generic copayment
 Defined by Premier Pharmacy Network - Not                                                              $40 brand copayment
 Physician Network. Prescriptions filled at a non-
 network pharmacy are not covered.                                                 Maintenance Drugs through Mail Order (90-day Supply)
                                                                                                  $16 generic copayment
                                                                                                   $80 brand copayment
(1) Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's renewal date. Contact
    your employer to determine the renewal date applicable to your program.
(2) Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered
    depending on your group’s prescription drug program.
(3) State mandated minimum benefits may apply to a diagnosis of serious mental illness. (If the above grid does not show a limit, your mental health benefit
    days and visits are unlimited.)
(4) Highmark Healthcare Management Services (HMS) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-related,
    inpatient admission. Some facility providers will contact HMS and obtain precertification of the inpatient admission on your behalf. Be sure to verify that your
    provider is contacting HMS for precertification. If not, you are responsible for contacting HMS. If this does not occur and it is later determined that all or part of the
    inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered.
(5) Prescriptions are covered as long as they are listed on the prescription drug formulary applicable to your plan. To obtain a prescription medication that is not included
    on this formulary, your doctor must complete the 'Prescription Drug Medication Request Form' and return it to the Pharmacy Affairs Department for clinical review.
    Under the mandatory generic provision, you are responsible for the payment differential when a generic drug is available and you or your doctor specifies a brand
    name drug. Your payment is the price difference between the brand name drug and the generic drug in addition to the brand name drug copayment or coinsurance
    amounts, which may apply.




                                     Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                     -1-
PPOBlue Split Copayment 100/80
This chart is not intended as a contract of benefits. It is designed purely as a reference to help you compare the programs available through the Manufacturer & Business Association.

Benefit                                                                                                  Network                                                             Out-of-Network
Benefit Period(1)                                                                                                                              Contract Year
Deductible (per benefit period)
   Individual                                                                                                 None                                                                   $500
   Family                                                                                                     None                                                                  $1,000
Plan Payment Level – Based on the provider’s                                                                  100%                                                            80% after deductible
reasonable charge (PRC)
Out-of-Pocket Maximums (Once met, plan
payment level becomes 100%)
   Individual                                                                                                                              $3,000 Combined
   Family                                                                                                                                  $6,000 Combined
Lifetime Maximum (per person)                                                                                                            $2,000,000 Combined
Primary Care Physician Office Visits                                                          100% after $20 copayment                                                        80% after deductible
Specialist Office Visits                                                                      100% after $40 copayment                                                        80% after deductible
Preventive Care
   Adult
       Routine physical exams                                                                 100% after $20 copayment                                                           Not Covered
       Adult Immunizations                                                                             100%                                                                   80% after deductible
       Colorectal Cancer Screening
           Diagnostic Services                                                                         100%                                                               80% after deductible
           Medical Surgical                                                                            100%                                                               80% after deductible
       Routine gynecological exams, including a                                               100% after $40 copayment                                               80% (deductible does not apply)
       Pap Test
       Mammograms, annual routine and                                                                         100%                                                            80% after deductible
       medically necessary
    Pediatric
       Routine physical exams                                                                 100% after $20 copayment                               Not Covered
       Pediatric immunizations                                                                         100%                                 80% (deductible does not apply)
Emergency Room Services                                                                                    100% after $100 copayment (waived if admitted)
Spinal Manipulations                                                                          100% after $40 copayment                            80% after deductible
                                                                                                                    Limit: 20 visits/benefit period
Physical Medicine                                                                             100% after $40 copayment                            80% after deductible
                                                                                                                    Limit: 20 visits/benefit period
Speech Therapy                                                                                100% after $40 copayment                            80% after deductible
                                                                                                                    Limit: 20 visits/benefit period
Occupational Therapy                                                                          100% after $40 copayment                            80% after deductible
                                                                                                                    Limit: 20 visits/benefit period
Allergy Extracts and Injections                                                                        100%                                       80% after deductible
Ambulance                                                                                               80%                                 80% (deductible does not apply)
Assisted Fertilization Procedures                                                                                           Not Covered
Dental Services Related to Accidental Injury                                                           100%                                       80% after deductible
Diabetes Treatment                                                                                     100%                                       80% after deductible
Diagnostic Services (including routine)
 Advanced Imaging (MRI, CAT Scan, PET scan,                                                                   100%                                                            80% after deductible
 etc.)
 Basic Diagnostic Services (standard imaging,                                                                 100%                                                            80% after deductible
 diagnostic medical, lab/pathology, allergy
 testing)
Durable Medical Equipment, Orthotics and                                                                       80%                                                            80% after deductible
Prosthetics
Enteral Formulae                                                                                              100%                                                   80% (deductible does not apply)
Home Infusion Therapy                                                                                                                                100%
Home Health Care                                                                                               80%                                                            80% after deductible
Hospice                                                                                                       100%                                                            80% after deductible
Hospital Services – Inpatient                                                                                 100%                                                            80% after deductible
Hospital Services – Outpatient                                                                                100%                                                            80% after deductible
                                               Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                                             -1-
 Benefit                                                                         Network                                            Out-of-Network
 Infertility Counseling, Testing and                                                 100%                                            80% after deductible
 Treatment(2)
 Maternity (facility & professional services)                                     100%                                             80% after deductible
 Medical/Surgical Expenses (except office visits)                                 100%                                             80% after deductible
 Mental Health – Inpatient(3)                                                     100%                                             80% after deductible
 Mental Health – Outpatient(3)                                           100% after $40 copayment                                  80% after deductible
 Private Duty Nursing                                                              80%                                        80% (deductible does not apply)
 Respiratory Therapy                                                                                              100%
 Skilled Nursing Facility Care                                                       80%                                   80% after deductible
                                                                                              Limit: 100 days/benefit period
 Substance Abuse – Inpatient Detoxification                                       100%                                     80% after deductible
 Substance Abuse – Inpatient Rehabilitation                                       100%                                     80% after deductible
 Substance Abuse – Outpatient                                            100% after $40 copayment                          80% after deductible
 Therapy Services (Cardiac Rehab, Infusion                                        100%                                     80% after deductible
 Therapy, Chemotherapy, Radiation Therapy and
 Dialysis)
 Transplant Services                                                                 100%                                            80% after deductible
 Precertification Requirements(4)                                                                                  Yes
 Prescription Drug Deductible
    Individual                                                                                        $100 per Contract year
    Family                                                                                            $200 per Contract year
 Premier Prescription Drug Program                                                               Retail Drugs (31-day Supply)
 Mandatory Generic(5)                                                                             Plan pays 70% after deductible
 Defined by Premier Pharmacy Network - Not                                                $15 minimum member payment per prescription
 Physician Network. Prescriptions filled at a non-                                        $100 maximum member payment per prescription
 network pharmacy are not covered.
                                                                                   Maintenance Drugs through Mail Order (90-day Supply)
                                                                                                Plan pays 70% after deductible
                                                                                        $30 minimum member payment per prescription
                                                                                       $200 maximum member payment per prescription
(1) Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's renewal date. Contact your
    employer to determine the renewal date applicable to your program.
(2) Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered
    depending on your group’s prescription drug program.
(3) State mandated minimum benefits may apply to a diagnosis of serious mental illness. (If the above grid does not show a limit, your mental health benefit days and
    visits are unlimited.)
(4) Highmark Healthcare Management Services (HMS) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-related
    inpatient admission. Some facility providers will contact HMS and obtain precertification of the inpatient admission on your behalf. Be sure to verify that your
    provider is contacting HMS for precertification. If not, you are responsible for contacting HMS. If this does not occur and it is later determined that all or part of the
    inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered
(5) Prescriptions are covered as long as they are listed on the prescription drug formulary applicable to your plan. To obtain a prescription medication that is not included
    on this formulary, your physician must complete the 'Prescription Drug Medication Request Form' and return it to the Pharmacy Affairs Department for clinical review.
    Under the mandatory generic provision, you are responsible for the payment differential when a generic drug is available and you or your doctor specifies a brand name
    drug. Your payment is the price difference between the brand drug and the generic drug in addition to the brand drug copayment or coinsurance amounts, which may
    apply.




                                     Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                    -1-
PPOBlue Split Copayment Low Cost 90/70
This chart is not intended as a contract of benefits. It is designed purely as a reference to help you compare the programs available through the Manufacturer & Business Association.

Benefit                                                                                                  Network                                                             Out-of-Network
Benefit Period(1)                                                                                                                              Contract Year
Deductible (per benefit period)
   Individual                                                                                             $250                                                                       $500
   Family                                                                                                 $500                                                                      $1,000
Plan Payment Level – Based on the provider’s                                                       90% after deductible                                                       70% after deductible
reasonable charge (PRC)
Out-of-Pocket Maximums (Once met, plan
payment level becomes 100%)
   Individual                                                                                                 $1,500                                                                     $3,000
   Family                                                                                                     $3,000                                                                     $6,000
Lifetime Maximum (per person)                                                                                                            $2,000,000 Combined
Primary Care Physician Office Visits                                                          100% after $20 copayment                                                        70% after deductible
Specialist Office Visits                                                                      100% after $30 copayment                                                        70% after deductible
Preventive Care
   Adult
       Routine physical exams                                                                 100% after $20 copayment                                                           Not Covered
       Adult Immunizations                                                                      90% after deductible                                                          70% after deductible
       Colorectal Cancer Screening
           Diagnostic Services                                                                  90% after deductible                                                      70% after deductible
           Medical Surgical                                                                     90% after deductible                                                      70% after deductible
       Routine gynecological exams, including a                                               100% after $30 copayment                                               70% (deductible does not apply)
       Pap Test
       Mammograms, annual routine and                                                    100% (deductible does not apply)                                                     70% after deductible
       medically necessary
    Pediatric
       Routine physical exams                                                               100% after $20 copayment                                Not Covered
       Pediatric immunizations                                                           100% (deductible does not apply)                  70% (deductible does not apply)
Emergency Room Services                                                                                   100% after $75 copayment (waived if admitted)
Spinal Manipulations                                                                        100% after $30 copayment                             70% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Physical Medicine                                                                           100% after $30 copayment                             70% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Speech Therapy                                                                              100% after $30 copayment                             70% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Occupational Therapy                                                                        100% after $30 copayment                             70% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Allergy Extracts and Injections                                                               90% after deductible                               70% after deductible
Ambulance                                                                                                          90% after network deductible
Assisted Fertilization Procedures                                                                                          Not Covered
Dental Services Related to Accidental Injury                                                  90% after deductible                               70% after deductible
Diabetes Treatment                                                                            90% after deductible                               70% after deductible
Diagnostic Services (including routine)
 Advanced Imaging (MRI, CAT Scan, PET                                                              90% after deductible                                                       70% after deductible
 scan, etc.)
 Basic Diagnostic Services (standard imaging,                                                      90% after deductible                                                       70% after deductible
 diagnostic medical, lab/pathology, allergy
 testing)
Durable Medical Equipment, Orthotics and                                                           90% after deductible                                                       70% after deductible
Prosthetics
Enteral Formulae                                                                          90% (deductible does not apply)                70% (deductible does not apply)
Home Infusion Therapy                                                                                               90% after network deductible
Home Health Care                                                                               90% after deductible                            70% after deductible
Hospice                                                                                        90% after deductible                            70% after deductible
Hospital Services – Inpatient                                                                  90% after deductible                            70% after deductible
Hospital Services – Outpatient                                                                 90% after deductible                            70% after deductible
                                               Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                                             -1-
 Benefit                                                                          Network                                             Out-of-Network
 Infertility Counseling, Testing and                                          90% after deductible                                     70% after deductible
 Treatment(2)
 Maternity (facility & professional services)                                 90% after deductible                                     70% after deductible
 Medical/Surgical Expenses                                                    90% after deductible                                     70% after deductible
 (Except Office Visits)
 Mental Health – Inpatient(3)                                               90% after deductible                            70% after deductible
 Mental Health – Outpatient(3)                                            100% after $30 copayment                          70% after deductible
 Private Duty Nursing                                                                            90% after network deductible
 Respiratory Therapy                                                                             90% after network deductible
 Skilled Nursing Facility Care                                              90% after deductible                            70% after deductible
 Substance Abuse – Inpatient Detoxification                                 90% after deductible                            70% after deductible
 Substance Abuse – Inpatient Rehabilitation                                 90% after deductible                            70% after deductible
 Substance Abuse – Outpatient                                             100% after $30 copayment                          70% after deductible
 Therapy Services (Cardiac Rehab, Infusion                                  90% after deductible                            70% after deductible
 Therapy, Chemotherapy, Radiation Therapy and
 Dialysis)
 Transplant Services                                                          90% after deductible                                     70% after deductible
 Precertification Requirements(4)                                                                                    Yes
 Prescription Drug Deductible
    Individual                                                                                            $50 per Contract year
    Family                                                                                               $100 per Contract year
 Premier Prescription Drug Program                                                                   Retail Drugs (31-day Supply)
 Mandatory Generic(5)                                                                                    $8 generic copayment
 Defined by Premier Pharmacy Network - Not                                                                $40 brand copayment
 Physician Network. Prescriptions filled at a non-
 network pharmacy are not covered.                                                  Maintenance Drugs through Mail Order (90-day Supply)
                                                                                                   $16 generic copayment
                                                                                                    $80 brand copayment
(1)   Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's renewal date. Contact
      your employer to determine the renewal date applicable to your program.
(2)   Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered
      depending on your group’s prescription drug program.
(3)   State mandated minimum benefits may apply to a diagnosis of serious mental illness. (If the above grid does not show a limit, your mental health benefit days and
      visits are unlimited.)
(4)   Highmark Healthcare Management Services (HMS) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-related
      inpatient admission. Some facility providers will contact HMS and obtain precertification of the inpatient admission on your behalf. Be sure to verify that your
      provider is contacting HMS for precertification. If not, you are responsible for contacting HMS. If this does not occur and it is later determined that all or part of the
      inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered.
(5)   Prescriptions are covered as long as they are listed on the prescription drug formulary applicable to your plan. To obtain a prescription medication that is not included
      on this formulary, your doctor must complete the 'Prescription Drug Medication Request Form' and return it to the Pharmacy Affairs Department for clinical review.
      Under the mandatory generic provision, you are responsible for the payment differential when a generic drug is available and you or your doctor specifies a brand
      name drug. Your payment is the price difference between the brand name drug and the generic drug in addition to the brand name drug copayment or coinsurance
      amounts, which may apply.




                                      Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                     -1-
PPOBlue 90/70
This chart is not intended as a contract of benefits. It is designed purely as a reference to help you compare the programs available through the Manufacturer & Business Association.

Benefit                                                                                                  Network                                                            Out-of-Network
Benefit Period(1)                                                                                                                             Contract Year
Deductible (per benefit period)
   Individual                                                                                                  None                                                                 $500
   Family                                                                                                      None                                                                $1,000
Plan Payment Level – Based on the provider’s                                                                   90%                                                           70% after deductible
reasonable charge (PRC)
Out-of-Pocket Maximums (Once met, plan
payment level becomes 100%)
   Individual                                                                                          $1,500                                                                      $3,000
   Family                                                                                              $3,000                                                                      $6,000
Lifetime Maximum (per person)                                                                        Unlimited                                                                  $1,000,000
Primary Care Physician Office Visits                                                          100% after $20 copayment                                                       70% after deductible
Specialist Office Visits                                                                      100% after $20 copayment                                                       70% after deductible
Preventive Care
   Adult
       Routine physical exams                                                                 100% after $20 copayment                                                          Not Covered
       Adult Immunizations                                                                              90%                                                                  70% after deductible
       Colorectal Cancer Screening
           Diagnostic Services                                                                          90%                                                              70% after deductible
           Medical Surgical                                                                             90%                                                              70% after deductible
       Routine gynecological exams, including a                                               100% after $20 copayment                                              70% (deductible does not apply)
       Pap Test
       Mammograms, annual routine and                                                                         100%                                                           70% after deductible
       medically necessary
    Pediatric
       Routine physical exams                                                                 100% after $20 copayment                              Not Covered
       Pediatric immunizations                                                                         100%                                70% (deductible does not apply)
Emergency Room Services                                                                                    100% after $50 copayment (waived if admitted)
Spinal Manipulations                                                                          100% after $20 copayment                           70% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Physical Medicine                                                                             100% after $20 copayment                           70% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Speech Therapy                                                                                100% after $20 copayment                           70% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Occupational Therapy                                                                          100% after $20 copayment                           70% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Allergy Extracts and Injections                                                                         90%                                      70% after deductible
Ambulance                                                                                                                       90%
Assisted Fertilization Procedures                                                                                          Not Covered
Dental Services Related to Accidental Injury                                                            90%                                      70% after deductible
Diabetes Treatment                                                                                      90%                                      70% after deductible
Diagnostic Services (including routine)
 Advanced Imaging (MRI, CAT Scan, PET                                                                          90%                                                           70% after deductible
 scan, etc.)
 Basic Diagnostic Services (standard imaging,                                                                  90%                                                           70% after deductible
 diagnostic medical, lab/pathology, allergy
 testing)
Durable Medical Equipment, Orthotics and                                                                       90%                                                           70% after deductible
Prosthetics
Enteral Formulae                                                                                               90%                                                  70% (deductible does not apply)
Home Infusion Therapy                                                                                                                                90%
Home Health Care                                                                                               90%                                                           70% after deductible
Hospice                                                                                                        90%                                                           70% after deductible
Hospital Services – Inpatient                                                                                  90%                                                           70% after deductible
Hospital Services – Outpatient                                                                                 90%                                                           70% after deductible
                                               Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                                             -1-
Benefit                                                                        Network                                           Out-of-Network
Infertility Counseling, Testing and                                                 90%                                            70% after deductible
Treatment(2)
Maternity (facility & professional services)                                        90%                                            70% after deductible
Medical/Surgical Expenses                                                           90%                                            70% after deductible
(Except Office Visits)
Mental Health – Inpatient(3)                                                     90%                                               70% after deductible
Mental Health – Outpatient(3)                                          100% after $20 copayment                                    70% after deductible
Private Duty Nursing                                                                                            90%
Respiratory Therapy                                                                                             90%
Skilled Nursing Facility Care                                                       90%                                          70% after deductible
                                                                                                                             Limit: 100 days/benefit period
Substance Abuse – Inpatient Detoxification                                       90%                                             70% after deductible
Substance Abuse – Inpatient Rehabilitation                                       90%                                             70% after deductible
Substance Abuse – Outpatient                                           100% after $20 copayment                                  70% after deductible
Therapy Services (Cardiac Rehab, Infusion                                        90%                                             70% after deductible
Therapy, Chemotherapy, Radiation Therapy and
Dialysis)
Transplant Services                                                                 90%                                            70% after deductible
Precertification Requirements(4)                                                                                 Yes
Prescription Drug Deductible
   Individual                                                                                                None
   Family                                                                                                    None
Premier Prescription Drug Program                                                                Retail Drugs (31-day Supply)
Mandatory Generic(5)                                                                                 $8 generic copayment
Defined by Premier Pharmacy Network - Not                                                            $40 brand copayment
Physician Network. Prescriptions filled at a non-
network pharmacy are not covered.                                                Maintenance Drugs through Mail Order (90-day Supply)
                                                                                                $16 generic copayment
                                                                                                 $80 brand copayment
(1)   Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's renewal date. Contact
      your employer to determine the renewal date applicable to your program.
(2)   Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered
      depending on your group’s prescription drug program.
(3)   State mandated minimum benefits may apply to a diagnosis of serious mental illness. (If the above grid does not show a limit, your mental health
      benefit days and visits are unlimited.)
(4)   Highmark Healthcare Management Services (HMS) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-
      related inpatient admission. Some facility providers will contact HMS and obtain precertification of the inpatient admission on your behalf. Be sure to verify that
      your provider is contacting HMS for precertification. If not, you are responsible for contacting HMS. If this does not occur and it is later determined that all or
      part of the inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered.
(5)   Prescriptions are covered as long as they are listed on the prescription drug formulary applicable to your plan. To obtain a prescription medication that is not
      included on this formulary, the physician must complete the 'Prescription Drug Medication Request Form' and return it to the Pharmacy Affairs Department for
      clinical review. Under the mandatory generic provision, you are responsible for the payment differential when a generic drug is available and you or your doctor
      specifies a brand name drug. Your payment is the price difference between the brand drug and the generic drug in addition to the brand drug copayment or
      coinsurance amounts, which may apply.




                                    Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                  -1-
PPOBlue 80/60
This chart is not intended as a contract of benefits. It is designed purely as a reference to help you compare the programs available through the Manufacturer & Business Association.

Benefit                                                                                                  Network                                                             Out-of-Network
Benefit Period(1)                                                                                                                              Contract Year
Deductible (per benefit period)
   Individual                                                                                                  None                                                                  $750
   Family                                                                                                      None                                                                 $1,500
Plan Payment Level – Based on the provider’s                                                                   80%                                                            60% after deductible
reasonable charge (PRC)
Out-of-Pocket Maximums (Once met, plan
payment level becomes 100%)
   Individual                                                                                                 $4,000                                                                      $8,000
   Family                                                                                                     $8,000                                                                     $16,000
Lifetime Maximum (per person)                                                                                                            $5,000,000 Combined
Primary Care Physician Office Visits                                                                           80%                                                            60% after deductible
Specialist Office Visits                                                                                       80%                                                            60% after deductible
Preventive Care
   Adult
       Routine physical exams                                                                                 100%                                                               Not Covered
       Adult Immunizations                                                                                    100%                                                            60% after deductible
       Colorectal Cancer Screening
           Diagnostic Services                                                                                 80%                                                        60% after deductible
           Medical Surgical                                                                                    80%                                                        60% after deductible
       Routine gynecological exams, including a                                                               100%                                                   60% (deductible does not apply)
       Pap Test
       Mammograms, annual routine and                                                                         100%                                                            60% after deductible
       medically necessary
    Pediatric
       Routine physical exams                                                                                 100%                                                           Not Covered
       Pediatric immunizations                                                                                100%                                                   60% (deductible does not apply)
Emergency Room Services                                                                                                                               80%
Spinal Manipulations                                                                                           80%                                               60% after deductible
                                                                                                                                   Limit: 20 visits/benefit period
Physical Medicine                                                                                              80%                                               60% after deductible
                                                                                                                                   Limit: 20 visits/benefit period
Speech Therapy                                                                                                 80%                                               60% after deductible
                                                                                                                                   Limit: 20 visits/benefit period
Occupational Therapy                                                                                           80%                                               60% after deductible
                                                                                                                                   Limit: 20 visits/benefit period
Allergy Extracts and Injections                                                                                80%                                               60% after deductible
Ambulance                                                                                                                                       80%
Assisted Fertilization Procedures                                                                                                          Not Covered
Dental Services Related to Accidental Injury                                                                   80%                                               60% after deductible
Diabetes Treatment                                                                                             80%                                               60% after deductible
Diagnostic Services (including routine)
 Advanced Imaging (MRI, CAT Scan, PET                                                                          80%                                                            60% after deductible
 scan, etc.)
 Basic Diagnostic Services (standard imaging,                                                                  80%                                                            60% after deductible
 diagnostic medical, lab/pathology, allergy
 testing)
Durable Medical Equipment, Orthotics and                                                                       80%                                                            60% after deductible
Prosthetics
Enteral Formulae                                                                                               80%                                                   60% (deductible does not apply)
Home Infusion Therapy                                                                                                                                 80%
Home Health Care                                                                                               80%                                                            60% after deductible
Hospice                                                                                                        80%                                                            60% after deductible
Hospital Services – Inpatient                                                                                  80%                                                            60% after deductible
Hospital Services – Outpatient                                                                                 80%                                                            60% after deductible
                                               Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                                             -1-
 Benefit                                                                          Network                                             Out-of-Network
 Infertility Counseling, Testing and Treatment(2)                                      80%                                             60% after deductible
 Maternity (facility & professional services)                                          80%                                             60% after deductible
 Medical/Surgical Expenses                                                             80%                                             60% after deductible
 (Except Office Visits)
 Mental Health – Inpatient(3)                                                          80%                                             60% after deductible
 Mental Health – Outpatient(3)                                                         80%                                             60% after deductible
 Private Duty Nursing                                                                                               80%
 Respiratory Therapy                                                                                                80%
 Skilled Nursing Facility Care                                                         80%                                           60% after deductible
                                                                                                                                 Limit: 100 days/benefit period
 Substance Abuse – Inpatient Detoxification                                            80%                                           60% after deductible
 Substance Abuse – Inpatient Rehabilitation                                            80%                                           60% after deductible
 Substance Abuse – Outpatient                                                          80%                                           60% after deductible
 Therapy Services (Cardiac Rehab, Infusion                                             80%                                           60% after deductible
 Therapy, Chemotherapy, Radiation Therapy and
 Dialysis)
 Transplant Services                                                                   80%                                             60% after deductible
 Precertification Requirements(4)                                                                                    Yes
 Prescription Drug Deductible
    Individual                                                                                          None per Contract year
    Family                                                                                              None per Contract year
 Premier Prescription Drug Program                                                                   Retail Drugs (31-day Supply)
 Mandatory Generic(5)                                                                                    $8 generic copayment
 Defined by Premier Pharmacy Network - Not                                                               $40 brand copayment
 Physician Network. Prescriptions filled at a non-
 network pharmacy are not covered.                                                  Maintenance Drugs through Mail Order (90-day Supply)
                                                                                                   $16 generic copayment
                                                                                                    $80 brand copayment
(1) Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's renewal date. Contact
    your employer to determine the renewal date applicable to your program.
(2) Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered
    depending on your group’s prescription drug program.
(3) State mandated minimum benefits may apply to a diagnosis of serious mental illness. (If the above grid does not show a limit, your mental health benefit days and
    visits are unlimited.)
(4) Highmark Healthcare Management Services (HMS) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-related
    inpatient admission. Some facility providers will contact HMS and obtain precertification of the inpatient admission on your behalf. Be sure to verify that your
    provider is contacting HMS for precertification. If not, you are responsible for contacting HMS. If this does not occur and it is later determined that all or part of the
    inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered.
(5) Prescriptions are covered as long as they are listed on the prescription drug formulary applicable to your plan. To obtain a prescription medication that is not included
    on this formulary, your doctor must complete the 'Prescription Drug Medication Request Form' and return it to the Pharmacy Affairs Department for clinical review.
    Under the mandatory generic provision, you are responsible for the payment differential when a generic drug is available and you or your doctor specifies a brand
    name drug. Your payment is the price difference between the brand name drug and the generic drug in addition to the brand name drug copayment or coinsurance
    amounts, which may apply.




                                     Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                     -1-
PPOBlue 70/50
This chart is not intended as a contract of benefits. It is designed purely as a reference to help you compare the programs available through the Manufacturer & Business Association.

Benefit                                                                                                  Network                                                             Out-of-Network
Benefit Period(1)                                                                                                                              Contract Year
Deductible (per benefit period)
   Individual                                                                                                  None                                                                 $1,000
   Family                                                                                                      None                                                                 $2,000
Plan Payment Level – Based on the provider’s                                                                   70%                                                            50% after deductible
reasonable charge (PRC)
Out-of-Pocket Maximums (Once met, plan
payment level becomes 100%)
   Individual                                                                                                 $4,000                                                                      $8,000
   Family                                                                                                     $8,000                                                                     $16,000
Lifetime Maximum (per person)                                                                                                            $5,000,000 Combined
Primary Care Physician Office Visits                                                                           70%                                                            50% after deductible
Specialist Office Visits                                                                                       70%                                                            50% after deductible
Preventive Care
   Adult
       Routine physical exams                                                                                 100%                                                               Not Covered
       Adult Immunizations                                                                                    100%                                                            50% after deductible
       Colorectal Cancer Screening
           Diagnostic Services                                                                                 70%                                                        50% after deductible
           Medical Surgical                                                                                    70%                                                        50% after deductible
       Routine gynecological exams, including a                                                               100%                                                   50% (deductible does not apply)
       Pap Test
       Mammograms, annual routine and                                                                         100%                                                            50% after deductible
       medically necessary
    Pediatric
       Routine physical exams                                                                                 100%                                                           Not Covered
       Pediatric immunizations                                                                                100%                                                   50% (deductible does not apply)
Emergency Room Services                                                                                                                               70%
Spinal Manipulations                                                                                           70%                                               50% after deductible
                                                                                                                                   Limit: 20 visits/benefit period
Physical Medicine                                                                                              70%                                               50% after deductible
                                                                                                                                   Limit: 20 visits/benefit period
Speech Therapy                                                                                                 70%                                               50% after deductible
                                                                                                                                   Limit: 20 visits/benefit period
Occupational Therapy                                                                                           70%                                               50% after deductible
                                                                                                                                   Limit: 20 visits/benefit period
Allergy Extracts and Injections                                                                                70%                                               50% after deductible
Ambulance                                                                                                                                       70%
Assisted Fertilization Procedures                                                                                                          Not Covered
Dental Services Related to Accidental Injury                                                                   70%                                               50% after deductible
Diabetes Treatment                                                                                             70%                                               50% after deductible
Diagnostic Services (including routine)
 Advanced Imaging (MRI, CAT Scan, PET scan,                                                                    70%                                                            50% after deductible
 etc.)
 Basic Diagnostic Services (standard imaging,                                                                  70%                                                            50% after deductible
 diagnostic medical, lab/pathology, allergy
 testing)
Durable Medical Equipment, Orthotics and                                                                       70%                                                            50% after deductible
Prosthetics
Enteral Formulae                                                                                               70%                                                   50% (deductible does not apply)
Home Infusion Therapy                                                                                                                                 70%
Home Health Care                                                                                               70%                                                            50% after deductible
Hospice                                                                                                        70%                                                            50% after deductible
Hospital Services – Inpatient                                                                                  70%                                                            50% after deductible
Hospital Services – Outpatient                                                                                 70%                                                            50% after deductible
                                               Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                                             -1-
 Benefit                                                                          Network                                             Out-of-Network
 Infertility Counseling, Testing and Treatment(2)                                      70%                                             50% after deductible
 Maternity (facility & professional services)                                          70%                                             50% after deductible
 Medical/Surgical Expenses                                                             70%                                             50% after deductible
 (Except Office Visits)
 Mental Health – Inpatient(3)                                                         70%                                              50% after deductible
 Mental Health – Outpatient(3)                                                        70%                                              50% after deductible
 Private Duty Nursing                                                                                               70%
 Respiratory Therapy                                                                                                70%
 Skilled Nursing Facility Care                                                         70%                                           50% after deductible
                                                                                                                                 Limit: 100 days/benefit period
 Substance Abuse
     Inpatient Detoxification                                                         70%                                              50% after deductible
     Inpatient Rehabilitation                                                         70%                                              50% after deductible
     Outpatient                                                                       70%                                              50% after deductible
 Therapy Services (Cardiac Rehab, Infusion                                            70%                                              50% after deductible
 Therapy, Chemotherapy, Radiation Therapy and
 Dialysis)
 Transplant Services                                                                   70%                                             50% after deductible
 Precertification Requirements(4)                                                                                    Yes
 Prescription Drug Deductible
    Individual                                                                                          None per Contract year
    Family                                                                                              None per Contract year
 Premier Prescription Drug Program                                                                   Retail Drugs (31-day Supply)
 Mandatory Generic(5)                                                                                    $8 generic copayment
 Defined by Premier Pharmacy Network - Not                                                               $40 brand copayment
 Physician Network. Prescriptions filled at a non-
 network pharmacy are not covered.                                                  Maintenance Drugs through Mail Order (90-day Supply)
                                                                                                   $16 generic copayment
                                                                                                    $80 brand copayment

(1) Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's renewal date. Contact
    your employer to determine the renewal date applicable to your program.
(2) Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered
    depending on your group’s prescription drug program.
(3) State mandated minimum benefits may apply to a diagnosis of serious mental illness. (If the above grid does not show a limit, your mental health benefit days and
    visits are unlimited.)
(4) Highmark Healthcare Management Services (HMS) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-related
    inpatient admission. Some facility providers will contact HMS and obtain precertification of the inpatient admission on your behalf. Be sure to verify that your
    provider is contacting HMS for precertification. If not, you are responsible for contacting HMS. If this does not occur and it is later determined that all or part of the
    inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered.
(5) Prescriptions are covered as long as they are listed on the prescription drug formulary applicable to your plan. To obtain a prescription medication that is not included
    on this formulary, your doctor must complete the 'Prescription Drug Medication Request Form' and return it to the Pharmacy Affairs Department for clinical
    review.Under the mandatory generic provision, you are responsible for the payment differential when a generic drug is available and you or your doctor specifies a
    brand name drug. Your payment is the price difference between the brand name drug and the generic drug in addition to the brand name drug copayment or
    coinsurance amounts, which may apply.




                                     Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                     -1-
PPOBlue Value Plus 250
This chart is not intended as a contract of benefits. It is designed purely as a reference to help you compare the programs available through the Manufacturer & Business Association.

Benefit                                                                                                  Network                                                             Out-of-Network
Benefit Period(1)                                                                                                                              Contract Year
Deductible (per benefit period)
   Individual                                                                                             $250                                                                       $500
   Family                                                                                                 $500                                                                      $1,000
Plan Payment Level – Based on the provider’s                                                       80% after deductible                                                       60% after deductible
reasonable charge (PRC)
Out-of-Pocket Maximums (Once met, plan
payment level becomes 100%)
   Individual                                                                                          $2,500                                                                       $5,000
   Family                                                                                              $5,000                                                                      $10,000
Lifetime Maximum (per person)                                                                        Unlimited                                                                   $1,000,000
Primary Care Physician Office Visits                                                          100% after $20 copayment                                                        60% after deductible
Specialist Office Visits                                                                      100% after $20 copayment                                                        60% after deductible
Preventive Care
   Adult
       Routine physical exams                                                                 100% after $20 copayment                                                           Not Covered
       Adult Immunizations                                                                      80% after deductible                                                          60% after deductible
       Colorectal Cancer Screening
           Diagnostic Services                                                                  80% after deductible                                                      60% after deductible
           Medical Surgical                                                                     80% after deductible                                                      60% after deductible
       Routine gynecological exams, including a                                               100% after $20 copayment                                               60% (deductible does not apply)
       Pap Test
       Mammograms, annual routine and                                                     80% (deductible does not apply)                                                     60% after deductible
       medically necessary
    Pediatric
       Routine physical exams                                                               100% after $20 copayment                                 Not Covered
       Pediatric immunizations                                                            80% (deductible does not apply)                   60% (deductible does not apply)
Emergency Room Services                                                                                            80% (deductible does not apply)
Spinal Manipulations                                                                        100% after $20 copayment                              60% after deductible
                                                                                                                    Limit: 20 visits/benefit period
Physical Medicine                                                                           100% after $20 copayment                              60% after deductible
                                                                                                                    Limit: 20 visits/benefit period
Speech Therapy                                                                              100% after $20 copayment                              60% after deductible
                                                                                                                    Limit: 20 visits/benefit period
Occupational Therapy                                                                        100% after $20 copayment                              60% after deductible
                                                                                                                    Limit: 20 visits/benefit period
Allergy Extracts and Injections                                                                80% after deductible                               60% after deductible
Ambulance                                                                                                          80% (deductible does not apply)
Assisted Fertilization Procedures                                                                                           Not Covered
Dental Services Related to Accidental Injury                                                   80% after deductible                               60% after deductible
Diabetes Treatment                                                                             80% after deductible                               60% after deductible
Diagnostic Services (including routine)
 Advanced Imaging (MRI, CAT Scan, PET scan,                                                        80% after deductible                                                       60% after deductible
 etc.)
 Basic Diagnostic Services (standard imaging,                                                      80% after deductible                                                       60% after deductible
 diagnostic medical, lab/pathology, allergy
 testing)
Durable Medical Equipment, Orthotics and                                                           80% after deductible                                                       60% after deductible
Prosthetics
Enteral Formulae                                                                          80% (deductible does not apply)               60% (deductible does not apply)
Home Infusion Therapy                                                                                              100% after network deductible
Home Health Care                                                                               80% after deductible                           60% after deductible
Hospice                                                                                        80% after deductible                           60% after deductible
Hospital Services – Inpatient                                                                  80% after deductible                           60% after deductible
Hospital Services – Outpatient                                                                 80% after deductible                           60% after deductible
                                               Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                                             -1-
 Benefit                                                                          Network                                             Out-of-Network
 Infertility Counseling, Testing and                                          80% after deductible                                     60% after deductible
 Treatment(2)
 Maternity (facility & professional services)                               80% after deductible                            60% after deductible
 Medical/Surgical Expenses (except office visits)                           80% after deductible                            60% after deductible
 Mental Health – Inpatient(3)                                               80% after deductible                            60% after deductible
 Mental Health – Outpatient(3)                                            100% after $20 copayment                          60% after deductible
 Private Duty Nursing                                                                            80% after network deductible
 Respiratory Therapy                                                                             80% after network deductible
 Skilled Nursing Facility Care                                              80% after deductible                            60% after deductible
                                                                                                                       Limit: 100 days/benefit period
 Substance Abuse – Inpatient Detoxification                                 80% after deductible                            60% after deductible
 Substance Abuse – Inpatient Rehabilitation                                 80% after deductible                            60% after deductible
 Substance Abuse – Outpatient                                             100% after $20 copayment                          60% after deductible
 Therapy Services (Cardiac Rehab, Infusion                                  80% after deductible                            60% after deductible
 Therapy, Chemotherapy, Radiation Therapy and
 Dialysis)
 Transplant Services                                                          80% after deductible                                     60% after deductible
 Precertification Requirements(4)                                                                                    Yes
 Prescription Drug Deductible
    Individual                                                                                         $100 per Contract year
    Family                                                                                             $200 per Contract year
 Premier Prescription Drug Program                                                                Retail Drugs (31-day Supply)
 Mandatory Generic(5)                                                                              Plan pays 80% after deductible
 Defined by Premier Pharmacy Network - Not                                                 $10 minimum member payment per prescription
 Physician Network. Prescriptions filled at a non-                                         $50 maximum member payment per prescription
 network pharmacy are not covered.
                                                                                    Maintenance Drugs through Mail Order (90-day Supply)
                                                                                                 Plan pays 80% after deductible
                                                                                         $20 minimum member payment per prescription
                                                                                        $100 maximum member payment per prescription
(1)   Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's renewal date. Contact
      your employer to determine the renewal date applicable to your program.
(2)   Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered
      depending on your group’s prescription drug program.
(3)   State mandated minimum benefits may apply to a diagnosis of serious mental illness. (If the above grid does not show a limit, your mental health benefit days and
      visits are unlimited.)
(4)   Highmark Healthcare Management Services (HMS) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-related
      inpatient admission. Some facility providers will contact HMS and obtain precertification of the inpatient admission on your behalf. Be sure to verify that your
      provider is contacting HMS for precertification. If not, you are responsible for contacting HMS. If this does not occur and it is later determined that all or part of the
      inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered.
(5)   Prescriptions are covered as long as they are listed on the prescription drug formulary applicable to your plan. To obtain a prescription medication that is not included
      on this formulary, your doctor must complete the 'Prescription Drug Medication Request Form' and return it to the Pharmacy Affairs Department for clinical review.
      Under the mandatory generic provision, you are responsible for the payment differential when a generic drug is available and you or your doctor specifies a brand
      name drug. Your payment is the price difference between the brand name drug and the generic drug in addition to the brand name drug copayment or coinsurance
      amounts, which may apply.




                                      Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                     -1-
PPOBlue Value Plus 500
This chart is not intended as a contract of benefits. It is designed purely as a reference to help you compare the programs available through the Manufacturer & Business Association.

Benefit                                                                                                  Network                                                             Out-of-Network
Benefit Period(1)                                                                                                                              Contract Year
Deductible (per benefit period)
   Individual                                                                                             $500                                                                      $1,000
   Family                                                                                                $1,000                                                                     $2,000
Plan Payment Level – Based on the provider’s                                                       80% after deductible                                                       60% after deductible
reasonable charge (PRC)
Out-of-Pocket Maximums (Once met, plan
payment level becomes 100%)
   Individual                                                                                                 $4,000                                                                      $5,000
   Family                                                                                                     $8,000                                                                     $10,000
Lifetime Maximum (per person)                                                                                                                    $2,000,000
Primary Care Physician Office Visits                                                          100% after $25 copayment                                                        60% after deductible
Specialist Office Visits                                                                      100% after $25 copayment                                                        60% after deductible
Preventive Care
   Adult
       Routine physical exams                                                                 100% after $25 copayment                                                           Not Covered
       Adult Immunizations                                                                      80% after deductible                                                          60% after deductible
       Colorectal Cancer Screening
           Diagnostic Services                                                                  80% after deductible                                                      60% after deductible
           Medical Surgical                                                                     80% after deductible                                                      60% after deductible
       Routine gynecological exams, including a                                               100% after $25 copayment                                               60% (deductible does not apply)
       Pap Test
       Mammograms, annual routine and                                                    100% (deductible does not apply)                                                     60% after deductible
       medically necessary
    Pediatric
       Routine physical exams                                                               100% after $25 copayment                                Not Covered
       Pediatric immunizations                                                           100% (deductible does not apply)                  60% (deductible does not apply)
Emergency Room Services                                                                                   100% after $100 copayment (waived if admitted)
Spinal Manipulations                                                                        100% after $25 copayment                             60% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Physical Medicine                                                                           100% after $25 copayment                             60% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Speech Therapy                                                                              100% after $25 copayment                             60% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Occupational Therapy                                                                        100% after $25 copayment                             60% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Allergy Extracts and Injections                                                               80% after deductible                               60% after deductible
Ambulance                                                                                                          80% after network deductible
Assisted Fertilization Procedures                                                                                          Not Covered
Dental Services Related to Accidental Injury                                                  80% after deductible                               60% after deductible
Diabetes Treatment                                                                            80% after deductible                               60% after deductible
Diagnostic Services (including routine)
 Advanced Imaging (MRI, CAT Scan, PET scan,                                                        80% after deductible                                                       60% after deductible
 etc.)
 Basic Diagnostic Services (standard imaging,                                                      80% after deductible                                                       60% after deductible
 diagnostic medical, lab/pathology, allergy
 testing)
Durable Medical Equipment, Orthotics and                                                           80% after deductible                                                       60% after deductible
Prosthetics
Enteral Formulae                                                                          80% (deductible does not apply)                60% (deductible does not apply)
Home Infusion Therapy                                                                                               80% after network deductible
Home Health Care                                                                               80% after deductible                            60% after deductible
Hospice                                                                                        80% after deductible                            60% after deductible
Hospital Services – Inpatient                                                                  80% after deductible                            60% after deductible
Hospital Services – Outpatient                                                                 80% after deductible                            60% after deductible
                                               Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                                             -1-
 Benefit                                                                          Network                                             Out-of-Network
 Infertility Counseling, Testing and                                          80% after deductible                                     60% after deductible
 Treatment(2)
 Maternity (facility & professional services)                               80% after deductible                            60% after deductible
 Medical/Surgical Expenses (except office visits)                           80% after deductible                            60% after deductible
 Mental Health – Inpatient(3)                                               80% after deductible                            60% after deductible
 Mental Health – Outpatient(3)                                            100% after $25 copayment                          60% after deductible
 Private Duty Nursing                                                                            80% after network deductible
 Respiratory Therapy                                                                             80% after network deductible
 Skilled Nursing Facility Care                                              80% after deductible                            60% after deductible
                                                                                                                       Limit: 100 days/benefit period
 Substance Abuse – Inpatient Detoxification                                 80% after deductible                            60% after deductible
 Substance Abuse – Inpatient Rehabilitation                                 80% after deductible                            60% after deductible
 Substance Abuse – Outpatient                                             100% after $25 copayment                          60% after deductible
 Therapy Services (Cardiac Rehab, Infusion                                  80% after deductible                            60% after deductible
 Therapy, Chemotherapy, Radiation Therapy and
 Dialysis)
 Transplant Services                                                          80% after deductible                                     60% after deductible
 Precertification Requirements(4)                                                                                    Yes
 Prescription Drug Deductible
    Individual                                                                                         $150 per Contract year
    Family                                                                                             $300 per Contract year
 Premier Prescription Drug Program                                                                Retail Drugs (31-day Supply)
 Mandatory Generic(4)                                                                              Plan pays 70% after deductible
 Defined by Premier Pharmacy Network - Not                                                 $15 minimum member payment per prescription
 Physician Network. Prescriptions filled at a non-                                         $100 maximum member payment per prescription
 network pharmacy are not covered.
                                                                                    Maintenance Drugs through Mail Order (90-day Supply)
                                                                                                 Plan pays 70% after deductible
                                                                                         $30 minimum member payment per prescription
                                                                                        $200 maximum member payment per prescription
(1)   Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's renewal date. Contact
      your employer to determine the renewal date applicable to your program.
(2)   Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered
      depending on your group’s prescription drug program.
(3)   State mandated minimum benefits may apply to a diagnosis of serious mental illness. (If the above grid does not show a limit, your mental health benefit days and
      visits are unlimited.)
(4)   Highmark Healthcare Management Services (HMS) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-related
      inpatient admission. Some facility providers will contact HMS and obtain precertification of the inpatient admission on your behalf. Be sure to verify that your
      provider is contacting HMS for precertification. If not, you are responsible for contacting HMS. If this does not occur and it is later determined that all or part of the
      inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered.
(5)   Prescriptions are covered as long as they are listed on the prescription drug formulary applicable to your plan. To obtain a prescription medication that is not included
      on this formulary, your doctor must complete the 'Prescription Drug Medication Request Form' and return it to the Pharmacy Affairs Department for clinical review.
      Under the mandatory generic provision, you are responsible for the payment differential when a generic drug is available and you or your doctor specifies a brand
      name drug. Your payment is the price difference between the brand name drug and the generic drug in addition to the brand name drug copayment or coinsurance
      amounts, which may apply.




                                      Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                     -1-
Out-of-Area PPO Value Plus 500
This chart is not intended as a contract of benefits. It is designed purely as a reference to help you compare the programs available through the Manufacturer & Business Association.

Benefit                                                                                                  Network                                                             Out-of-Network
Benefit Period(1)                                                                                                                              Contract Year
Deductible (per benefit period)
   Individual                                                                                             $500                                                                      $1,000
   Family                                                                                                $1,000                                                                     $2,000
Plan Payment Level – Based on the provider’s                                                       80% after deductible                                                       60% after deductible
reasonable charge (PRC)
Out-of-Pocket Maximums (Once met, plan
payment level becomes 100%)
   Individual                                                                                                 $4,000                                                                      $5,000
   Family                                                                                                     $8,000                                                                     $10,000
Lifetime Maximum (per person)                                                                                                                    $2,000,000
Primary Care Physician Office Visits                                                          100% after $25 copayment                                                        60% after deductible
Specialist Office Visits                                                                      100% after $25 copayment                                                        60% after deductible
Preventive Care
   Adult
       Routine physical exams                                                                 100% after $25 copayment                                                           Not Covered
       Adult Immunizations                                                                      80% after deductible                                                          60% after deductible
       Colorectal Cancer Screening
           Diagnostic Services                                                                  80% after deductible                                                      60% after deductible
           Medical Surgical                                                                     80% after deductible                                                      60% after deductible
       Routine gynecological exams, including a                                               100% after $25 copayment                                               60% (deductible does not apply)
       Pap Test
       Mammograms, annual routine and                                                    100% (deductible does not apply)                                                     60% after deductible
       medically necessary
    Pediatric
       Routine physical exams                                                               100% after $25 copayment                                Not Covered
       Pediatric immunizations                                                           100% (deductible does not apply)                  60% (deductible does not apply)
Emergency Room Services                                                                                   100% after $100 copayment (waived if admitted)
Spinal Manipulations                                                                        100% after $25 copayment                             60% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Physical Medicine                                                                           100% after $25 copayment                             60% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Speech Therapy                                                                              100% after $25 copayment                             60% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Occupational Therapy                                                                        100% after $25 copayment                             60% after deductible
                                                                                                                   Limit: 20 visits/benefit period
Allergy Extracts and Injections                                                               80% after deductible                               60% after deductible
Ambulance                                                                                                          80% after network deductible
Assisted Fertilization Procedures                                                                                          Not Covered
Dental Services Related to Accidental Injury                                                  80% after deductible                               60% after deductible
Diabetes Treatment                                                                            80% after deductible                               60% after deductible
Diagnostic Services (including routine)
  Advanced Imaging (MRI, CAT Scan, PET                                                             80% after deductible                                                       60% after deductible
  scan, etc.)
  Basic Diagnostic Services (standard imaging,                                                     80% after deductible                                                       60% after deductible
  diagnostic medical, lab/pathology, allergy
  testing)
Durable Medical Equipment, Orthotics and                                                           80% after deductible                                                       60% after deductible
Prosthetics
Enteral Formulae                                                                          80% (deductible does not apply)                60% (deductible does not apply)
Home Infusion Therapy                                                                                               80% after network deductible
Home Health Care                                                                               80% after deductible                            60% after deductible
Hospice                                                                                        80% after deductible                            60% after deductible
Hospital Services – Inpatient                                                                  80% after deductible                            60% after deductible
Hospital Services – Outpatient                                                                 80% after deductible                            60% after deductible
                                               Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                                             -1-
 Benefit                                                                         Network                                            Out-of-Network
 Infertility Counseling, Testing and                                        80% after deductible                                     60% after deductible
 Treatment(2)
 Maternity (facility & professional services)                              80% after deductible                            60% after deductible
 Medical/Surgical Expenses (except office visits)                          80% after deductible                            60% after deductible
 Mental Health – Inpatient(3)                                              80% after deductible                            60% after deductible
 Mental Health – Outpatient(3)                                           100% after $25 copayment                          60% after deductible
 Private Duty Nursing                                                                           80% after network deductible
 Respiratory Therapy                                                                            80% after network deductible
 Skilled Nursing Facility Care                                             80% after deductible                            60% after deductible
                                                                                                                      Limit: 100 days/benefit period
 Substance Abuse – Inpatient Detoxification                                80% after deductible                            60% after deductible
 Substance Abuse – Inpatient Rehabilitation                                80% after deductible                            60% after deductible
 Substance Abuse – Outpatient                                            100% after $25 copayment                          60% after deductible
 Therapy Services (Cardiac Rehab, Infusion                                 80% after deductible                            60% after deductible
 Therapy, Chemotherapy, Radiation Therapy and
 Dialysis)
 Transplant Services                                                        80% after deductible                                     60% after deductible
 Precertification Requirements(4)                                                                                  Yes
 Prescription Drug Deductible
    Individual                                                                                        $150 per Contract year
    Family                                                                                            $300 per Contract year
 Premier Prescription Drug Program                                                               Retail Drugs (31-day Supply)
 Mandatory Generic(5)                                                                             Plan pays 70% after deductible
 Defined by Premier Pharmacy Network - Not                                                $15 minimum member payment per prescription
 Physician Network. Prescriptions filled at a non-                                        $100 maximum member payment per prescription
 network pharmacy are not covered.
                                                                                   Maintenance Drugs through Mail Order (90-day Supply)
                                                                                                Plan pays 70% after deductible
                                                                                        $30 minimum member payment per prescription
                                                                                       $200 maximum member payment per prescription
(1) Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's renewal date. Contact your
    employer to determine the renewal date applicable to your program.
(2) Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered
    depending on your group’s prescription drug program.
(3) State mandated minimum benefits may apply to a diagnosis of serious mental illness. (If the above grid does not show a limit, your mental health benefit days and
    visits are unlimited.)
(4) Highmark Healthcare Management Services (HMS) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-related
    inpatient admission. Some facility providers will contact HMS and obtain precertification of the inpatient admission on your behalf. Be sure to verify that your
    provider is contacting HMS for precertification. If not, you are responsible for contacting HMS. If this does not occur and it is later determined that all or part of the
    inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered.
(5) Prescriptions are covered as long as they are listed on the prescription drug formulary applicable to your plan. To obtain a prescription medication that is not included
    on this formulary, your doctor must complete the 'Prescription Drug Medication Request Form' and return it to the Pharmacy Affairs Department for clinical review.
    Under the mandatory generic provision, you are responsible for the payment differential when a generic drug is available and you or your doctor specifies a brand name
    drug. Your payment is the price difference between the brand name drug and the generic drug in addition to the brand name drug copayment or coinsurance amounts,
    which may apply.




                                     Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                    -1-
HDHP 100/80 $1,250 Deductible Value
Qualified High Deductible Health Plan (HDHP)
  This program is a qualified high deductible plan as defined by the Internal Revenue Service. It is designed for use with a Health Savings
                Account (HSA). This program should not be combined with any funding arrangement other than an HSA.

If you enroll as an individual, the deductible and out-of-pocket maximums for the “Employee Only Plan” apply. If you enroll as a family,
the deductible and out-of -pocket maximums for the “Family Plan” apply and can be satisfied by one or more of your family members.
Benefit                                                            Network                                     Out-of-Network
Benefit Period(1)                                                                          Contract Year
Deductible per benefit period (Applies to
Medical and Prescription Drug benefits)
   Employee Only Plan                                                                    $1,250 Combined
   Family Plan                                                                           $2,500 Combined
Plan Payment Level – Based on the provider’s                  100% after deductible                             80% after deductible
reasonable charge (PRC)
Out-of-Pocket Maximums (Includes prescription
drug expenses and copayments. Once met, plan
payment level becomes 100%)
   Employee Only Plan                                                 None                                             $1,500
   Family Plan                                                        None                                             $3,000
Lifetime Maximum (per person)                                                          $5,000,000 Combined
Primary Care Physician Office Visits                          100% after deductible                             80% after deductible
Specialist Office Visits                                      100% after deductible                             80% after deductible
Preventive Care
   Adult
       Routine physical exams                           100% (deductible does not apply)                           Not Covered
       Adult Immunizations                                  100% after deductible                               80% after deductible
       Colorectal Cancer Screening
           Diagnostic Services                              100% after deductible                               80% after deductible
           Medical Surgical                                 100% after deductible                               80% after deductible
       Routine gynecological exams, including a         100% (deductible does not apply)                   80% (deductible does not apply)
       Pap Test
       Mammograms, annual routine and              Routine: 100% (deductible does not apply)                    80% after deductible
       medically necessary                         Medically necessary: 100% after deductible
    Pediatric
       Routine physical exams                           100% (deductible does not apply)                           Not Covered
       Pediatric immunizations                          100% (deductible does not apply)                  80% (deductible does not apply)
Emergency Room Services                                                              100% after deductible
Spinal Manipulations                                        100% after deductible                               80% after deductible
                                                                                  Limit: 20 visits/benefit period
Physical Medicine                                           100% after deductible                               80% after deductible
                                                                                  Limit: 20 visits/benefit period
Speech Therapy                                              100% after deductible                               80% after deductible
                                                                                  Limit: 20 visits/benefit period
Occupational Therapy                                        100% after deductible                               80% after deductible
                                                                                  Limit: 20 visits/benefit period
Allergy Extracts and Injections                             100% after deductible                               80% after deductible
Ambulance                                                                            100% after deductible
Assisted Fertilization Procedures                                                         Not Covered
Dental Services Related to Accidental Injury                100% after deductible                               80% after deductible
Diabetes Treatment                                          100% after deductible                               80% after deductible




                             Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                     -1-
 Benefit                                                                          Network                                           Out-of-Network
 Diagnostic Services (including routine)                                    100% after deductible                                     80% after deductible
   Advanced Imaging (MRI, CAT Scan, PET
   scan, etc.)
   Basic Diagnostic Services (standard imaging,                             100% after deductible                                     80% after deductible
   diagnostic medical, lab/pathology, allergy
   testing)
 Durable Medical Equipment, Orthotics and                                   100% after deductible                                     80% after deductible
 Prosthetics
 Enteral Formulae                                                           100% after deductible                                     80% after deductible
 Home Infusion Therapy                                                                                   100% after deductible
 Home Health Care                                                           100% after deductible                                     80% after deductible
 Hospice                                                                    100% after deductible                                     80% after deductible
 Hospital Services – Inpatient                                              100% after deductible                                     80% after deductible
 Hospital Services – Outpatient                                             100% after deductible                                     80% after deductible
 Infertility Counseling, Testing and                                        100% after deductible                                     80% after deductible
 Treatment(2)
 Maternity (facility & professional services)                               100% after deductible                                     80% after deductible
 Medical/Surgical Expenses (except office visits)                           100% after deductible                                     80% after deductible
 Mental Health – Inpatient(3)                                               100% after deductible                                     80% after deductible
 Mental Health – Outpatient(3)                                              100% after deductible                                     80% after deductible
 Private Duty Nursing                                                                                    100% after deductible
 Respiratory Therapy                                                                                     100% after deductible
 Skilled Nursing Facility Care                                              100% after deductible                                   80% after deductible
                                                                                                                                Limit: 100 days/benefit period
 Substance Abuse – Inpatient Detoxification                                 100% after deductible                                   80% after deductible
 Substance Abuse – Inpatient Rehabilitation                                 100% after deductible                                   80% after deductible
 Substance Abuse – Outpatient                                               100% after deductible                                   80% after deductible
 Therapy Services (Cardiac Rehab, Infusion                                  100% after deductible                                   80% after deductible
 Therapy, Chemotherapy, Radiation Therapy and
 Dialysis)
 Transplant Services                                                        100% after deductible                                     80% after deductible
 Precertification Requirements(4)                                                                                   Yes
 Prescription Drug Deductible
    Employee Only Plan                                                                            Integrated with medical deductible
    Family Plan                                                                                   Integrated with medical deductible
 Premier Prescription Drug Program                                                                  Retail Drugs (31-day Supply)
 Mandatory Generic(5)                                                                              Plan pays 100% after deductible
 Defined by Premier Pharmacy Network - Not
 Physician Network. Prescriptions filled at a non-                                 Maintenance Drugs through Mail Order (90-day Supply)
 network pharmacy are not covered.                                                            Plan pays 100% after deductible
(1) Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's renewal date. Contact
    your employer to determine the renewal date applicable to your program.
(2) Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered
    depending on your group’s prescription drug program.
(3) State mandated minimum benefits may apply to a diagnosis of serious mental illness. (If the above grid does not show a limit, your mental health benefit days and
    visits are unlimited.)
(4) Highmark Healthcare Management Services (HMS) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-related
    inpatient admission. Some facility providers will contact HMS and obtain precertification of the inpatient admission on your behalf. Be sure to verify that your
    provider is contacting HMS for precertification. If not, you are responsible for contacting HMS. If this does not occur and it is later determined that all or part of the
    inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered.
(5) At a retail or mail order pharmacy, if your deductible has not been met, you pay the entire cost for your prescription drug at the discounted rate Highmark has
    negotiated. The amount you paid for your prescription will be applied to your deductible. If your deductible has been met, you will only pay any member coinsurance
    required based on the benefit level indicated above. You will pay this amount at the pharmacy when you have your prescription filled.




                                     Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                     -1-
HDHP 100/80 $1,500 Deductible Value
Qualified High Deductible Health Plan (HDHP)
  This program is a qualified high deductible plan as defined by the Internal Revenue Service. It is designed for use with a Health Savings
                Account (HSA). This program should not be combined with any funding arrangement other than an HSA.

If you enroll as an individual, the deductible and out-of-pocket maximums for the “Employee Only Plan” apply. If you enroll as a family,
the deductible and out-of -pocket maximums for the “Family Plan” apply and can be satisfied by one or more of your family members.
Benefit                                                            Network                                     Out-of-Network
Benefit Period(1)                                                                          Contract Year
Deductible per benefit period (Applies to
Medical and Prescription Drug benefits)
   Employee Only Plan                                                                    $1,500 Combined
   Family Plan                                                                           $3,000 Combined
Plan Payment Level – Based on the provider’s                  100% after deductible                             80% after deductible
reasonable charge (PRC)
Out-of-Pocket Maximums (Includes prescription
drug expenses and copayments. Once met, plan
payment level becomes 100%)
   Employee Only Plan                                                 None                                             $1,500
   Family Plan                                                        None                                             $3,000
Lifetime Maximum (per person)                                                          $5,000,000 Combined
Primary Care Physician Office Visits                          100% after deductible                             80% after deductible
Specialist Office Visits                                      100% after deductible                             80% after deductible
Preventive Care
   Adult
       Routine physical exams                           100% (deductible does not apply)                           Not Covered
       Adult Immunizations                                  100% after deductible                               80% after deductible
       Colorectal Cancer Screening
           Diagnostic Services                              100% after deductible                               80% after deductible
           Medical Surgical                                 100% after deductible                               80% after deductible
       Routine gynecological exams, including a         100% (deductible does not apply)                   80% (deductible does not apply)
       Pap Test
       Mammograms, annual routine and              Routine: 100% (deductible does not apply)                    80% after deductible
       medically necessary                         Medically necessary: 100% after deductible
    Pediatric
       Routine physical exams                           100% (deductible does not apply)                           Not Covered
       Pediatric immunizations                          100% (deductible does not apply)                  80% (deductible does not apply)
Emergency Room Services                                                              100% after deductible
Spinal Manipulations                                        100% after deductible                               80% after deductible
                                                                                  Limit: 20 visits/benefit period
Physical Medicine                                           100% after deductible                               80% after deductible
                                                                                  Limit: 20 visits/benefit period
Speech Therapy                                              100% after deductible                               80% after deductible
                                                                                  Limit: 20 visits/benefit period
Occupational Therapy                                        100% after deductible                               80% after deductible
                                                                                  Limit: 20 visits/benefit period
Allergy Extracts and Injections                             100% after deductible                               80% after deductible
Ambulance                                                                            100% after deductible
Assisted Fertilization Procedures                                                         Not Covered
Dental Services Related to Accidental Injury                100% after deductible                               80% after deductible
Diabetes Treatment                                          100% after deductible                               80% after deductible




                             Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                     -1-
 Benefit                                                                          Network                                           Out-of-Network
 Diagnostic Services (including routine)                                    100% after deductible                                     80% after deductible
   Advanced Imaging (MRI, CAT Scan, PET
   scan, etc.)
   Basic Diagnostic Services (standard imaging,                             100% after deductible                                     80% after deductible
   diagnostic medical, lab/pathology, allergy
   testing)
 Durable Medical Equipment, Orthotics and                                   100% after deductible                                     80% after deductible
 Prosthetics
 Enteral Formulae                                                           100% after deductible                                     80% after deductible
 Home Infusion Therapy                                                                                   100% after deductible
 Home Health Care                                                           100% after deductible                                     80% after deductible
 Hospice                                                                    100% after deductible                                     80% after deductible
 Hospital Services – Inpatient                                              100% after deductible                                     80% after deductible
 Hospital Services – Outpatient                                             100% after deductible                                     80% after deductible
 Infertility Counseling, Testing and                                        100% after deductible                                     80% after deductible
 Treatment(2)
 Maternity (facility & professional services)                               100% after deductible                                     80% after deductible
 Medical/Surgical Expenses (except office visits)                           100% after deductible                                     80% after deductible
 Mental Health – Inpatient(3)                                               100% after deductible                                     80% after deductible
 Mental Health – Outpatient(3)                                              100% after deductible                                     80% after deductible
 Private Duty Nursing                                                                                    100% after deductible
 Respiratory Therapy                                                                                     100% after deductible
 Skilled Nursing Facility Care                                              100% after deductible                                   80% after deductible
                                                                                                                                Limit: 100 days/benefit period
 Substance Abuse – Inpatient Detoxification                                 100% after deductible                                   80% after deductible
 Substance Abuse – Inpatient Rehabilitation                                 100% after deductible                                   80% after deductible
 Substance Abuse – Outpatient                                               100% after deductible                                   80% after deductible
 Therapy Services (Cardiac Rehab, Infusion                                  100% after deductible                                   80% after deductible
 Therapy, Chemotherapy, Radiation Therapy and
 Dialysis)
 Transplant Services                                                        100% after deductible                                     80% after deductible
 Precertification Requirements(4)                                                                                   Yes
 Prescription Drug Deductible
    Employee Only Plan                                                                            Integrated with medical deductible
    Family Plan                                                                                   Integrated with medical deductible
 Premier Prescription Drug Program                                                                  Retail Drugs (31-day Supply)
 Mandatory Generic(5)                                                                              Plan pays 100% after deductible
 Defined by Premier Pharmacy Network - Not
 Physician Network. Prescriptions filled at a non-                                 Maintenance Drugs through Mail Order (90-day Supply)
 network pharmacy are not covered.                                                            Plan pays 100% after deductible
(1) Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's renewal date. Contact
    your employer to determine the renewal date applicable to your program.
(2) Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered
    depending on your group’s prescription drug program.
(3) State mandated minimum benefits may apply to a diagnosis of serious mental illness. (If the above grid does not show a limit, your mental health benefit days and
    visits are unlimited.)
(4) Highmark Healthcare Management Services (HMS) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-related
    inpatient admission. Some facility providers will contact HMS and obtain precertification of the inpatient admission on your behalf. Be sure to verify that your
    provider is contacting HMS for precertification. If not, you are responsible for contacting HMS. If this does not occur and it is later determined that all or part of the
    inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered.
(5) At a retail or mail order pharmacy, if your deductible has not been met, you pay the entire cost for your prescription drug at the discounted rate Highmark has
    negotiated. The amount you paid for your prescription will be applied to your deductible. If your deductible has been met, you will only pay any member coinsurance
    required based on the benefit level indicated above. You will pay this amount at the pharmacy when you have your prescription filled.




                                     Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                     -1-
HDHP 100/80 $2,000 Deductible Value
Qualified High Deductible Health Plan (HDHP)
  This program is a qualified high deductible plan as defined by the Internal Revenue Service. It is designed for use with a Health Savings
                Account (HSA). This program should not be combined with any funding arrangement other than an HSA.

If you enroll as an individual, the deductible and out-of-pocket maximums for the “Employee Only Plan” apply. If you enroll as a family,
the deductible and out-of -pocket maximums for the “Family Plan” apply and can be satisfied by one or more of your family members.
Benefit                                                            Network                                     Out-of-Network
Benefit Period(1)                                                                          Contract Year
Deductible per benefit period (Applies to
Medical and Prescription Drug benefits)
   Employee Only Plan                                                                    $2,000 Combined
   Family Plan                                                                           $4,000 Combined
Plan Payment Level – Based on the provider’s                  100% after deductible                             80% after deductible
reasonable charge (PRC)
Out-of-Pocket Maximums (Includes prescription
drug expenses and copayments. Once met, plan
payment level becomes 100%)
   Employee Only Plan                                                 None                                             $1,500
   Family Plan                                                        None                                             $3,000
Lifetime Maximum (per person)                                                          $5,000,000 Combined
Primary Care Physician Office Visits                          100% after deductible                             80% after deductible
Specialist Office Visits                                      100% after deductible                             80% after deductible
Preventive Care
   Adult
       Routine physical exams                           100% (deductible does not apply)                           Not Covered
       Adult Immunizations                                  100% after deductible                               80% after deductible
       Colorectal Cancer Screening
           Diagnostic Services                              100% after deductible                               80% after deductible
           Medical Surgical                                 100% after deductible                               80% after deductible
       Routine gynecological exams, including a         100% (deductible does not apply)                   80% (deductible does not apply)
       Pap Test
       Mammograms, annual routine and              Routine: 100% (deductible does not apply)                    80% after deductible
       medically necessary                         Medically necessary: 100% after deductible
    Pediatric
       Routine physical exams                           100% (deductible does not apply)                           Not Covered
       Pediatric immunizations                          100% (deductible does not apply)                  80% (deductible does not apply)
Emergency Room Services                                                              100% after deductible
Spinal Manipulations                                        100% after deductible                               80% after deductible
                                                                                  Limit: 20 visits/benefit period
Physical Medicine                                           100% after deductible                               80% after deductible
                                                                                  Limit: 20 visits/benefit period
Speech Therapy                                              100% after deductible                               80% after deductible
                                                                                  Limit: 20 visits/benefit period
Occupational Therapy                                        100% after deductible                               80% after deductible
                                                                                  Limit: 20 visits/benefit period
Allergy Extracts and Injections                             100% after deductible                               80% after deductible
Ambulance                                                                            100% after deductible
Assisted Fertilization Procedures                                                         Not Covered
Dental Services Related to Accidental Injury                100% after deductible                               80% after deductible
Diabetes Treatment                                          100% after deductible                               80% after deductible




                             Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                     -1-
 Benefit                                                                          Network                                           Out-of-Network
 Diagnostic Services (including routine)                                    100% after deductible                                     80% after deductible
   Advanced Imaging (MRI, CAT Scan, PET
   scan, etc.)
   Basic Diagnostic Services (standard imaging,                             100% after deductible                                     80% after deductible
   diagnostic medical, lab/pathology, allergy
   testing)
 Durable Medical Equipment, Orthotics and                                   100% after deductible                                     80% after deductible
 Prosthetics
 Enteral Formulae                                                           100% after deductible                                     80% after deductible
 Home Infusion Therapy                                                                                   100% after deductible
 Home Health Care                                                           100% after deductible                                     80% after deductible
 Hospice                                                                    100% after deductible                                     80% after deductible
 Hospital Services – Inpatient                                              100% after deductible                                     80% after deductible
 Hospital Services – Outpatient                                             100% after deductible                                     80% after deductible
 Infertility Counseling, Testing and                                        100% after deductible                                     80% after deductible
 Treatment(2)
 Maternity (facility & professional services)                               100% after deductible                                     80% after deductible
 Medical/Surgical Expenses (except office visits)                           100% after deductible                                     80% after deductible
 Mental Health – Inpatient(3)                                               100% after deductible                                     80% after deductible
 Mental Health – Outpatient(3)                                              100% after deductible                                     80% after deductible
 Private Duty Nursing                                                                                    100% after deductible
 Respiratory Therapy                                                                                     100% after deductible
 Skilled Nursing Facility Care                                              100% after deductible                                   80% after deductible
                                                                                                                                Limit: 100 days/benefit period
 Substance Abuse – Inpatient Detoxification                                 100% after deductible                                   80% after deductible
 Substance Abuse – Inpatient Rehabilitation                                 100% after deductible                                   80% after deductible
 Substance Abuse – Outpatient                                               100% after deductible                                   80% after deductible
 Therapy Services (Cardiac Rehab, Infusion                                  100% after deductible                                   80% after deductible
 Therapy, Chemotherapy, Radiation Therapy and
 Dialysis)
 Transplant Services                                                        100% after deductible                                     80% after deductible
 Precertification Requirements(4)                                                                                   Yes
 Prescription Drug Deductible
    Employee Only Plan                                                                            Integrated with medical deductible
    Family Plan                                                                                   Integrated with medical deductible
 Premier Prescription Drug Program                                                                  Retail Drugs (31-day Supply)
 Mandatory Generic(5)                                                                              Plan pays 100% after deductible
 Defined by Premier Pharmacy Network - Not
 Physician Network. Prescriptions filled at a non-                                 Maintenance Drugs through Mail Order (90-day Supply)
 network pharmacy are not covered.                                                            Plan pays 100% after deductible
(1) Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's renewal date. Contact
    your employer to determine the renewal date applicable to your program.
(2) Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered
    depending on your group’s prescription drug program.
(3) State mandated minimum benefits may apply to a diagnosis of serious mental illness. (If the above grid does not show a limit, your mental health benefit days and
    visits are unlimited.)
(4) Highmark Healthcare Management Services (HMS) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-related
    inpatient admission. Some facility providers will contact HMS and obtain precertification of the inpatient admission on your behalf. Be sure to verify that your
    provider is contacting HMS for precertification. If not, you are responsible for contacting HMS. If this does not occur and it is later determined that all or part of the
    inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered.
(5) At a retail or mail order pharmacy, if your deductible has not been met, you pay the entire cost for your prescription drug at the discounted rate Highmark has
    negotiated. The amount you paid for your prescription will be applied to your deductible. If your deductible has been met, you will only pay any member coinsurance
    required based on the benefit level indicated above. You will pay this amount at the pharmacy when you have your prescription filled.




                                     Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                     -1-
PPOBlue HDHP 100/80 $2,600
Qualified High Deductible Health Plan (HDHP)
  This program is a qualified high deductible plan as defined by the Internal Revenue Service. It is designed for use with a Health Savings
                Account (HSA). This program should not be combined with any funding arrangement other than an HSA.

If you enroll as an individual, the deductible and out-of-pocket maximums for the “Employee Only Plan” apply. If you enroll as a family,
the deductible and out-of -pocket maximums for the “Family Plan” apply and can be satisfied by one or more of your family members.
Benefit                                                            Network                                     Out-of-Network
Benefit Period(1)                                                                          Contract Year
Deductible per benefit period (Applies to
Medical and Prescription Drug benefits)
   Employee Only Plan                                                                    $2,600 Combined
   Family Plan                                                                           $5,200 Combined
Plan Payment Level – Based on the provider’s                  100% after deductible                             80% after deductible
reasonable charge (PRC)
Out-of-Pocket Maximums (Includes prescription
drug expenses and copayments. Once met, plan
payment level becomes 100%)
   Employee Only Plan                                                 None                                             $1,500
   Family Plan                                                        None                                             $3,000
Lifetime Maximum (per person)                                                          $5,000,000 Combined
Primary Care Physician Office Visits                          100% after deductible                             80% after deductible
Specialist Office Visits                                      100% after deductible                             80% after deductible
Preventive Care
   Adult
       Routine physical exams                           100% (deductible does not apply)                           Not Covered
       Adult Immunizations                                  100% after deductible                               80% after deductible
       Colorectal Cancer Screening
           Diagnostic Services                              100% after deductible                               80% after deductible
           Medical Surgical                                 100% after deductible                               80% after deductible
       Routine gynecological exams, including a         100% (deductible does not apply)                   80% (deductible does not apply)
       Pap Test
       Mammograms, annual routine and              Routine: 100% (deductible does not apply)                    80% after deductible
       medically necessary                         Medically necessary: 100% after deductible
    Pediatric
       Routine physical exams                           100% (deductible does not apply)                           Not Covered
       Pediatric immunizations                          100% (deductible does not apply)                  80% (deductible does not apply)
Emergency Room Services                                                              100% after deductible
Spinal Manipulations                                        100% after deductible                               80% after deductible
                                                                                  Limit: 20 visits/benefit period
Physical Medicine                                           100% after deductible                               80% after deductible
                                                                                  Limit: 20 visits/benefit period
Speech Therapy                                              100% after deductible                               80% after deductible
                                                                                  Limit: 20 visits/benefit period
Occupational Therapy                                        100% after deductible                               80% after deductible
                                                                                  Limit: 20 visits/benefit period
Allergy Extracts and Injections                             100% after deductible                               80% after deductible
Ambulance                                                                            100% after deductible
Assisted Fertilization Procedures                                                         Not Covered
Dental Services Related to Accidental Injury                100% after deductible                               80% after deductible
Diabetes Treatment                                          100% after deductible                               80% after deductible




                             Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                     -1-
 Benefit                                                                          Network                                           Out-of-Network
 Diagnostic Services (including routine)                                    100% after deductible                                     80% after deductible
   Advanced Imaging (MRI, CAT Scan, PET
   scan, etc.)
   Basic Diagnostic Services (standard imaging,                             100% after deductible                                     80% after deductible
   diagnostic medical, lab/pathology, allergy
   testing)
 Durable Medical Equipment, Orthotics and                                   100% after deductible                                     80% after deductible
 Prosthetics
 Enteral Formulae                                                           100% after deductible                                     80% after deductible
 Home Infusion Therapy                                                                                   100% after deductible
 Home Health Care                                                           100% after deductible                                     80% after deductible
 Hospice                                                                    100% after deductible                                     80% after deductible
 Hospital Services – Inpatient                                              100% after deductible                                     80% after deductible
 Hospital Services – Outpatient                                             100% after deductible                                     80% after deductible
 Infertility Counseling, Testing and                                        100% after deductible                                     80% after deductible
 Treatment(2)
 Maternity (facility & professional services)                               100% after deductible                                     80% after deductible
 Medical/Surgical Expenses (except office visits)                           100% after deductible                                     80% after deductible
 Mental Health – Inpatient(3)                                               100% after deductible                                     80% after deductible
 Mental Health – Outpatient(3)                                              100% after deductible                                     80% after deductible
 Private Duty Nursing                                                                                    100% after deductible
 Respiratory Therapy                                                                                     100% after deductible
 Skilled Nursing Facility Care                                              100% after deductible                                   80% after deductible
                                                                                                                                Limit: 100 days/benefit period
 Substance Abuse – Inpatient Detoxification                                 100% after deductible                                   80% after deductible
 Substance Abuse – Inpatient Rehabilitation                                 100% after deductible                                   80% after deductible
 Substance Abuse – Outpatient                                               100% after deductible                                   80% after deductible
 Therapy Services (Cardiac Rehab, Infusion                                  100% after deductible                                   80% after deductible
 Therapy, Chemotherapy, Radiation Therapy and
 Dialysis)
 Transplant Services                                                        100% after deductible                                     80% after deductible
 Precertification Requirements(4)                                                                                   Yes
 Prescription Drug Deductible
    Employee Only Plan                                                                   Applies to Medical and Prescription Drug Benefits
    Family Plan                                                                          Applies to Medical and Prescription Drug Benefits
 Premier Prescription Drug Program(5)                                                             Retail Drugs (31-day Supply)
 Defined by Premier Pharmacy Network - Not                                                        Plan pays 100% after deductible
 Physician Network. Prescriptions filled at a non-
 network pharmacy are not covered.                                                 Maintenance Drugs through Mail Order (90-day Supply)
                                                                                              Plan pays 100% after deductible
(1) Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's renewal date. Contact
    your employer to determine the renewal date applicable to your program.
(2) Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered
    depending on your group’s prescription drug program.
(3) State mandated minimum benefits may apply to a diagnosis of serious mental illness. (If the above grid does not show a limit, your mental health benefit days and
    visits are unlimited.)
(4) Highmark Healthcare Management Services (HMS) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-related
    inpatient admission. Some facility providers will contact HMS and obtain precertification of the inpatient admission on your behalf. Be sure to verify that your
    provider is contacting HMS for precertification. If not, you are responsible for contacting HMS. If this does not occur and it is later determined that all or part of the
    inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered.
(5) At a retail or mail order pharmacy, if your deductible has not been met, you pay the entire cost for your prescription drug at the discounted rate Highmark has
    negotiated. The amount you paid for your prescription will be applied to your deductible. If your deductible has been met, you will only pay any member coinsurance
    required based on the benefit level indicated above. You will pay this amount at the pharmacy when you have your prescription filled.




                                     Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                     -1-
Out-of-Area PPO Out-of-Area HDHP 100/80 $2,600
Deductible
Qualified High Deductible Health Plan (HDHP)
  This program is a qualified high deductible plan as defined by the Internal Revenue Service. It is designed for use with a Health Savings
                Account (HSA). This program should not be combined with any funding arrangement other than an HSA.

If you enroll as an individual, the deductible and out-of-pocket maximums for the “Employee Only Plan” apply. If you enroll as a family,
the deductible and out-of -pocket maximums for the “Family Plan” apply and can be satisfied by one or more of your family members.
Benefit                                                            Network                                     Out-of-Network
Benefit Period(1)                                                                          Contract Year
Deductible per benefit period (Applies to
Medical and Prescription Drug benefits)
   Employee Only Plan                                                                    $2,600 Combined
   Family Plan                                                                           $5,200 Combined
Plan Payment Level – Based on the provider’s                  100% after deductible                             80% after deductible
reasonable charge (PRC)
Out-of-Pocket Maximums (Includes prescription
drug expenses and copayments. Once met, plan
payment level becomes 100%)                                           None                                             $1,500
   Employee Only Plan                                                 None                                             $3,000
   Family Plan
Lifetime Maximum (per person)                                                          $5,000,000 Combined
Primary Care Physician Office Visits                          100% after deductible                             80% after deductible
Specialist Office Visits                                      100% after deductible                             80% after deductible
Preventive Care
   Adult
       Routine physical exams                           100% (deductible does not apply)                           Not Covered
       Adult Immunizations                                  100% after deductible                               80% after deductible
       Colorectal Cancer Screening
           Diagnostic Services                              100% after deductible                               80% after deductible
           Medical Surgical                                 100% after deductible                               80% after deductible
       Routine gynecological exams, including a         100% (deductible does not apply)                   80% (deductible does not apply)
       Pap Test
       Mammograms, annual routine and              Routine: 100% (deductible does not apply)                    80% after deductible
       medically necessary                         Medically Necessary: 100% after deductible
    Pediatric
       Routine physical exams                           100% (deductible does not apply)                           Not Covered
       Pediatric immunizations                          100% (deductible does not apply)                 80% (deductible does not apply)
Emergency Room Services                                                               100% after deductible
Spinal Manipulations                                        100% after deductible                               80% after deductible
                                                                                  Limit: 20 visits/benefit period
Physical Medicine                                           100% after deductible                               80% after deductible
                                                                                  Limit: 20 visits/benefit period
Speech Therapy                                              100% after deductible                               80% after deductible
                                                                                  Limit: 20 visits/benefit period
Occupational Therapy                                        100% after deductible                               80% after deductible
                                                                                  Limit: 20 visits/benefit period
Allergy Extracts and Injections                             100% after deductible                               80% after deductible
Ambulance                                                                             100% after deductible
Assisted Fertilization Procedures                                                         Not Covered
Dental Services Related to Accidental Injury                100% after deductible                               80% after deductible
Diabetes Treatment                                          100% after deductible                               80% after deductible



                             Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                     -1-
 Benefit                                                                         Network                                            Out-of-Network
 Diagnostic Services (including routine)                                    100% after deductible                                    80% after deductible
    Advanced Imaging (MRI, CAT Scan, PET
    scan, etc.)
    Basic Diagnostic Services (standard imaging,                            100% after deductible                                    80% after deductible
    diagnostic medical, lab/pathology, allergy
    testing)
 Durable Medical Equipment, Orthotics and                                   100% after deductible                                    80% after deductible
 Prosthetics
 Enteral Formulae                                                           100% after deductible                                    80% after deductible
 Home Infusion Therapy                                                                                   100% after deductible
 Home Health Care                                                           100% after deductible                                    80% after deductible
 Hospice                                                                    100% after deductible                                    80% after deductible
 Hospital Services – Inpatient                                              100% after deductible                                    80% after deductible
 Hospital Services – Outpatient                                             100% after deductible                                    80% after deductible
 Infertility Counseling, Testing and                                        100% after deductible                                    80% after deductible
 Treatment(2)
 Maternity (facility & professional services)                               100% after deductible                                    80% after deductible
 Medical/Surgical Expenses (except office visits)                           100% after deductible                                    80% after deductible
 Mental Health – Inpatient(3)                                               100% after deductible                                    80% after deductible
 Mental Health – Outpatient(3)                                              100% after deductible                                    80% after deductible
 Private Duty Nursing                                                                                    100% after deductible
 Respiratory Therapy                                                                                     100% after deductible
 Skilled Nursing Facility Care                                              100% after deductible                                   80% after deductible
                                                                                                                                Limit: 100 days/benefit period
 Substance Abuse – Inpatient Detoxification                                 100% after deductible                                   80% after deductible
 Substance Abuse – Inpatient Rehabilitation                                 100% after deductible                                   80% after deductible
 Substance Abuse – Outpatient                                               100% after deductible                                   80% after deductible
 Therapy Services (Cardiac Rehab, Infusion                                  100% after deductible                                   80% after deductible
 Therapy, Chemotherapy, Radiation Therapy and
 Dialysis)
 Transplant Services                                                        100% after deductible                                    80% after deductible
 Precertification Requirements(4)                                                                                   Yes
 Prescription Drug Deductible
    Employee Only Plan                                                                   Applies to Medical and Prescription Drug Benefits
    Family Plan                                                                          Applies to Medical and Prescription Drug Benefits
 Premier Prescription Drug Program (5)                                                            Retail Drugs (31-day Supply)
 Defined by Premier Pharmacy Network - Not                                                        Plan pays 100% after deductible
 Physician Network. Prescriptions filled at a non-
 network pharmacy are not covered.                                                 Maintenance Drugs through Mail Order (90-day Supply)
                                                                                              Plan pays 100% after deductible
(1) Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's renewal date. Contact
    your employer to determine the renewal date applicable to your program.
(2) Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered
    depending on your group’s prescription drug program.
(3) State mandated minimum benefits may apply to a diagnosis of serious mental illness. (If the above grid does not show a limit, your mental health benefit days and
    visits are unlimited.)
(4) Highmark Healthcare Management Services (HMS) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-related
    inpatient admission. Some facility providers will contact HMS and obtain precertification of the inpatient admission on your behalf. Be sure to verify that your
    provider is contacting HMS for precertification. If not, you are responsible for contacting HMS. If this does not occur and it is later determined that all or part of the
    inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered.
(5) At a retail or mail order pharmacy, if your deductible has not been met, you pay the entire cost for your prescription drug at the discounted rate Highmark has
    negotiated. The amount you paid for your prescription will be applied to your deductible. If your deductible has been met, you will only pay any member coinsurance
    required based on the benefit level indicated above. You will pay this amount at the pharmacy when you have your prescription filled.




                                     Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                     -1-
PPOBlue HDHP 90/70 $2,600
Qualified High Deductible Health Plan (HDHP)
  This program is a qualified high deductible plan as defined by the Internal Revenue Service. It is designed for use with a Health Savings
                Account (HSA). This program should not be combined with any funding arrangement other than an HSA.

If you enroll as an individual, the deductible and out-of-pocket maximums for the “Employee Only Plan” apply. If you enroll as a family,
the deductible and out-of -pocket maximums for the “Family Plan” apply and can be satisfied by one or more of your family members.
Benefit                                                            Network                                      Out-of-Network
Benefit Period(1)                                                                           Contract Year
Deductible per benefit period (Applies to
Medical and Prescription Drug benefits)
   Employee Only Plan                                                                      $2,600 Combined
   Family Plan                                                                             $5,200 Combined
Plan Payment Level – Based on the provider’s                   90% after deductible                              70% after deductible
reasonable charge (PRC)
Out-of-Pocket Maximums (Includes prescription
drug expenses and copayments. Once met, plan
payment level becomes 100%)
   Employee Only Plan                                                 $1,000                                            $2,000
   Family Plan                                                        $2,000                                            $4,000
Lifetime Maximum (per person)                                                          $5,000,000 Combined
Primary Care Physician Office Visits                           90% after deductible                              70% after deductible
Specialist Office Visits                                       90% after deductible                              70% after deductible
Preventive Care
   Adult
       Routine physical exams                            90% (deductible does not apply)                            Not Covered
       Adult Immunizations                                    90% after deductible                               70% after deductible
       Colorectal Cancer Screening
           Diagnostic Services                                90% after deductible                               70% after deductible
           Medical Surgical                                   90% after deductible                               70% after deductible
       Routine gynecological exams, including a          90% (deductible does not apply)                    70% (deductible does not apply)
       Pap Test
       Mammograms, annual routine and               Routine: 90% (deductible does not apply)                     70% after deductible
       medically necessary                          Medically necessary: 90% after deductible
    Pediatric
       Routine physical exams                            90% (deductible does not apply)                           Not Covered
       Pediatric immunizations                           90% (deductible does not apply)                  70% (deductible does not apply)
Emergency Room Services                                                                90% after deductible
Spinal Manipulations                                          90% after deductible                              70% after deductible
                                                                                  Limit: 20 visits/benefit period
Physical Medicine                                             90% after deductible                              70% after deductible
                                                                                  Limit: 20 visits/benefit period
Speech Therapy                                                90% after deductible                              70% after deductible
                                                                                  Limit: 20 visits/benefit period
Occupational Therapy                                          90% after deductible                              70% after deductible
                                                                                  Limit: 20 visits/benefit period
Allergy Extracts and Injections                               90% after deductible                              70% after deductible
Ambulance                                                                              90% after deductible
Assisted Fertilization Procedures                                                         Not Covered
Dental Services Related to Accidental Injury                  90% after deductible                              70% after deductible
Diabetes Treatment                                            90% after deductible                              70% after deductible




                             Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                     -1-
 Benefit                                                                          Network                                           Out-of-Network
 Diagnostic Services (including routine)                                     90% after deductible                                     70% after deductible
   Advanced Imaging (MRI, CAT Scan, PET
   scan, etc.)
   Basic Diagnostic Services (standard imaging,                              90% after deductible                                     70% after deductible
   diagnostic medical, lab/pathology, allergy
   testing)
 Durable Medical Equipment, Orthotics and                                    90% after deductible                                     70% after deductible
 Prosthetics
 Enteral Formulae                                                            90% after deductible                                     70% after deductible
 Home Infusion Therapy                                                                                    90% after deductible
 Home Health Care                                                            90% after deductible                                     70% after deductible
 Hospice                                                                     90% after deductible                                     70% after deductible
 Hospital Services – Inpatient                                               90% after deductible                                     70% after deductible
 Hospital Services – Outpatient                                              90% after deductible                                     70% after deductible
 Infertility Counseling, Testing and                                         90% after deductible                                     70% after deductible
 Treatment(2)
 Maternity (facility & professional services)                                90% after deductible                                     70% after deductible
 Medical/Surgical Expenses (except office visits)                            90% after deductible                                     70% after deductible
 Mental Health – Inpatient(3)                                                90% after deductible                                     70% after deductible
 Mental Health – Outpatient(3)                                               90% after deductible                                     70% after deductible
 Private Duty Nursing                                                                                     90% after deductible
 Respiratory Therapy                                                                                      90% after deductible
 Skilled Nursing Facility Care                                               90% after deductible                                   70% after deductible
                                                                                                                                Limit: 100 days/benefit period
 Substance Abuse – Inpatient Detoxification                                  90% after deductible                                   70% after deductible
 Substance Abuse – Inpatient Rehabilitation                                  90% after deductible                                   70% after deductible
 Substance Abuse – Outpatient                                                90% after deductible                                   70% after deductible
 Therapy Services (Cardiac Rehab, Infusion                                   90% after deductible                                   70% after deductible
 Therapy, Chemotherapy, Radiation Therapy and
 Dialysis)
 Transplant Services                                                         90% after deductible                                     70% after deductible
 Precertification Requirements(4)                                                                                   Yes
 Prescription Drug Deductible
    Employee Only Plan                                                                   Applies to Medical and Prescription Drug Benefits
    Family Plan                                                                          Applies to Medical and Prescription Drug Benefits
 Premier Prescription Drug Program(5)                                                             Retail Drugs (31-day Supply)
 Defined by Premier Pharmacy Network - Not                                                         Plan pays 90% after deductible
 Physician Network. Prescriptions filled at a non-
 network pharmacy are not covered.                                                 Maintenance Drugs through Mail Order (90-day Supply)
                                                                                               Plan pays 90% after deductible
(1) Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's renewal date. Contact
    your employer to determine the renewal date applicable to your program.
(2) Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered
    depending on your group’s prescription drug program.
(3) State mandated minimum benefits may apply to a diagnosis of serious mental illness. (If the above grid does not show a limit, your mental health benefit days and
    visits are unlimited.)
(4) Highmark Healthcare Management Services (HMS) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-related
    inpatient admission. Some facility providers will contact HMS and obtain precertification of the inpatient admission on your behalf. Be sure to verify that your
    provider is contacting HMS for precertification. If not, you are responsible for contacting HMS. If this does not occur and it is later determined that all or part of the
    inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered.
(5) At a retail or mail order pharmacy, if your deductible has not been met, you pay the entire cost for your prescription drug at the discounted rate Highmark has
    negotiated. The amount you paid for your prescription will be applied to your deductible. If your deductible has been met, you will only pay any member coinsurance
    required based on the benefit level indicated above. You will pay this amount at the pharmacy when you have your prescription filled.




                                     Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                     -1-
PPOBlue HDHP 90/70 $3,500 Deductible
Qualified High Deductible Health Plan (HDHP)
  This program is a qualified high deductible plan as defined by the Internal Revenue Service. It is designed for use with a Health Savings
                Account (HSA). This program should not be combined with any funding arrangement other than an HSA.

If you enroll as an individual, the deductible and out-of-pocket maximums for the “Employee Only Plan” apply. If you enroll as a family,
the deductible and out-of -pocket maximums for the “Family Plan” apply and can be satisfied by one or more of your family members.
Benefit                                                            Network                                      Out-of-Network
Benefit Period(1)                                                                           Contract Year
Deductible per benefit period (Applies to
Medical and Prescription Drug benefits)
   Employee Only Plan                                                                      $3,500 Combined
   Family Plan                                                                             $7,000 Combined
Plan Payment Level – Based on the provider’s                   90% after deductible                              70% after deductible
reasonable charge (PRC)
Out-of-Pocket Maximums (Includes prescription
drug expenses and copayments. Once met, plan
payment level becomes 100%)
   Employee Only Plan                                                 $1,000                                            $2,000
   Family Plan                                                        $2,000                                            $4,000
Lifetime Maximum (per person)                                                          $5,000,000 Combined
Primary Care Physician Office Visits                           90% after deductible                              70% after deductible
Specialist Office Visits                                       90% after deductible                              70% after deductible
Preventive Care
   Adult
       Routine physical exams                            90% (deductible does not apply)                            Not Covered
       Adult Immunizations                                    90% after deductible                               70% after deductible
       Colorectal Cancer Screening
           Diagnostic Services                                90% after deductible                               70% after deductible
           Medical Surgical                                   90% after deductible                               70% after deductible
       Routine gynecological exams, including a          90% (deductible does not apply)                    70% (deductible does not apply)
       Pap Test
       Mammograms, annual routine and               Routine: 90% (deductible does not apply)                     70% after deductible
       medically necessary                          Medically necessary: 90% after deductible
    Pediatric
       Routine physical exams                            90% (deductible does not apply)                           Not Covered
       Pediatric immunizations                           90% (deductible does not apply)                  70% (deductible does not apply)
Emergency Room Services                                                                90% after deductible
Spinal Manipulations                                          90% after deductible                              70% after deductible
                                                                                  Limit: 20 visits/benefit period
Physical Medicine                                             90% after deductible                              70% after deductible
                                                                                  Limit: 20 visits/benefit period
Speech Therapy                                                90% after deductible                              70% after deductible
                                                                                  Limit: 20 visits/benefit period
Occupational Therapy                                          90% after deductible                              70% after deductible
                                                                                  Limit: 20 visits/benefit period
Allergy Extracts and Injections                               90% after deductible                              70% after deductible
Ambulance                                                                              90% after deductible
Assisted Fertilization Procedures                                                         Not Covered
Dental Services Related to Accidental Injury                  90% after deductible                              70% after deductible
Diabetes Treatment                                            90% after deductible                              70% after deductible




                             Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                     -1-
 Benefit                                                                          Network                                           Out-of-Network
 Diagnostic Services (including routine)                                     90% after deductible                                     70% after deductible
   Advanced Imaging (MRI, CAT Scan, PET
   scan, etc.)
   Basic Diagnostic Services (standard imaging,                              90% after deductible                                     70% after deductible
   diagnostic medical, lab/pathology, allergy
   testing)
 Durable Medical Equipment, Orthotics and                                    90% after deductible                                     70% after deductible
 Prosthetics
 Enteral Formulae                                                            90% after deductible                                     70% after deductible
 Home Infusion Therapy                                                                                    90% after deductible
 Home Health Care                                                            90% after deductible                                     70% after deductible
 Hospice                                                                     90% after deductible                                     70% after deductible
 Hospital Services – Inpatient                                               90% after deductible                                     70% after deductible
 Hospital Services – Outpatient                                              90% after deductible                                     70% after deductible
 Infertility Counseling, Testing and                                         90% after deductible                                     70% after deductible
 Treatment(2)
 Maternity (facility & professional services)                                90% after deductible                                     70% after deductible
 Medical/Surgical Expenses (except office visits)                            90% after deductible                                     70% after deductible
 Mental Health – Inpatient(3)                                                90% after deductible                                     70% after deductible
 Mental Health – Outpatient(3)                                               90% after deductible                                     70% after deductible
 Private Duty Nursing                                                                                     90% after deductible
 Respiratory Therapy                                                                                      90% after deductible
 Skilled Nursing Facility Care                                               90% after deductible                                   70% after deductible
                                                                                                                                Limit: 100 days/benefit period
 Substance Abuse – Inpatient Detoxification                                  90% after deductible                                   70% after deductible
 Substance Abuse – Inpatient Rehabilitation                                  90% after deductible                                   70% after deductible
 Substance Abuse – Outpatient                                                90% after deductible                                   70% after deductible
 Therapy Services (Cardiac Rehab, Infusion                                   90% after deductible                                   70% after deductible
 Therapy, Chemotherapy, Radiation Therapy and
 Dialysis)
 Transplant Services                                                         90% after deductible                                     70% after deductible
 Precertification Requirements(4)                                                                                   Yes
 Prescription Drug Deductible
    Employee Only Plan                                                                   Applies to Medical and Prescription Drug Benefits
    Family Plan                                                                          Applies to Medical and Prescription Drug Benefits
 Premier Prescription Drug Program(5)                                                             Retail Drugs (31-day Supply)
 Defined by Premier Pharmacy Network - Not                                                         Plan pays 90% after deductible
 Physician Network. Prescriptions filled at a non-
 network pharmacy are not covered.                                                 Maintenance Drugs through Mail Order (90-day Supply)
                                                                                               Plan pays 90% after deductible
(1) Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's renewal date. Contact
    your employer to determine the renewal date applicable to your program.
(2) Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered
    depending on your group’s prescription drug program.
(3) State mandated minimum benefits may apply to a diagnosis of serious mental illness. (If the above grid does not show a limit, your mental health benefit days and
    visits are unlimited.)
(4) Highmark Healthcare Management Services (HMS) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-related
    inpatient admission. Some facility providers will contact HMS and obtain precertification of the inpatient admission on your behalf. Be sure to verify that your
    provider is contacting HMS for precertification. If not, you are responsible for contacting HMS. If this does not occur and it is later determined that all or part of the
    inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered.
(5) At a retail or mail order pharmacy, if your deductible has not been met, you pay the entire cost for your prescription drug at the discounted rate Highmark has
    negotiated. The amount you paid for your prescription will be applied to your deductible. If your deductible has been met, you will only pay any member coinsurance
    required based on the benefit level indicated above. You will pay this amount at the pharmacy when you have your prescription filled.




                                     Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                     -1-
PPOBlue HDHP 80/60 Value
Qualified High Deductible Health Plan (HDHP)
  This program is a qualified high deductible plan as defined by the Internal Revenue Service. It is designed for use with a Health Savings
                Account (HSA). This program should not be combined with any funding arrangement other than an HSA.

If you enroll as an individual, the deductible and out-of-pocket maximums for the “Employee Only Plan” apply. If you enroll as a family,
the deductible and out-of -pocket maximums for the “Family Plan” apply and can be satisfied by one or more of your family members.
Benefit                                                            Network                                      Out-of-Network
Benefit Period(1)                                                                           Contract Year
Deductible per benefit period (Applies to
Medical and Prescription Drug benefits)
   Employee Only Plan                                                                      $1,250 Combined
   Family Plan                                                                             $2,500 Combined
Plan Payment Level – Based on the provider’s                   80% after deductible                              60% after deductible
reasonable charge (PRC)
Out-of-Pocket Maximums (Includes prescription
drug expenses and copayments. Once met, plan
payment level becomes 100%)
   Employee Only Plan                                                 $1,500                                            $3,000
   Family Plan                                                        $3,000                                            $6,000
Lifetime Maximum (per person)                                                          $5,000,000 Combined
Primary Care Physician Office Visits                           80% after deductible                              60% after deductible
Specialist Office Visits                                       80% after deductible                              60% after deductible
Preventive Care
   Adult
       Routine physical exams                            80% (deductible does not apply)                            Not Covered
       Adult Immunizations                                    80% after deductible                               60% after deductible
       Colorectal Cancer Screening
           Diagnostic Services                                80% after deductible                               60% after deductible
           Medical Surgical                                   80% after deductible                               60% after deductible
       Routine gynecological exams, including a          80% (deductible does not apply)                    60% (deductible does not apply)
       Pap Test
       Mammograms, annual routine and               Routine: 80% (deductible does not apply)                     60% after deductible
       medically necessary                          Medically necessary: 80% after deductible
    Pediatric
       Routine physical exams                            80% (deductible does not apply)                           Not Covered
       Pediatric immunizations                           80% (deductible does not apply)                  60% (deductible does not apply)
Emergency Room Services                                                                80% after deductible
Spinal Manipulations                                          80% after deductible                              60% after deductible
                                                                                  Limit: 20 visits/benefit period
Physical Medicine                                             80% after deductible                              60% after deductible
                                                                                  Limit: 20 visits/benefit period
Speech Therapy                                                80% after deductible                              60% after deductible
                                                                                  Limit: 20 visits/benefit period
Occupational Therapy                                          80% after deductible                              60% after deductible
                                                                                  Limit: 20 visits/benefit period
Allergy Extracts and Injections                               80% after deductible                              60% after deductible
Ambulance                                                                              80% after deductible
Assisted Fertilization Procedures                                                         Not Covered
Dental Services Related to Accidental Injury                  80% after deductible                              60% after deductible
Diabetes Treatment                                            80% after deductible                              60% after deductible




                             Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                     -1-
 Benefit                                                                          Network                                           Out-of-Network
 Diagnostic Services (including routine)                                     80% after deductible                                     60% after deductible
   Advanced Imaging (MRI, CAT Scan, PET
   scan, etc.)
   Basic Diagnostic Services (standard imaging,                              80% after deductible                                     60% after deductible
   diagnostic medical, lab/pathology, allergy
   testing)
 Durable Medical Equipment, Orthotics and                                    80% after deductible                                     60% after deductible
 Prosthetics
 Enteral Formulae                                                            80% after deductible                                     60% after deductible
 Home Infusion Therapy                                                                                    80% after deductible
 Home Health Care                                                            80% after deductible                                     60% after deductible
 Hospice                                                                     80% after deductible                                     60% after deductible
 Hospital Services – Inpatient                                               80% after deductible                                     60% after deductible
 Hospital Services – Outpatient                                              80% after deductible                                     60% after deductible
 Infertility Counseling, Testing and                                         80% after deductible                                     60% after deductible
 Treatment(2)
 Maternity (facility & professional services)                                80% after deductible                                     60% after deductible
 Medical/Surgical Expenses (except office visits)                            80% after deductible                                     60% after deductible
 Mental Health – Inpatient(3)                                                80% after deductible                                     60% after deductible
 Mental Health – Outpatient(3)                                               80% after deductible                                     60% after deductible
 Private Duty Nursing                                                                                     80% after deductible
 Respiratory Therapy                                                                                      80% after deductible
 Skilled Nursing Facility Care                                               80% after deductible                                   60% after deductible
                                                                                                                                Limit: 100 days/benefit period
 Substance Abuse – Inpatient Detoxification                                  80% after deductible                                   60% after deductible
 Substance Abuse – Inpatient Rehabilitation                                  80% after deductible                                   60% after deductible
 Substance Abuse – Outpatient                                                80% after deductible                                   60% after deductible
 Therapy Services (Cardiac Rehab, Infusion                                   80% after deductible                                   60% after deductible
 Therapy, Chemotherapy, Radiation Therapy and
 Dialysis)
 Transplant Services                                                         80% after deductible                                     60% after deductible
 Precertification Requirements(4)                                                                                   Yes
 Prescription Drug Deductible
    Employee Only Plan                                                                   Applies to Medical and Prescription Drug Benefits
    Family Plan                                                                          Applies to Medical and Prescription Drug Benefits
 Premier Prescription Drug Program(5)                                                             Retail Drugs (31-day Supply)
 Defined by Premier Pharmacy Network - Not                                                         Plan pays 80% after deductible
 Physician Network. Prescriptions filled at a non-
 network pharmacy are not covered.                                                 Maintenance Drugs through Mail Order (90-day Supply)
                                                                                               Plan pays 80% after deductible
(1) Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's renewal date. Contact
    your employer to determine the renewal date applicable to your program.
(2) Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered
    depending on your group’s prescription drug program.
(3) State mandated minimum benefits may apply to a diagnosis of serious mental illness. (If the above grid does not show a limit, your mental health benefit days and
    visits are unlimited.)
(4) Highmark Healthcare Management Services (HMS) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-related
    inpatient admission. Some facility providers will contact HMS and obtain precertification of the inpatient admission on your behalf. Be sure to verify that your
    provider is contacting HMS for precertification. If not, you are responsible for contacting HMS. If this does not occur and it is later determined that all or part of the
    inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered.
(5) At a retail or mail order pharmacy, if your deductible has not been met, you pay the entire cost for your prescription drug at the discounted rate Highmark has
    negotiated. The amount you paid for your prescription will be applied to your deductible. If your deductible has been met, you will only pay any member coinsurance
    required based on the benefit level indicated above. You will pay this amount at the pharmacy when you have your prescription filled.




                                     Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                     -1-
EPOBlue Essential Coinsurance Indexed
An EPO, or Exclusive Provider Organization, offers one level of benefits. Except for emergencies, all covered services must be received from an
EPO network provider. There is no requirement to select a Primary Care Physician (PCP) to coordinate your care. EPOBlue Essential covers
eligible annual expenses up to $75,000 per individual/per benefit period, and covers generic prescription drugs only. Below are specific benefit
levels that apply during your benefit period. The annual maximum will be indexed at $5,000 per year.
Benefit                                                                                               Coverage
Benefit Period(1)                                                                                     Contract Year
Deductible (per benefit period)
   Individual                                                                                             $250
   Family                                                                                                 $500
Plan Payment Level – Based on the provider’s reasonable charge                                     80% after deductible
(PRC)
Out-of-Pocket Maximums (Once met, plan payment level
becomes 100%)
   Individual                                                                                             None
   Family                                                                                                 None
Lifetime Maximum                                                                                       $2,000,000
Annual Maximum (per person)                                                                     $75,000 per benefit period
Primary Care Physician Office Visits                                                              80% after deductible
Specialist Office Visits                                                                          80% after deductible
Preventive Care
   Adult
       Routine physical exams                                                                 80% deductible does not apply
       Adult Immunizations                                                                        80% after deductible
       Colorectal Cancer Screening
           Basic Diagnostic Services                                                              80% after deductible
           Medical Surgical                                                                       80% after deductible
       Routine gynecological exams, including a Pap Test                                      80% deductible does not apply
       Mammograms, annual routine and medically necessary                                     80% deductible does not apply
   Pediatric
       Routine physical exams                                                                 80% deductible does not apply
       Pediatric immunizations                                                                80% deductible does not apply
Emergency Room Services                                                                           80% after deductible
Spinal Manipulations                                                                              80% after deductible
                                                                                              Limit: 20 visits/benefit period
Physical Medicine                                                                                 80% after deductible
                                                                                              Limit: 20 visits/benefit period
Speech Therapy                                                                                    80% after deductible
                                                                                              Limit: 20 visits/benefit period
Occupational Therapy                                                                              80% after deductible
                                                                                              Limit: 20 visits/benefit period
Allergy Extracts and Injections                                                                   80% after deductible
Ambulance                                                                                         80% after deductible
Assisted Fertilization Procedures                                                                     Not Covered
Dental Services Related to Accidental Injury                                                      80% after deductible
Diabetes Treatment                                                                                80% after deductible
Diagnostic Services (including routine)
  Advanced Imaging (MRI, CAT Scan, PET scan, etc.)                                                 80% after deductible
  Basic Diagnostic Services (standard imaging, diagnostic                                          80% after deductible
  medical, lab/pathology, allergy testing)
Durable Medical Equipment, Orthotics and Prosthetics                                               80% after deductible
Enteral Formulae                                                                              80% deductible does not apply
Home Infusion Therapy                                                                              80% after deductible
Home Health Care                                                                                   80% after deductible
Hospice                                                                                            80% after deductible
Hospital Services – Inpatient(2)                                                                   80% after deductible
                                                                                       Plus $250 inpatient deductible per admission
Hospital Services – Outpatient                                                                     80% after deductible
                                 Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                         -1-
   Benefit                                                                                                              Coverage
   Infertility Counseling, Testing and Treatment(3)                                                                 80% after deductible
   Maternity (facility & professional services)                                                                    80% after deductible(2)
   Medical/Surgical Expenses (except office visits)                                                                 80% after deductible
   Mental Health
       Inpatient(4)                                                                                              80% after deductible(2)
       Outpatient(4)                                                                                              80% after deductible
   Private Duty Nursing                                                                                           80% after deductible
   Respiratory Therapy                                                                                            80% after deductible
   Skilled Nursing Facility Care                                                                                 80% after deductible(2)
                                                                                                              Limit: 100 days/benefit period
   Substance Abuse
       Inpatient Detoxification                                                                                    80% after deductible(2)
       Inpatient Rehabilitation                                                                                    80% after deductible(2)
       Outpatient                                                                                                   80% after deductible
   Therapy Services (Cardiac Rehab, Infusion Therapy,                                                               80% after deductible
   Chemotherapy, Radiation Therapy and Dialysis)
   Transplant Services                                                                                             80% after deductible
   Precertification Requirements(5)                                                                                        Yes
   Prescription Drug Deductible
      Individual                                                                                                         None
      Family                                                                                                             None
   Premier Prescription Drug Program(6)                                                                      Retail Drugs (31-day Supply)
   Defined by Premier Pharmacy Network - Not Physician Network.                                                 $10 generic copayment
   Prescriptions filled at a non-network pharmacy are not covered.
                                                                                             Maintenance Drugs through Mail Order (90-day Supply)
                                                                                                            $20 generic copayment
                                                                                             Brand name drugs are not covered (Discount is available)
(1) Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's renewal date. Contact your
    employer to determine the renewal date applicable to your program.
(2) A $250 deductible per admission applies to all inpatient admissions. This is in addition to the overall $250 program deductible.
(3) Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered
    depending on your group’s prescription drug program.
(4) State mandated minimum benefits may apply to a diagnosis of serious mental illness. (If the above grid does not show a limit, your mental health benefit days and visits
    are unlimited.)
(5) Highmark Healthcare Management Services (HMS) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-related
    inpatient admission. Some facility providers will contact HMS and obtain precertification of the inpatient admission on your behalf. Be sure to verify that your provider
    is contacting HMS for precertification. If not, you are responsible for contacting HMS. If this does not occur and it is later determined that all or part of the inpatient
    stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered.
(6) Your prescription drug program covers only generic drugs. Brand name drugs are not covered. However, you can receive a discount off the brand name drug retail price
    by showing your Highmark identification card at a Premier network pharmacy, or by using the mail order option.




                                        Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                       -1-
KeystoneBlue HMO
KeystoneBlue is an HMO product that does not require referrals although selection of a PCP is still necessary. Except for emergencies, all covered
services must be received from a Keystone Health Plan West network provider. Below are specific benefit levels that apply during your benefit
period.
This chart is not intended as a contract of benefits. It is designed purely as a reference to help you compare the programs available through the Manufacturer & Business Association.

Benefit                                                                                                                                                     Network
Benefit Period(1)                                                                                                                                         Contract Year
Deductible (per benefit period)
   Individual                                                                                                                                                   None
   Family                                                                                                                                                       None
Plan Payment Level – Based on the provider’s reasonable charge                                                                                                  100%
(PRC)
Out-of-Pocket Maximums (Once met, plan payment level
becomes 100%)
   Individual                                                                                                                                              None
   Family                                                                                                                                                  None
Lifetime Maximum (per person)                                                                                                                           Unlimited
Primary Care Physician Office Visits                                                                                                             100% after $10 copayment
Specialist Office Visits                                                                                                                         100% after $10 copayment
Preventive Care
   Adult
       Routine physical exams                                                                                                                    100% after $10 copayment
       Adult Immunizations                                                                                                                                100%
       Colorectal Cancer Screening
          Basic Diagnostic Services                                                                                                                       100%
          Medical Surgical                                                                                                                                100%
       Routine gynecological exams, including a Pap Test                                                                                         100% after $10 copayment
       Mammograms, annual routine and medically necessary                                                                                                 100%
   Pediatric
       Routine physical exams                                                                                                             100% after $10 copayment
       Pediatric immunizations                                                                                                                       100%
Emergency Room Services                                                                                                          100% after $35 copayment (waived if admitted)
Spinal Manipulations                                                                                                                      100% after $10 copayment
                                                                                                                                         Limit: 20 visits/benefit period
Physical Medicine                                                                                                                         100% after $10 copayment
                                                                                                                                         Limit: 20 visits/benefit period
Speech Therapy                                                                                                                            100% after $10 copayment
                                                                                                                                         Limit: 20 visits/benefit period
Occupational Therapy                                                                                                                      100% after $10 copayment
                                                                                                                                         Limit: 20 visits/benefit period
Allergy Extracts and Injections                                                                                                                      100%
Ambulance                                                                                                                                            100%
Assisted Fertilization Procedures                                                                                                                Not Covered
Dental Services Related to Accidental Injury                                                                                                         100%
Diabetes Treatment                                                                                                                                   100%
Diagnostic Services (including routine)
  Advanced Imaging (MRI, CAT Scan, PETscan, etc.)                                                                                                               100%
  Basic Diagnostic Services (standard imaging, diagnostic                                                                                                       100%
  medical, lab/pathology, allergy testing)
Durable Medical Equipment, Orthotics and Prosthetics                                                                                                            100%
Enteral Formulae                                                                                                                                                100%
Home Infusion Therapy                                                                                                                                           100%
Home Health Care                                                                                                                                                100%
Hospice                                                                                                                                                         100%




                                               Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                                             -1-
 Benefit                                                                                                                 Network
 Hospital Services – Inpatient                                                                                           100%
                                                                                        (Admissions primarily for Physical Medicine, Speech Therapy, and/or
                                                                                     Occupational Therapy Services are limited to a combined total of sixty (60)
                                                                                   calendar days, per course of treatment, for the same condition, beginning on the
                                                                                                         date of the rehabilitation admission)
 Hospital Services – Outpatient                                                                                          100%
 Infertility Counseling, Testing and Treatment(2)                                      100% after 50% coinsurance up to a $200 maximum per benefit period
 Maternity (facility & professional services)                                                                            100%
 Medical/Surgical Expenses                                                                                               100%
 (Except Office Visits)
 Mental Health – Inpatient(3)                                                                                              100%
 Mental Health – Outpatient(3)                                                                                  100% after $10 copayment
 Private Duty Nursing                                                                                                      100%
 Respiratory Therapy                                                                                                       100%
 Skilled Nursing Facility Care                                                                                             100%
                                                                                                               Limit: 100 days/benefit period
 Substance Abuse – Inpatient Detoxification                                                                                100%
 Substance Abuse – Inpatient Rehabilitation                                                                                100%
 Substance Abuse – Outpatient                                                                                   100% after $10 copayment
 Therapy Services (Cardiac Rehab, Infusion Therapy,                                                                        100%
 Chemotherapy, Radiation Therapy and Dialysis)
 Transplant Services                                                                                                      100%
 Precertification Requirements                                                                                     Performed by Provider
 Prescription Drug Deductible
    Individual                                                                                                            None
    Family                                                                                                                None
 Premier Prescription Drug Program                                                                            Retail Drugs (31-day Supply)
 Mandatory Generic(4)                                                                                             $8 generic copayment
 Defined by Premier Pharmacy Network - Not Physician Network.                                                     $30 brand copayment
 Prescriptions filled at a non-network pharmacy are not covered.
                                                                                             Maintenance Drugs through Mail Order (90-day Supply)
                                                                                                            $16 generic copayment
                                                                                                             $60 brand copayment
(1) Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's renewal date. Contact your
    employer to determine the renewal date applicable to your program.
(2) Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered
    depending on your group’s prescription drug program.
(3) State mandated minimum benefits may apply to a diagnosis of serious mental illness. (If the above grid does not show a limit, your mental health benefit days and visits
    are unlimited.)
(4) Prescriptions are covered as long as they are listed on the prescription drug formulary applicable to your plan. To obtain a prescription medication that is not included on
    this formulary, your doctor must complete the 'Prescription Drug Medication Request Form' and return it to the Pharmacy Affairs Department for clinical review. Under
    the mandatory generic provision, you are responsible for the payment differential when a generic drug is available and you or your doctor specifies a brand name drug.
    Your payment is the price difference between the brand name drug and the generic drug in addition to the brand name drug copayment or coinsurance amounts, which
    may apply.




                                       Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

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Signature 65
Signature 65 is a Medicare-complementary benefit program that fills in the coverage gaps and cost sharing of the traditional Medicare program
(Medicare Part A and Medicare Part B). In order to enroll in Signature 65, you must be enrolled in Medicare Part A and/or Medicare Part B.
Medicare Part A Covered Services
Covered Services                   Medicare Pays                       Plan Pays                             Member Pays
 Inpatient Hospital Days           All but Part A Deductible           Medicare Part A Deductible            Nothing
 1-60
 Inpatient Hospital Days 61-90     All but Part A Coinsurance          Medicare Part A Coinsurance           Nothing
 Inpatient Hospital Days 91-150    All but Part A Coinsurance          Medicare Part A Coinsurance           Nothing
 (may be used once per lifetime)
Additional Inpatient Hospital      Nothing                             100% of Medicare-eligible             Nothing for the first 365 additional
Days                                                                   expenses for 365 additional           inpatient hospital days per benefit
                                                                       days per benefit period, after the    period, 100% thereafter.
                                                                       sixty (60) Medicare inpatient
                                                                       hospital lifetime reserve days
                                                                       are exhausted.
Skilled Nursing Facility Days 1-   100%                                Nothing                               Nothing
20
Skilled Nursing Facility Days      All but Part A Coinsurance          Medicare Part A Coinsurance           Nothing
21-100
Skilled Nursing Facility Days      Nothing                             Nothing                               100%
101 and beyond
Blood                              Nothing for the first 3 pints per   100% for the first three pints per    Nothing
                                   calendar year, 100% thereafter.     calendar year, nothing
                                                                       thereafter.
Medicare Part B Covered Services
Most Medicare Part B Covered       All but the Part B Deductible       Medicare Part B Coinsurance           Medicare Part B Deductible
Services                           and Part B Coinsurance
Blood                              Nothing for the first 3 pints per   100% for the first three pints per    Nothing for the first 3 pints per
                                   calendar year, 80% after the        calendar year, nothing                calendar year, 20% thereafter (if the
                                   Part B Deductible thereafter.       thereafter.                           Part B Deductible has been satisfied).
Major Medical Benefits (for services not covered by Medicare)
Deductible                                                                                                $250
Plan Payment Level – Based on the provider’s reasonable charge           80% after deductible until out-of-pocket maximum is met. Then 100%
(PRC)
Out-of-Pocket Maximum (Once met, plan payment level becomes                                                 $2,000
100%)
Lifetime Maximum                                                                                       $500,000
Physician Office Visits                                                                            80% after deductible
Preventive Care
 Adult
  Routine physical exams                                                                             Not Covered
  Routine gynecological exams, including a PAP Test                                          80% (deductible does not apply)
  Colorectal cancer screening, routine and medically necessary                                    80% after deductible
  Mammograms, as required                                                                    80% (deductible does not apply)
 Pediatric
  Routine physical exams                                                                             Not Covered
  Pediatric immunizations                                                                   80% (deductible does not apply)
Emergency Care                                                                                   80% after deductible
Spinal Manipulations                                                               80% after deductible; Limit: 20 visits/calendar year
Physical Medicine                                                                  80% after deductible; Limit: 20 visits/calendar year
Speech Therapy                                                                     80% after deductible; Limit: 20 visits/calendar year
Occupational Therapy                                                               80% after deductible; Limit: 20 visits/calendar year
Ambulance                                                                                        80% after deductible
Assisted Fertilization Procedures                                                                    Not Covered
Diagnostic Services (including routine)                                                          80% after deductible
   Advanced Imaging (MRI, CAT Scan, PET scan, etc.)

                               Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                        -1-
    Basic Diagnostic Services (standard imaging, diagnostic medical,                                  80% after deductible
    lab/pathology, allergy testing)
  Durable Medical Equipment, Orthotics and Prosthetics                                                80% after deductible
  Home Health Care                                                                                    80% after deductible
  Hospice                                                                                                 Not Covered
  Hospital Services – Inpatient                                                                       80% after deductible
  Hospital Services – Outpatient                                                                      80% after deductible
  Infertility counseling, testing and treatment                                                       80% after deductible
  Maternity (facility and professional services)                                                      80% after deductible
  Medical/Surgical Expenses (except office visits)                                                    80% after deductible
  Mental Health – Inpatient                                                                          80% after deductible
  Mental Health – Outpatient                                                                         50% after deductible
  Private Duty Nursing                                                                                80% after deductible
  Skilled Nursing Facility Care                                                                       80% after deductible
  Substance Abuse – Inpatient Detoxification                                                          80% after deductible
  Substance Abuse – Inpatient Rehabilitation                                                          80% after deductible
  Substance Abuse – Outpatient                                                                        50% after deductible
  Precertification Requirements                                                                     Performed by Member
  Prescription Drugs                                                                                      Not Covered
  Premium                                                                                                  $227.19
 If the provider does not accept assignment from Medicare, any difference between the provider’s change and the combined Medicare/Highmark
  payment shall be the personal responsibility of the member.
 State mandated benefits (30 inpatient days and 60 outpatient visits annually with the right to exchange inpatient days for outpatient visits on a one-for-
  two basis) may apply to a diagnosis of serious mental illness.
 Member is required to contact Highmark Health Care Management Services prior to a planned inpatient admission or within 48 hours of an emergency
  or maternity-related admission. If this does not occur and it is later determined that all or part of the inpatient stay was not medically necessary or
  appropriate, the patient will be responsible for payment of any costs not covered.




                                  Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

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BlueRx Medicare Prescription Drug Plan
    Annual Deductible                                        There is no deductible.
                                                             For up to a 34-day supply at a retail pharmacy, you pay:
                                                                           $5 for Generic
                                                                           $25 for preferred Brand
    Until the total drug costs are $2,830                                  $55 for non-preferred Brand
    (Your share and BlueRx share                              For up to a 90-day supply from mail order*, you pay:
    combined.)                                                             $ 10 for Generic
                                                                           $ 50 for preferred Brand
                                                                           $110 for non-preferred Brand
                                                                 33% Coinsurance for Specialty Drugs
                                                             There is coverage for Generic drugs only:
    After $2,830 in total drug costs (Your                    For up to a 34-day supply at retail:
    share and BlueRx share combined),                                  You pay $5
    until your share reaches $4,550.                          For up to a 90-day supply through mail order*:
                                                                       You pay $10

                                                              If the drug is Generic:
                                                                        You pay the greater of 5% or $2.50
    Over $4,550 in drug costs (Your share).
                                                              If the drug is Brand:
                                                                        You pay the greater of 5% or $6.30

    Formulary                                                 Incentive
    Premium                                                   $95.00

   If you or your physician specifies a brand name drug when a generic drug is available, you will pay the
    difference in the cost between the brand name drug and the generic drug in addition to your coinsurance
    or copayment amount.
   The BlueRx Medicare-approved formulary is a long list of FDA-approved generic and brand name
    prescription drugs selected for their safety and effectiveness. Your program includes coverage for both
    formulary and non-formulary drugs at the specific copayment or coinsurance amounts listed above.
         *You can purchase up to a 90-day supply at a retail pharmacy for three times the retail copayment
         amount.
This is a brief description of your prescription drug plan. Please review the enclosed Summary of Benefits for details about this
program




                            Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

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FreedomBlue PPO
If you receive services in the Plan Service Area from network providers, you will receive the highest level of benefits. No referrals required. The
benefit levels are listed below.
This chart is not intended as a contract of benefits. It is designed purely as a reference to help you compare the programs available through the Manufacturer & Business Association.

Benefits                                                                                                               Network                                                   Out-of-Network
Deductible                                                                                                                   $125                                                    $250
Coinsurance                                                                                                                  10%                                                     20%
                                                                                                                                                                         50% Durable Medical Equipment
Maximum Annual Out-of-Pocket                                                                                               $500                                                     $3,400
Lifetime Maximum                                                                                                         Unlimited                                                Unlimited
Preventive Care                                                                                                        Network                                                   Out-of-Network
Annual Physical Exam                                                                                                  $15 copay                                            Covered at 80%; you pay 20%
Preventive Screening PAP/Pelvic Exams                                                                               Covered at 100%                                             Covered at 100%
Preventive Screening Mammograms                                                                                     Covered at 100%                                             Covered at 100%
Colorectal Preventive Screening Exams                                                                               Covered at 100%                                             Covered at 100%
Prostate Preventive Screening Exams                                                                                 Covered at 100%                                             Covered at 100%
Bone Mass Measurement Preventive Screening Exams                                                                    Covered at 100%                                             Covered at 100%
Immunizations (Not covered for purposes of travel)                                                                  Covered at 100%                                             Covered at 100%
Vision Care (Davis Vision Network)                                                                                     Network                                                   Out-of-Network
Annual Routine Vision Exam (includes refraction)                                                                  $15 copay                                              Covered at 80%; you pay 20%
Routine Vision Eye Wear                                                                              100% coverage for standard eyeglass                               $100 benefit maximum for eye wear
Benefit limited to one pair of eyeglass frames AND either one                                          frames, lenses, or contact lenses
pair of contact lenses OR one pair eyeglass lenses every two                                         $100 benefit maximum for specialty
years                                                                                                               frames
                                                                                                     $100 benefit maximum for specialty
                                                                                                                contact lenses
Hearing Services                                                                                                       Network                                                   Out-of-Network
Annual Routine Hearing Exam                                                                                      $20 copay                                                 Covered at 80%; you pay 20%
Hearing Aids                                                                                       $500 benefit maximum for one or more
                                                                                                       hearing aids every three years
Outpatient Services                                                                                                    Network                                                   Out-of-Network
Primary Care Home/Office Visits                                                                                        $15 copay                                           Covered at 80%; you pay 20%
Specialist Home/Office Visits                                                                                          $20 copay                                           Covered at 80%; you pay 20%
Outpatient Surgery and Invasive Procedures                                                                           Covered at 90%                                        Covered at 80%; you pay 20%
(per visit/per day/per provider)
Diagnostic Procedures/Tests                                                                                          Covered at 90%                                        Covered at 80%; you pay 20%
Lab Services                                                                                                         Covered at 90%                                        Covered at 80%; you pay 20%
X-Rays and Diagnostic Radiological Services                                                                          Covered at 90%                                        Covered at 80%; you pay 20%
Emergent and Urgent Care                                                                                               Network                                                   Out-of-Network
Emergency Room Services (Worldwide Coverage)                                                                        $50 per visit                                                    $50 per visit
Urgently Needed Care (Worldwide Coverage; not                                                                  $50 or $20 non-hospital                                          $50 or $20 non-hospital
emergency care; usually out of the service area)
Medicare Covered Part B Drugs                                                                                          Network                                                   Out-of-Network
Medicare Part B Drugs                                                                                     Covered at 90%; you pay 10%                                    Covered at 80%; you pay 20%
                                                                                                           $300 Quarterly Maximum                                    coinsurance of the lesser of the Out-of-
                                                                                                                                                                      Network charge or network allowed
                                                                                                                                                                                     amount
Inpatient Facility Services                                                                                            Network                                                   Out-of-Network
Inpatient Hospital Care                                                                                              Covered at 90%                                        Covered at 80%; you pay 20%
Skilled Nursing Facility Care (100 days per Medicare                                                                 Covered at 90%                                        Covered at 80%; you pay 20%
benefit period)
Mental Health Services                                                                                                 Network                                                   Out-of-Network
Inpatient Psychiatric Hospital Care (Limited to 190 days                                                             Covered at 90%                                        Covered at 80%; you pay 20%
per lifetime)


                                               Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

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Outpatient Mental Health/Psychiatric Services                               Covered at 90%                     Covered at 80%; you pay 20%
(per individual or group session)
Outpatient Chemical Dependency Substance Abuse                              Covered at 90%                     Covered at 80%; you pay 20%
Treatment (per individual or group session)
Outpatient Partial Hospitalization                                          Covered at 90%                     Covered at 80%; you pay 20%
Prescription Drugs (Medicare Covered Part D Drugs)
Initial Coverage Period                                           For up to a 34-day retail supply:
Until the total drug costs are $4,830                                        $15 generic
(Your share and FreedomBlue PPO share combined.)                         $30 preferred brand
                                                                       $60 non-preferred brand
                                                                                                              Member responsible for paying the
                                                                         33% Specialty Drug
                                                                                                           difference between the Out-of-Network
                                                                   For up to a 90-day mail order
                                                                                                             retail price and the network allowed
                                                                               supply:
                                                                                                           amount as well as network copayment.
                                                                           $37.50 generic
                                                                         $75 preferred brand
                                                                                                            Member will pay 10% at point of sale
                                                                      $150 non-preferred brand
Coverage Gap Period                                                         No coverage
From $4,831 in total drug costs to $4,550
in total member out-of-pocket drug expenses
Catastrophic Coverage Period                                                       Member pays the greater of the following:
After $4,550 in total member out-of-pocket drug expenses                                  5% member coinsurance
(your cost sharing only)                                                              $2.50 generic/multi-source brand
                                                                                            $6.30 all other drugs
Premium                                                                                      $139 per month
Notes:
 Diagnostic or outpatient surgery cost-sharing may apply for non-screening preventive services.
 Physician office visit cost sharing may apply if a separately billable physician service is rendered.
 Certain categories of Medicare Part B drugs have been excluded from member cost sharing. They include certain vaccines and toxoids, certain
    miscellaneous drugs and solutions, certain miscellaneous pathology and laboratory
    drugs, and certain contrast materials. Prior authorization is necessary for coverage of certain medications.
    Medicare Part B drugs are not available via retail pharmacy network.




                              Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

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SecurityBlue HMO Enhanced
If you receive services in the Plan Service Area from network providers, you will receive the highest level of benefits. No referrals required. The
benefit levels are listed below.
This chart is not intended as a contract of benefits. It is designed purely as a reference to help you compare the programs available through the Manufacturer & Business Association.

Benefits                                                                                                                                                 Network
Maximum Annual Out-of-Pocket                                                                                                                               $3400
Lifetime Maximum                                                                                                                                          Unlimited
Preventive Care                                                                                                                                          Network
Annual Physical Exam                                                                                                                                 $10 copay
Preventative Screening PAP/Pelvic Exams                                                                                                          Covered at 100%
                                                                                                                                        Office visit cost sharing may apply
Preventive Screening Mammograms                                                                                                                  Covered at 100%
Colorectal Preventive Screening Exams                                                                                                            Covered at 100%
Prostate Preventive Screening Exams                                                                                                              Covered at 100%
Bone Mass Measurement                                                                                                                            Covered at 100%
Preventive Screening Exams
Immunizations                                                                                                                                        Covered at 100%
(Not covered for purposes of travel)
Vision Care (Davis Vision Network)                                                                                                                       Network
Annual Routine Vision Exam (includes refraction)                                                                                                          $20 copay
(deductible and annual pocket limits do not apply)
Routine Vision Eye Wear                                                                                                    100% coverage for standard eyeglass frames, lenses,
Benefit limited to one pair of eyeglass frames AND either one                                                                               or contact lenses
pair of contact lenses OR one pair eyeglass lenses every two                                                                   $100 benefit maximum for specialty frames
years                                                                                                                       $100 benefit maximum for specialty contact lenses
Hearing Services                                                                                                                                Network
Annual Routine Hearing Exam                                                                                                                    $20 copay
                                                                                                                           $500 benefit maximum for one or more hearing aids
Hearing Aids                                                                                                                                every three years
Primary Care Home/Office Visits                                                                                                                $10 copay
Specialist Home/Office Visits                                                                                                                  $20 copay
Outpatient Surgery and Invasive Procedures                                                                                                  Covered at 100%
(per visit/per day/per provider)
Diagnostic Procedures/Tests                                                                                                                          Covered at 100%
Lab Services                                                                                                                                         Covered at 100%
X-Rays and Diagnostic Radiological Services                                                                                                          Covered at 100%
Supplies and Services                                                                                                                                    Network
Ambulance                                                                                                                                           $25 Copay per trip
(Emergent Services per one way trip)
Ambulance                                                                                                                                           $25 Copay per trip
(Non-emergent Services per one way trip;
Requires a Physican Certification Statement)
Durable Medical Equipment/Prosthetics/Orthotics                                                                                            Covered at 85%; you pay 15%
(oxygen/oxygen supplies covered 100%)                                                                                                      $500 out of pocket maximum
Diabetic Testing Supplies                                                                                                                  Covered at 85%; you pay 15%
(Glucose monitors, test strips, and lancets)
Home Health Care                                                                                                                                     Covered at 100%
Physical, Speech, Occupational,                                                                                                                        $20 copay
and Cardiac Rehab Therapy
(per visit/per day/per provider)
Emergent and Urgent Care                                                                                                                                 Network
Emergency Room Services                                                                                                                                  $50 per visit
(Worldwide Coverage)
Urgently Needed Care                                                                                                                      $50 hospital or $20 non-hospital
(Worldwide Coverage; not emergency care;
usually out of the service area)

                                               Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

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Medicare Covered Part B Drugs                                                                        Network
Medicare Part B Drugs                                                                       Covered at 90%; you pay 10%
                                                                                             $300 Quarterly Maximum
Inpatient Facility Services                                                                          Network
Inpatient Hospital Care                                                                            Covered at 100%
Skilled Nursing Facility Care                                                                      Covered at 100%
(100 days per Medicare benefit period)
Mental Health Services                                                                               Network
Inpatient Psychiatric Hospital Care                                                                Covered at 100%
(Limited to 190 days per lifetime)
Outpatient Mental Health/Psychiatric Services                                                         $20 copay
(per individual or group session)
Outpatient Chemical Dependency                                                                        $20 copay
Substance Abuse Treatment
(per individual or group session)
Outpatient Partial Hospitalization                                                                  100% covered
Prescription Drugs (Medicare Covered Part D Drugs)
Drug Formulary                                                                                        Network
Initial Coverage Period                                                                  For up to a 34-day retail supply:
Until the total drug costs are $2,830                                                                 $20 generic
(Your share and SecurityBlue HMO share combined.)                                                 $20 preferred brand
                                                                                                $50 non-preferred brand
                                                                                                  $50 Specialty Drug
                                                                                       For up to a 90-day mail order supply:
                                                                                                      $50 generic
                                                                                                  $50 preferred brand
                                                                                               $125 non-preferred brand
Coverage Gap Period                                                                                  No Coverage
From $2,831 in total drug costs to $4,550
in total member out-of-pocket drug expenses
(your cost sharing only)
Catastrophic Coverage Period                                                         Member pays the greater of the following:
After $4,550 in total member out-of-pocket drug expenses                                    5% member coinsurance
(your cost sharing only)                                                                $2.50 generic/multi-source brand
                                                                                              $6.30 all other drugs
Premium                                                                                        $125 per month
Notes:
 Diagnostic or outpatient surgery cost sharing may apply for non-screening preventive services.
 Physician office visit cost sharing may apply if a separately billable physician service is rendered.
 Certain categories of Medicare Part B drugs have been excluded from member cost sharing. They include certain vaccines and toxoids, certain
    miscellaneous drugs and solutions, certain miscellaneous pathology and laboratory drugs, and certain contrast materials. Prior authorization is
    necessary for coverage of certain medications. Medicare Part B drugs are not available via retail pharmacy network.




                               Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                        -1-
 Vision Plan Options




Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                        -86-
The Davis Vision provider network is being used for these vision products through a contractual
arrangement between Davis Vision and Highmark. Davis Vision is an independent company that
manages a network of licensed vision providers in both private practice and retail locations. Network
providers are reviewed and credentialed to ensure that standards for quality service are maintained.
To find a network provider, your employees can call Member Service toll-free at 1-800-223-4795 and
access the Interactive Voice Response (IVR) Unit or access the Vision Provider Directory online at
www.highmarkbcbs.com.

How do my employees receive services from a                           Member Service Representatives are available:
provider in the network?                                              • Monday through Friday, 8:00 a.m. to 5:00 p.m.,
• Call the network provider of their choice and                         Eastern Standard Time (EST)
  schedule an appointment.
• Identify themselves as a Highmark member, or
  eligible dependent, in a vision plan administered                   Information about Low Vision Services:
  by Davis Vision.                                                    Your employees and their covered dependents are
• Provide the office with their identification (ID)                   entitled to a comprehensive low vision evaluation
  number (located on their Highmark ID card), and                     once every five years and low vision aids up to the
  the name and birth date of the covered dependent                    plan maximum. Up to four follow-up care visits will
  receiving services.                                                 be covered during the five-year period.
The provider’s office will verify their eligibility for
services. No claim forms are required!
                                                                      Are there any exclusions?
                                                                      This vision program excludes coverage for certain
What about retail locations?                                          items and services, including:
In order to provide the greatest amount of flexibility                • Medical treatment of eye disease or injury
and convenience, the network includes a number of                     • Vision therapy
retail establishments. Benefits at the retail locations               • Special lens designs or coatings, other than those
may vary slightly from other locations, as noted in this                previously described
benefit description. However, the value is comparable.                • Replacement of lost eyewear
                                                                      • Non-prescription (plano) lenses
Your employees can call Member                                        • Services not performed by licensed personnel
Service at 1-800-223-4795 (TTY users
call 1-800-523-2847) to:
• Find a participating provider
• Verify eligibility for themselves or their dependents
• Request an out-of-network provider reimbursement
  form



                         Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                 -87-
Value-added Features
Replacement Contact Lens Program - Highmark offers
a contact lens replacement program to its members.
This mail order program, Lens 1-2-3!®, exclusively
allows your employees and their dependents to enjoy
the guaranteed lowest prices on their contact lens
replacement materials. Members can conveniently call
1-800-LENS123 or visit the web at www.LENS123.
com with a current prescription for this value-added
service, and every order comes with a complimentary
starter kit.


Information About Laser Vision Correction
Services
Your employees and their covered dependents can
realize substantial discounts on laser correction
procedures. Members will be entitled to savings of up
to 25% off the provider’s usual and customary fees,
or a 5% discount on any advertised special through a
network of credentialed physicians affiliated with Eye
Centers of Excellence. Some centers provide a flat fee
equating to these discount levels.


Please note: Although the vision rates for the MBA are
discounted 2 percent, the premium will be subject to standard
billing fees if the product is purchased on a standalone basis.




                             Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                     -88-
      Vision Plans

Fashion Advantage Option I
This chart is not intended as a contract of benefits. It is designed purely as a reference to help you compare the programs available through the Manufacturer & Business Association.




                                      Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

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      Vision Plans

                                                                                                                                              Fashion Advantage Option I | continued...




(1) If you choose an out-of-network provider, you must pay the provider directly for all charges and then submit a claim for reimbursement.
(2) Eligibility will be determined from the date of the last similar service paid under this program, or any other Highmark Blue Cross Blue Shield vision program for this group.
(3) Includes glass, plastic or oversized lenses.
(4) Progressive multifocals can be worn by most people. Conventional bifocals will be supplied at no additional charge for anyone who is unable to adapt to progressive lenses, however the
    discounted price will not be refunded.
(5) Discounted member price waived for monocular patients and patients with prescriptions +/- 6.00 diopters or greater.
(6) Contact lenses can be worn by most people. Once the contact lens option is selected and the lenses fitted, they may not be exchanged for eyeglasses.
(7) Disposable contact lens wearers will receive four multi-packs of lenses. Planned replacement contact lens wearers will receive two multi-packs of lenses.
(8) Reimbursement amount covers contact lens evaluation, fitting and cost of contact lenses.




                                          Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

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      Vision Plans

Fashion Advantage Option V
This chart is not intended as a contract of benefits. It is designed purely as a reference to help you compare the programs available through the Manufacturer & Business Association.




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                                                                                                                                           Fashion Advantage Option V | continued...




(1) If you choose an out-of-network provider, you must pay the provider directly for all charges and then submit a claim for reimbursement.
(2) Eligibility will be determined from the date of the last similar service paid under this program, or any other Highmark Blue Cross Blue Shield vision program for this group.
(3) Includes glass, plastic or oversized lenses.
(4) Progressive multifocals can be worn by most people. Conventional bifocals will be supplied at no additional charge for anyone who is unable to adapt to progressive lenses, however the
    discounted price will not be refunded.
(5) Discounted member price waived for monocular patients and patients with prescriptions +/- 6.00 diopters or greater.
(6) Contact lenses can be worn by most people. Once the contact lens option is selected and the lenses fitted, they may not be exchanged for eyeglasses.
(7) Disposable contact lens wearers will receive four multi-packs of lenses. Planned replacement contact lens wearers will receive two multi-packs of lenses.
(8) Reimbursement amount covers contact lens evaluation, fitting and cost of contact lenses.




                                          Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

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      Vision Plans

Fashion Advantage Gold Option I
This chart is not intended as a contract of benefits. It is designed purely as a reference to help you compare the programs available through the Manufacturer & Business Association.




                                      Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                        -93-
      Vision Plans

                                                                                                                                     Fashion Advantage Gold Option I | continued...




(1) If you choose an out-of-network provider, you must pay the provider directly for all charges and then submit a claim for reimbursement.
(2) Eligibility will be determined from the date of the last similar service paid under this program, or any other Highmark Blue Cross Blue Shield vision program for this group.
(3) Includes glass, plastic or oversized lenses.
(4) Progressive multifocals can be worn by most people. Conventional bifocals will be supplied at no additional charge for anyone who is unable to adapt to progressive lenses, however the
    discounted price will not be refunded.
(5) Discounted member price waived for monocular patients and patients with prescriptions +/- 6.00 diopters or greater.
(6) Contact lenses can be worn by most people. Once the contact lens option is selected and the lenses fitted, they may not be exchanged for eyeglasses.
(7) Disposable contact lens wearers will receive four multi-packs of lenses. Planned replacement contact lens wearers will receive two multi-packs of lenses.
(8) Reimbursement amount covers contact lens evaluation, fitting and cost of contact lenses.




                                          Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                               -94-
      Vision Plans

Fashion Advantage Gold Option V
This chart is not intended as a contract of benefits. It is designed purely as a reference to help you compare the programs available through the Manufacturer & Business Association.




                                      Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                        -95-
      Vision Plans

                                                                                                                                                                                    |continued...




(1) If you choose an out-of-network provider, you must pay the provider directly for all charges and then submit a claim for reimbursement.
(2) Eligibility will be determined from the date of the last similar service paid under this program, or any other Highmark Blue Cross Blue Shield vision program for this group.
(3) Includes glass, plastic or oversized lenses.
(4) Progressive multifocals can be worn by most people. Conventional bifocals will be supplied at no additional charge for anyone who is unable to adapt to progressive lenses, however the
    discounted price will not be refunded.
(5) Discounted member price waived for monocular patients and patients with prescriptions +/- 6.00 diopters or greater.
(6) Contact lenses can be worn by most people. Once the contact lens option is selected and the lenses fitted, they may not be exchanged for eyeglasses.
(7) Disposable contact lens wearers will receive four multi-packs of lenses. Planned replacement contact lens wearers will receive two multi-packs of lenses.
(8) Reimbursement amount covers contact lens evaluation, fitting and cost of contact lenses.




                                          Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                                               -96-
                Underwriting
                Regulations




Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                        -97-
     Underwriting Regulations

A. INITIAL ENROLLMENT PROCEDURES                                                    Note 4: Dependent coverage will be permitted on the employee’s
1. New Members – Except as noted below, new members may enroll                      effective date. Subsequent enrollment for dependent coverage
   in any of the Association-sponsored Highmark plans on the first day              other than for birth, marriage, adoption or loss of coverage will
   of the second month following membership approval by the Board of                be permitted on January, April, July and October 1st of each year.
   Governors. This is provided that all required information is received            Dependents 19 years of age to 25 years of age must provide proof of
   by Highmark’s underwriting department at least 31 days prior to the              full-time student status from an accredited institution to remain an
   start of coverage. Refer to page 3 for documentation requirements.               eligible dependent on the coverage. Proof of full-time student status
                                                                                    includes a letter from the registrar, bill or class schedule.
   Effective January 1, 2007, member companies who terminate
   their participation in one of the Association’s health plans must                Note 5: A separate out-of-area pool has been established to enroll
   maintain membership in the Association for a period of no less                   out-of-area employees of companies headquartered in western
                                                                                    Pennsylvania. For groups in this pool, out-of-area employees may
   than 12 months prior to eligibility for re-enrollment in any
                                                                                    make up a maximum of 50% of the total eligible employees. Out-
   Association-sponsored plan.
                                                                                    of-area employees can not enroll in in-area products. However,
                                                                                    employees/members living in a contiguous county of Highmark’s
   Note 1: If a client moves from an all-blue or partial blue association/
                                                                                    service area are an exception and can enroll in an in-area product.
   risk pool to another partial blue association/risk pool, the group receives
                                                                                    The service area for PPO products is the 49 counties of western
   developed rates until the first renewal that occurs after the group has          and central PA. The service area for KeystoneBlue or ClassicBlue
   been with the new association/pool for six months. If the group’s                Traditional, is the 29 counties of western PA. (See the service map
   former association/pool renews before the group becomes eligible for             inside the front cover.) Otherwise, out-of-area employees must
   the new association/pool’s rates, the group receives developed rates as          enroll in an out-of-area product. Furthermore, in order for out-
   well. Commission not paid to the POR for first 12 months.                        of-area employees to establish coverage, in-area employees must
                                                                                    be covered under a Highmark group. The group has the option of
   Note 2: New members who elect to enroll at a later date must submit              offering PPO BlueCard® for out-of-area employees.
   all required documentation to Highmark at least 31 days prior to the
   start of coverage. Refer to page 3 for documentation requirements.               No out-of-area employees may enroll in KeystoneBlue. If, for any
                                                                                    reason, the group’s out-of-area enrollment becomes greater than
   Note 3: Initial employee enrollment will be permitted on the first               50% of the total group enrolled with Highmark, the entire group will
   day of the month following hire, subject to individual company                   be terminated for failing to meet participation guidelines.
   waiting periods. Eligible employees who decline or voluntarily
   terminate will be permitted to enroll or re-enroll effective January,            Note 6: ENROLLMENT FOR OVER AGE 65 RETIREES IS
   April, July and October 1st of the following year, unless valid proof            NOT PERMITTED WITHIN THE ACTIVE GROUP. ALL
   of loss of coverage due to hour reduction or loss of employment                  ASSOCIATION-SPONSORED PLAN ENROLLMENTS ARE
   is provided. Coverage will then be effective the first of the month              RESTRICTED TO ACTIVE FULL-TIME EMPLOYEES
   following the date of loss of previous coverage.                                 ONLY. UPON REACHING THE AGE OF 65, ACTIVE
                                                                                    EMPLOYEES SHOULD NOT BE AUTOMATICALLY
                                                                                    TERMINATED FROM THE ACTIVE GROUP PLAN.
   An eligible employee is one as defined by the employer. Highmark
                                                                                    FOR FURTHER INFORMATION, PLEASE CONTACT
   may request copies of human resource materials to define the
                                                                                    YOUR INSURANCE REPRESENTATIVE OR THE
   employers’ criteria of a full-time employee including hours
                                                                                    MANUFACTURER & BUSINESS ASSOCIATION.
   worked. To qualify for Highmark group coverage, in no instance
   may an employer’s definition of a full-time employee be less than
                                                                                 2. Current Members – Current member firms who elect to enroll in
   Highmark’s which is: An individual who, regardless of age, has                   one of the Association-sponsored health care plans will be subject to
   an employee-employer relationship, works a minimum of 20 or                      the rules applied to new members.
   more hours per week, at least nine months per year, appears on
   the payroll, is actively at work, and receives a regular wage. (It is         B. CHANGE OF OPTION PROCEDURE
   imperative that employees over the age of 65 and working full-time            1. Total Replacement – Member firms enrolled in any Association-
   be considered the same as any other employees within the group.)                 sponsored option wishing to change to another plan option may do
   For corporations, partners, and sole-proprietors with employees                  so by sending a Small Group Business Application and all necessary
   involved in the management/ maintenance of rental properties, those              Highmark underwriting documentation to Highmark Blue Cross
   individuals must manage a minimum of six rental units or a single                Blue Shield, Small Group Submissions, 120 Fifth Avenue, Suite
   dwelling with a minimum of 12,000 square feet to be considered                   1025, Pittsburgh PA 15222-3099. All information must be received
   full-time employees.                                                             at least 31 days prior to the effective date. (Example: Documents
                                                                                    received by June 30 will be given an August 1 effective date.) Refer
                                                                                    to page 3 for documentation requirements.


                                 Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                             -98-
     Underwriting Regulations

	   Note 1:	Total	replacement	of	plan	options	other	than	at	open	                  Note 1: GROUP SIZE AND ENROLLMENT PERCENTAGE
    enrollment	(January,	April,	July	and	October	1)	may	only	take	place	           REQUIREMENTS
    when	the	client	is	transferring	to	a	lower	benefit	cost	design.
                                                                               	   	           Number	                          Minimum
2. Dual Option	–	Demographically	rated	groups	are	limited	to	two	              	   	    of	Eligible	Enrollment	            Employees	Percentage	
   product	options	(unless	there	is	an	out-of-area	option	needed.)             	   	           2	to	4	                             100%
	 •	 A	“Keystone	only”	product	offering	is	subject	to	the	standard		 	         	   	           5	to	15	                         100%	less	1
   	 underwriting	minimum	participation	percentages	listed	in	the		 	          	   	         16	or	more	                           75%
   	 participation	requirements	charts	on	page	12	of	the	guidelines.           	
	 	                                                                            	   Note 2: A	spousal	allowance	will	be	granted	to	any	group.	The	
	 •	 For	groups	with	9	or	less	enrolling,	KeystoneBlue	HMO	or	any		                remaining	employees	are	then	considered	to	be	the	“eligible	
   	 “value”	product	can	be	offered	to	eligible	groups	along	with		                employees”	and	subject	to	participating	percentages.	The	number	
   	 one	other	benefit	option.	For	groups	with	10	or	more	enrolling,		             of	eligible	employees	may	be	reduced	by	up	to	40%	for	employees	
   	 any	two	products	can	be	offered	together.	Groups	offering	dual		              who	have	coverage	through	a	spouse’s	group	benefits	program.	
   	 option	products	must	meet	“minimum	participation	requirements”	       	       Within	that	40%	maximum,	up	to	20%	of	the	employees	may	opt	
   	 as	noted	in	respective	chart.	Please	note	that	dual	options	are	not		         out	for	coverage	under	a	spouse’s	non-Highmark	group	program.	
   	 available	for	supplemental	coverage.                                          Standardized	rounding	procedures	apply	to	eligible	employee	
                                                                                   counts;	that	is,	0.5	and	greater	is	rounded	up,	less	than	0.5	is	
C. COVERAGE TRANSFER ACTIVITY                                                      rounded	down.	If	you	have	additional	questions,	please	contact	
1. Member Firms	who	are	terminated	from	the	Association	plan	will	                 your	authorized	appointed	agent	to	discuss	the	Highmark	Corporate	
   be	permitted	only	one	re-enrollment.	Members	terminated	by	the	                 Underwriting	Guidelines	in	detail.
   Association	for	nonpayment	of	premium	will	be	eligible	for	re-
   enrollment	effective	the	first	of	the	thirteenth	month	from	the	date	       E. EMPLOYER LOCATION
   they	notify	the	Association	by	letter	of	intent.	All	membership	and	        	 Member Firms	may	be	located	in	the	Manufacturer	&	Business	
   underwriting	regulations	will	apply.                                           Association	29-county	Highmark	service	area	to	be	eligible	for	the	
                                                                                  Association-sponsored	health	insurance	plans.
	   Note 1: Highmark	Blue	Cross	Blue	Shield	reserves	the	right	
                                                                               	   Note:	Location	is	defined	as	the	physical	location	of	the	company,	
    to	investigate	each	case	to	ensure	that	the	basic	intent	of	the	
                                                                                   corporate	headquarters,	executive	offices,	or	local	business	of	an	
    underwriting	regulations	is	not	being	circumvented.
                                                                                   outside	company.
2. Group Contract Termination
                                                                               F. INELIGIBLE EMPLOYEES
	 The	client	may	cancel	the	contract	on	any	contract	anniversary	date	
                                                                               	 Ineligible Employees	include	inactive	employees	including	those	
   by	giving	written	notice	to	Highmark	at	least	30	days	in	advance.
                                                                                  laid	off,	retired,	on	leave	of	absence	(with	no	expected	return	date),	
                                                                                  casual	employees	(generally	those	who	work	from	time	to	time	with	
	   The	contract	shall	be	cancelled	by	Highmark	if	the	group	has	committed	
                                                                                  no	definite	work	schedule	or	work	less	than	20	hours	per	week).	
    an	act	or	practice	that	constitutes	fraud	or	misrepresentation.
                                                                                  Also	ineligible	are	seasonal	employees	who	work	only	during	a	
	   The	client	fails	to	remit	premium	by	due	date.                                certain	period	of	the	year,	absentee	owners,	partners	and	officers	
                                                                                  who	are	not	actively	involved	with	the	management	of	the	company	
	   The	client	fails	to	maintain	participation	requirements.                      and	not	appearing	on	official	payroll	records	and	individuals	with	no	
                                                                                  employee-employer	relationship.	Principal	stockholders,	directors,	
    Retroactive client termination requests will not be permitted.                professional	associates,	trustees,	and	consultants	are	ineligible	
                                                                                  unless	actively	employed	full-time	and	on	the	payroll	of	the	
D. EMPLOYER SIZE                                                                  company.
1. Enrollment	in	the	Association-sponsored	Highmark	Blue	Cross	                	
   Blue	Shield	programs	will	be	limited	to	member	organizations	                  Ineligible Dependents:	Domestic	partners	are	not	covered	under	the	
   with	a	minimum	of	two	employees	and	a	total	work	force	of	not	                 MBA’s	Highmark	plans.
   more	than	500	active	employees.	Size	limitation	does	not	apply	to	
   firms	currently	enrolled	in	the	program.	The	size	limitation	applies	       G. CHANGES TO THE PROGRAMS
   to	conditions	at	the	time	of	enrollment	–	i.e.,	once	accepted	into	         	 As Plan Administrator and Contract Holder,	the	Association	
   the	program,	a	member	firm	would	not	be	required	to	terminate	                 reserves	the	right	to	modify	the	Highmark	Blue	Cross	Blue	Shield	
   coverage	should	this	limit	be	exceeded	through	natural	growth.                 programs	when	deemed	to	be	in	the	best	interest	of	the	participating	
                                                                                  member	firms.	Every	effort	will	be	made	to	provide	as	much	
                                                                                  advance	notice	as	possible.


                                 Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                           -99-
     Underwriting Regulations

H. RATE DETERMINATIONS                                                        For new and existing MBA groups making changes, send all
   Demographic rating applies to groups with 50 contracts or less.            documentation to:
   Factors utilized in determining rates include group size, industry,           Highmark Blue Cross Blue Shield
   geographic location, gender and average age of employees.                     Small Group Submissions
                                                                                 120 Fifth Avenue, Suite 1025
   Experience rating will be utilized for groups with more than 50               Pittsburgh PA 15222-3099
   contracts.

I. CONSOLIDATED OMNIBUS BUDGET RECONCILIATION                                    IF A SPECIFIC SITUATION IS NOT ADDRESSED IN THIS
   ACT OF 1985 (COBRA)                                                           MANUAL, INSURANCE PRODUCERS SHOULD DEFER TO
   Member firms with 20 or more employees on payroll are subject to              THE MOST RECENT HIGHMARK UNDERWRITING AND
   COBRA. Specifically excluded from COBRA coverage are: member                  RATING GUIDELINES FOR SMALL EMPLOYER GROUPS.
   firms with less than 20 employees on payroll for 50% of the previous
   calendar year.

J. RE- AUDITS
   Highmark Blue Cross Blue Shield and/or the MBA reserve the right
   to re-underwrite existing business at anytime to ensure compliance
   with current corporate underwriting guidelines. Those groups not
   in compliance with underwriting guidelines may be terminated for
   noncompliance.

K. DOCUMENTATION REQUIREMENTS
   • Most recent UC-2 marked with part-time employees, full-time
     employees, employees opting out and why
   • For employees covered under a spouse’s agreement, please list
     the spouse’s name, spouse’s identification number and name of
     the spouse’s carrier
   • Completed agency transmittal
   • Premium check for one month’s premium
   • Membership applications completed and signed by the owner of
     the company
   • Sales entry form or small group ICIS entry form
   • Producer of Record letter for new client submissions
   • Waiver Form

   New start-up businesses will be required to provide, on their
   letterhead:
   • Start date of the business
   • List of employees
   • Copy of business cards or marketing material to verify
     new business
   • EIN tax identification numbers




                                Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                         -100-
      Rating and Billing
        Procedures




Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                        -101-
      Demographic Rating

DEMOGRAPHIC FACTORS                                                                   C. Dual Option Groups…Average age is based on the “renewal
Five demographic factors are used to determine rates for small groups in                 demographics” which are calculated approximately 6-9 months
associations/pools.                                                                      prior to the group’s renewal.
• Size categories…demographic rating applies to groups with 1 to 50
                                                                                 •    Gender
   contracts. Groups with 51 or more employees are master-rated.
•    Industry…based on SIC code, groups are categorized into one of              Adjustments for incorrect or changed demographics
     three SIC code industry bands. The SIC code is required when the            • Any initial rate quoted based on incorrect demographic information
     group is submitted. The industry classification for a particular group         will be revised to reflect the correct data upon enrollment of the
     is based on the overall description of the company’s business and not          group.
     on the individual duties of its employees. Accurate SIC assignment is
                                                                                 •    When a group’s demographic characteristics change, its rates will
     provided in the Dun & Bradstreet industry classification manual.
                                                                                      be adjusted at the new renewal.
•    Geographic location…refers to the physical location of the company.
•    Average age…is based on the number of employees enrolling across            HOW RATES ARE CALCULATED AT RENEWAL
     all Highmark and Keystone Health Plan West products, including              • Existing business…The Base Experience Period (BEP) rates are
     those enrolling in the out-of-area programs the group offers to               calculated approximately 6-9 months prior to the effective date of
     its employees. When calculating average age, include only those               renewal. The average age is a “snapshot” of the last month of the
     employees enrolling. Because average age can change daily, the                BE; group size is based on a twelve-month average of the BEP.
     following rules are applied:                                                •    If a client totally replaces an existing Highmark health product
     A.New Groups…Average age is calculated as of the requested                       or adds a new Highmark health product to an existing one…the
       effective date for the new coverage.                                           entire client is subject to re-underwriting, and the demographics are
                                                                                      based on the “snapshot” renewal demographics.
     B. Replacement Groups…Average age is based on the “renewal
        demographics” which are calculated approximately 6-9 months              •    Demographic rate change…Highmark does reserve the right to
        prior to the group’s renewal.                                                 review and adjust a client’s demographics in “unusual case studies”
                                                                                      including, but not exclusive to, common ownership.




        ACTION                                                                       PROCEDURE
      ADDING              1. Complete the appropriate enrollment form
     EMPLOYEES            2. Complete the adjustment form
                          3. Send the enrollment form, adjustment form, payment coupon and payment to the Billing department
    TERMINATING           1. Complete the adjustment form
     EMPLOYEES            2. Deduct appropriate amount from the total
                          3. Send the adjustment form, the payment coupon and payment to the Billing department
      EMPLOYEE            1. Complete the appropriate enrollment form
      COVERAGE            2. Complete the adjustment form
       CHANGES            3. Send the adjustment form, the payment coupon and payment to the Billing department
        ADDING            1. Complete the appropriate enrollment form
     DEPENDENTS           2. Complete the adjustment form
      INCLUDING           3. Send the enrollment form, adjustment form, payment coupon and payment to Highmark Sales Service
      NEWBORNS
      CHANGING            1. Complete the “Small Group Business Application”
        GROUP             2. Complete the appropriate enrollment forms
         PLAN             3. Send “Small Group Business Application”, enrollments and all necessary information
       OPTIONS
    FILING CLAIMS         Hospitalization: Done by hospital
                          Medical/Surgical: Done by Physician
                          Major Medical: Submit to Highmark with Major Medical form
       BILLING            1-800-207-9307
      QUESTIONS
    BENEFIT BOOKS         www.mbausa.org
      CLAIM OR            Highmark: 1-800-835-4290
       BENEFIT            65 Special: 1-800-345-7808
      QUESTIONS           KeystoneBlue: 1-800-547-9378
       SUPPLIES           412-544-2300

                                 Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                              -102-
     Billing System Procedures

All coverages are billed on a monthly basis.

BILLING DATE
Invoices will be mailed by the fourth working day of the month preceding coverage. The invoices must be paid within ten business days of the
mailing date in order to avoid late payment charges.



CHECKS
Make checks payable to Manufacturer & Business Association Insurance Plan
  Mail To:       Manufacturer & Business Association Insurance Plan
                 PO Box 535194
                 Pittsburgh, PA 15253-5194



AUTO PAY OPTION
Call for an application 1-800-207-9307
• Fill out the application and authorization
• Submit with a Voided Check



ADDITIONS, TERMINATIONS, AND CHANGES
Additions are always effective the first of the month following date of hire and/or fulfillment of company waiting period. Terminations are always
effective the first day of the month following termination. Additions, terminations and changes can be made retroactively to a maximum of three
months, depending on individual carrier underwriting rules.

Enrolling New Employees – In the “Addition” section of the Adjustment Form, insert all requested information including name, Social Security
Number, effective date of enrollment, coverage code, medical code and corresponding premium and fees. Completed enrollment forms for all
coverage must be sent with the invoice and payment. Include the necessary payment for the new enrollments. If addition is due to change from part-
time to full-time status, you must indicate in the margin of the enrollment form the date the change was effective.

Terminating Employees – In the “Terminations” section of the Adjustment Form, list the requested information including name, Social Security
Number, effective date of termination, the term all (TA) or term select (TS) indicator, the term code and the corresponding premium and fees. Deduct
applicable amounts from your payment.

Changes – When an employee adds or deletes dependent coverage or is entitled to an increase or additional benefits, complete the “Coverage Changes”
section of the Adjustment Form. Insert the requested information including name, Social Security Number, effective date of change, coverage code and
medical code. Subtract the current premium (old) and add the premium that corresponds to the new coverage level (new). Adjust your payment by the net
amount of the changes. The appropriate change forms must be completed and returned with the payment and the Adjustment Form.



 COVERAGE                                        CHANGE TYPE                      FORM REQUIRED                              FORM #
 Traditional/Comprehensive                     Address or Dependents             Member Change Form                            21131
 KeystoneBlue                                  Address or Dependents             Member Change Form                            21131
 PPOBlue                                       Address or Dependents             Member Change Form                            21131
 PPO BlueCard                                  Address or Dependents             Member Change Form                            21131




                               Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                       -103-
     Billing System Procedures

EBDSWEB online enrollment is also available to employer groups – For more details log onto: www.ebdsbenefits.com/gbomaint/

Adding Dependents – Coverage for dependents who were not added upon enrollment may only be added during the annual open enrollment period of
January 1 or the first day of the month following a documented qualifying event.

 EVENT                               EFFECTIVE FIRST DAY OF MONTH AFTER                                     DOCUMENTATION REQUIRED
 Birth                          Date of Birth                                                     Date of Birth on Enrollment/Change Form
 Adoption                       Date of Adoption                                                  Copy of Legal Adoption Document
 Loss of Coverage               Date of Loss                                                      Notice from Dependent’s Carrier or Employer
 Marriage                       Date of Marriage                                                  Indicate in Margin on POS Enrollment Form or in
                                                                                                  Date of Marriage Box on Change Form

Full-Time Students – Highmark will automatically terminate coverage for a dependent the first of the month following the dependent’s 19th birthday.
If a dependent is a full-time student, please submit verification from the school (i.e., invoice, schedule, or letter of registration) and a change form to
reinstate and/or continue coverage with your premium payment/invoice. All dependents will be removed the first of the month following their 25th
birthday. Appropriate rate changes will be made at that time.

It is essential that all changes be fully and accurately noted on the invoices and any required enrollment or change forms be remitted with the invoice for
any month in which changes in personnel or status occur. We cannot add or terminate employees or make changes to the billing for any coverage that was
not properly indicated.




PREVIOUS MONTH TRANSACTIONS
Each invoice includes a detailed listing of all changes you reported with your previous month’s payment. This listing will verify all additions, deletions
and changes you requested. The correct charges or credits for each individual will be shown. The total for all of these adjustments will be added to or
subtracted from the original amount billed for that month and the premium due after all changes are shown. The amount is then compared with what you
actually paid. If you paid more or less than the amount due, the difference is then identified on your current bill as an “Adjustment” and is added to or
subtracted from the current payment due.

NOTE: If changes due to renewal or option change are not reflected on your current invoice, pay as billed or adjust the payment to the amount
quoted. Adjustments will be made the following month. Please continue to make a monthly payment to avoid cancellation.




                                 Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                           -104-
     Billing, Administrative Fees and Procedures

Billing and administrative services for the Manufacturer & Business              Note: A $15 charge for returned checks will be applied. In
Association Insurance Plan are provided through Employee Benefit                 addition, a $25 reinstatement fee will be applied if the premium is
Data Services of Pittsburgh. The schedule of fees applied to the monthly         not received by the last day of the month prior to coverage.
premium billing is as follows:
                                                                                 ACH Payment Option is also available:
A. Service Charge…The monthly service charge consists of three parts:            Note: Withdrawals are made on the 8th business day of each
   1. A $6.00 basic charge per group. Groups with several Highmark               month for the next month’s coverage. (i.e. Dec 10, 2008 for January
      medical groups must be reported separately to Highmark;                    2009 coverage)
      however, you may now combine groups on a single invoice and
      receive a discount of $2.00 for each additional Highmark medical           A Signed Authorization form along with a voided check identifying
      group. Example: a group with Point of Service and Comprehensive            the account # is required for signup.
      would previously have received two invoices with a total basic
      charge of $12.00. The group may consolidate both coverages on a            Member firms must submit, in writing, all requests for administrative
      single invoice and pay a total basic charge of only $10.00.                changes regarding company name, address, telephone number,
   2. $.45 per participating employee for one to three benefit coverages         ownership and billing correspondence to:
      including individually, Blue Cross, Blue Shield, Major Medical                   The Manufacturer & Business Association
      and other benefits offered through the Association, such as Life,                2171 West 38th Street
      AD, Weekly Disability Income and Dental.                                         Erie, PA 16508
   3. $.03 per participating employee for each coverage column in
                                                                                 Please also note all administrative changes on the invoice.
      excess of three. The maximum monthly total charge for Items
      2 & 3 will be $60.
                                                                             F. Premium Invoices will only be mailed to member companies. If
                                                                                rates are not available to EBDS from the carrier by the last business
B. DAMP Charge… $2.00 per participating employee for Data
                                                                                day of the month; they will show retroactively on the next invoice.
   Analysis Management Program (DAMP). This is a separate charge
   and is not included in determining the $60 maximum total service             Any problems or questions related to billing should be directed to
   charge. There is a maximum DAMP charge of $100/month per                     Employee Benefit Data Services by calling the following toll-free
   participating group.                                                         number: 1-800-207-9307.


C. Premium Delinquency Charge…Premium payments are due                       G. Additional Services…Employee Benefit Data Services can
   and payable by the 15th day of the month prior to the coverage               administer COBRA for your company. Please call 1-800-207-9307
   month, or 10 business days from the mailing date. A charge of 2%             and ask for coverage continuation details.
   of premium with a $10 minimum is made when it is necessary to
   initiate premium delinquency procedures.                                      EBDS offers partial COBRA administration at a cost of .10/
                                                                                 active employee.
D. Reinstatement Charge…Should reinstatement be approved under                   Services include:
   extenuating circumstances following cancellation of coverage due              • supplying qualifying event notices to the employer groups for
   to nonpayment of premium or persistent premium delinquency, a                   distribution
   charge of $25 will be applied.                                                • monthly billing to COBRA participants

NOTE: All checks received after the last day of the month prior to               • monthly reporting of all additions, terminations and changes
the coverage month will be returned to the sender and reinstatement                to the carrier and to the employer group
procedures will be necessary to continue coverage. Reinstatement includes
remittance of late fees, reinstatement fees and two months of premium.           EBDS also offers full COBRA administration at a cost of .25/
                                                                                 active employee.
E. Premium Payments                                                              Services include:
                                                                                 • supplying the qualified subscriber(s) with a notification letter
   Make checks payable to Manufacturer & Business Association                      upon termination from the active group
   Insurance Plan                                                                • monthly billing to COBRA participants
   Mail To:     Manufacturer & Business Association Insurance Plan
                                                                                 • monthly reporting of all additions terminations and changes to
                PO Box 535194
                                                                                   the carrier and to the employer group
                Pittsburgh, PA 15253-5194




                                Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                        -105-
     Optional Enhanced COBRA Administration

The Employee Benefits Security Administration of the US Department of            Highmark Blue Cross Blue Shield and
Labor has issued final rules governing the COBRA notice requirements.            Mini-COBRA Legislation
The rules are effective for the first plan year beginning on or after
January 1, 2005. For most MBA plans the effective date will be                   Mini-COBRA refers to legislation passed by Pennsylvania and signed
January 1, 2005.                                                                 into law with an effective date of July 10, 2009. Under the legislation,
                                                                                 participants whose coverage was terminated involuntarily between
     EBDS can take the worry out of COBRA by providing                           July 10, 2009 and December 31, 2009 may be eligible for a 65%
     full-service administration for participants that experience                premium subsidy (funded through the American Recovery and
     a COBRA qualified loss of group health plan coverage. In                    Reinvestment Act through December 31, 2009).
     addition to the traditional EBDS COBRA service offering,
     the enhanced service includes the required COBRA notices.                   The participant is eligible for the subsidy only if the Qualifying
     The Plan Administrator at your company will notify EBDS
                                                                                 Event occurred between July 10, 2009 and December 31, 2009. The
     when there is a loss of coverage in the group health plan due
                                                                                 participant must also have been continuously insured under the group
     to death of the employee, termination of the employee for
                                                                                 policy (or for similar benefits under any group policy which it replaced)
     any reason, reduction in the number of hours worked by the
                                                                                 for three consecutive months ending with the employee’s termination.
     employee, or attainment of Medicare eligibility. The notice
     to EBDS will be made either via paper notice (mailed, hand
                                                                                 Mini-COBRA:
     delivered, or faxed) or via the submission of the information
     through the EBDSWEB site.                                                   •	 applies to employer groups with between 2 and 19 employees on a
                                                                                    typical business day in the prior calendar year
In the case of divorce or legal separation of the covered employee, the          •	 applies to medical coverage only (not dental and/or vision
end of eligibility as a dependent child, or a second qualifying event under         coverage)
COBRA, the participant in the plan will notify EBDS directly without             •	 does not apply to HRA and FSA accounts
need for involvement by anyone from the company.                                 •	 continuation of coverage lasts a maximum of nine months

Within 14 days of receiving timely notice of the qualifying event -- EBDS        The mini-COBRA administrator or group may charge an administration
will determine whether a notice from the participant is made timely --           fee of up to 5% of the group premium rate being charged to the member
EBDS will mail, via regular first class mail, the required COBRA election        (100% or 35%). The legislation also makes the insurer – in your case,
notice and rights statement. When necessary, EBDS will mail the new              Highmark – responsible for the 65% portion of the premium.
Notice of Unavailability of Coverage (i.e., when COBRA coverage does
not have to be provided because the participant provides late notice of a        Notification Process
second qualifying event). EBDS keeps records of all such mailings so that
                                                                                 •	 Your group (the employer) has 30 days from the date of the
proof of mailing can be made, if necessary.
                                                                                    Qualifying Event to notify the member of his/her rights under
                                                                                    mini-COBRA.
COBRA qualified beneficiaries should return their completed election
                                                                                 •	 If your group uses the services of a third party COBRA
forms to EBDS. Thereafter, EBDS will send monthly invoices and
                                                                                    Administrator, you have that same 30-day period to notify the
receive payment directly from the participants. EBDS will track and
                                                                                    third-party Administrator that a Qualifying Event has occurred.
reconcile all payments and remit the applicable premiums to Highmark
                                                                                    The Administrator has 14 days to notify the member of his/her
each month.
                                                                                    rights under mini-COBRA.
                                                                                 •	 In either case, the member then has 30 days to elect to continue
EBDS COBRA administration includes all processing required for partial,
                                                                                    benefits under mini-COBRA
late and grace period payment based upon the legal requirements and the
applicable rules of the plan. EBDS will mail the newly required Notice
of Early Termination of Coverage to any participant whose COBRA                  Call 1-800-207-9307 for a quote.
coverage ends prior to the end of the maximum coverage period. In
addition, the final termination of COBRA coverage notice will include
a HIPAA Certificate of Creditable Coverage for the COBRA coverage
period.

The entire EBDS COBRA administration process is supported by a full-
service customer service center staffed by trained professionals available
to answer inquiries from participants during regular business hours.




                                 Manufacturer & Business Association-Sponsored Highmark Blue Cross Blue Shield Programs

                                                                             -106-
Away from Home Care, PreferredBlue, BlueCard, BlueCard Worldwide, DirectBlue, Blue Cross, Blue Shield and the Cross and Shield symbols
are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.

           PPOBlue, KeystoneBlue, ShortTermBlue, MedigapBlue, FreedomBlue, SecurityBlue, Baby BluePrints and BlueAccount
                                   are service marks of the Blue Cross and Blue Shield Association.

                   Keystone Health Plan West is an independent licensee of the Blue Cross and Blue Shield Association.

                                     Highmark and Pay-It-Easy are registered marks of Highmark Inc.
                                    CompleteCare and SpecialCare are service marks of Highmark Inc.

								
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