1. Your Benefits at a Glance Using Your Health Benefit Plan with an HRA The City of Martin

2. Is a not for profit organization. Is the state's leader in health care financing Was founded in 1945 and now serves nearly 3 million people in Tennessee and 5 million across the United States Paid more than 65 million claims and $16.4 billion in health care benefits last year. Is headquartered in Chattanooga with regional offices in Knoxville, Memphis and Nashville BlueCross BlueShield of Tennessee: Blue Basics

3. Your Benefit Materials

4. 4 Your Benefit Changes CurrentNew HSAHRA 100% after Ded.$10/$35/$50

5. Your Blue Network Your Blue Network letter name can be found on the front of your ID card: Your plan’s Blue Network

6. Your 2010 Health Care Benefits In-NetworkOut-of-Network Health Reimbursement Arrangement (HRA) $4,750 Individual $9,500 Family $0 Individual $0 Family Deductible$5,000 Individual $10,000 Family $10,000 Individual $20,000 Family CoinsurancePlan pays 100% after deductible Plan pays 50% after deductible Annual Out-of-Pocket Maximum $5,000 Individual $10,000 Family $15,000 Individual $30,000 Family Office VisitPlan pays 100% after deductible Plan pays 50% after deductible Preventive CarePlan pays 100% up to $750 annual limit Plan pays 50% after deductible Emergency RoomPlan pays 100% after deductible Outpatient Diagnostic/Non- routine Labe/X-ray Plan pays 100% after deductible Plan pays 50% after deductible

7. 7 Your Health Care Benefits What is an HRA? The Health Reimbursement Arrangement (HRA) is a deductible/coinsurance medical plan in which The City of Martin helps pay your medical cost by putting money into an HRA fund for you and your family The City of Martin puts $4,750 (individual) and $9,500 (family) into your HRA Fund Once you meet $250 of your $5000 deductible (individual) or $500 of your $10,000 deductible (family), the HRA will cover the remaining deductible which is: – $4,750 (individual) – $9,500 (family) Once you reach your deductible, which includes your HRA Fund, the plan will pay 100% for all in-network eligible medical expenses until the out-of-pocket maximum is reached. What is the HRA?

8. 8 Physician Services Current PlanNew Plan Office Visits100% after 100% after deductibledeductible Preventive Care$20 Copay100% after deductible Emergency Room100% after100% after deductibledeductible Prescription Drugs100% after$10/$35/$50 deductibleNO HRA reimbursement allowed Your Health Care Benefit Changes Preferred Provider Benefits

9. 9 Your Pharmacy Benefits Prescription Drugs Preferred Pharmacy Benefits: Current Plan Percentage-Based 100% After Prescription Deductible Drugs New Plan Copay Prescription $10 / $35 / $50 Drugs

10. 10 Your Health Care Benefit Changes Your HRA Claims Reimbursement Automatic Reimbursement 1.1. Give your provider your ID card that has HRA Plan 2.2. Provider will submit your claim to BCBST 3.3. BCBST will process claim according to your medical benefits 4.4. BCBST will pay the provider (on your behalf) if any HRA dollars are available 5.5. You will receive and Explanation of Benefits (EOB) form showing how payment was applied 6.6. You can check your HRA balance, claim information and Personal Health Statement anytime online at www.bcbst.com

11. Consumer Coaches Better understand the details of the HRA plan through the special support center of Consumer Coaches These benefits experts can assist you with: Health Plan specifics HRA financial plan details Information about how the HRA works Online Consumer Health Tool instructions, other web resources and much more. For help with your HRA plan, call 1-800-527-9206 or e-mail consumercoach@bcbst.com Get Help with your HRA

12. Your Evidence of Coverage Want to know what is and what is not covered in your health benefit plan? Your Evidence of Coverage has all of the answers.

13. Health and wellness services Weight-loss programs Discount drug card Vision care and LASIK Vitamins, supplements and more Everyone likes perks and your coverage includes BluePerks ® discounts. You can save money on non- covered services: For more information, call 1-800-227-5911 or visit bcbst.com. Your Well+Wise BluePerks®

14. PPO coverage gives you a choice of doctors and hospitals. Your Health Benefit Plan

15. Key advantages of using preferred providers: Greater level of health care benefits Less out-of-pocket expenses No claims paperwork Greater provider knowledge of plan requirements Available 24 hours a day, seven days a week Using Preferred Providers

16. Using Out-of-Network Providers  Out-of-Network Providers do not have a contract with BCBST.  This means they may be able to charge You more than the Maximum Allowable Charge (the amount set by the Plan in its contracts with Network Providers).

17. Is Your Doctor in the Network? Click here

18. BlueAccess and Member Self-Service See what’s covered under your plan Look up submitted claims (except Rx) Check what benefits you’ve used Update your address Order replacement ID card Access health tools and resources, including a Personal Health Analysis Personal Health Statement and HRA balance Benefits information available anytime. Register at bcbst.com to:

19. Your Benefits Go With You! Your Benefits extend from coast-to-coast… and beyond.

20. BlueCard ® PPO To find a doctor or hospital outside of Tennessee, call toll-free: 1-800-810-BLUE (This number is also on the back of your member ID card.)