BCBS MA APPLICATION AGREEMENT

I understand that I (and, as applicable, my dependents) am eligible for Direct Pay coverage due to the fact that I am a Massachusetts resident and actually live in Massachusetts. I understand that I may be asked to provide additional information for validation of my residency. The information supplied on this form is true and complete and I understand that any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application containing a false, incomplete or deceptive statement may be guilty of insurance fraud. I grant Blue Cross and Blue Shield of Massachusetts, Inc. or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc., depending on my choice of plan, any legal right that I and/or my covered dependents have to recover the cost of services for an illness or injury caused by someone else when these services have been or will be paid by Blue Cross and Blue Shield. I understand that Blue Cross and Blue Shield may obtain personal and medical information about me and/or my covered dependents to carry out its business, and that it may use and disclose that information in accordance with the law. I acknowledge that I may obtain further information about the collection, use, and disclosure of my and/or my covered dependents information in "Our Commitment to Confidentiality," the Blue Cross and Blue Shield notice of privacy practices. This information may be obtained upon request or by visiting www.bluecrossma.com. I understand that the benefits for which I and/or my covered dependents are eligible are those described in the applicable subscriber certificate. I understand that benefits and premium rates are subject to change, subject to limitations of state law. I understand that enrollment in this plan is contingent upon payment of premium.

Important Notes If you or any of your enrolled dependents: (a) obtain a health care benefit or payment from Blue Cross and Blue Shield of Massachusetts, that you know you are not entitled to receive or be paid; or (b) knowingly present or cause to be presented, with fraudulent intent, a claim that contains a false statement, you can be liable to Blue Cross and Blue Shield for the full amount of the health care benefit or payment made and for reasonable attorney's fees and costs, including cost of investigation.

Final rates and eligibility determinations are subject to your age at the time of enrollment and residency in Massachusetts for the plan effective date you have selected. The plan in which you enroll will automatically renew on your renewal date, except in certain situations if you lose eligibility for the plan, or the plan is terminated, as fully described in the Evidence of Coverage (EOC). To request an EOC, please call Blue Cross Blue Shield of Massachusetts at 1-800-422-3545.

Application Disclosure Notice If you chose a plan design with the Hospital Choice Cost Sharing feature, you have chosen a tiered network plan design. Please review and electronically sign the following to confirm that you understand your chosen plan's provider network.

This plan assigns network providers to benefit tiers.

Upon enrollment, you will receive a member identification card that will display the name of your provider network. The designation "Tiered" will be on the top right hand side of the card.

-I understand that I may not change plans during a policy year because of changes to the provider network. -I understand that the plan I have chosen assigns network providers to benefit tiers. -I understand that I will pay different levels of cost share (such as copayments and/or coinsurance) based on a provider's assigned benefit tier. -I understand that providers may be assigned to different benefit tiers but that overall changes to the benefits tiers of providers will happen no more than once each calendar year. -I understand that if a provider is reassigned to a different benefit tier, I am responsible to pay different cost share (such as copayments and/or coinsurance) as applicable. Based on my plan selection, I have reviewed the provider directory that applies for my selected plan and understand that symbols displayed next to each provider identify the exact tier the provider is assigned. -I certify that I have received the "Limited, Regional and Tiered Network Plans: Choosing the Health Plan That's Right for You" guild prior to beginning and completing the application/enrollment process.