FOR EMPLOYERS WITH 51+ EMPLOYEES PersonalCare Plans. Available to your employees living or working in King, Pierce, or Snohomish counties

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1 FOR EMPLOYERS WITH 51+ EMPLOYEES PersonalCare Plans Available to your employees living or working in King, Pierce, or Snohomish counties

2 PersonalCare Plans connect your employees doctors, hospitals, and specialists for streamlined care. This helps keep costs as low as possible and simple to understand.

3 CHOICE, CONVENIENCE, AND QUALITY a better healthcare experience Is a PersonalCare Plan right for your employees? Premera PersonalCare Plans are available to your employees living or working in King, Pierce, or Snohomish counties. The value of PersonalCare Plans With Premera Blue Cross, you get our commitment to help make healthcare work better. For your employees, that means: Timely doctor appointments See a specialist in 15 days or fewer. Preventive care services Get preventive services at no cost. Free 24-Hour NurseLine Call for advice at any time. Virtual care services Consult with a doctor by phone or online video, usually at the same cost as an in-person office visit. Mobile app Find in-network care, view their digital ID card, and see deductible and out-of-pocket maximum information with our personalized, easy-to-use mobile app. Online pharmacy tool Search for prescription costs. 10 essential health benefits Enjoy coverage that aligns with the 10 essential health benefits in our health plan summaries on premera.com. Get more It pays to add Premera dental, hearing, and vision to your medical plan: Together, Premera s medical, dental, vision, and hearing plans encourage healthy habits and better outcomes which means taking great care of your employees with a wellrounded benefits package all in one place. Wellness programs: Employees who feel better do better. Ask your Premera representative or producer if Premera s Wellness Program is included with your group s medical plan and about other options for creating a culture of well-being within your workplace. NEW FOR 2018 Low-cost fitness center memberships: Get access to 9,000 fitness centers nationwide for only $25 a month (plus $25 enrollment fee and applicable taxes). Pregnancy and newborn support: BestBeginnings Maternity engages parents from pregnancy through newborn care with personalized tools and support that encourages discovering risks early. Additionally, our NICU Program is available to help reduce costs associated with high-risk pregnancies or newborns who end up in neonatal intensive care units (NICU).

4 How it works A PersonalCare Plan is designed so your employees have a: Partner System: a local group of trusted providers that serve as their central point of care. Each system of hospitals, clinics, and doctors commits to work together with us to provide care that saves you time. PersonalCare Plans provide Premera customers with access to 6 different Partner systems. Primary Care Provider (PCP): the doctor they visit for most of their care and the person responsible for coordinating their care. This doctor must be selected from within the chosen Partner System and may require referrals to providers outside of the selected system. After your employees enroll We make starting out with a PersonalCare Plan easy for your employees by choosing a Partner System for them and their covered family members. This selection is based on where your employees live and the doctors they may have visited within a Partner System, or they can choose a new PCP within their Partner System.

5 Review the guide below to find out which of our 6 Partner Systems offer hospitals, clinics, and doctors in your county. Referrals outside of the Partner System are rare and your employees should discuss this with their PCP prior to receiving care. A PCP can complete a referral for care that is not available within the Partner System if it is deemed necessary to see another provider in Premera s Heritage Prime network. One of the best things your employees get with a PersonalCare Plan is our commitment to partner with doctors and hospitals within the PersonalCare Partner Systems for a better healthcare experience. PARTNER SYSTEM COUNTY KING PIERCE SNOHOMISH EvergreenHealth Partners MultiCare Connected Care Northwest Physicians Network The Everett Clinic Integrated Care Network UW Medicine Accountable Care Network Virginia Mason Medical Center

6 Cost-share options Cost-share amounts represent customers costs. Not all plan option combinations are offered. See your sales representative for clarification. IN-NETWORK Individual Deductible PCY Family Deductible PCY Coinsurance $500 $750 $1,000 $1,500 2x Individual 20% Individual Out-of-Pocket Maximum PCY (Includes deductible, coinsurance, and copay) $4,000 Family Out-of-Pocket Maximum PCY (Includes deductible, coinsurance, and copay) 2x Individual Fourth Quarter Deductible Carryover $25 Office Visit Cost Share: Specialist $40 Annual Plan Maximum Not covered except for emergencies or as required by law Excluded Office Visit Cost Share: PCP Inpatient Cost Share OUT-OF-NETWORK Not covered except for emergencies or as required by law In-network deductible and coinsurance None Note: Coinsurance amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera Blue Cross. PCY = Per Calendar Year PCP = Primary Care Physician

7 Covered services Preventive care and counseling visit Preventive screenings Vaccinations (Including seasonal vaccinations received at a pharmacy or other mass vaccination location paid as in-network) Benefits apply after calendar-year deductible is met, unless otherwise noted. Benefits subject to medical necessity except for preventive care. PCY = Per Calendar Year BENEFIT LIMITS IN-NETWORK OUT-OF-NETWORK Subject to federal and state guidelines 1 Covered in full 2 Professional Office Visit (Including urgent care) Other Outpatient Professional Services Inpatient Professional Services No visit maximum Office visit cost share Preferred coinsurance Participating coinsurance Not covered Manipulations (Spinal and other) Acupuncture 12 visits PCY or no limit 12 visits PCY Office visit cost share PCP Naturopathic Services No visit maximum Office visit cost share Mammography (Non-preventive) Outpatient diagnostic imaging and laboratory services No visit maximum In-network coinsurance Emergency Care (Copay waived if directly admitted to inpatient facility) Ambulance Transportation (Air and ground) No maximum No trip or dollar maximum In-network coinsurance PLUS copay of $200 $200 copay In-network coinsurance Same as in-network Inpatient Facility Care Outpatient Facility Care No day or visit limit Inpatient cost share In-network coinsurance Skilled Nursing Facility 60 days PCY Inpatient cost share Maternity Care (Prenatal, delivery, and postnatal care) Mental Health and Chemical Dependency Treatment No visit or day maximum; covered for: subscriber, spouse/domestic partner, and dependents No visit or day maximums In-network coinsurance Outpatient: office visit cost share PCP; Inpatient: inpatient cost share Rehabilitation (Including: physical, occupational, speech, and massage therapy) (Including: cardiac/pulmonary rehab and chronic pain) Supplies, equipment, prosthetics, and orthotics Temporomandibular joint disorders (TMJ) 25 visits/30 days PCY Outpatient: office visit cost share specialist; Inpatient: inpatient cost share No visit maximum No maximum, except $300 max PCY for foot orthotics that are not diabetes-related No dollar maximum In-network coinsurance Outpatient: Office visit cost share Inpatient: Inpatient cost share Not covered Home health agency services 130 visits PCY In-network coinsurance Hospice care Outpatient: No visit maximum (within 6 month lifetime max) Respite: 240 hours (within 6-month lifetime max) Inpatient options: 10 days (within 6-month lifetime max) Outpatient and respite: In-network coinsurance Inpatient: Inpatient cost share Transplants (Organ and bone marrow) No dollar maximums, except for $7,500 travel and lodging limit per transplant Outpatient: Office visit cost share Inpatient: Inpatient Cost Share Retail pharmacy (Subject to medical deductible) 30-day supply $10/$40/$80 Mail order pharmacy (Subject to medical deductible) 90-day supply $30/$120/$240 Specialty pharmacy (Subject to medical deductible) 30-day supply through preferred specialty pharmacies $100 Note: Amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera Blue Cross. 1 A list of preventive screenings and other preventive services is available on premera.com in the Miscellaneous Forms page of the producer and employer websites. 2 Not subject to copay, deductible, or coinsurance. This is only a brief summary of the major benefits provided by our plans. This is not a contract.

8 Premera s vision and hearing plans Offering vision and hearing benefits along with your employees medical and dental coverage is easier to manage for both your business and your employees. In fact, routine eye and hearing exams can lead to earlier diagnosis of chronic diseases. Plus, offering all of your employees benefits with Premera means you get the ease of dealing with just one health plan and your employees enjoy the simplicity of one card, one customer service phone number, and one website. Adult vision coverage (19 and older) also includes pediatric coverage (18 and younger). See the grid below. When a group offers vision coverage as a separate option, benefits for customers younger than 19 are the same as benefits for adults. More optional benefits Stop-loss coverage LifeWise Assurance Company * assists groups with creating the right medical stop loss for their needs. If you elect to self fund your medical plan, this product provides a reinsurance contract to protect your group from catastrophic losses. Personal funding accounts Employers can take advantage of an integrated system for implementing and administering a flexible spending account (FSA), and health reimbursement arrangement (HRA). These products can help manage healthcare costs by putting healthcare spending in the hands of employees. By spending their own money, employees pay more attention to their health and healthcare. * LifeWise Assurance Company is an independent company which does not provide Blue Cross Blue Shield products or services. PersonalCare Plan vision and hearing options BENEFIT LIMITS PCY = Per Calendar Year CY = Calendar Year COVERAGE Vision Adult Exam and eyewear 1 routine exam PCY; Hard ware: $150 PCY Exam: $25 Hardware: Covered in full Vision Pediatric (Pediatric exam cost shares accrue to the out-of-pocket maximum) Exam and eyewear 1 routine exam PCY; Hardware: 1 pair of glasses PCY (frames and lenses); 12-month supply of contacts PCY, in lieu of glasses (frames and lenses) Exam: $25 Hardware: Covered in full Hearing Exam with aids and hardware 1 exam every 2 CY; Hardware: $1,000 every 3 CY Exam: $25 Hardware: Covered in full This is only a brief summary of the major benefits provided by our plans. This is not a contract. For information and details regarding general exclusions and limitations, please contact your Premera representative.

9 Premera s dental plans You get: Administrative ease. If you already offer a medical plan from Premera, you ll get a one-stop-shopping experience that makes it easier to manage your benefits. Your choice of coverage options. We offer a variety of plans to meet your needs and budget. Whether you want to offer comprehensive coverage or just the core essentials you can choose the level of coverage that works best for your business needs. A boost to your benefits package. Job seekers look for well-rounded benefit packages. You ll be able to attract and retain the best talent by offering benefits that are important to your employees. Healthier, happier, employees. Oral health is key to overall health. If your employees get the care they need for healthy smiles, they ll be better prepared to meet the needs of your business. Your employees get: A broad network. We offer access to a large network of dentists. Premera contracts with thousands of network dentists in the state of Washington and hundreds of thousands nationally. Emphasis on prevention. When you offer your employees Premera dental benefits they will not pay a deductible for routine oral exams, and most plans will cover preventive services in full. Dedicated customer service team. Our trained representatives are ready to help every step of the way. Easy online tools. Your employees and their covered dependents can find in-network care, and see how much dental services will cost, or even a licensed dentist. Dental expertise. We ve been serving dental customers for more than 30 years.

10 Choose from five dental plan options

11 With any Premera dental plan, your employees and their covered dependents get: Access to any in-network or out-of-network * dentist nationwide Freedom to choose any licensed dental provider Preventive and diagnostic services such as routine oral exams, cleanings, and x-rays covered with no deductibles Benefits for periodontal maintenance up to 4 visits per year to help manage gum disease or chronic conditions * Balance billing may apply with out-of-network dentists. PLAN HIGHLIGHTS DENTAL OPTIMA DENTAL PREFERENCE DENTAL COPAY SELECT DENTAL ESSENTIALS DENTAL PREVENTIVE + Optional TMJ coverage available Comprehensive benefits for major services Employer-funded plan option 1 Access to nationwide Choice dental network Optional orthodontia coverage available for groups with 26 or more enrolled employees 2 Benefit Enhancement Option Employee-funded plan option 3 Access to nationwide Select dental network Note: For a summary of plan benefits and limitations, see plan details to follow. 1 Employer contributes 50% 100% of premium. Minimum enrollment is 50% of eligible employees. 2 Not available on Dental Copay Select voluntary plans. 3 Employer contributes 0% 49% of premium. Minimum enrollment is 30% of eligible employees.

12 Dental Optima With Dental Optima, you can choose from several cost share options giving your employees and their covered dependents choice and control over their spending. You can decide to have routine diagnostic and preventive services that won t count toward the annual maximum on the plan. To help encourage regular oral health maintenance, basic services such as fillings and extractions are covered. Additionally, there s no waiting period for major services such as crowns, implants, and dentures, so your employees can get the care they need as soon as their coverage starts. Covered services Annual deductible PCY Maximum allowance per person, PCY DIAGNOSTIC AND PREVENTIVE 4 Cleanings limited to 2 PCY Emergency exams unlimited Fluoride treatments limited to 2 applications PCY for customers under the age of 19 Routine oral exams limited to 2 PCY Routine x-rays bitewing x-rays unlimited; complete series or panoramic x-ray once per 36 consecutive months Sealants limited to permanent teeth for customers under age 19 Space maintainers for customers under age 19 BASIC Endodontic (root canal) treatment limited to once per tooth every 2 calendar years Fillings limited to once per tooth surface every 24 consecutive months General anesthesia limited to covered dental procedures at a dental-care provider s office when dentally necessary Oral surgery including simple and surgical extractions Periodontal maintenance limited to 4 visits PCY Periodontal surgery unlimited Periodontal scaling limited to once per quadrant every 2 calendar years Repair and recementing of crowns, inlays, bridgework, and dentures MAJOR Implants, dentures, partials, and fixed bridges replacements for dentures, partials, and fixed bridges limited to once every 5 calendar years Inlays, onlays, and crowns replacements limited to once per tooth every 5 years Benefits apply after calendar year deductible is met, unless otherwise noted. Deductible and Coinsurance represent customers cost share PCY = Per Calendar Year COST SHARES FOR DENTAL OPTIMA PLANS INDIVIDUAL $25 $50 $0 $25 $50 $75 1 $400 $500 2 $25 $50 $75 FAMILY $75 $150 $0 $75 $150 $225 $600 $1,500 2 $75 $150 $225 $1,000, $1,500, $2,000, or $2,500 IN- AND OUT-OF-NETWORK $750 3, $1,000, $1,500, $2,000, or $2,500 IN- AND OUT-OF-NETWORK $1,000 or $1,500 $1,000 or $1,500 $750, $1,000, or $1,500 IN- AND OUT-OF-NETWORK IN- AND OUT-OF-NETWORK IN- AND OUT-OF-NETWORK 0% 0% 0% 0% 20% 10% 20% 20% 20% 20% 40% 50% 50% 50% 50% Note: Coinsurance amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera Blue Cross. 1 $75 deductible is not available with $2,500 maximum allowance. 2 Deductible applies only to major services. 3 $750 maximum allowance only available with $50/$150 and $75/$225 deductibles. 4 Annual deductible waived for diagnostic and preventive services.

13 Dental Preference With Dental Preference, you can choose from several cost share options giving your employees and their covered dependents choice and control over their spending. To help encourage regular oral health maintenance, basic services such as fillings and extractions are covered. Additionally, there s no waiting period for major services such as crowns, implants, and dentures, so your employees can get the care they need as soon as their coverage starts. Covered services Annual deductible PCY Maximum allowance per person, PCY Benefits apply after calendar year deductible is met, unless otherwise noted. Deductible and Coinsurance represent customers cost share PCY = Per Calendar Year COST SHARES FOR DENTAL PREFERENCE PLANS INDIVIDUAL $25 $50 $25 $50 $25 $50 $75 $25 $50 $75 FAMILY $75 $150 $75 $150 $75 $150 $225 $75 $150 $225 $1,000, $1,500, $2,000, or $2,500 $1,000, $1,500, $2,000, or $2,500 $1,000, $1,500 or $2,000 $1,000, $1,500 or $2,000 DIAGNOSTIC AND PREVENTIVE 1 Cleanings limited to 2 PCY Fluoride treatments limited to 2 applications PCY for customers under the age of 19 Routine oral exams limited to 2 PCY Routine x-rays bitewing x-rays unlimited; complete series or panoramic x-ray once per 36 consecutive months Sealants limited to permanent teeth for customers under age 19 BASIC Emergency exams unlimited Fillings limited to once per tooth surface every 24 consecutive months Periodontal maintenance limited to 4 visits PCY Periodontal scaling limited to once per quadrant every 2 calendar years Recementing of crowns, inlays, bridgework, and dentures Simple and surgical extractions Space maintainers for customers under age 19 MAJOR Implants, dentures, partials, and fixed bridges replacements for dentures, partials, and fixed bridges limited to once every 5 calendar years Endodontic (root canal) treatment limited to once per tooth every 2 calendar years General anesthesia limited to covered dental procedures at a dental-care provider s office when dentally necessary Inlays, onlays, and crowns replacements limited to once per tooth every 5 years Oral surgery Periodontal surgery limited to once per quadrant every 3 calendar years Repair of crowns, inlays, bridgework, and dentures IN OUT IN OUT IN OUT IN OUT 0% 20% 0% 20% 0% 20% 20% 30% 0% 20% 10% 20% 20% 40% 20% 40% 40% 60% 40% 60% 50% 60% 50% 60% Note: Coinsurance amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera Blue Cross. 1 Annual deductible waived for diagnostic and preventive services.

14 Dental Copay Select With Dental Copay Select, you can offer your employees and their covered dependents complete, quality dental coverage. This plan offers full dental benefits on a reduced budget and keeps costs predictable with set copays for each of the 200 covered services. Choose to cover the costs of coverage, or offer your employees as a voluntary option. Dental Copay Select plan features. Benefits apply after calendar year deductible is met, unless otherwise noted. Deductible and Coinsurance represent customer s cost share PCY = Per Calendar Year Covered services COST SHARES FOR DENTAL COPAY SELECT VOLUNTARY 1 Annual deductible PCY INDIVIDUAL $50 $50 $75 $50 $75 FAMILY $150 $150 $225 $150 $225 Maximum allowance per person, PCY $1,000, $1,500 $1,000, $1,500 $1,000 $1,000 $1,000 DIAGNOSTIC AND PREVENTIVE 2 Bitewing x-rays Cleanings limited to 2 PCY Fluoride treatments limited to 2 applications PCY for customers under the age of 19 Routine oral exams limited to 2 PCY Sealants limited to permanent teeth for customers under age 19 BASIC Complete series or panoramic x-ray per 36 consecutive months Periapical and occlusal x-rays Emergency palliative treatment Fillings limited to once per tooth surface every 24 consecutive months Periodontal maintenance limited to 4 visits PCY Recementing of crowns, inlays, bridgework, and dentures Repair of crowns, bridgework, and dentures Simple extractions non-surgical Space maintainers for customers under age 19 MAJOR Dentures and fixed bridges replacements limited to once every 5 calendar years Endodontic (root canal) treatment limited to once per tooth every 2 calendar years General anesthesia limited to covered dental procedures at a dental care provider s office when dentally necessary Onlays and crowns replacement limited to once per tooth every 5 years Oral surgery including surgical extractions Periodontal scaling limited to once per quadrant every 2 calendar years Periodontal surgery limited to once per quadrant every 3 calendar years IN OUT IN OUT IN OUT IN OUT IN OUT Copay 0% Copay 20% Copay 30% Copay 20% Copay 30% Copay 30% Copay 40% Copay 50% Copay 40% Copay 50% Copay 60% Copay 60% Copay 70% Copay 60% Copay 70% Note: Applicable copay depends on the service rendered. For a complete listing of covered services by code with the applicable copay, see premera.com. Coinsurance amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera Blue Cross. 1 A 12-month waiting period for major services applies to customers who have not had continuous comparable dental coverage under the group s prior dental plan. 2 Deductible waived for diagnostic and preventive services.

15 Here are a few examples of common services and copays: PCY = Per Calendar Year Annual deductible PCY DEDUCTIBLE INDIVIDUAL $50 / $75 FAMILY $150 / $225 Maximum allowance per person, PCY $1,000 DIAGNOSTIC AND PREVENTIVE COPAY 1 Copay (deductible waived) Oral exams limited to 2 PCY $0 Bitewing x-rays $0 Cleanings limited to 2 PCY $20 Fluoride treatments limited to 2 applications PCY for customers under the age of 19 $0 Sealants limited to permanent teeth for customers under age 19 $0 BASIC Deductible, then copay Fillings limited to once per tooth surface every 24 consecutive months $30 Periodontal maintenance limited to 4 visits PCY $40 Recementing of crowns $20 Crown repair $25 Simple extractions non-surgical $30 Space maintainers for customers under age 19 $65 MAJOR Crowns, onlays, dentures, partials, and bridges Endodontic (root canal) treatment limited to once per tooth every 2 calendar years General anesthesia limited to covered dental procedures at a dental-care provider s office when dentally necessary Deductible, then copay Copays vary based on the tooth location and type of material used. Visit premera.com for a complete list of covered services and copays for more information. anterior tooth: $385 molar tooth: $515 bicuspid tooth: $435 Oral surgery including surgical extractions $115 Periodontal scaling limited to once per quadrant every 2 calendar years $60 Periodontal surgery limited to once per quadrant every 3 calendar years $350 1 Out-of-network coinsurance amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera Blue Cross. Visit premera.com for details on out-of-network provider coverage. $75

16 Dental Essentials Plus With Dental Essentials Plus, you can offer dental coverage at little or no cost to you. Choose between letting your employees and their covered dependents pay the full cost of their monthly health plan bills or funding up to 50 percent. To help encourage regular oral health maintenance, basic services such as fillings and extractions are covered. Covered services Annual deductible PCY Benefits apply after calendar year deductible is met, unless otherwise noted. Deductible and Coinsurance represent customer s cost share PCY = Per Calendar Year COST SHARES FOR DENTAL ESSENTIALS PLUS PLANS INDIVIDUAL $25 $50 $75 $25 $50 $75 $25 $50 $75 FAMILY $75 $150 $225 $75 $150 $225 $75 $150 $225 Maximum allowance per person, PCY $750, $1,000 or $1,500 $750, $1,000 or $1,500 $750, $1,000 or $1,500 DIAGNOSTIC AND PREVENTIVE 1 Cleanings limited to 2 PCY Fluoride treatments limited to 2 applications PCY for customers under the age of 19 Routine oral exams limited to 2 PCY Routine x-rays bitewing x-rays unlimited; complete series or panoramic x-ray once per 36 consecutive months Sealants limited to permanent teeth for customers under age 19 BASIC Emergency exams unlimited Fillings limited to once per tooth surface every 24 consecutive months Periodontal maintenance limited to 4 visits PCY Periodontal scaling limited to once per quadrant every 2 calendar years Recementing of crowns, inlays, bridgework, and dentures Simple and surgical extractions Space maintainers for customers under age 19 MAJOR 2 Dentures, partials, and fixed bridges replacements limited to once every 5 calendar years Endodontic (root canal) treatment limited to once per tooth every 2 calendar years General anesthesia limited to covered dental procedures at a dental-care provider s office when dentally necessary Inlays, onlays, and crowns replacements limited to once per tooth every 5 years Periodontal surgery limited to once per quadrant every 3 calendar years Oral surgery Repair of crowns, inlays, bridgework, and dentures IN OUT IN OUT IN OUT 0% 20% 0% 0% 20% 30% 20% 40% 20% 20% 20% 40% 50% 60% 50% 50% 50% 60% Note: Coinsurance amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera Blue Cross. 1 Annual deductible waived for diagnostic and preventive services. 2 A 12-month waiting period for major services applies to customers who have not had continuous comparable dental coverage under the group s prior dental plan.

17 Dental Preventive + Dental Preventive + is available as an employer-sponsored or voluntary plan, so you can offer basic dental coverage to your employees at a lower cost than a comprehensive dental plan. In addition, there s no waiting period for services, so your employees and their covered dependents can get the care they need as soon as their coverage starts. This plan is available in one of two ways. Employer-sponsored: Employers pay from 50 to 100 percent of the premium. Voluntary: Employers pay from 0 to 49 percent of the premium. Covered services Benefits apply after calendar year deductible is met, unless otherwise noted Deductible & Coinsurance represent customer s cost share PCY = Per Calendar Year Annual deductible PCY COST SHARES FOR DENTAL PREVENTIVE + PLANS INDIVIDUAL $0 $0 FAMILY $0 $0 Maximum allowance per person, PCY $500 or $750 $500 or $750 DIAGNOSTIC AND PREVENTIVE Cleanings limited to 2 PCY Fluoride treatments limited to 2 applications PCY for customers under the age of 19 Routine oral exams limited to 2 PCY Routine x-rays bitewing x-rays unlimited; complete series or panoramic x-ray once per 36 consecutive months Sealants limited to permanent teeth for customers under age 19 BASIC Emergency exams unlimited Fillings limited to once per tooth surface every 24 consecutive months Periodontal maintenance limited to 4 visits PCY Periodontal scaling limited to once per quadrant every 2 calendar years Recementing of crowns, inlays, and bridgework Simple extractions non-surgical Space maintainers for customers under age 19 IN- AND OUT-OF-NETWORK IN- AND OUT-OF-NETWORK 0% 0% 0% 20% Note: Coinsurance amounts based on allowable charges. Balance billing may apply if a provider is not contracting with Premera Blue Cross.

18 More dental options You can choose to offer additional dental coverage to customize your Premera dental plans. Optional benefits DENTAL OPTIMA DENTAL PREFERENCE DENTAL COPAY SELECT DENTAL ESSENTIALS DENTAL PREVENTIVE + BENEFIT ENHANCEMENT RIDER Endodontic (root canal) and surgical periodontal treatment Covered under Major instead of Basic services Covered under Basic instead of Major services N/A N/A N/A Preventive services do not count toward maximum allowance Optional N/A N/A N/A N/A ORTHODONTIA 1 Diagnostic services and active/retention treatment including appliances Monthly orthodontic adjustments including retention treatment Covered in full 2 up to Lifetime maximum N/A N/A Lifetime maximum per person (choose one) $1,000, $1,500 or $2,000 $1,000 or $1,500 Age limit (choose one) No age limit or Under age 19 TMJ DENTAL SERVICES 3 Temporomandibular Joint Disorder (TMJ) exams and x-rays, occlusal guards and TMJ surgical procedures, manipulations under anesthesia Deductible and basic coinsurance apply Annual benefit maximum $1,000 Lifetime maximum per person $5,000 1 Not available for a voluntary plan or the $75 deductible Copay Plan. 2 Benefits provided at 100% of allowable charges; not subject to deductible or coinsurance. 3 Balance billing may apply if a provider is not contracting with Premera Blue Cross.

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20 LEARN MORE Visit premera.com/personalcare. Call Talk with your producer, also known as a licensed agent. This brochure is not a contract. It is only a summary of the major benefits provided by these plans. For full coverage provisions, including a description of waiting periods, limitations, and exclusions, please contact your Premera representative or producer ( )