2. MyBlue Individual Care Blue PLUS SM Flexible Blue II SM 1500 Flexible Blue II SM 2500 Flexible Blue II SM 5000 Young Adult Blue Max SM Keep Fit SM OneBlue SM Smart Select SM

3. In-Network  Deductible  Co-Insurance  Co-Insurance Max  Out of Pocket Max  Office Visit  Emergency  $1000/$2000*  30%  $2,500/$5,000*  $3,500/$7,000*  70% no deductible  70% after deductible Individual Care Blue PLUS PPO * Family Contract

4. In-Network  Deductible  Co-Insurance  Co-Insurance Max  Out of Pocket Max  Office Visit  Emergency  $1,500/$3,000*  20%  $2,500/$5,000*  $4,000/$8,000*  80% after deductible Flexible Blue II 1500 PPO * Family Contract

5. In-Network  Deductible  Co-Insurance  Co-Insurance Max  Out of Pocket Max  Office Visit  Emergency  $2,500/$5,000*  20%  $2,500/$5,000*  $5,000/$10,000*  80% after deductible Flexible Blue II 2500 PPO * Family Contract

6. In-Network  Deductible  Co-Insurance  Co-Insurance Max  Out of Pocket Max  Office Visit  Emergency  $5,000/$10,000*  20%  $800/$1,600*  $5,800/$11,600*  80% after deductible Flexible Blue II 5000 PPO * Family Contract

7. In-Network  Deductible  Co-Insurance  Co-Insurance Max  Out of Pocket Max  Office Visit  Emergency  $1,000  30%  $2,500  $3,500  $30**  70% after in-network deductible plus $150 copay*** Young Adult Blue Max PPO ** Professional services:

8. In-Network  Deductible  Co-Insurance  Co-Insurance Max  Out of Pocket Max  Office Visit  Emergency  $1,500, $2,500, $5,000, $7,500 or $10,000  30%  $3,500/$7,000  Deductible plus co- insurance max  $40.00**  100% after outpatient deductible plus $250 copay*** Keep Fit SM PPO *** Emergency: ** Professional services

9. In-Network  Deductible  Co-Insurance  Co-Insurance Max  Out of Pocket Max  Office Visit  Emergency  $500/$1,000*  20%  $5,000/$10,000*  $5,500/$11,000*  $30.00  $100.00 OneBlue SM HMO * Family Contract

10. In-Network  Deductible  Co-Insurance  Co-Insurance Max  Out of Pocket Max  Office Visit  Emergency  $1,500, $2,500 or $5,000  20% 50% for select service  $5,000/$10,000  Deductible plus co- insurance max  $30.00  $200.00 copay after deductible Smart Select SM HMO