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Fifth Avenue

Pittsburgh, PA 15222-3099

#BWNDBQH #OCS8923275026360# ADEBOLA A WHALEY 281 CYPRESS HILL PENN HILLS PA 15235

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JUNE 11, 2011 Page 1 of

Explanation of Benefits
Need Help? Call 1-800-485-2889

THIS IS NOT A BILL

Contract Holder Name: ADEBOLA A WHALEY Member ID: 107672497001 Group Name: HIGHMARK INC Group ID: 013044-002 Claim Activity For: ADEBOLA A WHALEY Claim Number: 11157522977 EXPLANATION AT A GLANCE Date of Service: 06/03/11 We Sent Payment To: MEDICAL EXPRESS DEPOT SUBSIDIARY OF CCS MEDICAL Claim Payment Amount: Provider May Bill You (If Not Already Paid): Member Responsibility Plan Amount Allowance Remaining (Covered Charges)
2.45 2.45

$ $

2.20 0.25

Provider Date of Service Type of Service Service Code (Number of Services)

MEDICAL EXPRESS DEPOT 06/03/11 SUPPLIES A4245 (1) TOTALS

Provider's Charge

Non-Billable To Member

Health Plan Pays At

90%

Health Plan Pays

2.20

Your Share of Amount Remaining

0.25

Amount You Owe Provider (Total of Shaded Columns)

0.25

15.20

12.75 J4047

15.20

12.75

2.45

2.45

2.20

0.25

0.25

Claim Activity For: ADEBOLA A WHALEY Claim Number: 11157522978

EXPLANATION AT A GLANCE Date of Service: 06/03/11 We Sent Payment To: MEDICAL EXPRESS DEPOT SUBSIDIARY OF CCS MEDICAL Claim Payment Amount: Provider May Bill You (If Not Already Paid): $ $ 203.92 272.66

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JUNE 11, 2011 Page 2 of

Need Help? Call 1-800-485-2889

Provider Date of Service Type of Service Service Code (Number of Services)

MEDICAL EXPRESS DEPOT 06/03/11 SUPPLY K0603 (8) MEDICAL EXPRESS DEPOT 06/03/11 SUPPLIES A4232 (30) MEDICAL EXPRESS DEPOT 06/03/11 SUPPLIES A4230 (30) TOTALS

Provider's Charge

Non-Billable To Member

Plan Allowance (Covered Charges)

4.08

Member Responsibility Your Amount Deductible Remaining

Health Plan Pays At

90%

Health Plan Pays

3.67

Your Share of Amount Remaining

0.41

Amount You Owe Provider (Total of Shaded Columns)

0.41

118.00

113.92 J4047

0.00

4.08

225.00

127.50 J4047

97.50

0.00

97.50

90%

87.75

9.75

9.75

1050.00

675.00 J4047

375.00

250.00

125.00

90%

112.50

12.50

262.50

1393.00

916.42

476.58

250.00

226.58

203.92

22.66

272.66

Explanation of Remark Codes

J4047 - This is the difference between the provider's charge and our allowance. responsible for this amount. Since the provider is in-network, you are not

PATIENT BENEFIT SUMMARY

Patient: ADEBOLA A WHALEY Benefit Period: 01/01/11 $22.91 has been applied to Patient: ADEBOLA A WHALEY Benefit Period: 10/01/10 You have satisfied $250.00 12/31/11 your $1,000.00 individual in network out-of-pocket amount. 12/31/11 of your $250.00 individual in network deductible.

Please refer to your benefit booklet or agreement for further information. Amount(s) shown may include totals from claims which are still being processed and for which you have not been notified.

PROGRAM BENEFIT SUMMARY

Benefit Period: 01/01/11 - 12/31/11 $22.91 has been applied to your $2,000.00 program in network out-of-pocket amount.

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JUNE 11, 2011 Page 3 of

Need Help? Call 1-800-485-2889

PROGRAM BENEFIT SUMMARY (Continued)

Benefit Period: 10/01/10 - 12/31/11 You have satisfied $250.00 of your $500.00 program in network deductible. Please refer to your benefit booklet or agreement for further information. Amount(s) shown may include totals from claims which are still being processed and for which you have not been notified.

Visit Our Website For online member service, view or update other insurance information, check eligibility or claims status, logon to our website at: www.highmark.com

Member Service Member Service: 8:00 am - 5:00 pm Monday - Friday 1-800-485-2889

If a claim has been denied in whole or in part, please refer to the Administration section of your Benefit Booklet for additional information. You have the right to request a review of a denied claim. To appeal a claim, file a WRITTEN OR ORAL APPEAL WITHIN 180 DAYS AFTER RECEIVING THE EXPLANATION OF BENEFITS STATEMENT. If you have any questions or want to file an oral appeal, please contact our Member Service Department at the telephone number identified above. Written appeals can be submitted to us at: HIGHMARK BLUE SHIELD PO BOX 535072 PITTSBURGH PA 15253-5072 (TTY services via 1-800-452-8086 for the hearing and speech impaired.)

If you suspect fraud or abuse involving your health insurance, please call the toll-free fraud or abuse hotline at 1-800-438-2478.

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