Guaranteed Issue HMO

1901 MARKET STREET PHILADELPHIA, PA 19103-1480

Dear prospective member:

Thank you for your interest in Personal Choice®, which is our popular Preferred Provider Organization

(PPO) health plan.

YOUR PERSONAL CHOICE OPTIONS

We would like to provide you with information to help you choose the plan that’s right for you. We offer

three types of plans with a choice of six Personal Choice options. All plans provide coverage in and out of

network and give you the freedom to see specialists directly, without referrals.

Basic I and II. These plans offer comprehensive coverage, including prescription drug coverage,

physician office visits, X-ray/lab testing, and hospitalization.

Value HSA. This is an HSA-qualified, high-deductible health plan that offers prescription drug

coverage, physician office visits, X-ray/lab testing, and hospitalization. This plan also allows you to

use it in combination with a health savings account (HSA).

HospitalCare I, II, and III. These plans provide coverage for inpatient/outpatient hospital services,

along with X-ray/lab testing. They also include limited office visit coverage.

This chart compares what you would pay with each option for doctor’s visits and hospitalizations. For a

more detailed description of each of these programs, please review the enclosed information.

Plan Deductible

Individual/family

Doctor’s visit

Specialist’s visit

Hospital Emergency room

Basic I $500/$1,000 $30 copay, no deductible

$50 copay, no deductible

20%, after deductible


1

Basic II $1,000/$2,000 $35 copay, no deductible




1

Value HSA $5,000/$10,000 $0, after deductible

$0, after deductible



HospitalCare I None $40 copay2 $75 copay

2

$1,000 per admission

$1501

HospitalCare II $1,000/$2,000 $40 copay2,

no deductible $75 copay

2,

no deductible 20%, after deductible


1

HospitalCare III $2,000/$4,000 $40 copay2,

no deductible $75 copay

2,

no deductible 40%, after deductible


1

1Not waived if admitted. 2Limited to three office visits per year for a primary care physician and specialist (combined in- and out-of-network).

HOW TO APPLY

To enroll in Personal Choice coverage, complete the enclosed application, sign it, and return it in the

envelope provided. You do not need to send any money at this time. We will bill you after your

application is processed. If you have any questions as you are completing your application, call Customer

Service at 1-800-ASK-BLUE (1-800-275-2583). We will make sure you get the answers you need to

make an informed decision about your health care coverage.

Sincerely,

Paula Sunshine

Vice President, Product Services PC CVR LTR (1/11)

www.ibx.com

Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield –

independent licensees of the Blue Cross and Blue Shield Association.

INDIVIDUAL 2010-0453 (1/11)

Benefits underwritten and administered by QCC Insurance Company, a subsidiary of Independence Blue Cross — independent licensees of the Blue Cross and Blue Shield Association.

The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

We’re here for you every step of the way.

www.ibx.com

Why Choose Blue?• You will join 2.4 million members in the Philadelphia five-county region who carry a Blue Cross® card.

• You get access to the tools to help you make informed health care decisions.

• You can be confident that you’re covered by one of the leading health insurers in southeastern Pennsylvania, with more than 70 years of experience.

1 Through the BlueCard PPO program, Personal Choice members can access all Blue plans’ BlueCard PPO networks anywhere in the United States.2 Healthy Lifestyles programs are value-added programs and services—they are not benefits under the health care that you purchased and are therefore

subject to change without notice.3 This benefit is part of the Blue365 program. There is no fee to use the Blue365 program. However, for access to certain vendors offering discounts, members may be required to pay an

annual fee to get the vendor discount.4 Some benefits require precertification. If you use an out-of-network provider and do not obtain a precertification, the penalty is a 50% reduction in benefit. 5 Limited to 3 per year for specialist and primary care physician visits; combined in- and out-of-network.6 Not waived if admitted.

® WebMD is an independent company offering health information and wellness education to Independence Blue Cross members.

® Weight Watchers is a registered mark of Weight Watchers International, Inc.

This summary represents only a partial listing of the benefits of the Personal Choice program. Benefits and exclusions may be further defined by medical policy. As a result, this managed care plan may not cover all of your health care expenses. Read your contract carefully for a complete listing of the terms, limitations, and exclusions of the program. If you need more information, please call 1-800-ASK-BLUE (1-800-275-2583).

Personal Choice is available to individuals living in Bucks, Chester, Delaware, Montgomery, and Philadelphia counties.

GG FlexibleGbenefits

GG ReliableGhealthGinformation

GG ValuableGrewardsGandGdiscounts

Personal Choice®

It’s always your choiceWith Personal Choice you don’t need to select a primary care physician, and you never need a referral to see a specialist. Our network includes more than 58,000 physicians and specialists and more than 100 hospitals, including the area’s premier teaching hospitals. You also have access to BlueCard® PPO, which means you have in-network coverage from coast to coast with more than 676,000 PPO physicians and more than 5,500 participating hospitals in the United States.1

You’re covered in-network or out-of-network when you need:

• primary care • preventive care • hospitalization

• specialist care • emergency care • X-rays and blood tests

Get rewarded for healthy living2

We offer cash rewards, discounts, and more to help you and your family lead a healthier life, including:

Cash rewards

• Up to $150 reimbursement on fitness center fees.

• Up to $200 reimbursement for completing a tobacco cessation program.

• Up to $200 reimbursement on weight management programs like Weight Watchers®.

Discounts3

• Receive discounts on products and services to help you lose weight, get fit, reduce stress, and more from retailers like Reebok®, eDiets®, Snap Fitness, and Willow Stream Spas.

Support and information

• 24/7 access to a Health Coach, who can help with everyday health concerns or significant treatment decisions.

• Health encyclopedia, audio library, and decision-support tools.

Visit ibx.com or call us at 1-800-ASK-BLUE (1-800-275-2583).

Select the plan that’s right for youChoose from our six Personal Choice plans to best meet your health insurance needs. The chart below shows what you pay when you get treatment from a participating doctor or hospital.

One of the additional benefits of the Personal Choice Value HSA plan is that you may pair it with a Health Savings Account (HSA). HSAs are tax-advantaged, personal bank accounts that you can set up and fund to reimburse covered medical expenses or to supplement your retirement savings. You can use any bank you like, or you can open an HSA with IBC’s preferred HSA vendor, The Bancorp Bank. For more information about Bancorp HSAs, visit www.mybancorpHSA.com.

Manage your benefits onlineYou have access to your benefits 24/7 on ibxpress.com, our member website. We’ve partnered with WebMD®, one of the most widely recognized names in health information, to provide you with reliable, up-to-date information to make medical decisions that are right for you. At ibxpress.com you can:

• take the Personal Health Profile and get a personalized action plan;

• get in-depth information on doctors and hospitals;

• use the Symptom Checker to get information on your health concerns;

• use Lifestyle Improvement Programs to help you stop smoking, lose weight, eat better, reduce stress, start exercising, and more;

• request a new ID card;

• check the status of a claim;

• estimate treatment costs.

To learn more about our plans and to find rate information, please review the enclosed rates and benefits information.

Plan Deductible Doctor’s visit Specialist’s visit Hospital/days4 Emergency room



20%, after deductible/unlimited days 20%, after deductible6

Basic II $1,000/$2,000 $35 copay,no deductible

$60 copay,no deductible

20%, after deductible/ unlimited days 20%, after deductible6

Value HSA $5,000/$10,000 $0, after deductible $0, after deductible $0, after deductible/ unlimited days $0, after deductible

HospitalCare I None $40 copay5 $75 copay5 $1,000 per admission/ unlimited days $1506

HospitalCare II $1,000/$2,000 $40 copay,no deductible5

$75 copay,no deductible5


HospitalCare III $2,000/$4,000 $40 copay,no deductible5



#1 PPO in the region*

Receiving care Costs Ease of use

In network locally or through a BlueCard® PPO provider

Visit any preferred provider directly without selecting a primary care physician (PCP)

Lower out-of-pocket costs and no balance-billing

- No PCP- No referrals- No claim forms to complete

Out of network Visit any nonparticipating provider directly

Higher out-of-pocket costs with potential for balance-billing by nonparticipating providers

May require claim filing

* According to a leading independent consumer magazine.

Personal Choice®

It’s always your choiceWith Personal Choice you don’t need to select a primary care physician, and you never need a referral to see a specialist. Our network includes more than 58,000 physicians and specialists and more than 100 hospitals, including the area’s premier teaching hospitals. You also have access to BlueCard® PPO, which means you have in-network coverage from coast to coast with more than 676,000 PPO physicians and more than 5,500 participating hospitals in the United States.1

You’re covered in-network or out-of-network when you need:

• primary care • preventive care • hospitalization

• specialist care • emergency care • X-rays and blood tests

Get rewarded for healthy living2

We offer cash rewards, discounts, and more to help you and your family lead a healthier life, including:

Cash rewards

• Up to $150 reimbursement on fitness center fees.

• Up to $200 reimbursement for completing a tobacco cessation program.

• Up to $200 reimbursement on weight management programs like Weight Watchers®.

Discounts3

• Receive discounts on products and services to help you lose weight, get fit, reduce stress, and more from retailers like Reebok®, eDiets®, Snap Fitness, and Willow Stream Spas.

Support and information

• 24/7 access to a Health Coach, who can help with everyday health concerns or significant treatment decisions.

• Health encyclopedia, audio library, and decision-support tools.

Visit ibx.com or call us at 1-800-ASK-BLUE (1-800-275-2583).

Select the plan that’s right for youChoose from our six Personal Choice plans to best meet your health insurance needs. The chart below shows what you pay when you get treatment from a participating doctor or hospital.

One of the additional benefits of the Personal Choice Value HSA plan is that you may pair it with a Health Savings Account (HSA). HSAs are tax-advantaged, personal bank accounts that you can set up and fund to reimburse covered medical expenses or to supplement your retirement savings. You can use any bank you like, or you can open an HSA with IBC’s preferred HSA vendor, The Bancorp Bank. For more information about Bancorp HSAs, visit www.mybancorpHSA.com.

Manage your benefits onlineYou have access to your benefits 24/7 on ibxpress.com, our member website. We’ve partnered with WebMD®, one of the most widely recognized names in health information, to provide you with reliable, up-to-date information to make medical decisions that are right for you. At ibxpress.com you can:

• take the Personal Health Profile and get a personalized action plan;

• get in-depth information on doctors and hospitals;

• use the Symptom Checker to get information on your health concerns;

• use Lifestyle Improvement Programs to help you stop smoking, lose weight, eat better, reduce stress, start exercising, and more;

• request a new ID card;

• check the status of a claim;

• estimate treatment costs.

To learn more about our plans and to find rate information, please review the enclosed rates and benefits information.

Plan Deductible Doctor’s visit Specialist’s visit Hospital/days4 Emergency room



20%, after deductible/unlimited days 20%, after deductible6

Basic II $1,000/$2,000 $35 copay,no deductible

$60 copay,no deductible


Value HSA $5,000/$10,000 $0, after deductible $0, after deductible $0, after deductible/ unlimited days $0, after deductible

HospitalCare I None $40 copay5 $75 copay5 $1,000 per admission/ unlimited days $1506

HospitalCare II $1,000/$2,000 $40 copay,no deductible5



HospitalCare III $2,000/$4,000 $40 copay,no deductible5



#1 PPO in the region*

Receiving care Costs Ease of use

In network locally or through a BlueCard® PPO provider

Visit any preferred provider directly without selecting a primary care physician (PCP)

Lower out-of-pocket costs and no balance-billing

- No PCP- No referrals- No claim forms to complete

Out of network Visit any nonparticipating provider directly

Higher out-of-pocket costs with potential for balance-billing by nonparticipating providers

May require claim filing

* According to a leading independent consumer magazine.

INDIVIDUAL 2010-0453 (1/11)

Benefits underwritten and administered by QCC Insurance Company, a subsidiary of Independence Blue Cross — independent licensees of the Blue Cross and Blue Shield Association.

The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

We’re here for you every step of the way.

www.ibx.com

Why Choose Blue?• You will join 2.4 million members in the Philadelphia five-county region who carry a Blue Cross® card.

• You get access to the tools to help you make informed health care decisions.

• You can be confident that you’re covered by one of the leading health insurers in southeastern Pennsylvania, with more than 70 years of experience.

1 Through the BlueCard PPO program, Personal Choice members can access all Blue plans’ BlueCard PPO networks anywhere in the United States.2 Healthy Lifestyles programs are value-added programs and services—they are not benefits under the health care that you purchased and are therefore

subject to change without notice.3 This benefit is part of the Blue365 program. There is no fee to use the Blue365 program. However, for access to certain vendors offering discounts, members may be required to pay an

annual fee to get the vendor discount.4 Some benefits require precertification. If you use an out-of-network provider and do not obtain a precertification, the penalty is a 50% reduction in benefit. 5 Limited to 3 per year for specialist and primary care physician visits; combined in- and out-of-network.6 Not waived if admitted.

® WebMD is an independent company offering health information and wellness education to Independence Blue Cross members.

® Weight Watchers is a registered mark of Weight Watchers International, Inc.

This summary represents only a partial listing of the benefits of the Personal Choice program. Benefits and exclusions may be further defined by medical policy. As a result, this managed care plan may not cover all of your health care expenses. Read your contract carefully for a complete listing of the terms, limitations, and exclusions of the program. If you need more information, please call 1-800-ASK-BLUE (1-800-275-2583).

Personal Choice is available to individuals living in Bucks, Chester, Delaware, Montgomery, and Philadelphia counties.

GG FlexibleGbenefits

GG ReliableGhealthGinformation

GG ValuableGrewardsGandGdiscounts

Below are monthly premium rates for Individual Personal Choice guaranteed enrollment plans. Rates are based on the age of the oldest family member covered under the policy.

To determine your rate, find the age category of the oldest member covered under the policy, select the plan you would like, and then locate the rate that corresponds with your current coverage type (Individual, Individual and child, etc.)

Age 18to 29

Basic I Basic II Value HSA HospitalCare I HospitalCare II HospitalCare IIISingle $324.90 $272.44 $199.29 $186.83 $154.17 $129.66 Husband/Wife $649.79 $544.88 $398.57 $373.66 $308.34 $259.32 Parent/Child $487.96 $408.66 $299.53 $280.25 $231.25 $194.49 Parent/Children $651.00 $544.88 $399.78 $373.66 $308.34 $259.32 Family $975.90 $817.33 $599.06 $560.49 $462.50 $388.98

Age 30to 39

Basic I Basic II Value HSA HospitalCare I HospitalCare II HospitalCare IIISingle $444.47 $372.71 $262.09 $229.39 $186.45 $154.23

Husband/Wife $888.94 $745.43 $524.19 $458.79 $372.89 $308.47

Parent/Child $607.53 $508.94 $362.34 $322.81 $263.53 $219.06

Parent/Children $770.57 $645.16 $462.59 $416.22 $340.61 $283.89

Family $1,215.04 $1,017.87 $724.68 $645.62 $527.06 $438.13

Age 40to 49

Basic I Basic II Value HSA HospitalCare I HospitalCare II HospitalCare IIISingle $562.83 $471.97 $363.55 $298.15 $238.60 $193.93 Husband/Wife $1,125.67 $943.93 $727.10 $596.30 $477.21 $387.86 Parent/Child $725.89 $608.19 $463.80 $391.56 $315.69 $258.76 Parent/Children $888.94 $744.41 $564.04 $484.98 $392.77 $323.59 Family $1,451.78 $1,216.37 $927.59 $783.13 $631.38 $517.52

Age 50to 59

Basic I Basic II Value HSA HospitalCare I HospitalCare II HospitalCare IIISingle $783.86 $657.31 $532.64 $412.75 $325.52 $260.08

Husband/Wife $1,567.72 $1,314.62 $1,065.28 $825.50 $651.05 $520.16

Parent/Child $946.92 $793.53 $632.89 $506.17 $402.61 $324.91

Parent/Children $1,109.97 $929.75 $733.13 $599.58 $479.69 $389.74

Family $1,893.83 $1,587.07 $1,265.77 $1,012.33 $805.22 $649.82

Age 60 andover

Basic I Basic II Value HSA HospitalCare I HospitalCare II HospitalCare IIISingle $946.92 $818.35 $702.94 $528.17 $413.07 $326.71 Husband/Wife $1,951.80 $1,636.70 $1,405.88 $1,056.34 $826.14 $653.42 Parent/Child $1,138.96 $954.57 $803.19 $621.58 $490.15 $391.54 Parent/Children $1,302.01 $1,090.79 $903.43 $715.00 $567.24 $456.37 Family $2,277.91 $1,909.14 $1,606.38 $1,243.17 $980.31 $783.08

Individual guaranteed enrollment plansRates effective March 1, 2012

2011-0489 (01/12)

Please be advised that benefits and rates are subject to change upon approval of the Pennsylvania Insurance Department.

Personal Choice PPO products are underwritten and administered by QCC Insurance Company, a subsidiary of Independence Blue Cross, independent licensees of the Blue Cross and Blue Shield Association.

www.ibx.comWe’re here for you every step of the way.

INDIVIDUAL COVERAGE PERSONAL CHOICEAPPLICATION FORM

PLEASE TYPE OR PRINT

1. ENROLLMENT INFORMATION (Please complete your name and address if information below is missing or incorrect.)Any person eligible for Medicare or Medicare disability benefits is not eligible to enroll in this coverage.

Requested Effective Date of Coverage*: _____ _____ / _____ _____ / _____ _____ _____ _____*The requested effective date cannot be guaranteed and cannot be more than 30 days prior to the receipt of the application.

| | | | | | | | | | | | | | | | | | | | | | | | | | Last name First name MI

| | | | | | | | | | | | | | | | | | | | | | | | | | Street address

| | | | | | | | | | | | | | | | | | | | | | | | | | City State ZIP

2. COVERAGE INFORMATION Coverage underwritten by QCC Insurance Company. Please check the coverage you want:o PPO Value HSA o Yes, I’d like an HSA account set up through Bancorp. Please send Bancorp my information. o PPO Basic I o PPO Basic II o PPO HospitalCare I o PPO HospitalCare II o PPO HospitalCare III

3. PERSONS TO BE COVEREDPlease complete the following information regarding yourself and dependents to be covered. Dependents include your spouse, dependent children (under age 26), and eligible handicapped children over age 26. Attach a separate list for additional dependents, if needed.

NAME(included last name if different from applicant)

Last First MISEX

DATE OF BIRTHSOCIAL SECURITY NUMBER

HANDICAPPED CHILDREN

(Over Age 26)MM DD YY

Self o M o F N/ASpouse o M o F N/A

o M o F

o M o F

o M o FPlease answer the questions below:A. Do any of the persons listed above have health insurance with a Blue Cross® and/or Blue Shield® Plan or any other insurance company? o Yes o NoB. Do you have any other accident and health insurance in force? o Yes o NoC. If yes, do you intend to replace your current accident and health insurance with this insurance? o Yes o No (Please see Section 1 on the reverse.)

4. PRIOR INSURANCEWas your prior insurance through: o Employer/group o Individual planWho was your prior Insurer? o No prior insurance o Blue Cross/Blue Shield o Aetna o Assurant o Celtic o Coventry o CIGNA o Health America o United HealthCare o Other ______________________________________How long has it been since you were insured? o Currently insured o 1 – 3 months o 3 – 6 months o 7 – 11 months o 1 – 2 yrs o 2+ yrs o NeverWhat is your primary reason for applying for health care coverage? o No longer covered under employer plan o Dependent, no longer covered under parent’s plano Unemployed o Employer doesn’t offer health insuranceo Self-employed o Not satisfied with current plano New job, waiting for benefit eligibility o Other

5. IMPORTANT! READ THE REVERSE SIDE OF THIS FORM, BEFORE SIGNING AND DATING BELOWThe information supplied on the application is accurate and complete to the best of my knowledge, and I have read and agree to the terms set forth on the reverse side of this form. SIGNATURE OF APPLICANT: ___________________________________________ DATE: _______/________/______

Email: _________________________________________

Home phone: (______) _____________________________

If you are a current member, please provide your identification number: ______________________________________________________

08488 1/11

IMPORTANT — PLEASE READ CAREFULLY1. NOTICE OF PRE-EXISTING CONDITION(S) EXCLUSIONQCC Insurance Company (“Company”) will not pay benefits during the first 12 months of the policy for charges related to any medical condition or illness for which medical advice or treatment was recommended or received within a 12-month period preceding the effective date of coverage. This preexisting condition exclusion does not apply to you or to any of your dependents (a) previously enrolled in any Blue Cross or Blue Shield policy, or in a policy of an affiliate of the Company, for a period of 12 months and are transferring directly without a break in coverage and (b) to an enrollee under the age of 19.

2. DECLARATIONI elect coverage under the plan specified on this application for the persons listed on the reverse side and agree to abide by the conditions of the policy and pay required premiums for the plan as selected. I and my listed eligible dependent(s) authorize any hospital, physician, or health care provider to furnish the Company, its assignee of designee, with such medical information about the applicant and dependent(s) listed on the application as the Company may require for claims payment, utilization review, quality assurance, or fulfillment of obligations imposed by applicable state or federal law. I understand that my coverage will become effective upon the approval of my Application. I understand and agree that: (1) the policy contains a pre-existing condition exclusion; (2) the policy shall be binding on the Company only if all of statement(s) are complete and true.

3. NOTICE REGARDING FRAUDULENT INFORMATIONAny person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or state-ment of claim containing any materially false information or conceals for the purposes of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

4. CONDITIONS OF ENROLLMENTI understand that if I and my dependents receive care from Non-Network Providers (Non-Participating Health Care Facilities and Non-Participating Professional Providers), except for emergencies, I will be responsible for higher Non-Network deductibles and coinsurance, and in some cases, the entire cost of the care.

5. SUBSCRIBER INFORMATIONPLEASE NOTE: Most elective admissions require Pre-Admission Certification. Services that are rendered by Non-Network Providers are subject to deductible and coinsurance provisions. See your contract for details about your coverage, its limitations and exclusions, or call Personal Choice Customer Service at 1-800-ASK-BLUE (1-800-275-2583). Inquiries about your coverage should include your name, identification number, group number, and home address.

6. PLEASE NOTEIf you must provide coverage for a child not living with you due to a court order, please contact us for the appropriate paperwork.

WIPMK2158A 2010-0330 (1/11)

Please return this application in the enclosed postage-paid envelope!Send no money now — we will bill you later.

1901 Market Street, Philadelphia, PA 19103-1480

Benefits underwritten by QCC Insurance Company, a subsidiary of Independence Blue Cross — independent licensees of the Blue Cross and Blue Shield Association.

Important information about Individual health plans

Procedures that support safe prescribingIBC utilizes an independent pharmacy benefi ts management (PBM) company, FutureScripts®, to manage the administration of its commercial prescription drug programs. As our PBM, FutureScripts is responsible for providing a network of participating pharmacies, administering pharmacy benefi ts, and providing customer service to our members and providers.

Prior authorizationPrior authorization is a requirement that your physician obtain approval from your health plan for coverage of, or payment for, your medication. IBC requires prior authorization of certain covered drugs to ensure that the drug prescribed is medically necessary and appropriate and is being prescribed according to the Food and Drug Administration (FDA) guidelines. The approval criteria were developed and endorsed by the FutureSrcipts Pharmacy and Therapeutics Committee, which is an established group of medical directors and practicing area physicians and pharmacists.

Using these approved criteria, clinical pharmacists evaluate requests for these drugs based on clinical data, information submitted by the member’s prescribing physician, and the member’s available prescription drug therapy history. Their review includes a determination that there are no drug interactions or contraindications, that dosing and length of therapy are appropriate, and that other drug therapies, if necessary, were utilized.

Without prior authorization, the member’s prescription will not be covered at the retail or mail order pharmacy (see 96-Hour Temporary Supply Program). The prior authorization process may take up to two working days once complete information from the prescribing physician has been Continue to next page...

Important notice to persons on MedicareThis insurance duplicates some Medicare benefi ts. This is not Medicare Supplement Insurance.This insurance pays limited reimbursement for expenses if you meet the conditions listed in the policy. It also pays a fi xed amount, regardless of your expenses, if you meet other policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement Insurance. This insurance duplicates Medicare benefi ts: Any expenses or services covered by the policy are also covered by Medicare; It pays the fi xed dollar amount stated in the policy and Medicare covers the same event.Medicare generally pays for most of all these expenses. Medicare pays benefi ts for medically necessary services regardless of the reason you need them. These include: hospitalization physician services hospice care other approved items and services Before you buy this insurance: Check the coverage in all health insurance policies you already have. For more information about Medicare and Medicare Supplement Insurance, review the “Guide to Health Insurance for People with Medicare,” available from the insurance company. For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.

Personal Choice® member disclosureEmergency servicesAn emergency is defi ned as the sudden and unexpected onset of a medical or psychiatric condition manifestingitself in acute symptoms of suffi cient severity or severe pain — such that a prudent layperson who possesses anaverage knowledge of health and medicine could reasonably expect the absence of immediate medical attentionto result in placing the member’s health, or in the case of a pregnant member, the health of the unborn child, in jeopardy; serious impairment to bodily functions; or dysfunction of any bodily organ or part.

Emergency care includes covered services provided to a member in an emergency, including emergencytransportation and related emergency services provided by a licensed ambulance service.

Utilization reviewTo assist Independence Blue Cross (IBC) in making coverage determinations regarding the medical necessity and appropriateness of requested services, IBC uses medical guidelines based on clinically credible evidence. This is called utilization review. Utilization review can be done before a service is performed (prenotifi cation/precertifi cation/preservice); during a hospital stay (concurrent review); or after services have been performed (retrospective/post-service review). IBC follows applicable state/federal standards pertaining to how and when these reviews are performed.

Complaints and grievancesYou have a right to appeal any adverse decision through the complaint and grievance process. Instructions for the appeal will be described in the denial notifi cations issued to you and in your benefi ts booklet.

A word about privacyAt IBC, protecting your privacy is very important to us. That is why we have taken numerous steps to see that your protected health information (PHI) is kept confi dential. Protected health information is individually identifi able health information about you. This information may be in oral, written, or electronic form. IBC may obtain or create your PHI while conducting its business of providing you with health care benefi ts.

IBC has implemented extensive policies and procedures regarding the collection, use, and release or disclosure of PHI by and within our organization. We continually review our policies and monitor our business processes to make sure that your information is protected, while assuring that the information is available as needed for the provision of health care services. For example, our procedures include steps to assist us in verifying the identity of someone calling to request PHI, procedures to limit who on our staff has access to your PHI, and to share only the minimum amount of information when PHI must be disclosed. We also protect any PHI transmitted electronically outside our organization by using only secure networks or by using encryption technology if the information is sent by email.

We do not use or share your PHI without your permission unless the law allows us to do so. Before using or disclosing your PHI for other purposes, we’ll obtain your written permission, also called an authorization. You may also direct us to share your PHI with someone you chose by giving us your written authorization. However, this authorization must include certain specifi c information in order to be valid. You may print a copy of our Authorization to Release Information form from our website www.ibx.com or request a copy by calling our Privacy Offi ce at 215-241-4735.

We are permitted to use or disclose your PHI for our payment and health care operations. Examples of these activities include paying claims for services you’ve received, coordinating the delivery of health care services, and monitoring the performance of our network providers to improve health care outcomes. We may also share your PHI in certain other circumstances, such as disclosures to health care oversight agencies for legally authorized health oversight activities like audits and investigations, or when we are required to do so by law. We may also share certain information with the sponsor of your group health plan so that they may perform their plan administration functions.

The laws that protect your privacy also give you certain rights related to your PHI. For example, you may request a copy of your PHI that we have in our “Designated Record Set.” Please remember that IBC does not typically have copies of your medical records. Your health care provider should be contacted for copies of your medical records.

Please review our Notice of Privacy Practices for more detailed information about your privacy rights and how we may use and share your PHI. You may view or print a copy of our notice from our website www.ibx.com by clicking on Privacy Policy, or you may call our Privacy Offi ce at 215-241-4735 to request that a copy of the notice be mailed to you.

Creditable coverage FAQsPreexisting condition exclusions for Individual plans (Personal Choice®, Keystone Health Plan East) and creditable coverage.

Q: What is a preexisting condition exclusion?A: A preexisting condition exclusion is a denial of coverage for services provided in connection with health conditions that existed before your health insurance policy became effective. If you had a medical condition or illness for which medical advice or treatment was recommended or received within a stated “look-back” period, all claims for this medical condition or illness will be denied by IBC for a certain period of time. Typically, a preexisting condition exclusion period is 12 months. You should review the contract or member materials for your health plan to determine whether your health plan has a preexisting condition exclusion and to identify the related preexisting condition “look-back” period. This preexisting condition exclusion does not apply to enrollees under age 19.

Q: What is creditable coverage?A: Creditable coverage is the previous health insurance coverage you had that may be used to reduce a preexisting exclusion period for your current coverage. You should review the contract or member materials for your health plan to determine whether your health plan has a preexisting condition exclusion period and to identify the related preexisting condition “look-back” period. This preexisting condition exclusion does not apply to enrollees under age 19.

Q: Do the Individual plans have preexisting condition exclusions?A: Yes. Like most individual plans, IBC’s Individual plans have preexisting condition exclusions. However, the preexisting condition exclusion may not apply if you have enough creditable coverage to waive the exclusion.

Q: When would a preexisting condition exclusion not apply or be reduced for an Individual plan?A: The preexisting condition exclusion in an Individual plan may be reduced if either: You had at least one month of coverage from a Blue Cross® and/or Blue Shield® plan and transfer directly into an Individual plan without a break in coverage. You had at least one month of coverage from a plan that is an affi liate of Independence Blue Cross and transfer directly into an Individual plan without a break in coverage. For this “Blue-to-Blue transfer” you will receive credit towards your preexisting condition waiting period for

up to 12 months for the time you were enrolled in the other Blue plan.Your preexisting condition exclusion period will be waived if you enroll in one of two designated Individual Personal Choice plans and you satisfy all of the eligibility requirements of the Health Insurance Portability and Accountability Act (HIPAA): You had health care coverage for the past 18 months without a break in coverage. Your most recent coverage is group coverage, which can be a governmental plan or church plan. (Note: COBRA coverage is considered group coverage.). Your most recent coverage was not terminated because of nonpayment of premium or fraud. You no longer qualify for any other group health coverage, Medicare or Medicaid, or coverage under a spouse’s policy and have exhausted your COBRA coverage, if available. You are not enrolled in an Individual (nongroup) plan or other health care coverage. You are applying for continued coverage in one of two designated HIPAA plans within 63 days of the termination date from your group plan. You are providing evidence of creditable coverage with a previous insurer. Evidence of creditable coverage may be through documentation (e.g., a Certifi cate of Continuous Coverage from your previous employer or health insurance identifi cation card) or non- documentary means (e.g., having your previous insurer call IBC or having IBC call your former employer or prior insurer to verify coverage). To discuss how best to provide non-documentary evidence of creditable coverage, call Customer Service at 1-800-453-2566.

Q: May dependents enroll in the Individual plans even if their parents do not enroll?A: Yes. Dependents may enroll separately from their parents if all other conditions are met. Please note that this is different from most other insurance plans that permit a dependent to enroll only if a parent enrolls. The dependent must meet the conditions for a “Blue-to-Blue transfer” or the conditions under HIPAA in order to reduce or waive the preexisting condition exclusion.

Q: Are there other individual plans that allow an individual to continue coverage without exclusions for preexisting conditions?A: The adultBasicSM and the Children’s Health Insurance Program (CHIP) allow enrollment without exclusions for preexisting conditions. This preexisting condition exclusion does not apply to enrollees under age 19. For information about the Individual plans, call Customer Service at 1-800-453-2566.

1-800-ASK-BLUE (1-800-275-2583)

www.ibx.comIndependence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.

received. Incomplete information will result in a delayed decision.

Prior authorization approvals for some drugs may be limited to 6 to 12 months. If the prior authorization for a drug is limited to a certain time frame, an expiration date will be given at the time the approval is made. If the physician wants a member to continue the drug therapy after the expiration date, a new prior authorization request will need to be submitted and approved in order for coverage to continue.

Currently, the drugs listed below are a part of the prior authorization program. Prior authorization applies to all formulations of these specifi c drugs, including, but not limited to, tablet, capsule, and oral suspension. AcipHex®, Actiq®, AdcircaTM, Afi nitor®, AlodoxTM, AltabaxTM, Ambien CR®, Amerge®, AmpyraTM, AMRIX®, Apidra®, Apidra® SoloSTAR®, AplenzinTM, Atacand®/Atacand HCT®, Avapro®/Avalide®, AvidoxyTMDK, Axert®, AZOR®, BanzelTM, Benicar®/Benicar HCT®, BepreveTM, BiDil®, Byetta®, Caduet®, Caverject®, CaystonTM, Celebrex®, Cesamet®, Cialis®, Cimzia®, ColcrysTM, Cozaar®/Hyzaar®, Crestor®, DaytranaTM, Diabetic Test Strips (except Autodisc®, Breeze® 2, Contour®, FreeStyle Lite® and Precision Xtra®), Diovan®/Diovan HCT®, Edex®, EdluarTM, Effi entTM, Enbrel®, ExalgoTM, Exforge®, EXFORGE HCT®, Exjade®, FanaptTM, Fentora®, Flector® Patch, ForteoTM, Frova®, Genotropin®, Gleevec®, GlumetzaTM, Humalog®, Humatrope®, Humira®, Humulin®, HYCAMTIN® Capsules, Imitrex®, Intuniv®, InvegaTM, Iressa®, KapidexTM, Keppra XRTM, Kineret®, Lantus®, Levitra®, Lipitor®, Livalo®, Lunesta®, Lyrica®, MagnacetTM, Maxalt®, Micardis®/Micardis HCT®, Mobic®, MUSE®, Myobloc®, Nexavar®, Nexium®, Norditropin®, Noxafi l®, NucyntaTM, NutriDoxTM, Nutropin®, Nutropin AQ®, Nuvigil®, OfortaTM, Omnitrope®, OnglyzaTM, OnsolisTM, Opana®/Opana®ER, Oracea®, PatadayTM, Pennsaid®, PrandiMetTM, Prevacid®, Prevacid/NapraPAC®, Prilosec® Suspension, PristiqTM, Protonix®, Provigil®, PyleraTM, Qualaquin®, Ranexa®, ReliON®/Novalin®, Relpax®, Renvela®, Requip® XLTM, RevatioTM, Revlimid®, RozeremTM, RyzoltTM, Sabril®, Saizen®, SamscaTM, Saphris®, SavellaTM, Seroquel XR®, Serostim®, Silenor®, Simcor®, SimponiTM, Singulair®, Sprycel®, Suboxone®, Subutex®, SumavelTM, Sutent®, Symlin®, Taclonex®, Taclonex Scalp® Suspension, Tarceva®, Tasigna®, Tekturna®/Tekturna HCT®, Temodar® Oral, Teveten®/Teveten HCT®, Tev-Tropin®, Thalomid®, ToviazTM, TreximetTM, Twynsta®, Tykerb®, Uloric®, Ultram® ER, Valturna®, VecticalTM, VeramystTM, Viagra®, Victoza®, Vimovo®, VimpatTM, Voltaren® Gel, VotrientTM, Vytorin®, VyvanseTM, XenazineTM, Xyzal®, Zelapar®, ZipsorTM, ZmaxTM, Zolinza®, Zorbtive® and Zyvox®. This list is subject to change.

Age and gender limitsThe FDA has established specifi c procedures that govern prescription prescribing practices. These rules are designed to prevent potential harm to patients and ensure that the medication is being prescribed according to FDA guidelines. For example, some drugs are approved by the FDA only for individuals 14 and older, such as Ciprofl oxacin®, or prescribed only for females, such as prenatal vitamins. The pharmacist’s computer provides up-to-date information about FDA rules. If the member’s prescription falls outside of the FDA guidelines, it will not be covered until prior authorization is obtained. The prescribing physician may request preapproval of restricted medications when medically necessary. The approval criteria for this review were developed and endorsed by the FutureScripts Pharmacy and Therapeutics Committee, which is an established group of medical directors and practicing area physicians and pharmacists. The member should contact the prescribing physician to request that he or she initiate the preapproval process. To determine if a covered prescription drug prescribed for you has an age or gender limit, call FutureScripts at 1-888-678-7012.

Quantity level limitsQuantity level limits are designed to allow a suffi cient supply of medication based upon FDA-approved maximum daily doses and length of therapy of a particular drug. We have several different types of quantity level limits, which are explained in detail below.

Rolling 30-day period. This quantity limit is based on dosing guidelines over a rolling 30-day period. Examples of quantity level limits per rolling 30-day period are Emend®

(four 125mg capsules + eight 80mg capsules or four trifold packs [one 125mg capsule + two 80mg capsules]); Boniva® (two 150mg tablets); Avonex® (one kit, four injections); Betaseron® (15 vials); Copaxone® (32 vials); Fosamax Plus DTM (fi ve tablets); Rebif® (12 injections); migraine drugs such as Amerge® (nine 2.5mg tablets), Imitrex® (36 50mg tablets), Maxalt® (12 10mg tablets), Migranal® (eight 4mg nasal spray units), Stadol NS® (four 10mg units), and Zomig® (nine 5mg tablets); sedative hypnotic drugs, such as Sonata® (14 capsules) and Ambien® (14 tablets); and oral narcotic drugs such as OxyContin® (90 units), Percocet® (180 units), and Percodan® (180 units). For example, if a member went to the pharmacy on October 1, 2009, for one of these medications, the computer sytem would have looked back 30 days to September 1, 2009, to see how much medication was dispensed. The purpose of these limits is to make certain that these drugs are being used appropriately and to guard against overuse or stockpiling.

Refi ll too soon. With this quantity level limit, if a member used less than 75 percent of the total day supply dispensed, the claim will be rejected at the pharmacy. This will ensure that the medication is being taken in accordance with the prescribed dose and frequency of administration.

Therapeutic drug class. This quantity level limit applies to some classes of drugs, such as narcotics (i.e., short-and- long-acting). If a member uses more than one drug within the same class, he or she may be unsafely duplicating medications and would be affected by the total quantity limits for a therapeutic drug class. Members will be able to obtain only a 30-day total supply of any combination of drugs in the same therapeutic drug class each month.

If a physician requires that a member needs a medication therapy that exceeds any of the quantity level limits described above, the physician must request a quantity limit override. The member is required to contact the prescribing physician to initiate a preapproval request for an override.

Some drugs may have a time period for quantity limit exceptions of 6 to 12 months. If the exception for a drug is limited to a certain time frame, an expiration date will be given at the time the approval is made. If the physician wants a member to continue the drug therapy that exceeds a quantity limit after the expiration date, a new request for a quantity limit exception will need to be submitted and approved in order for coverage to continue.

To determine if a covered prescription drug prescribed for you has a quantity level limit, call FutureScripts at 1-888-678-7012.

96-Hour Temporary Supply ProgramThe 96-Hour Temporary Supply Program applies to the following covered medications: most medications that require prior authorization; medications that are subject to age limits (preapproval

required for ages outside of recommended ranges); migraine medications with quantity level limits, such as

Amerge®, Imitrex®, Maxalt®, Migranal®, Stadol NS®, and Zomig® (preapproval of quantity override required for amounts over the quantity level limits).

Under the 96-Hour Temporary Supply Program, if a member’s doctor writes a prescription for a drug that requires prior authorization, has an age limit, or exceeds the quantity level limit for a medication, and prior authorization/preapproval has not been obtained by the doctor, the following steps will occur:1. The participating retail pharmacy will be instructed to release a 96-hour supply of the drug to the member with no out-of-pocket cost-sharing at that time.*2. By the next business day, our PBM will contact the member’s doctor to request that he or she submit the necessary documentation of medical necessity or medical appropriateness for review.3. Once the completed medical documentation is received by our PBM, the review will be completed and the medication will be approved or denied.4. If approved, the remainder of the prescription order will be fi lled, and the appropriate prescription drug out-of- pocket cost-sharing will be applied.*5. If denied, notifi cation will be sent to the doctor and the member.

Obtaining a 96-hour temporary supply does not guarantee that the prior authorization/preapproval request will be approved. Some medications are not eligible for the 96-Hour Temporary Supply Program due to packaging or other limitations, such as Retin-A® (tube), Enbrel® (2-week injection kit), medroxyprogesterone acetate (monthly injectable), and erectile dysfunction drugs. Additionally, certain drugs to treat hemophilia (antihemophilic factors) are not usually purchased at the pharmacy and must be special-ordered; therefore, they are not eligible for the 96-hour temporary supply.The process for requesting a prior authorization/preapproval or override is as follows: The physician prescribing the medication completes a

prior authorization form or writes a letter of medical necessity and submits it to our PBM by fax at 215-241- 3073 or 1-888-671-5285. A member’s physician may request the form by calling 1-888-678-7012. Members may request the form through Customer Service on behalf of their physician, but it must be completed and submitted by the doctor. The PBM will review the prior authorization request or

letter of medical necessity. If a clinical pharmacist can not approve the request based on established criteria, a medical director will review the document. A decision is made regarding the request. If approved, the prescribing physician will be notifi ed of

approval via fax or telephone, and the Rx Claim System will be coded with the approval. The member may call the Customer Service phone

number on his or her identifi cation card to determine if the prescription is approved. If denied, the prescribing physician will be notifi ed via

letter, fax, or telephone. The member is also notifi ed of all denied requests via

letter. The appeals process will be detailed on the denial letters

sent to the member and physician.

Coverage for medications not on the formulary (specifi c to Select Drug Program® members only) Providers may request formulary coverage of a covered non-formulary medication when all formulary alternatives have been exhausted or there are contraindications to using the formulary alternatives. The provider should complete the covered non-formulary appeal form providing detail to support use of the covered non-formulary medication and fax the request to 215-241-3073 or 1-888-671-5285. If the nonformulary request is approved, the drug will be paid at the appropriate formulary benefi t level. If the request is denied, the member and provider will receive a denial letter with the appropriate appeals language. Whether or not an appeal is fi led, the member may always obtain benefi ts for the covered non-formulary drug at the appropriate non-formulary benefi t level. Out-of-pocket expenses for non-formulary drugs are higher than for formulary drugs.

Appealing a decisionIf a request for prior authorization/preapproval or override results in a denial, the member, or the physician on the member’s behalf, may fi le an appeal. Both the member and his or her provider will receive written notifi cation of a denial, which will include the appropriate telephone number and address to direct an appeal. In all cases, the physician needs to be involved in the appeal process to provide the required medical information for the basis of the appeal.

Prescription drug program provider payment informationA PBM administers our prescription drug benefi ts and is re-sponsible for providing a network of participating pharmacies and processing pharmacy claims. The PBM also negotiates price discounts with pharmaceutical manufacturers and provides drug utilization and quality reviews. Price discounts may include rebates from a drug manufacturer based on the volume purchased. IBC anticipates that it will pass on a high percentage of the expected rebates it receives from its PBM through reductions in the overall cost of pharmacy benefi ts. Under most benefi t plans, prescription drugs are subject to a member copayment.

*Members with an integrated drug benefi t (e.g., CMM and Major Medical) will pay the discounted cost of the 96-hour supply as well as the remainder of the prescription order (if approved at the time of purchase, and the medical claim for reimbursement will be processed through standard procedures.

IBC Disclaimer 1/11

Documents

Guaranteed Issue HMO