<LOGO> <Return address> NOTICE OF RENEWAL AND 2015 PREMIUM RATES <Date> <Contact Name> <Company> <Address> <City, State, Zip> Group number: <XXXXXXXXXX> Dear [Employer]: Your group health insurance coverage is coming up for renewal. On <effective date> your group policy will be automatically renewed, as long as your group continues to be eligible, and your group’s members will be automatically re-enrolled unless you choose another policy. Included are changes we’ll be making to your policy, the new premium for this policy, and some information about options if you wish to change policies. Premium rate changes: The premium rates for your health insurance policy are changing. The new rates will take effect on <effective date>. The new rates listed in the Premium Rates section of the enclosed renewal kit have been approved by the New York State Department of Financial Services (DFS). You may visit the DFS website at www.dfs.ny.gov for more information regarding this rate change. You may also contact Empire by calling the GBA Contact Center at 866-422-2583 or via our website at empireblue.com/priorapproval for further information about this rate change. Other changes to your current health insurance policy: In 2015, there will be benefit changes to most plans, including cost-share changes to deductibles, copays, coinsurance, and out-of-pocket maximum amounts for hospital and doctor services and prescription drugs. The enclosed “Important Information” flyer displays a chart with the 2015 benefit changes for our small group plans. Coverage options: To renew your current policy, no action is needed, other than paying your premium when due. If you do not want your group’s present policy to automatically renew, you have the option of choosing a different policy either from us or from another insurer. To choose a different plan from Empire, follow the instructions on the “Next Steps” page of the renewal kit and return all required documentations to us before your group’s renewal effective date. You may purchase a new policy from us or another insurer directly, or with the assistance of a broker or agent. You may also purchase a policy (or policies) through the NY State of Health Small Business Marketplace (the “Marketplace”). The Marketplace allows you to offer your employees a choice of insurance policies with a variety of cost sharing options from different insurance companies. If you purchase coverage through the Marketplace, you may be eligible for a small business health care tax credit for qualified employers that can cover as much as 50% of your contribution toward employee premium c osts. If you are eligible for a small business health care tax credit, you generally can get that credit only if you buy a policy through the Marketplace. Please note that Empire does not participate on the Small Business Marketplace. You generally can buy coverage for a group at any time throughout the year, but to avoid gaps in coverage, you should enroll at least two weeks before your renewal date of <effective date>. To avoid gaps in coverage when purchasing a new policy, enrollment must be the end of the month, one month prior to the policy end date (for example, November 30th for January 1 renewals, December 31st for February 1 renewals). Before you decide: Call the insurer or visit the insurer’s website to check which doctors, other healthcare providers and prescription medications are covered by the new policy. This is an important step in selecting a policy that best meets the needs of your group. If you have questions: • Call your broker or Empire’s GBA Contact Center at 866-422-2583, Monday – Friday from 9a.m. – 5p.m., or visit our website at empireblue.com. • Visit www./nystateofhealth.ny.gov to learn more about the New York State of Health Marketplace, or call Marketplace customer service at 1-855-355-5777. Getting help in other languages: Para obtener asistencia en Espanol, Ilame al 866-422-2583. Subscriber Notification: Please communicate this information to the subscribers who receive coverage through this group policy. A subscriber notification called “Important Information for Empire members” is enclosed with this mailing. Please provide any additional information with this notice, such as expected changes in employee contribution levels, that may help your employees better understand their health coverage costs. Wishing you the best of health, <<Your <Empire BlueCross> <Empire BlueCross BlueShield> Team>> Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. Important Information These changes apply to your group health plan. We encourage you to review these changes with your broker or Empire BlueCross BlueShield Sales representative. Summary of benefits and coverage (SBCs) Per the Affordable Care Act, Summary of Benefits and Coverage (SBCs) can be accessed at sbc.empireblue.com. 2015 benefit changes and updated product naming structure In 2015, there will be changes to most plans, including cost-share changes to deductibles, copays, coinsurance and out-of-pocket maximum amounts for hospital and doctor services and prescription drugs. Below is the chart with the 2015 benefit changes for all our small group plans. More information can be found at empireblue.com/priorapproval. We are also updating our product naming structure. The product names include the following elements: Empire + metal tier + network name + product type + deductible/coinsurance/out-of-pocket maximum Example: Empire Gold Pathway HMO 1300/10%/6000 Applies to the following products (2014 product/plan names Applies to the following products (2015 product/plan names) 2015 benefit changes Empire Essential Guided Access Plus EPO — gwoa Empire Essential Guided Access Plus EPO (with adult dental) — gwoa Empire Silver Pathway EPO 1500/30%/5500 Plus Empire Silver Pathway EPO 1500/30%/5500 Plus (with adult dental) In-network Coinsurance will change from 35% to 30% and Single Out-of-Pocket Maximum will change from $6,350/$12,700 to $5,500/$11,000. Empire Preferred Guided Access Plus HMO with HSA — ghab Empire Gold Pathway HMO 1300/10%/6000 Plus with HSA Deductible will change from $1,250/$2,500 to $1,300/$2,600 and Out-of-Pocket Maximum will change from $6,350/$12,700 to $6,000/$12,000. Empire Core Guided Access Plus EPO with HSA — gugb Empire Bronze Pathway EPO 3500/20%/6350 Plus with HSA Rx cost share will change from Tier 1 $15/Tier 2 $50/Tier 3 Greater of $90 copay OR 25% to Tier 1 $15/Tier 2 $50/Tier 3 Greater of $90 copay OR 20%. Empire Core Guided Access Plus EPO with HSA — gwgb Empire Bronze Pathway EPO 4500/30%/6350 Plus with HSA No changes Empire Essential Guided Access Plus EPO with HSA — gbcb Empire Silver Pathway EPO 2500/20%/4500 Plus with HSA No changes Healthy New York — gpbf Empire Gold Healthy New York Pathway HMO 600/0%/4000 No changes Home Delivery Complete Small Group off-exchange products include the Home Delivery Complete pharmacy benefit, a mandatory mail-order pharmacy requirement for maintenance medications. Through the Home Delivery Complete benefit, members filling maintenance medications at a retail pharmacy are required to use the home delivery pharmacy to access their pharmacy benefits. Please share the enclosed flier, Getting Started with Home Delivery Pharmacy, with your employees so they can get started right away. 35485NYEENEBS Rev. 08/14 Mental health benefits changes Federal law requires group health plans to cover services for mental health care or substance abuse at the same levels as your medical services. Generally speaking, this means visit limits and the amounts you pay (such as copayments and deductibles) must be the same for covered services that treat body or mind. This is called “mental health parity.” For renewals on or after July 1, 2014, we reviewed your plan benefits to make sure they comply with the mental health parity laws. Residential Treatment Centers are now covered. Also, for Intensive Outpatient Programs and Partial Hospitalization Programs related to mental health or substance abuse, you will have the same outpatient cost-sharing levels you have for outpatient medical services. For more information, call your broker, Empire representative or the GBA Contact Center at 1-866-422-2583. ACA Insurer Fee and the ACA Reinsurance Fee Effective since January 1, 2014, the Affordable Care Act (ACA or health care reform law) imposes a new annual fee (ACA Insurer Fee) on health insurance providers based on their market share of net premiums written, or the sum of premiums earned from all policies, during the previous year. After 2018, it increases annually based on premium growth. Section 1341 of the Affordable Care Act provides that a transitional reinsurance program (ACA Reinsurance Fee) be established in each state to help stabilize premiums for coverage in the individual market during the years 2014 through 2016. All health insurance issuers and third-party administrators (TPAs) on behalf of self-insured group health plans, will submit contributions to support reinsurance payments to issuers that cover high-cost individuals in non-grandfathered individual market plans. This quotation includes amounts for the ACA Insurer Fee and ACA Reinsurance Fee. Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.