Common use of Blue Cross Blue Shield Global Core Program Clause in Contracts

Blue Cross Blue Shield Global Core Program. If you are outside the United States, (the Commonwealth of Puerto Rico and the U.S. Virgin Islands) (hereinafter: “Blue Cross Blue Shield Global Core Service Area”), you may be able to take advantage of the Blue Cross Blue Shield Global Core Program when accessing Covered Healthcare Services. The Blue Cross Blue Shield Global Core Program is unlike the BlueCard Program available in the United States, the Commonwealth of Puerto Rico and the U.S. Virgin Islands in certain ways. For instance, although the Blue Cross Blue Shield Global Core Program assists you with accessing a network of inpatient, outpatient and professional providers, the network is not served by a Host Blue. As such, when you receive care from providers outside the United States, the Commonwealth of Puerto Rico and the U.S. Virgin Islands, you will typically have to pay the providers and submit the claims yourself to obtain reimbursement for these services. • Inpatient Services In most cases, if you contact the Blue Cross Blue Shield Global Core Service Center for assistance, hospitals will not require you to pay for covered inpatient hospital services, except for their any cost sharing you may owe. In such cases, the Blue Cross Blue Shield Global Core Program contracting hospital will submit your claims to the Blue Cross Blue Shield Global Core Service Center to initiate claims processing. However, if you paid in full at the time of service, you must submit a claim to obtain reimbursement for Covered Services. You must contact us to obtain Precertification for non-emergency inpatient services. • Outpatient Services Physicians, urgent care centers and other outpatient providers located outside the Blue Cross Blue Shield Global Core Service Area will typically require you to pay in full at the time of service. You must submit a claim to obtain reimbursement for Covered Healthcare Services. • Submitting a Blue Cross Blue Shield Global Claim When you pay for Covered Services outside the Blue Cross Blue Shield Global Core Service Area, you must submit a claim to obtain reimbursement. For institutional and professional claims, you should complete a Blue Cross Blue Shield Global Core claim form and send the claim form with the provider’s itemized bill(s) to the Blue Cross Blue Shield Global Core Service Center (the address is on the form) to initiate claims processing. The claim form is available from us, the Blue Cross Blue Shield Global Core Service Center or online at ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. If you need assistance with the claim submissions, you should call the Blue Cross Blue Shield Global Core Service Center at ▇.▇▇▇.▇▇▇.▇▇▇▇ (2583) or call collect at ▇.▇▇▇.▇▇▇.▇▇▇▇, 24 hours a day, seven days a week. Group Exec Initials Sponsored Plan Acronym Leasing Company Acronym Company Name Physical Address Customer ID(BCBSM), Group ID(BCN) SubGroupID ClassID Leasing Company Name BCBSM Group Number Group Division Effective Date / / Phone - - County City State Zip Code Primary Nature Of Business - SIC DBA Doing Business As Company Fax Check here if this group is ERISA Exempt Are you currently in bankruptcy? Yes No Do you have any leased employees? Yes No Does this group have subsidiaries, offices, or branches located at other physical locations? Yes No If yes, submit multiple location report Is Work Force Unionized? Yes No Number of Employees Represented Local Number Contract Expiration Date National/International Name Local Representative Name Retiree Group: Is there a surviving spouse option? Medical $ % . Dental $ % . A. To be eligible for coverage an employee must work a minimum of 30 hours per week. Yes No Vision $ % . B. Eligible Dependent coverage will be effective on date of event, e.g., spouse, newborn, if written notification is received within 31 days thereof with billing prorated. If after 31 days, coverage will be effective at group's next annual reopening date. C. Enter appropriate BCBSM/BCN code selected from the New Hire/Rehire options table for newly hired full-time employees, or part-time employees who become full-time. Any requests that do not comply with BCBSM/BCN guidelines require underwriting review and approval, such as requests from large employers related to compliance with the employer mandate provisions of IRC 4980H: BCBSM Code BCN Code

Blue Cross Blue Shield Global Core Program. If you are outside the United States, (the Commonwealth of Puerto Rico and the U.S. Virgin Islands) (hereinafter: “Blue Cross Blue Shield Global Core Service Area”), you may be able to take advantage of the Blue Cross Blue Shield Global Core Program when accessing Covered Healthcare Services. The Blue Cross Blue Shield Global Core Program is unlike the BlueCard Program available in the United States, the Commonwealth of Puerto Rico and the U.S. Virgin Islands in certain ways. For instance, although the Blue Cross Blue Shield Global Core Program assists you with accessing a network of inpatient, outpatient and professional providers, the network is not served by a Host Blue. As such, when you receive care from providers outside the United States, the Commonwealth of Puerto Rico and the U.S. Virgin Islands, you will typically have to pay the providers and submit the claims yourself to obtain reimbursement for these services. • Inpatient Services In most cases, if you contact the Blue Cross Blue Shield Global Core Service Center for assistance, hospitals will not require you to pay for covered inpatient hospital services, except for their any cost sharing you may owe. In such cases, the Blue Cross Blue Shield Global Core Program contracting hospital will submit your claims to the Blue Cross Blue Shield Global Core Service Center to initiate claims processing. However, if you paid in full at the time of service, you must submit a claim to obtain reimbursement for Covered Services. You must contact us to obtain Precertification for non-emergency inpatient services. • Outpatient Services Physicians, urgent care centers and other outpatient providers located outside the Blue Cross Blue Shield Global Core Service Area will typically require you to pay in full at the time of service. You must submit a claim to obtain reimbursement for Covered Healthcare Services. • Submitting a Blue Cross Blue Shield Global Claim When you pay for Covered Services outside the Blue Cross Blue Shield Global Core Service Area, you must submit a claim to obtain reimbursement. For institutional and professional claims, you should complete a Blue Cross Blue Shield Global Core claim form and send the claim form with the provider’s itemized bill(s) to the Blue Cross Blue Shield Global Core Service Center (the address is on the form) to initiate claims processing. The claim form is available from us, the Blue Cross Blue Shield Global Core Service Center or online at ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. If you need assistance with the claim submissions, you should call the Blue Cross Blue Shield Global Core Service Center at ▇.▇▇▇.▇▇▇.▇▇▇▇ (2583) or call collect at ▇.▇▇▇.▇▇▇.▇▇▇▇, 24 hours a day, seven days a week. Group Exec Initials Sponsored Plan Acronym Leasing Company Acronym Company Name Physical Address Customer ID(BCBSM), Group ID(BCN) SubGroupID ClassID Leasing Company Name BCBSM Group Number Group Division Effective Date / / Phone - - County City State Zip Code Primary Nature Of Business - SIC DBA Doing Business As Company Fax Check here if this group is ERISA Exempt Are you currently in bankruptcy? Yes No Do you have any leased employees? Yes No Does this group have subsidiaries, offices, or branches located at other physical locations? Yes No If yes, submit multiple location report Is Work Force Unionized? Yes No Number of Employees Represented Local Number Contract Expiration Date National/International Name Local Representative Name Retiree Group: Is there a surviving spouse optionRetirees Enrolling? Medical $ % . Dental $ % .Yes No A. To be eligible for coverage an employee must work a minimum of 30 hours per week. Yes No Vision $ % . B. Eligible Dependent coverage will be effective on date of event, e.g., spouse, newborn, if written notification is received within 31 days thereof with billing prorated. If after 31 days, coverage will be effective at group's next annual reopening date. C. Enter appropriate BCBSM/BCN code selected from the New Hire/Rehire options table for newly hired full-time employees, or part-time employees who become full-time. Any requests that do not comply with BCBSM/BCN guidelines require underwriting review and approval, such as requests from large employers related to compliance with the employer mandate provisions of IRC 4980H: BCBSM Code BCN Code

Blue Cross Blue Shield Global Core Program. If you are outside the United States, (the Commonwealth of Puerto Rico and the U.S. Virgin Islands) (hereinafter: “Blue Cross Blue Shield Global Core Service Area”), you may be able to take advantage of the Blue Cross Blue Shield Global Core Program when accessing Covered Healthcare Services. The Blue Cross Blue Shield Global Core Program is unlike the BlueCard Program available in the United States, the Commonwealth of Puerto Rico and the U.S. Virgin Islands in certain ways. For instance, although the Blue Cross Blue Shield Global Core Program assists you with accessing a network of inpatient, outpatient and professional providers, the network is not served by a Host Blue. As such, when you receive care from providers outside the United States, the Commonwealth of Puerto Rico and the U.S. Virgin Islands, you will typically have to pay the providers and submit the claims yourself to obtain reimbursement for these services. • Inpatient Services In most cases, if you contact the Blue Cross Blue Shield Global Core Service Center for assistance, hospitals will not require you to pay for covered inpatient hospital services, except for their any cost sharing you may owe. In such cases, the Blue Cross Blue Shield Global Core Program contracting hospital will submit your claims to the Blue Cross Blue Shield Global Core Service Center to initiate claims processing. However, if you paid in full at the time of service, you must submit a claim to obtain reimbursement for Covered Services. You must contact us to obtain Precertification for non-emergency inpatient services. • Outpatient Services Physicians, urgent care centers and other outpatient providers located outside the Blue Cross Blue Shield Global Core Service Area will typically require you to pay in full at the time of service. You must submit a claim to obtain reimbursement for Covered Healthcare Services. • Submitting a Blue Cross Blue Shield Global Claim When you pay for Covered Services outside the Blue Cross Blue Shield Global Core Service Area, you must submit a claim to obtain reimbursement. For institutional and professional claims, you should complete a Blue Cross Blue Shield Global Core claim form and send the claim form with the provider’s itemized bill(s) to the Blue Cross Blue Shield Global Core Service Center (the address is on the form) to initiate claims processing. The claim form is available from us, the Blue Cross Blue Shield Global Core Service Center or online at ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. If you need assistance with the claim submissions, you should call the Blue Cross Blue Shield Global Core Service Center at ▇.▇▇▇.▇▇▇.▇▇▇▇ (2583) or call collect at ▇.▇▇▇.▇▇▇.▇▇▇▇, 24 hours a day, seven days a week. Group Exec Initials Sponsored Plan Acronym Leasing Company Acronym Company Name Physical Address Customer ID(BCBSM), Group ID(BCN) SubGroupID ClassID Leasing Company Name BCBSM Group Number Group Division Effective Date / / Phone - - County City State Zip Code Primary Nature Of Business - SIC DBA Doing Business As Company Fax Check here if this group is ERISA Exempt Are you currently in bankruptcy? Yes No Do you have any leased employees? Yes No Does this group have subsidiaries, offices, or branches located at other physical locations? Yes No If yes, submit multiple location report Is Work Force Unionized? Yes No Number of Employees Represented Local Number Contract Expiration Date National/International Name Local Representative Name Retiree Group: Is there a surviving spouse option? Medical $ % . Dental $ % . A. To be eligible for coverage an employee must work a minimum of 30 hours per week. Yes No Vision $ % . B. Eligible Dependent coverage will be effective on date of event, e.g., spouse, newborn, if written notification is received within 31 days thereof with billing prorated. If after 31 days, coverage will be effective at group's next annual reopening date. C. Enter appropriate BCBSM/BCN code selected from the New Hire/Rehire options table for newly hired full-time employees, or part-time employees who become full-time. Any requests that do not comply with BCBSM/BCN guidelines require underwriting review and approval, such as requests from large employers related to compliance with the employer mandate provisions of IRC 4980H: BCBSM Code BCN Code

Blue Cross Blue Shield Global Core Program. a. General Information If you Covered Persons are outside the United States, (the Commonwealth of Puerto Rico and the U.S. Virgin Islands) Islands (hereinafter: “Blue Cross Blue Shield Global Core Service AreaBlueCard service area”), you they may be able to take advantage of the Blue Cross Blue Shield Global Core Program when accessing Covered Healthcare Services. The Blue Cross Blue Shield Global Core Program is unlike the BlueCard Program available in the United States, the Commonwealth of Puerto Rico and the U.S. Virgin Islands BlueCard service area in certain ways. For instance, although the Blue Cross Blue Shield Global Core Program assists you Covered Persons with accessing a network of inpatient, outpatient and professional providers, the network is not served by a Host Blue. As such, when you Covered Persons receive care from providers outside the United StatesBlueCard service area, the Commonwealth of Puerto Rico and the U.S. Virgin Islands, you Covered Persons will typically have to pay the providers and submit the claims yourself themselves to obtain reimbursement for these services. • Inpatient Services In most cases, if you Covered Persons contact the Blue Cross Blue Shield Global Core Service Center service center for assistance, hospitals will not require you Covered Persons to pay for covered inpatient hospital services, except for their any cost sharing you may owecost-share amounts/deductibles, coinsurance, etc. In such cases, the Blue Cross Blue Shield Global Core Program contracting hospital will submit your Covered Person claims to the Blue Cross Blue Shield Global Core Service Center service center to initiate claims processing. However, if you the Covered Person paid in full at the time of service, you the Covered Person must submit a claim to obtain reimbursement for Covered Services. You Covered Persons must contact us BCBSNE to obtain Precertification precertification for non-emergency inpatient services. • Outpatient Services Physicians, urgent care centers and other outpatient providers located outside the Blue Cross Blue Shield Global Core Service Area BlueCard service area will typically require you Covered Persons to pay in full at the time of service. You Covered Persons must submit a claim to obtain reimbursement for Covered Healthcare Services. • Submitting a Blue Cross Blue Shield Global Core Claim When you Covered Persons pay for Covered Services outside the Blue Cross Blue Shield Global Core Service AreaBlueCard service area, you they must submit a claim to obtain reimbursement. For institutional and professional claims, you Covered Persons should complete a Blue Cross Blue Shield Global Core claim form and send the claim form with the provider’s itemized bill(s) ▇▇▇▇ to the Blue Cross Blue Shield Global Core Service Center (the service center address is on the form) form to initiate claims processing. The claim form is available from usBCBSNE, the Blue Cross Blue Shield Global Core Service Center service center, or online at ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. If you Covered Persons need assistance with the their claim submissions, you they should call the Blue Cross Blue Shield Global Core Service Center service center at ▇.▇▇▇.▇▇▇.▇▇▇▇ (2583) or call collect at ▇.▇▇▇.▇▇▇.▇▇▇▇, 24 hours a day, seven days a week. Group Exec Initials Sponsored Plan Acronym Leasing Company Acronym Company Name Physical Address Customer ID(BCBSM), Group ID(BCN) SubGroupID ClassID Leasing Company Name BCBSM Group Number Group Division Effective Date / / Phone - - County City State Zip Code Primary Nature Of Business - SIC DBA Doing Business As Company Fax Check here if this group is ERISA Exempt Are you currently in bankruptcy? Yes No Do you have any leased employees? Yes No Does this group have subsidiaries, offices, or branches located at other physical locations? Yes No If yes, submit multiple location report Is Work Force Unionized? Yes No Number of Employees Represented Local Number Contract Expiration Date National/International Name Local Representative Name Retiree Group: Is there a surviving spouse option? Medical $ % . Dental $ % . A. To b. Blue Cross Blue Shield Global Core Program Program-Related Fees THE GROUP understands and agrees to reimburse BCBSNE for certain fees and compensation which we are obligated under applicable Inter-Plan Arrangement requirements to pay to the Host Blues, to the Association and/or to vendors of Inter-Plan Arrangement-related services. The specific fees and compensation that are charged to THE GROUP under Blue Cross Blue Shield Global Core are set forth in Attachment 1. Fees and compensation under applicable Inter- Plan Arrangements may be eligible revised from time to time as provided for coverage an employee must work a minimum of 30 hours per week. Yes No Vision $ % in the “Modifications or Changes to Inter-Plan Arrangement Fees or Compensation” Section below. B. Eligible Dependent coverage will be effective on date of event, e.g., spouse, newborn, if written notification is received within 31 days thereof with billing prorated. If after 31 days, coverage will be effective at group's next annual reopening date. C. Enter appropriate BCBSM/BCN code selected from the New Hire/Rehire options table for newly hired full-time employees, or part-time employees who become full-time. Any requests that do not comply with BCBSM/BCN guidelines require underwriting review and approval, such as requests from large employers related to compliance with the employer mandate provisions of IRC 4980H: BCBSM Code BCN Code

Blue Cross Blue Shield Global Core Program. If you are outside the United States, (the Commonwealth of Puerto Rico and the U.S. Virgin Islands) (hereinafter: “Blue Cross Blue Shield Global Core Service Area”), you may be able to take advantage of the Blue Cross Blue Shield Global Core Program when accessing Covered Healthcare Services. The Blue Cross Blue Shield Global Core Program is unlike the BlueCard Program available in the United States, the Commonwealth of Puerto Rico and the U.S. Virgin Islands in certain ways. For instance, although the Blue Cross Blue Shield Global Core Program assists you with accessing a network of inpatient, outpatient and professional providers, the network is not served by a Host Blue. As such, when you receive care from providers outside the United States, the Commonwealth of Puerto Rico and the U.S. Virgin Islands, you will typically have to pay the providers and submit the claims yourself to obtain reimbursement for these services. • Inpatient Services In most cases, if you contact the Blue Cross Blue Shield Global Core Service Center for assistance, hospitals will not require you to pay for covered inpatient hospital services, except for their any cost sharing you may owe. In such cases, the Blue Cross Blue Shield Global Core Program contracting hospital will submit your claims to the Blue Cross Blue Shield Global Core Service Center to initiate claims processing. However, if you paid in full at the time of service, you must submit a claim to obtain reimbursement for Covered Services. You must contact us to obtain Precertification for non-emergency inpatient services. • Outpatient Services Physicians, urgent care centers and other outpatient providers located outside the Blue Cross Blue Shield Global Core Service Area will typically require you to pay in full at the time of service. You must submit a claim to obtain reimbursement for Covered Healthcare Services. • Submitting a Blue Cross Blue Shield Global Claim When you pay for Covered Services outside the Blue Cross Blue Shield Global Core Service Area, you must submit a claim to obtain reimbursement. For institutional and professional claims, you should complete a Blue Cross Blue Shield Global Core claim form and send the claim form with the provider’s itemized bill(s) to the Blue Cross Blue Shield Global Core Service Center (the address is on the form) to initiate claims processing. The claim form is available from us, the Blue Cross Blue Shield Global Core Service Center or online at ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. If you need assistance with the claim submissions, you should call the Blue Cross Blue Shield Global Core Service Center at ▇.▇▇▇.▇▇▇.▇▇▇▇ (2583) or call collect at ▇.▇▇▇.▇▇▇.▇▇▇▇, 24 hours a day, seven days a week. Group Exec Initials Sponsored Plan Acronym Leasing Company Acronym Company Name Physical Address Customer ID(BCBSM), Group ID(BCN) SubGroupID ClassID Leasing Company Name BCBSM Group Number Group Division Effective Date / / Phone - - County City State Zip Code Primary Nature Of Business - SIC DBA Doing Business As Company Fax Check here if this group is ERISA Exempt Are you currently in bankruptcy? Yes No Do you have any leased employees? Yes No Does this group have subsidiaries, offices, or branches located at other physical locations? Yes No If yes, submit multiple location report Is Work Force Unionized? Yes No Number of Employees Represented Local Number Contract Expiration Date National/International Name Local Representative Name Retiree Group: Is there a surviving spouse optionRetirees Enrolling? Medical $ % . Dental $ % .Yes No A. To be eligible for coverage an employee must work a minimum of 30 hours per week. Yes No Vision $ % . B. Eligible Dependent coverage will be effective on date of event, e.g., spouse, newborn, if written notification is received within 31 days thereof with billing prorated. If after 31 days, coverage will be effective at group's next annual reopening date. C. Enter appropriate BCBSM/BCN code selected from the New Hire/Rehire options table for newly hired full-time employees, or part-time employees who become full-time. Any requests that do not comply with BCBSM/BCN guidelines require underwriting review and approval, such as requests from large employers related to compliance with the employer mandate provisions of IRC 4980H: BCBSM Code BCN Code ▇. ▇▇▇▇▇▇▇▇▇ hired with an active BCBSM/BCN contract may transfer to this group without regard to above schedule (Item C, above). E. Exceptions: Managing Agent Name Agent Name: (first and last) MA Code Agent Code Mail to group Yes Group Exec Initials Federal Tax ID Number Previous or existing BCBSM/BCN Coverage? [ ] Yes [ ] No Previous Carrier If Yes, Plan Year (MM/DD) / If yes, Former Group Number BCBSM/BCN Cancellation Date / / Billing Contact - First Name Last Name Billing Phone Number - - Billing Contact - Job Title TPA or Billing Address-If other than Physical Address Billing Address County City State Zip Code Administrative Contact Person - First Name Last Name Contact Person's Phone Number - - Administrative Contact Job Title Mailing Address Mailing Address County City State Zip Code - - Group Exec Initials Federal Tax ID Number Chief Executive's email address: Billing Contact Person's email address: Administrative Contact Person's email address: Name of Principal Administrator you wish to appoint (could be self): First Name Last Name Principal Administrator's email address: Name of Mutual Voter you wish to appoint (could be self): Mailing Address First Name Last Name Mailing Address County City State Zip Code - Group Exec Initials

Blue Cross Blue Shield Global Core Program. If you are outside the United States, (the Commonwealth of Puerto Rico and the U.S. Virgin Islands) (hereinafter: “Blue Cross Blue Shield Global Core Service Area”), you may be able to take advantage of the Blue Cross Blue Shield Global Core Program when accessing Covered Healthcare Services. The Blue Cross Blue Shield Global Core Program is unlike the BlueCard Program available in the United States, the Commonwealth of Puerto Rico and the U.S. Virgin Islands in certain ways. For instance, although the Blue Cross Blue Shield Global Core Program assists you with accessing a network of inpatient, outpatient and professional providers, the network is not served by a Host Blue. As such, when you receive care from providers outside the United States, the Commonwealth of Puerto Rico and the U.S. Virgin Islands, you will typically have to pay the providers and submit the claims yourself to obtain reimbursement for these services. • Inpatient Services In most cases, if you contact the Blue Cross Blue Shield Global Core Service Center for assistance, hospitals will not require you to pay for covered inpatient hospital services, except for their any cost sharing you may owe. In such cases, the Blue Cross Blue Shield Global Core Program contracting hospital will submit your claims to the Blue Cross Blue Shield Global Core Service Center to initiate claims processing. However, if you paid in full at the time of service, you must submit a claim to obtain reimbursement for Covered Services. You must contact us to obtain Precertification for non-emergency inpatient services. • Outpatient Services Physicians, urgent care centers and other outpatient providers located outside the Blue Cross Blue Shield Global Core Service Area will typically require you to pay in full at the time of service. You must submit a claim to obtain reimbursement for Covered Healthcare Services. • Submitting a Blue Cross Blue Shield Global Claim When you pay for Covered Services outside the Blue Cross Blue Shield Global Core Service Area, you must submit a claim to obtain reimbursement. For institutional and professional claims, you should complete a Blue Cross Blue Shield Global Core claim form and send the claim form with the provider’s itemized bill(s) to the Blue Cross Blue Shield Global Core Service Center (the address is on the form) to initiate claims processing. The claim form is available from us, the Blue Cross Blue Shield Global Core Service Center or online at ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. If you need assistance with the claim submissions, you should call the Blue Cross Blue Shield Global Core Service Center at ▇.▇▇▇.▇▇▇.▇▇▇▇ (2583) or call collect at ▇.▇▇▇.▇▇▇.▇▇▇▇, 24 hours a day, seven days a week. Group Exec Initials Sponsored Plan Acronym Leasing Company Acronym Company Name Physical Address Customer ID(BCBSM), Group ID(BCN) SubGroupID ClassID Leasing Company Name BCBSM Group Number Group Division Effective Date / / Phone - - County City State Zip Code Primary Nature Of Business - SIC DBA Doing Business As Company Fax Check here if this group is ERISA Exempt Are you currently in bankruptcy? Yes No Do you have any leased employees? Yes No Does this group have subsidiaries, offices, or branches located at other physical locations? Yes No If yes, submit multiple location report Is Work Force Unionized? Yes No Number of Employees Represented Local Number Contract Expiration Date National/International Name Local Representative Name Retiree Group: Is there a surviving spouse optionRetirees Enrolling? Medical $ % . Dental $ % .Yes No A. To be eligible for coverage an employee must work a minimum of 30 hours per week. Yes No Vision $ % . B. Eligible Dependent coverage will be effective on date of event, e.g., spouse, newborn, if written notification is received within 31 days thereof with billing prorated. If after 31 days, coverage will be effective at group's next annual reopening date. C. Enter appropriate BCBSM/BCN code selected from the New Hire/Rehire options table for newly hired full-time employees, or part-time employees who become full-time. Any requests that do not comply with BCBSM/BCN guidelines require underwriting review and approval, such as requests from large employers related to compliance with the employer mandate provisions of IRC 4980H: BCBSM Code BCN Code

Blue Cross Blue Shield Global Core Program. a. General Information If you Covered Persons are outside the United States, (the Commonwealth of Puerto Rico and the U.S. Virgin Islands) Islands (hereinafter: “Blue Cross Blue Shield Global Core Service AreaBlueCard service area”), you they may be able to take advantage of the Blue Cross Blue Shield Global Core Program when accessing Covered Healthcare Services. The Blue Cross Blue Shield Global Core Program is unlike the BlueCard Program available in the United States, the Commonwealth of Puerto Rico and the U.S. Virgin Islands BlueCard service area in certain ways. For instance, although the Blue Cross Blue Shield Global Core Program assists you Covered Persons with accessing a network of inpatient, outpatient and professional providers, the network is not served by a Host Blue. As such, when you Covered Persons receive care from providers outside the United StatesBlueCard service area, the Commonwealth of Puerto Rico and the U.S. Virgin Islands, you Covered Persons will typically have to pay the providers and submit the claims yourself themselves to obtain reimbursement for these services. • Inpatient Services In most cases, if you Covered Persons contact the Blue Cross Blue Shield Global Core Service Center service center for assistance, hospitals will not require you Covered Persons to pay for covered inpatient hospital services, except for their any cost sharing you may owecost- share amounts/deductibles, coinsurance, etc. In such cases, the Blue Cross Blue Shield Global Core Program contracting hospital will submit your Covered Person claims to the Blue Cross Blue Shield Global Core Service Center service center to initiate claims processing. However, if you the Covered Person paid in full at the time of service, you the Covered Person must submit a claim to obtain reimbursement for Covered Services. You Covered Persons must contact us BCBSNE to obtain Precertification precertification for non-emergency inpatient services. • Outpatient Services Physicians, urgent care centers and other outpatient providers located outside the Blue Cross Blue Shield Global Core Service Area BlueCard service area will typically require you Covered Persons to pay in full at the time of service. You Covered Persons must submit a claim to obtain reimbursement for Covered Healthcare Services. • Submitting a Blue Cross Blue Shield Global Core Claim When you Covered Persons pay for Covered Services outside the Blue Cross Blue Shield Global Core Service AreaBlueCard service area, you they must submit a claim to obtain reimbursement. For institutional and professional claims, you Covered Persons should complete a Blue Cross Blue Shield Global Core claim form and send the claim form with the provider’s itemized bill(s) bill to the Blue Cross Blue Shield Global Core Service Center (the service center address is on the form) form to initiate claims processing. The claim form is available from usBCBSNE, the Blue Cross Blue Shield Global Core Service Center service center, or online at ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. If you Covered Persons need assistance with the their claim submissions, you they should call the Blue Cross Blue Shield Global Core Service Center service center at ▇.▇▇▇.▇▇▇.▇▇▇▇ (2583) or call collect at ▇.▇▇▇.▇▇▇.▇▇▇▇, 24 hours a day, seven days a week. Group Exec Initials Sponsored Plan Acronym Leasing Company Acronym Company Name Physical Address Customer ID(BCBSM), Group ID(BCN) SubGroupID ClassID Leasing Company Name BCBSM Group Number Group Division Effective Date / / Phone - - County City State Zip Code Primary Nature Of Business - SIC DBA Doing Business As Company Fax Check here if this group is ERISA Exempt Are you currently in bankruptcy? Yes No Do you have any leased employees? Yes No Does this group have subsidiaries, offices, or branches located at other physical locations? Yes No If yes, submit multiple location report Is Work Force Unionized? Yes No Number of Employees Represented Local Number Contract Expiration Date National/International Name Local Representative Name Retiree Group: Is there a surviving spouse option? Medical $ % . Dental $ % . A. To b. Blue Cross Blue Shield Global Core Program Program-Related Fees THE GROUP understands and agrees to reimburse BCBSNE for certain fees and compensation which we are obligated under applicable Inter-Plan Arrangement requirements to pay to the Host Blues, to the Association and/or to vendors of Inter-Plan Arrangement-related services. The specific fees and compensation that are charged to THE GROUP under Blue Cross Blue Shield Global Core are set forth in Attachment 1. Fees and compensation under applicable Inter-Plan Arrangements may be eligible revised from time to time as provided for coverage an employee must work a minimum of 30 hours per week. Yes No Vision $ % in the “Modifications or Changes to Inter-Plan Arrangement Fees or Compensation” Section below. B. Eligible Dependent coverage will be effective on date of event, e.g., spouse, newborn, if written notification is received within 31 days thereof with billing prorated. If after 31 days, coverage will be effective at group's next annual reopening date. C. Enter appropriate BCBSM/BCN code selected from the New Hire/Rehire options table for newly hired full-time employees, or part-time employees who become full-time. Any requests that do not comply with BCBSM/BCN guidelines require underwriting review and approval, such as requests from large employers related to compliance with the employer mandate provisions of IRC 4980H: BCBSM Code BCN Code

Blue Cross Blue Shield Global Core Program. a. General Information If you Covered Persons are outside the United States, (the Commonwealth of Puerto Rico and the U.S. Virgin Islands) Islands (hereinafter: “Blue Cross Blue Shield Global Core Service AreaBlueCard service area”), you they may be able to take advantage of the Blue Cross Blue Shield Global Core Program when accessing Covered Healthcare Services. The Blue Cross Blue Shield Global Core Program is unlike the BlueCard Program available in the United States, the Commonwealth of Puerto Rico and the U.S. Virgin Islands BlueCard service area in certain ways. For instance, although the Blue Cross Blue Shield Global Core Program assists you Covered Persons with accessing a network of inpatient, outpatient and professional providers, the network is not served by a Host Blue. As such, when you Covered Persons receive care from providers outside the United StatesBlueCard service area, the Commonwealth of Puerto Rico and the U.S. Virgin Islands, you Covered Persons will typically have to pay the providers and submit the claims yourself themselves to obtain reimbursement for these services. • Inpatient •Inpatient Services In most cases, if you Covered Persons contact the Blue Cross Blue Shield Global Core Service Center service center for assistance, hospitals will not require you Covered Persons to pay for covered inpatient hospital services, except for their any cost sharing you may owecost-share amounts/deductibles, coinsurance, etc. In such cases, the Blue Cross Blue Shield Global Core Program contracting hospital will submit your Covered Person claims to the Blue Cross Blue Shield Global Core Service Center service center to initiate claims processing. However, if you the Covered Person paid in full at the time of service, you the Covered Person must submit a claim to obtain reimbursement for Covered Services. You Covered Persons must contact us BCBSNE to obtain Precertification precertification for non-emergency inpatient services. • Outpatient •Outpatient Services Physicians, urgent care centers and other outpatient providers located outside the Blue Cross Blue Shield Global Core Service Area BlueCard service area will typically require you Covered Persons to pay in full at the time of service. You Covered Persons must submit a claim to obtain reimbursement for Covered Healthcare Services. • Submitting •Submitting a Blue Cross Blue Shield Global Core Claim When you Covered Persons pay for Covered Services outside the Blue Cross Blue Shield Global Core Service AreaBlueCard service area, you they must submit a claim to obtain reimbursement. For institutional and professional claims, you Covered Persons should complete a Blue Cross Blue Shield Global Core claim form and send the claim form with the provider’s itemized bill(s) ▇▇▇▇ to the Blue Cross Blue Shield Global Core Service Center (the service center address is on the form) form to initiate claims processing. The claim form is available from usBCBSNE, the Blue Cross Blue Shield Global Core Service Center service center, or online at ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. If you Covered Persons need assistance with the their claim submissions, you they should call the Blue Cross Blue Shield Global Core Service Center service center at ▇.▇▇▇.▇▇▇.▇▇▇▇ (2583) or call collect at ▇.▇▇▇.▇▇▇.▇▇▇▇, 24 hours a day, seven days a week. Group Exec Initials Sponsored Plan Acronym Leasing Company Acronym Company Name Physical Address Customer ID(BCBSM), Group ID(BCN) SubGroupID ClassID Leasing Company Name BCBSM Group Number Group Division Effective Date / / Phone - - County City State Zip Code Primary Nature Of Business - SIC DBA Doing Business As Company Fax Check here if this group is ERISA Exempt Are you currently in bankruptcy? Yes No Do you have any leased employees? Yes No Does this group have subsidiaries, offices, or branches located at other physical locations? Yes No If yes, submit multiple location report Is Work Force Unionized? Yes No Number of Employees Represented Local Number Contract Expiration Date National/International Name Local Representative Name Retiree Group: Is there a surviving spouse option? Medical $ % . Dental $ % . A. To b. Blue Cross Blue Shield Global Core Program Program-Related Fees THE GROUP understands and agrees to reimburse BCBSNE for certain fees and compensation which we are obligated under applicable Inter-Plan Arrangement requirements to pay to the Host Blues, to the Association and/or to vendors of Inter-Plan Arrangement-related services. The specific fees and compensation that are charged to THE GROUP under Blue Cross Blue Shield Global Core are set forth in Attachment 1. Fees and compensation under applicable Inter-Plan Arrangements may be eligible revised from time to time as provided for coverage an employee must work a minimum of 30 hours per week. Yes No Vision $ % in the “Modifications or Changes to Inter-Plan Arrangement Fees or Compensation” Section below. B. Eligible Dependent coverage will be effective on date of event, e.g., spouse, newborn, if written notification is received within 31 days thereof with billing prorated. If after 31 days, coverage will be effective at group's next annual reopening date. C. Enter appropriate BCBSM/BCN code selected from the New Hire/Rehire options table for newly hired full-time employees, or part-time employees who become full-time. Any requests that do not comply with BCBSM/BCN guidelines require underwriting review and approval, such as requests from large employers related to compliance with the employer mandate provisions of IRC 4980H: BCBSM Code BCN Code

Blue Cross Blue Shield Global Core Program. a. General Information If you Covered Persons are outside the United States, (the Commonwealth of Puerto Rico and the U.S. Virgin Islands) Islands (hereinafter: “Blue Cross Blue Shield Global Core Service AreaBlueCard service area”), you they may be able to take advantage of the Blue Cross Blue Shield Global Core Program when accessing Covered Healthcare Services. The Blue Cross Blue Shield Global Core Program is unlike the BlueCard Program available in the United States, the Commonwealth of Puerto Rico and the U.S. Virgin Islands BlueCard service area in certain ways. For instance, although the Blue Cross Blue Shield Global Core Program assists you Covered Persons with accessing a network of inpatient, outpatient and professional providers, the network is not served by a Host Blue. As such, when you Covered Persons receive care from providers outside the United StatesBlueCard service area, the Commonwealth of Puerto Rico and the U.S. Virgin Islands, you Covered Persons will typically have to pay the providers and submit the claims yourself themselves to obtain reimbursement for these services. • Inpatient •Inpatient Services In most cases, if you Covered Persons contact the Blue Cross Blue Shield Global Core Service Center service center for assistance, hospitals will not require you Covered Persons to pay for covered inpatient hospital services, except for their any cost sharing you may owecost-share amounts/deductibles, coinsurance, etc. In such cases, the Blue Cross Blue Shield Global Core Program contracting hospital will submit your Covered Person claims to the Blue Cross Blue Shield Global Core Service Center service center to initiate claims processing. However, if you the Covered Person paid in full at the time of service, you the Covered Person must submit a claim to obtain reimbursement for Covered Services. You Covered Persons must contact us BCBSNE to obtain Precertification precertification for non-emergency inpatient services. • Outpatient •Outpatient Services Physicians, urgent care centers and other outpatient providers located outside the Blue Cross Blue Shield Global Core Service Area BlueCard service area will typically require you Covered Persons to pay in full at the time of service. You Covered Persons must submit a claim to obtain reimbursement for Covered Healthcare Services. • Submitting •Submitting a Blue Cross Blue Shield Global Core Claim When you Covered Persons pay for Covered Services outside the Blue Cross Blue Shield Global Core Service AreaBlueCard service area, you they must submit a claim to obtain reimbursement. For institutional and professional claims, you Covered Persons should complete a Blue Cross Blue Shield Global Core claim form and send the claim form with the provider’s itemized bill(s) bill to the Blue Cross Blue Shield Global Core Service Center (the service center address is on the form) form to initiate claims processing. The claim form is available from usBCBSNE, the Blue Cross Blue Shield Global Core Service Center service center, or online at ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. If you Covered Persons need assistance with the their claim submissions, you they should call the Blue Cross Blue Shield Global Core Service Center service center at ▇.▇▇▇.▇▇▇.▇▇▇▇ (2583) or call collect at ▇.▇▇▇.▇▇▇.▇▇▇▇, 24 hours a day, seven days a week. Group Exec Initials Sponsored Plan Acronym Leasing Company Acronym Company Name Physical Address Customer ID(BCBSM), Group ID(BCN) SubGroupID ClassID Leasing Company Name BCBSM Group Number Group Division Effective Date / / Phone - - County City State Zip Code Primary Nature Of Business - SIC DBA Doing Business As Company Fax Check here if this group is ERISA Exempt Are you currently in bankruptcy? Yes No Do you have any leased employees? Yes No Does this group have subsidiaries, offices, or branches located at other physical locations? Yes No If yes, submit multiple location report Is Work Force Unionized? Yes No Number of Employees Represented Local Number Contract Expiration Date National/International Name Local Representative Name Retiree Group: Is there a surviving spouse option? Medical $ % . Dental $ % . A. To b. Blue Cross Blue Shield Global Core Program Program-Related Fees THE GROUP understands and agrees to reimburse BCBSNE for certain fees and compensation which we are obligated under applicable Inter-Plan Arrangement requirements to pay to the Host Blues, to the Association and/or to vendors of Inter-Plan Arrangement- related services. The specific fees and compensation that are charged to THE GROUP under Blue Cross Blue Shield Global Core are set forth in Attachment 1. Fees and compensation under applicable Inter-Plan Arrangements may be eligible revised from time to time as provided for coverage an employee must work a minimum of 30 hours per week. Yes No Vision $ % in the “Modifications or Changes to Inter-Plan Arrangement Fees or Compensation” Section below. B. Eligible Dependent coverage will be effective on date of event, e.g., spouse, newborn, if written notification is received within 31 days thereof with billing prorated. If after 31 days, coverage will be effective at group's next annual reopening date. C. Enter appropriate BCBSM/BCN code selected from the New Hire/Rehire options table for newly hired full-time employees, or part-time employees who become full-time. Any requests that do not comply with BCBSM/BCN guidelines require underwriting review and approval, such as requests from large employers related to compliance with the employer mandate provisions of IRC 4980H: BCBSM Code BCN Code

Blue Cross Blue Shield Global Core Program. If you are outside the United States, (the Commonwealth of Puerto Rico and the U.S. Virgin Islands) (hereinafter: “Blue Cross Blue Shield Global Core Service Area”), you may be able to take advantage of the Blue Cross Blue Shield Global Core Program when accessing Covered Healthcare Services. The Blue Cross Blue Shield Global Core Program is unlike the BlueCard Program available in the United States, the Commonwealth of Puerto Rico and the U.S. Virgin Islands in certain ways. For instance, although the Blue Cross Blue Shield Global Core Program assists you with accessing a network of inpatient, outpatient and professional providers, the network is not served by a Host Blue. As such, when you receive care from providers outside the United States, the Commonwealth of Puerto Rico and the U.S. Virgin Islands, you will typically have to pay the providers and submit the claims yourself to obtain reimbursement for these services. • Inpatient Services In most cases, if you contact the Blue Cross Blue Shield Global Core Service Center for assistance, hospitals will not require you to pay for covered inpatient hospital services, except for their any cost sharing you may owe. In such cases, the Blue Cross Blue Shield Global Core Program contracting hospital will submit your claims to the Blue Cross Blue Shield Global Core Service Center to initiate claims processing. However, if you paid in full at the time of service, you must submit a claim to obtain reimbursement for Covered Services. You must contact us to obtain Precertification for non-emergency inpatient services. • Outpatient Services Physicians, urgent care centers and other outpatient providers located outside the Blue Cross Blue Shield Global Core Service Area will typically require you to pay in full at the time of service. You must submit a claim to obtain reimbursement for Covered Healthcare Services. • Submitting a Blue Cross Blue Shield Global Claim When you pay for Covered Services outside the Blue Cross Blue Shield Global Core Service Area, you must submit a claim to obtain reimbursement. For institutional and professional claims, you should complete a Blue Cross Blue Shield Global Core claim form and send the claim form with the provider’s itemized bill(s) to the Blue Cross Blue Shield Global Core Service Center (the address is on the form) to initiate claims processing. The claim form is available from us, the Blue Cross Blue Shield Global Core Service Center or online at ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. If you need assistance with the claim submissions, you should call the Blue Cross Blue Shield Global Core Service Center at ▇.▇▇▇.▇▇▇.▇▇▇▇ (2583) or call collect at ▇.▇▇▇.▇▇▇.▇▇▇▇, 24 hours a day, seven days a week. Requested Effective Date Group Name (Full Legal Name) Federal Tax Id Sub Group ID Class ID Product Plans Deductible Co- Insurance Embedded Co-Insurance Maximum OOP Max Employer HRA/HSA Contribution Copay (OV/Spec/UC/ER) Rx-Includes MOPD3x-$10 and Contraceptives BCN HMO HMO Platinum 10% $0 10% $1,000 $5,000 N/A $20/$30/$35/$150 $4/$15/$40/$80/20%/20% HMO Platinum 20% $0 20% $1,000 $6,600 N/A $25/$35/$35/$150 $4/$15/$40/$80/20%/20% HMO Gold 30% $0 30% N/A $7,900 N/A $30/$50/$35/$250 $15/$40/$80/$100/20%/20% HMO Platinum $500 $500 0% N/A $1,500 N/A $20/$30/$35/$150 $4/$15/$40/$80/20%/20% HMO PCP Focus Platinum $500 $500 0% N/A $1,500 N/A $20/$30/$35/$150 $4/$15/$40/$80/20%/20% HMO Gold $500 $500 20% $5,000 $8,150 N/A $30/$50/$35/$250 $15/$40/$80/$100/20%/20% HMO Gold $1000 $1,000 20% $3,500 $8,150 N/A $20/$40/$50/$250 $15/$40/$80/$100/20%/20% HMO PCP Focus Gold $1000 $1,000 20% $3,500 $8,150 N/A $20/$40/$50/$250 $15/$40/$80/$100/20%/20% HMO Gold $1500 $1,500 20% $2,500 $8,150 N/A $20/$40/$50/$250 $10/$30/$60/$80/20%/20% HMO PCP Focus Gold $1500 $1,500 20% $2,500 $8,150 N/A $20/$40/$50/$250 $10/$30/$60/$80/20%/20% HMO Gold $2000 $2,000 30% $1,000 $6,600 N/A $20/$40/$50/$150 $10/$30/$60/$80/20%/20% HMO PCP Focus Gold $2000 $2,000 30% $1,000 $6,600 N/A $20/$40/$50/$150 $10/$30/$60/$80/20%/20% HMO Gold $2500 $2,500 20% $2,000 $7,350 N/A $30/$50/$50/$150 $4/$15/$40/$80/20%/20% HMO PCP Focus Gold $2500 $2,500 20% $2,000 $7,350 N/A $30/$50/$50/$150 $4/$15/$40/$80/20%/20% HMO Gold $3000 $3,000 20% $3,000 $8,150 N/A $30/$50/$50/$150 $4/$15/$40/$80/20%/20% HMO PCP Focus Gold $3000 $3,000 20% $3,000 $8,150 N/A $30/$50/$50/$150 $4/$15/$40/$80/20%/20% HMO Silver $4000 $4,000 30% N/A $8,150 N/A $40/$60/$60/$250 $15/$40/$80/$100/20%/20% HMO PCP Focus Silver $4000 $4,000 30% N/A $8,150 N/A $40/$60/$60/$250 $15/$40/$80/$100/20%/20% HMO Silver $4500 $4,500 20% N/A $8,150 N/A $40/$60/$60/$250 $15/$40/$80/$100/20%/20% BCN HMO Fixed Cost BCN HMO Fixed Cost Platinum $0 0% N/A $4,000 N/A $15/$40/$40/$250 $4/$15/$40/$80/$200/$300 BCN HMO Fixed Cost Gold $0 0% N/A $6,500 N/A $20/$50/$50/$250 $10/$30/$60/$80/$200/$300 Blue Elect Plus POS Blue Elect Plus POS Gold $500 $500 30% $4,500 $8,150 N/A $30/$50/$50/$250 $10/$30/$60/$80/20%/20% Blue Elect Plus POS Gold $1000 $1,000 20% $3,500 $7,350 N/A $30/$50/$50/$250 $10/$30/$60/$80/20%/20% Blue Elect Plus POS Gold $2000 $2,000 20% N/A $7,350 N/A $30/$50/$50/$250 $15/$40/$80/$100/20%/20% Blue Elect Plus POS Gold $3000 $3,000 20% N/A $8,150 N/A $30/$50/$50/$250 $15/$40/$80/$100/20%/20% Page 14 of 19, BCN New Business Small Group, July 1, 2021 Group Name (Full Legal Name) Group Exec Initials Sponsored Plan Acronym Leasing Company Acronym Company Group ID Federal Tax Id Sub Group ID Class ID Product Plans Deductible Co- Insurance Embedded Co-Insurance Maximum OOP Max Employer HRA/HSA Contribution Copay (OV/Spec/UC/ER) Rx-Includes MOPD3x-$10 and Contraceptives BCN HRA HMO Platinum $1500 $1,500 20% $500 $6,350 $750 $20/$40/$50/$150 $4/$15/$40/$80/20%/20% HMO Platinum $2000 $2,000 20% $500 $6,350 $1,000 $20/$40/$50/$150 $4/$15/$40/$80/20%/20% HMO Gold $2000 $2,000 20% N/A $6,350 $100 $30/$50/$50/$150 $6/$25/$50/$80/20%/20% HMO Gold $4000 $4,000 20% N/A $6,350 $300 $30/$50/$50/$150 $4/$15/$40/$80/20%/20% HMO Platinum $5000 $5,000 20% N/A $6,350 $2,500 $20/$40/$50/$150 $6/$25/$50/$80/20%/20% HMO PCP Focus Platinum $5000 $5,000 20% N/A $6,350 $2,500 $20/$40/$50/$150 $6/$25/$50/$80/20%/20% HMO Platinum $250 Enhanced $250 20% $500 $6,600 N/A $20/$30/$35/$150 $4/$15/$40/$80/20%/20% Standard $1,500 30% $2,500 $6,600 N/A $30/$40/$35/$150 $6/$25/$50/$80/20%/20% Healthy Blue Living HMO Platinum $500 Enhanced Standard $500 $1,250 0% 20% N/A $2,500 $1,500 $6,600 N/A N/A $20/$30/$35/$150 $30/$40/$50/$150 $4/$15/$40/$80/20%/20% $6/$25/$50/$80/20%/20% Note: HBL may only be offered at HMO Gold $1000 Enhanced Standard $1,000 $3,000 20% 30% $3,500 $4,000 $8,150 $8,150 N/A N/A $30/$40/$50/$150 $40/$60/$60/$250 $10/$30/$60/$80/20%/20% $15/$40/$60/$80/20%/20% the group’s renewal. Group HMO Gold $1500 Enhanced $1,500 20% $2,500 $6,600 N/A $30/$40/$50/$150 $6/$25/$50/$80/20%/20% agrees to annual health coach visit. Standard $4,000 30% N/A $6,600 N/A $40/$60/$60/$250 $10/$30/$60/$80/20%/20% HMO Gold $2000 Enhanced $2,000 20% $1,000 $6,600 N/A $30/$40/$50/$150 $10/$30/$60/$80/20%/20% Standard $4,000 30% $2,000 $6,600 N/A $40/$60/$60/$250 $15/$40/$60/$80/20%/20% BCN HSA HMO Gold $1500/20% $1,500 20% N/A $3,000 $0 Ded+coinsurance $10/$30/$60/$80/20%/20% HMO Gold $2000/0% $2,000 0% N/A $3,500 $0 Deductible $10/$30/$60/$80/20%/20% $1500/20% and HMO Gold $2800/0% $2,800 0% N/A $5,000 $300 Deductible $6/$25/$50/$80/20%/20% HMO Silver $3000/20% $3,000 20% N/A $6,000 $0 Ded+coinsurance $4/$15/$40/$80/20%/20% $2000/0% plans have an aggregate HMO Silver $3500/0% $3,500 0% N/A $6,350 $0 Deductible $1 5/$40/$80/$100/20%/20% deductible, the rest HMO Silver $4500/0% $4,500 0% N/A $6,650 $0 Deductible $10/$30/$60/$80/20%/20% of the HSA plans have an embedded HMO Bronze $6900/0% $6,900 0% N/A $6,900 $0 Deductible Deductible deductible. HMO PCP Focus Bronze $6900/0% $6,900 0% N/A $6,900 $0 Deductible Deductible Routine Care HMO Silver $3000/30% $3,000 30% N/A $8,150 N/A $30/D&C/$30/D&C* $6/$25/$60/$80/20%/20%** HMO Bronze $8400/0% $8,400 0% N/A $8,400 N/A $40/Ded/$40/Ded $15/$40/Deductible** *D&C = subject to Deductible & Coinsurance ** Deductible does not apply to Tiers 1A & 1B Group Name Physical Address Customer ID(BCBSM)(Full Legal Name) Group ID Federal Tax Id Sub Group ID Class ID PCP Focus Counties (Employer groups must be located in Bay, Calhoun, Clinton, ▇▇▇▇▇, Genesee, ▇▇▇▇▇▇, Kalamazoo, Kent, Livingston, Macomb, Monroe, Muskegon, Oakland, Ottawa, Saginaw, Shiawasee, St. Clair, Van Buren, Washtenaw, and ▇▇▇▇▇ counties.) HealthEquity and HSA Bank are independent companies that provide financial services to Blue Care Network of Michigan customers. BCN 65 BCN 65 $0 0% $0 N/A $25/$25/$50/$250 $10/$40/$80/20%/20% - Rx only OOPM: $7,150/$14,300 Statements of Prior Deductibles Included Blue Vision SM Blue Vision Easy Options 12-12-12, $5/$▇▇ ▇▇-▇▇-▇▇, $5/$▇▇ ▇▇-▇▇-▇▇, $5/$10 Voluntary Vision plans require 10+ vision contracts. Blue Vision Voluntary Easy Options 12-12-24, $10/$▇▇ ▇▇-▇▇-▇▇, $0/$25 Blue DentalSM (Group ID(BCNmust select a single checkbox that represents chosen plan/annual max combination) SubGroupID ClassID Leasing Company Name BCBSM Third party pediatric dental coverage. Requires dental coverage attestation. Non-Voluntary - PPO (Non-PPO) Annual Max - PPO (Non-PPO) Voluntary - PPO (Non-PPO) Annual Max - PPO (Non-PPO) * For Blue Voluntary Plans, (i) BCBSM/BCN will automatically provide the pediatric dental EHB to Refusing Subscribers and/or their dependents who otherwise qualify for pediatric dental EHBs and (ii) Group Number Group Division will pay an additional fee to BCBSM/BCN for each Qualifying Individual equal to the standard BCBSM/BCN charge in effect on the Effective Date / / Phone for pediatric dental benefits. PPO Plus 100/80/50 $1,000 $1,500 PPO Plus 100/80/50 $1,000 PPO Plus 100/50/50 $1,000 PPO Plus 100/50/50 $1,000 PPO Plus 80/50/50 $1,000 PPO Plus 80/50/50 $1,000 PPO 100/80/50 (80/50/50) $1,250 ($800) PPO 100/80/50 (80/50/50) $1,000 ($800) PPO 100/80/50 (50/50/50) $1,000 $1,500 EPO 100/80/50 $1,250 PPO 80/50/50 (50/50/50) $800 Waive Waiting Period (Proof of prior dental coverage required) Voluntary Dental plans require a minimum participation of 30% with 10+ dental contracts. Does not apply to groups enrolled in voluntary dental prior to 10/1/11. EPO 100/80/50 $1,250 50% Ortho (Employer Paid - lifetime max matches in-network annual max, Voluntary - County City State Zip Code Primary Nature Of Business lifetime max is $1,000, except EPO 100/80/50 is $1,250) Customer name Customer contact email Renewal date Federal Tax Id - SIC DBA Doing Business As Company Fax Check here if this group is ERISA Exempt Are Effective date Do you currently in bankruptcyhave multiple employer groups or common control? Yes No Do you have any leased employees? Yes No Does this group have subsidiaries, offices, or branches located at other physical locations? Yes No Current company mailing address Other mailing address If yes, submit multiple location report Is Work Force Unionized? Yes No Number please provide a letter from your group's CPA or tax attorney (on his or her letterhead) certifying that your companies meet the Internal Revenue Service definition of Employees Represented Local Number Contract Expiration Date National/International Name Local Representative Name Retiree Groupa controlled group, and the relationship between the companies. Street address State Zip City I am not a sole proprietor or a sole shareholder. I am a partnership with no employees. I am a sole proprietor or a sole shareholder AND: Is there a surviving spouse option? Medical $ % My employees are enrolled in medical health care coverage that I sponsor. Dental $ % . A. To be eligible for My employees are not enrolled in medical health care coverage that I sponsor. My group health plan is an employee must work benefit plan established or maintained by an employer or an employee organization (such as a minimum union). My group’s health plan is a nonfederal government plan. (i.e. states, municipalities, special districts, such as: school districts, park districts, and airport districts.) My group’s health plan is an ERISA-exempt church plan (i.e. church plan, a convention or an association of 30 hours per week. Yes No Vision $ % . B. Eligible Dependent coverage churches) AND: Rebate will be effective on date sent to the group. The plan agrees to use any rebate issued for the benefit of event, e.g., spouse, newborn, if written notification is received within 31 days thereof with billing proratedthe group health plan subscribers. If after 31 days, coverage Rebate will be effective at group's next annual reopening datesent to the plan subscribers. The plan does not agree to use any rebate issued for the benefit of the group health plan subscribers. C. Enter appropriate BCBSM/BCN code selected from the New Hire/Rehire options table for newly hired full-time employees, or part-time employees who become full-time. Any requests that do not comply with BCBSM/BCN guidelines require underwriting review and approval, such as requests from large employers related to compliance with the employer mandate provisions of IRC 4980H: BCBSM Code BCN Code