Blue Cross and Blue Shield of

Louisiana’s BlueSaver provides

the comfort of reliable health care

coverage today while you build a

financial cushion for medical and

non-medical needs of tomorrow.

Please read on to learn more about

BlueSaver, Blue Cross and Blue Shield

of Louisiana’s high-deductible health

insurance plan.

Blu

eSav

er

® ®

For Groups

23XX3126 R1/05 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company

An independent licensee of the Blue Cross and Blue Shield Association www.bcbsla.com

• hospital room and board and general nursing services

• use of an operating room, treatmentroom, recovery room and emergencyroom

• anesthesia and its administration

• laboratory tests

• oxygen and its administration

• diagnostic services such as radiology, laboratory and pathology services

• telemetry unit for heart patients or an isolation unit

• outpatient medical services rendered inthe home, office or other outpatientvisits for examination, diagnosis andtreatment of an illness or injury otherthan pre-operative and post-operativemedical visits

• eligible organ, tissue and bone marrowtransplants ($250,000 lifetime maximum includes up to $50,000 per acquisition expense maximum; accrues to overall$5 million lifetime maximum)

• drugs and medicines

• intravenous injections and solutions

• transfusion fees and equipment

• medical and surgical supplies

• use of special care units

• satisfies requirements of the Internal Revenue Code defining high-deductible health plans

• lifetime protection of $5 million for each covered member

• a choice of deductibles* for individuals or families

• prescription drug coverage

• wellness benefits

• doctors’ office visits for covered illness or injury

• emergency room coverage

After you meet your individual or family deductible, covered expenses are paid at 100 percent of the allowable charge for carereceived from our PPO network of physicians and hospitals. For other providers, covered services will be paid at 80 percent ofthe allowable charges.

The out-of pocket maximum* includes your deductible and coinsurance. After you meet your out-of-pocket maximum, coveredexpenses are paid at 100 percent of the allowable charge for that benefit period. Please see the BlueSaver illustration for specificdeductibles and out-of-pocket maximums quoted.

Once you meet your individual deductible, covered expenses are paid at 80 percent of the allowable charge. The familydeductible, which is an aggregate deductible, may be satisfied by any and all family members. Once the entire family deductibleis met, covered expenses are paid for all family members at 80 percent of the allowable charge. The out-of-pocket maxi-mum* includes your deductible and coinsurance. After you meet your out-of-pocket maximum, covered expenses are paid at100 percent of the allowable charge for that benefit period. Please see the BlueSaver illustration for specific deductibles andout-of-pocket maximums quoted.

* In order to comply with federal regulations, deductibles and out-of-pocket maximums may have to be adjusted annuallyto reflect changes in the Consumer Price Index (CPI).

T H E B L U E S A V E R P A C K A G E

T R A D I T I O N A L C O V E R A G E

P P O C O V E R A G E

B L U E S A V E R C O V E R S T H E S E H O S P I T A L &O U T P A T I E N T F A C I L I T Y E X P E N S E S

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For your protection, we also offer coverage for occupational injuries and diseases for qualified company owners. Qualified ownersare covered subscribers who own at least 50 percent of the company and can opt not to purchase Workers’ Compensation cov-erage for themselves. To qualify, each must choose not to elect Workers’ Compensation coverage. Owners who are coveredunder this option must notify Blue Cross and Blue Shield of Louisiana if they no longer meet the requirements stated above.

This coverage option requires written documentation and home-office approval. See your representative for details.

Trad i t i ona l Cove rage — Key Phys i c i an Ne two rk and Member Hosp i t a l Ne two rkYour BlueSaver policy gives you access to the Key Physician Network, a special network made up of the majority of physiciansthroughout the state. These physicians accept what is called an “allowable charge” for the health care services they provide, andagree not to bill patients for any balance of the fee for covered services in excess of the allowable charge. Benefits, however, arenot limited to Key Physicians.

Blue Cross and Blue Shield of Louisiana also contracts with nearly every acute-care hospital in the state to serve its policyholders.These “member hospitals” have agreed to charge negotiated prices for services they render to our customers. There is a 30 percent reduction in benefits for services received in non-member hospitals.

All services are subject to deductible and/or coinsurance.

The PPO Op t i on — P re fe r red P rov i de r O rgan i za t i on Ne two rkThe PPO network is a select network of preferred provider organization hospitals, physicians and other health care providers whohave agreed to give our PPO customers greater discounts for covered services.

The PPO benefit option provides the highest level of benefits when you see a PPO network provider. If you use a provider outside of this network, you receive reduced benefits. There is a 30 percent reduction in benefits for services received in non-member hospitals.

O W N E R 2 4 - H O U R C O V E R A G E O P T I O N

O U R P R O V I D E R N E T W O R K S G I V E Y O U S A V I N G S& T H E P O W E R T O C H O O S E

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• office visits for covered illness or injury

• surgeon’s fees and assistant surgeon’s fees

• consulting doctor’s fees

• anesthesiologist’s fees

• hospital visits by the doctor

• blood, blood plasma, blood derivativesand blood processing

• prescription drugs and medicines for useoutside the hospital

• outpatient private-duty nursing by a registered nurse or licensed practical nurse up to $5,000 per calendar year

• durable medical equipment, prosthetic appliances and orthotic devices up to anaggregate maximum of $25,000 per calendar year

• licensed ambulance services for emergency transportation to or from the nearesthospital

• oral surgery benefits for accidental injury to sound natural teeth, extraction ofimpacted teeth and other services as listed in your contract

• certain X-rays and laboratory tests performed in a doctor’s office or clinic

• laboratory and X-ray analysis

• a full list of state-mandated benefits

P L U S T H E S E D O C T O R E X P E N S E S

Most full-time employees, working a minimum of 30 hours per week, and their qualified dependents, are eligible to apply.Individuals on retainer (examples: attorneys, accountants, business consultants and 1099 contract employees) and members ofboards of directors are not eligible.

E L I G I B L E E M P L O Y E E S

Insured employees may cover their eligible spouses. They also may cover their eligible unmarried children and grandchildren whoare under 21 years of age (or under 25 if enrolled as a full-time student at an accredited high school, college, university or vocational-technical/trade school). Grandchildren must also reside with and be in legal custody of the employee.

Unmarried children and grandchildren (in legal custody and residing with the employee), who are mentally or physically disabledmay be eligible for coverage. They also must be incapable of self-support prior to attaining either of the limiting ages stated above.

E L I G I B L E D E P E N D E N T S

Rates may increase after the first 12 months and every six months thereafter due to factors including, but not limited to:

• demographic changes of the group, including age changes

• claims experience of all groups in the class of business

• a group's claims experience, health status and duration of coverage

• an overall rise in medical costs

• regulatory considerations

• changes to benefit plan design

G R O U P R A T E S

All benefit plans are renewable at the employer’s option, except for any of the following reasons:

• nonpayment of premium

• fraud or misrepresentation

• noncompliance with plan provisions, including not meeting minimum participation and eligibility requirements

• termination of all employer plans in the class of business (90 days’ advance notice will be given)

The employer or Blue Cross and Blue Shield of Louisiana can terminate the contract with 60 days’ advance notice.

R E N E W A B I L I T Y

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Coordination of benefits will be conducted when a participant has additional group coverage. This provision helps keep premiumslow by preventing duplicate payments for the same services.

C O O R D I N A T I O N O F B E N E F I T S

All employee groups are eligible to apply. There are no industry restrictions. Firms that have been in business less than one yearare subject to home-office rating. Firms that do not have a current carrier, or are seasonal, also are subject to approval. In somecases, firms with a significant number of employees living outside of Louisiana may not be eligible.

E L I G I B L E G R O U P S

Prescription drugs are common medical expenses incurred by most people. After the deductible is met, the BlueSaver plan provides coverage for generic drugs at 100 percent of the allowable charge and brand-name drugs at 80 percent of the allowablecharge. Certain exclusions apply.

P R E S C R I P T I O N D R U G C O V E R A G E

BlueSaver offers a full list of wellness and preventive care benefits. The deductible does not apply to the following services:

• one routine Pap smear per benefit period

• one prostate (PSA) screening and one digital rectal exam per benefit period for members age 50 and older, or as recommended by your physician

• one mammography exam per calendar year

• one routine physical exam per benefit period

• one routine colon (hemoccult) test per benefit period

• well-baby care

• one routine gynecological exam each benefit period

• immunizations as recommended by physician

W E L L N E S S A N D P R E V E N T I V E C A R E

This option provides coverage for pregnancy care at the same coinsurance and deductible levels you select for major medicalcoverage. For groups with less than 15 members, this benefit is optional. Pregnancy benefits automatically are included for groupswith 15 or more members. Note: Miscarriages and ectopic pregnancies are covered regardless of whether you choose the pregnancy option.

P R E G N A N C Y C O V E R A G E

Covered rehabilitation services include physical, occupational and speech therapy. This benefit provides coverage for

inpatient, outpatient and professional services subject to the same deductible, coinsurance limits and lifetime maximum

applicable to other services under the contract. Speech therapy benefits are limited to 20 visits per member per

calendar year.

R E H A B I L I T A T I O N S E R V I C E S

M E N T A L D I S O R D E R S / A L C O H O L & D R U G A B U S EC O V E R A G E O P T I O N S

Option 1 — Coverage for mental disorders is limited to 45 days for inpatient care and 52 outpatient visits per calendar

year, subject to any applicable deductible and coinsurance amounts. Coinsurance applies to the out-of-pocket maximums.

Alcohol and drug abuse care is limited to seven days of inpatient care and 20 outpatient visits per calendar year, subject to

any applicable deductible and coinsurance amounts, which do not apply to the out-of-pocket maximum.

orOption 2 — Coverage for mental disorders and alcohol and drug abuse care is paid the same as any other illness. All

benefits are subject to any applicable deductible and coinsurance amounts. Coinsurance applies to the

out-of-pocket maximums.

Please refer to the quote sheets included for the specific option and appropriate deductible and/or coinsurance quoted.

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As an extra value, covered members receive instant discounts from our special network of vision and hearing providers. Whilethese are not contracted benefits, you’ll realize significant savings on these discounted fees. Simply present your Blue Cross IDcard to one of the participating providers and immediately receive significant savings.

D I S C O U N T F E A T U R E S

B E N E F I T S T H A T T R A V E L

The BlueCard® Program — When our members travel, they take their health care benefits with them — across the country and around the world. The BlueCard® program, offered exclusively to Blue Cross and Blue Shield members, features a globalnetwork of health care providers. More than 85 percent of all doctors and hospitals throughout the United States contract with BlueCross and Blue Shield Plans. Outside of the United States, our members have access to doctors and hospitals in more than 200 coun-tries. So our members have the peace of mind knowing they’ll find the care they need if they get sick or injured on the road.

It’s easy for members to access a provider outside of their service area:• They can visit the BlueCard Doctor and Hospital Finder website at www.bcbs.com; or• call the BlueCard Access line at 1.800.810.BLUE.

H E A L T H Q U E S T I O N S

P R I O R G R O U P C O V E R A G E

When replacing another group insurer, Blue Cross and Blue Shield of Louisiana adheres to all Louisiana replacement requirements.Credit will be given for any time served toward a waiting period for pre-existing conditions. This applies to employees listed on thecurrent invoice of the previous insurer.

Applicants in groups that have two through 19 eligible employees must answer all health questions on the employee applicationand are subject to full medical underwriting. For groups with 20 through 50 eligible employees, those who apply out of theireligibility period are also subject to full medical underwriting. Coverage for all such individuals is subject to home-office approval.

P R E - E X I S T I N G C O N D I T I O N S

A Pre-existing Condition is Defined as:A physical or mental condition for which medical advice, diagnosis, care or treatment was recommended or received within thesix-month period immediately prior to the eligible member's enrollment date. Genetic information will not be treated as a pre-existing condition in the absence of a diagnosis of the condition related to that information. Pregnancy will not be treated as apre-existing condition.

Pre-existing Condition Exclusion PeriodNo benefits will be provided for any charges incurred for any pre-existing conditions, subject to the following exclusion periods:

• initial enrollees of a new group policy — 12-month exclusion period (60 days for mental disorders)

• new-hire enrollees if application is received when first eligible — 12-month exclusion period (60 days for mental disorders)

• special enrollees — 12-month exclusion period (60 days for mental disorders)

• late enrollees — 18-month exclusion period (60 days for mental disorders)5

• charges exceeding the allowable charge

• investigational treatments

• sales tax or interest

• infertility treatments

• cosmetic surgery

• weight reduction surgery or programs

• routine eye exams

• eyeglasses and contact lenses

• correction for refractive errors of the eye

• custodial care

See contract for complete list.

C O N T R A C T L I M I T A T I O N S A N D E X C L U S I O N SI N C L U D I N G B U T N O T L I M I T E D T 0 :

P R E - E X I S T I N G C O N D I T I O N S ( C O N T I N U E D )

Prior Creditable CoverageCredit will be given for all or part of the pre-existing condition exclusion period if proof of prior creditable coverageis provided. This credit will apply when the other eligible creditable coverage was in force within 63 days prior tothe effective date under this coverage.

Pre-existing Condition Exclusions Do Not Apply to:

• newborns, provided a complete request for enrollment is received within 30 days of the birth;

• adopted children, provided a complete request for enrollment is received within 30 days of adoption or placementof adoption; or

• pregnancy.

This proposal is presented for general information only. It is not a contract, nor intended to be a

contract. If there is a discrepancy between this document and the contract, the provisions of the

contract will govern. Please refer to the contract (40XX0779) for complete information.

® ® An independent licensee of the Blue Cross and Blue Shield Association

A P R O V E N R E C O R D O F S E R V I C E

70 years of serv ice in Louis iana

Walk- in local serv ice off ices statewide

An ID card recognized throughout the wor ld

F O R M O R E I N F O R M A T I O N A B O U T B L U E S A V E RC A L L

Alexandr ia 318.448.1660

Baton Rouge 225.295.2556

Houma 985.223.3499

Lafayette 337.232.7527

Lake Char les 337.562.0595

Monroe 318.323.1479

New Or leans 504.832.5800

Shreveport 318.795.0573