Group Master Application Benefit Selections Large Heritageselect

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Anchorage, AK 99503-2737 / fax 907-258-1619

GROUP MASTER APPLICATION BENEFIT SELECTIONS—HERITAGESELECT

LARGE GROUP
This form is part of the Group Master Application.

GROUP NAME

Note: / No customizations will be allowed without prior approval.
No customization required (only standard options taken)
Yes, approved Product Customization Request form attached
Cost-share amounts represent members’ costs.

GROUP ID

ALPHA PLAN PREFIX

Default values are shown as bold-faced options. / (Completed by Premera Blue Cross Blue Shield of Alaska)
1. /

BENEFIT COVERAGE SELECTION

A. / How many benefit plans will the group offer?
Note: If this plan is for dental only, complete only section 10 of this form.
B. /

Class Selection

If you are differentiating your benefit coverage selection by class of employee, you will need to complete a benefit coverage selection worksheet for each separate class of employee you wish to cover. Select both a class and subclass from B1 and B2 below.
1. /

Class:

/ Active / Retiree* / Early Retiree* / Other, please specify
* Requires Underwriting Approval
2. /

Subclass:

All employees

/ Management / Salaried / Hourly / Part-time / Full-time

Union

/ Non-Union / Other, please specify
2. / MEDICAL COST-SHARE OPTIONS
Helpful Hint: The Deductible and Coinsurance options you select below (sections 2A-2C) will not apply to the Prescription Drug benefits in Section 8 and the Dental benefits in Section 10. Subsequent sections of this form will allow you to further customize your cost-share options by applying Deductible/Coinsurance or Copays to specific benefits. Please note that references to “Deductible and Coinsurance” as a benefit choice in this worksheet will select whatever deductible and coinsurance options were chosen in this Section 2.
A. / Individual Deductible(per calendar year)
In-Network / Out-of-Network(Hospitals, Hospital-Based Chemical Dependency Programs Only)
Note: If separate out-of-network deductible is taken, it must be at least 2 times the in-network deductible.
None / $1,000 / $100 / $1,000
$100 / $1,500 / $200 / $1,500
$200 / $2,000 / $300 / $2,000
$250 / $2,500 / $400 / $3,000
$300 / $3,000 / $500 / $4,000
$500 / $4,000 / $600 / $10,000
$750 / $5,000 / $750 / Shared with In-Network Deductible
B. /

Family Deductible(per calendar year)

3 times the individual deductible
2 times the individual deductible
No family deductible
C. / Coinsurance
In-Network / Out-of-Network (Hospitals, Hospital-Based Chemical Dependency programs only)
0% / 20% / 20% / 40%
10% / 30% / 30% / 50%
Note: Out-of-Network must be at least 20 percentage points higher than in-network
2. / MEDICAL COST-SHARE OPTIONS (CONTINUED)
D. / Individual Out-of-Pocket Maximum(per calendar year) *The out-of-pocket maximum includes any deductible

Out-of-Network (Hospitals, Hospital-Based Chemical Dependency Programs Only)

In-Network /

(If an in-network out-of-pocket maximum is chosen, and out-of-network services do not share in-network out-of-pocket maximum, then out-of-network out-of-pocket maximum must be at least double the in-network out-of-pocket maximum.)

$500 / $2,000 / $6,000 / No limit / $2,400 / $9,000
$700 / $2,100 / $7,500 / $500 / $2,500 / $10,000
$750 / $2,250 / $9,000 / $750 / $3,000 / $12,000
$1,000 / $2,300 / No Limit / $1,000 / $3,750 / $20,000
$1,100 / $2,500 / $1,250 / $4,000 / Shared with in-network
$1,200 / $3,000 / $1,500 / $4,500
$1,250 / $3,500 / $1,750 / $5,000
$1,300 / $4,000 / $2,000 / $6,000
$1,500 / $4,500 / $2,200 / $7,000
$1,750 / $5,000 / $2,300 / $8,000
E. / Family Out-of-Pocket Maximum
Note: If both family deductible and family out-of-pocket maximum are selected, the family-to-individual ratio (3 times or 2 times) on both must be the same.
3 times the individual out-of-pocket maximum
2 times the individual out-of-pocket maximum
None
F. / Office Visit Cost-Share
Deductible & Coinsurance
Copay of: / $20 / $25
G. / Lifetime Benefit Maximum
$1 Million / $2 Million / Unlimited
3. / FACILITY CARE OPTIONS
A. / Inpatient Facility Care
In-Network / Out-of-Network (Hospitals, Hospital-Based Chemical Dependency Programs Only)
Deductible & Coinsurance / Deductible & Coinsurance
Copay of $100Per Admit
B. / Skilled Nursing Facility(per calendar year)
20 days / 60 days / 100 days / 120 days
4. / EMERGENCY CARE OPTIONS
A. /

Emergency Room Care

Note: If Copay option is selected, copay waived if direct admit to an inpatient facility.

In-Network/Out-of-Network(Hospitals, Hospital-Based Chemical Dependency Programs Only)

Deductible & Coinsurance
Deductible & Coinsurance PLUS Copay of: / $50 / $100 / $150
B. /

Air or Surface Transportation

1-way transportation for sudden, life-endangering illness or injury
3 round trips PCY (option only available to 200+ groups)
5. / DIAGNOSTIC SERVICES OPTIONS

Note: Out-of-NetworkHospitals and Hospital-based Chemical Dependency Programs are subject to the out-of-network deductible and coinsurance. Member costshare for mammography must be less than or equal to the costshare for preventive services.

Preventive

Basic / Major

Mammography

Covered in Full*

Deductible & Coinsurance

Covered in Full*

Waive Deductible; Subject to Coinsurance

Covered in Full*

*Benefits provided at 100% of allowable charge, not subject to deductible or coinsurance.
6. / PREVENTIVE CARE OPTIONS
A. / Preventive Exams(including Immunizations)
Note: Limits shared by both in- and out-of-network providers.
1. / Preventive Exam Cost-share
Not Covered
Covered in Full
2. /

Child/Adult Exam

/ Newborn Exam / Immunizations*
Not Covered / Not Covered / Not Covered
Unlimited / Unlimited / Unlimited
*Immunization benefits provided at 100% of allowable charge, not subject to deductible or coinsurance. Includes Seasonal Immunizations provided at a pharmacy.
B. / Health Management
Note:Limits shared by both in and out-of-network providers. Covered services are covered in full up to the benefit limit.* Diabetes education is not subject to a benefit limit even if other health management services are not selected.
Health Education / Community Wellness / Nicotine Dependency
Not Covered /

Not Covered

/ Not Covered
$250 / Shared with health education limit / Shared with health education limit
$500 / Shared with health education limit / Shared with health educationlimit
Unlimited / $250 / $250
*Benefits provided at 100% of allowable charge, not subject to deductible or coinsurance.
7. / OTHER SERVICE OPTIONS
A. / Complementary and Alternative Medicine/Chiropractic Care(per calendar year)
Note:All options include benefits for naturopathy with no benefit limit.
Acupuncture /

Spinal and Other

Manipulations / Nutritional Therapy*
12 visits / 12 visits / 4 visits
12 visits / 24 visits / 4 visits
12 visits / Unlimited / 4 visits
Unlimited** / Unlimited / Unlimited
*Visit limits do not apply to nutritional therapy for diabetes.
B. /

Supplies, Equipment and Prosthetics(per calendar year)

Note:Limits shared both in- and out-of-network.

Medical Equipment

Medical Supplies

Prosthetics

Foot Orthotics &Orthopedic Shoes

$10,000

Shared with equipment limit

$300; shared with equipment limit

$5,000

Unlimited

Shared with equipment limit

$300; shared with equipment limit

$5,000

Shared with equipment limit

Unlimited

$300; shared with equipment limit

Unlimited*

Unlimited

*Requires underwriting approval
7. / OTHER SERVICE OPTIONS (CONTINUED)
C. / Home and Hospice Care Note:Limits shared both in- and out-of-network.
1. / Home Health Care (per calendar year)
130 visits / Unlimited
2. / Hospice Inpatient / Respite care / Overall Benefit Limit
10 days / 240 hours / 6 months
30 days / 240 hours / 6 months
Unlimited* / 240 hours / 6 months
*Requires underwriting approval
D. /

Therapeutic Injections(includes allergy injections and allergy testing)

Deductible & Coinsurance

Waive Deductible; Subject to Coinsurance

Covered in Full*

*Benefits provided at 100% of allowable charge, not subject to deductible or coinsurance.

E. /

Rehabilitation and Neurodevelopmental Therapy(per calendar year)

Note:Limits shared both in- and out-of-network.
Outpatient
Rehabilitation / Inpatient
Rehabilitation / Outpatient Neuro-
developmental Therapy / Inpatient Neuro-
developmental Therapy
15 visits / 30 days / 15 visits / 30 days
45 visits / 30 days / 45 visits / 30 days
60 visits / 60 days / 60 visits / 60 days
F. /

Temporomandibular Joint (TMJ) Disorders

Not covered / $1,000 per calendar year; $5,000 lifetime maximum
Note:For members covered under the medical plan, only medical TMJ services will be covered unlessa dental plan is selected; in that case, dental TMJ services will also be covered.
G. / Orthognathic and Maxillofacial Surgery(Jaw Augmentation or Reduction)
Not covered / $5000 lifetime
H. / Infertility(per calendar year)
Not covered / $5,000 / $10,000 / $20,000 / Unlimited*
*Requires underwriting approval
I. / Contraceptive Management Benefit Limit Options
Not covered (contraceptive drugs, devices, supplies, and services)
Cover as any other medical service, prescription drug or device
8. / Prescription Drug Coverage Options

Dispensing limits

Retail: 90-day supply per prescription refill (1 copay per 30-day supply)

Mail: 90-day supply per prescription refill (1 copay per 90-day supply)

Complete only one option A, B, orC within this section.
A. / 3-Tier Program

Deductible

Retail Pharmacy

Mail-Order Pharmacy Service

Out-of-Pocket Maximum

Generic

Preferred Brand

Non-Preferred Brand

Generic

Preferred Brand

Non-Preferred Brand

None / $10 /

$20

$40

$25

$50

$100

Not Limited

None / $10 /

$25

$40

$25

$62

$100

Not Limited

$150* / $10 /

$25

$40

$25

$62

$100

Not Limited

$300* / $10 /

$25

$45

$25

$62

$112

Not Limited

None / $10 /

$30

$50

$25

$75

$125

Not Limited

None / $10 /

25%

50%

$25

20%

45%

Not Limited

None / $15 /

$25

$50

$37

$62

$125

Not Limited

$150* / $15 /

$25

$50

$37

$62

$125

Not Limited

None / $20 /

$50

50%

$50

$125

45%

$5,000

*Deductible waived for generics

8. / Prescription Drug Coverage Options (CONTINUED)
B. / 2-Tier Program
Deductible / Retail Pharmacy / Mail-Order Pharmacy Service / Out-of-Pocket Maximum

Generic

Brand

Generic

Brand

None / $10 /

$25

/ $25 /

$62

Not Limited

$150* / $10 /

$25

/ $25 /

$62

Not Limited

None / $10 /

$30

/ $25 /

$75

Not Limited

* Deductible waived for generics

C. / Generic-Only Program
Deductible / Retail Pharmacy / Mail-Order Pharmacy Service / Out-of-Pocket Maximum
None / $10 / $25 /

Not Limited

D. / Rx Family Deductible* (only available if an individual Rx deductible taken)
No / Yes

*An Rx family deductible can only be chosen when the plan includes a medical family deductible. The individual/family ratio must match the medical individual/family ratio.

E. / Mandatory Generic Substitution – Dispensed As Written Waiver
Yes / No (optional for 200+ groups only)
9. / SUPPLEMENTAL BENEFIT OPTIONS
A. /

Vision Benefits

1. /

Routine Vision Exam (per calendar year)

Not Covered

1 Exam; Covered in full*

1 Exam; Waive Deductible, subject to 20% coinsurance**
1 Exam; subject to a $25 copay
*Benefits provided at 100% of allowable charge, not subject to deductible or coinsurance.
**Packaged with 20% vision hardware benefit in section A2; not available separately.
2. / Vision Hardware
Note: Only available if routine vision exam selected in section A1 above.
Not covered
$150 per calendar year
$200 per calendar year
$300 per 2 calendar years
1 set of lenses per cal year; 1 frame per 2 cal years (20% coinsurance required; must
be taken with 20% coinsurance exam benefit in section A1)
B. /

Hearing Benefits

1. / Routine Hearing Exam (includes testing)
Not covered
1 visit per calendar year; subject to office visit cost-share
1 visit per calendar year; covered in full*
1 visit per 2 calendar years; subject to office visit cost-share
1 visit per 2 calendar years; covered in full*
Waive deductible, 20% coinsurance to $800 per 3 calendar years (packaged with 20% coinsurance hardware benefit in section B2 below; not available separately)
*Benefits provided at 100% of allowable charge, not subject to deductible or coinsurance.
2. / Hearing Hardware Note: Only available if routine hearing exam selected in section B1 above.
Not covered
$3,000 every 3 calendar years
Waive deductible, 20% coinsurance, shared with $800 exam limit per 3 calendar years (packaged with 20% coinsurance exam benefit
above; not available separately)
10. /

Dental Cost-Share Options

Note: Dental Standard and Dental Progressive products are no longer available to new groups. Complete only one plan option A, B, C orD;then continue to optional benefits E, F G within this section.
A. /

Renewal Groups Only

Renew Dental Standard or Dental Progressive as is — no benefit changes; form complete; stop here.
B. / Dental Optima [ded - (fam) / coins / max]
Note: The deductible, if any, is waived for Preventive and Diagnostic services.
$0 ($0) / 0% - 20% - 50% / $2,000 / $50 ($150) / 0% - 20% - 50% / $2,000
$0 ($0) / 0% - 20% - 50% / $1,500 / $50 ($150) / 0% - 20% - 50% / $1,500
$0 ($0) / 0% - 20% - 50% / $1,000 / $50 ($150) / 0% - 20% - 50% / $1,000
$0 ($0) / 20% - 20% - 50% / $2,000 / $50 ($150) / 20% - 20% - 50% / $2,000
$0 ($0) / 20% - 20% - 50% / $1,500 / $50 ($150) / 20% - 20% - 50% / $1,500
$0 ($0) / 20% - 20% - 50% / $1,000 / $50 ($150) / 20% - 20% - 50% / $1,000
C. /

Dental Preventive [ded - (fam) / coins / max]

$0 ($0) / 0% – NC – NC / $500

D. /

Voluntary Plans [ded - (fam) / coins / max]

1. /

Dental Essentials

Note: Includes 12-month waiting period for major services

$50 ($150) / 0% - 20% - 50% / $1,000

$50 ($150) / 20% - 20% - 50% / $1,000

$50 ($150) / 0% - 20% - 50$ / $1,500

2. /

Preventive

$0 ($0) / 0% - NC – NC / $500

E. /

Orthodontia Benefit Options

Lifetime Limit
Not Covered
$1,000 / $1,500
$1,000 Note: Up to age 19 / $1,500 Note: Up to age 19
F. /

Temporomandibular Joint (TMJ) Disorders

Note: Option only available to dental only plans.
If members are offered PBCBSAK medical coverage, the TMJ benefit must be a part of the medical plan.
Not covered / $1,000 per calendar year; $5,000 lifetime maximum Note: Only dental TMJ services will be covered.
G. / Benefit Enhancement Rider— Endodontic and Periodontal Treatment from Major Services to Basic Services
Buy-Up Endodontic and Periodontal Treatment from Major Services to Basic Services
11. / COMMENTS
013392 (07-2010) / GROUP MASTER APPLICATION BENEFIT SELECTIONS LARGE—HERITAGESELECT / PAGE 1 OF 6