Effective Date: 04/01/2012 Applicant: 25, Male Spouse: 26, Female Children: 0

Click Plan Name for more information Monthly Premium Benefit Period Deductible Single Two-Person Family(1) Network Coinsurance - You Pay In-Network Providers Out-of-Network Providers Out of Pocket Maximum Single Two-Person Family(1) Lifetime Benefit Maximum Office Services - You Pay In-Network Providers

Blue Priority HSA/Alliance Select 1700B $ 296.65 Coordinates with drug deductible (5) $1,700 Family Deductibles apply $3,400 Wellmark Blue Cross and Blue Shield of Iowa 20% 40%

Blue Advantage Premier (SM) 1500 Blue Rx Value $ 351.85

Alliance Select Enhanced 1250 $ 453.95

Alliance Select Comprehensive 1000 $ 668.35

$1,500 $3,000 Wellmark Health Plan of Iowa, Inc. 30% coinsurance(9) Only allowed with Wellmark approval

$1,250 $2,500 $3,750

$1,000 $2,000 $3,000

Wellmark Blue Cross Wellmark Blue Cross and and Blue Shield of Iowa Blue Shield of Iowa 20% 40% 10% 30%

$3,700 In-Network/$5,700 Out-ofNetwork(4) Family Out-of-Pocket Maximums apply. $7,400 In-Network/$11,400 Out-ofNetwork(4) Unlimited Deductible and coinsurance apply to Office Visits, Office X-rays and Office Lab work

$4,500

$2,250 $4,500

$2,000 $4,000 $6,000 Unlimited

$9,000 Unlimited

$6,750 Unlimited

30% coinsurance, deductible waived

20% coinsurance; deductible waived

10% coinsurance; deductible waived Deductible; followed by 30% coinsurance

Out-of-Network Providers

Deductible and coinsurance apply Only allowed with Wellmark Deductible; followed by to Office Visits, Office X-rays and approval 40% coinsurance Office Lab work Deductible and coinsurance apply Deductible followed by coinsurance

Emergency Room Preventive and Routine Care (including well-child care up to age 7) In-Network Providers Out-of-Network Providers Maternity Prescription Drugs(10) Benefit Period Drug Deductible Tier 1 Tier 2 Tier 3 Tier 4 Specialty Preferred Specialty Non-Preferred Out-of-State Coverage/BlueCard Program Mental Health and Chemical Dependency Treatment Chiropractic Care Contraceptives

$150 (waived if admitted $100 (waived if admitted as inpatient following as inpatient following ER) ER)

Covered. Deductible and coinsurance waived. Covered. Deductible and coinsurance apply. Complications Only. Optional maternity benefit is available(6)

Covered. Deductible and coinsurance waived. Not Covered Complications Only. Optional maternity benefit is available(6). Blue Rx Value(12) $200 Single/$400 Family, waived for Tier 1 Greater of $5 or 25% Greater of $40 or 25% No Coverage No Coverage $100 copay Not Covered Only allowed for emergency services and accidental injury Covered; Limited Covered; Limited Covered

Covered. Deductible and Covered. Deductible and coinsurance waived. coinsurance waived. Covered. Deductible and Covered. Deductible and coinsurance apply. coinsurance apply. Complications Only Covered

Coordinates with medical deductible(5) After deductible, you pay greater of $8 or 25% After deductible, you pay greater of $35 or 25% After deductible, you pay greater of $50 or 25%

$0 Greater of $8 or 25% Greater of $30 or 25% Greater of $45 or 25%

$0 Greater of $8 or 25% Greater of $30 or 25% Greater of $45 or 25%

Yes Not Covered Covered Available as Optional Benefit

Yes Not Covered Covered Available as Optional Benefit

Yes Covered; Limited Covered Available as Optional Benefit

$500 Supplemental Accident (Optional) Dental (Optional) Monthly Premium

Not Available Available $ 296.65

Not Available Available $ 351.85

Available Available $ 453.95

Available Available $ 668.35

*A monthly service fee is applied to every contract. *Blue Advantage plans are underwritten by Wellmark Health Plan of Iowa, Inc. *Standard rates have been used to provide your quote. Actual rates vary based on your relative health status, demographics, tobacco usage, optional benefits and plan selection. Coverage is subject to the terms, limits and conditions of the contract. (1) The family deductible and out-of-pocket maximum can be met through any combination of family members. No one member will be required to meet more than the single deductible or out-of-pocket maximum amount to receive benefits for covered services during a benefit period. For HSAQualified plans, the entire family deductible must be met before benefits are payable. (2) Primary Care Practitioners (PCPs) include Family Practitioners, General Practitioners, Internal Medicine Practitioners, Obstetricians/Gynecologists, Pediatricians, Physicians Assistants and Advanced Registered Nurse Practitioners. For purposes of your copayment responsibility, Alliance Select and BlueCard PPO providers are classified as either primary care practitioners or nonprimary care practitioners. Before you receive office services from an Alliance Select or BlueCard PPO practitioner, call the customer service number on your ID card to determine whether your provider is classified as a primary care practitioner or a non-primary care practitioner for purposes of your copayment. The classification of providers in the Wellmark Provider Directory does not determine whether a provider is primary care or non-primary care for purposes of your office exam copayment. For example, a provider might be listed under multiple specialties in the Provider Directory (such as internal medicine and oncology), but is classified as a non-primary care practitioner for purposes of your copayment. (3) First three office visits in a benefit period. The terms of the benefit period deductible, coinsurance, and copayment for office visits depend in part upon whether an office visit is one of the first three per person in a benefit period. (4) Out-of-pocket amounts you pay for Alliance Select or non-Alliance Select covered services apply to both the Alliance Select and non-Alliance Select out-of-pocket maximums. (5) Amounts paid toward covered medical services or prescription drugs apply toward the benefit period deductible and out-of-pocket maximum. (6) If you chose the optional maternity coverage on your application, coverage for maternity services except for complications of pregnancy, will be subject to an exclusion period of 12 months. (7) Benefit Period Drug Deductible is $200 single; $400 two-person; $600 family. (8) Benefit Period Drug Deductible is $100 single; $200 two-person; $300 family. (9) Prosthetic limbs are subject to 20% coinsurance when using in-network providers. (10) Routine immunizations waive deductible, copayments and/or coinsurance when using the Blue Rx Preferred drug card. (11) Once your annual deductible is met, the additional $1,000 added to the out-of-pocket maximum must be met through the drug cost-sharing. (12) Members have the option under the Premier plan to buy down to Blue Rx Value. Members have the option under the Standard plan to buy up to Blue Rx Complete.