Document:

Comprehensive Non-Qualified Deferred Compensation Plan

 Exhibit 10.3 
 WELLPOINT, INC. 
 COMPREHENSIVE NON-QUALIFIED DEFERRED 

COMPENSATION PLAN 
 (AS AMENDED AND RESTATED EFFECTIVE 
 JANUARY 1, 2011) 

 TABLE OF CONTENTS 

 

							
	 	  	 	  	Page	 
	 ARTICLE I
	  	HISTORY AND PURPOSE	  	 	1	  
	 1.01
	  	History	  	 	1	  
	 1.02
	  	Purpose	  	 	2	  
	 ARTICLE II
	  	DEFINITIONS	  	 	2	  
	 2.01
	  	“Account”	  	 	2	  
	 2.02
	  	“Administrator”	  	 	3	  
	 2.03
	  	“Affiliate”	  	 	3	  
	 2.04
	  	“Anthem LTIP”	  	 	3	  
	 2.05
	  	“Anthem Plan”	  	 	3	  
	 2.06
	  	“Anthem SERP”	  	 	3	  
	 2.07
	  	“Anthem SERP Participant”	  	 	3	  
	 2.08
	  	“Beneficiary”	  	 	3	  
	 2.09
	  	“Bonus”	  	 	3	  
	 2.10
	  	“Bonus Deferral”	  	 	3	  
	 2.11
	  	“Code”	  	 	3	  
	 2.12
	  	“Committee”	  	 	3	  
	 2.13
	  	“Company”	  	 	4	  
	 2.14
	  	“Company Contribution”	  	 	4	  
	 2.15
	  	“Compensation”	  	 	4	  
	 2.16
	  	“Compensation Deferral”	  	 	4	  
	 2.17
	  	“Election Form”	  	 	4	  
	 2.18
	  	“Eligible Employee”	  	 	4	  
	 2.19
	  	“Eligible Executive”	  	 	4	  
	 2.20
	  	“In-Service Payout”	  	 	4	  
	 2.21
	  	“Key Employee”	  	 	4	  
	 2.22
	  	“Make-Up Contribution”	  	 	4	  
	 2.23
	  	“Matching Contribution”	  	 	4	  
	 2.24
	  	“Merged Plan”	  	 	5	  
	 2.25
	  	“Participant”	  	 	5	  
	 2.26
	  	“Pension Benefit”	  	 	5	  
	 2.27
	  	“Pension Plan”	  	 	5	  
	 2.28
	  	“Plan”	  	 	5	  
	 2.29
	  	“Plan Year”	  	 	5	  
	 2.30
	  	“Predecessor Plan”	  	 	5	  
	 2.31
	  	“Predecessor Plan Account”	  	 	5	  
	 2.32
	  	“Predecessor Plan Participant”	  	 	5	  
	 2.33
	  	“Regulations”	  	 	5	  
	 2.34
	  	“Salary”	  	 	5	  
	 2.35
	  	“Salary Deferral”	  	 	5	  
	 2.36
	  	“Savings Plan”	  	 	5	  
	 2.37
	  	“Separation from Service”	  	 	5	  
	 2.38
	  	“Trigon Plan”	  	 	6	  

  
 i 

							
	 2.39
	  	“Trigon SERP”	  	 	6	  
	 2.40
	  	“UGS Pension Plan”	  	 	6	  
	 2.41
	  	“WellPoint Plan”	  	 	6	  
	 2.42
	  	“WellPoint SERP Participant”	  	 	6	  
	 2.43
	  	“2005 Anthem SERP”	  	 	6	  
	 2.44
	  	“2005 WellPoint Plan”	  	 	6	  
	 2.45
	  	“2005 Anthem Plan”	  	 	6	  
	 2.46
	  	“2005 Trigon Plan”	  	 	6	  
	 2.47
	  	“2005 Trigon SERP”	  	 	6	  
	 ARTICLE III
	  	ELIGIBILITY AND PARTICIPATION	  	 	6	  
	 3.01
	  	Eligibility	  	 	6	  
	 3.02
	  	Participation	  	 	7	  
	 3.03
	  	Enrollment Requirements	  	 	7	  
	 3.04
	  	Cessation of Participation	  	 	7	  
	 ARTICLE IV
	  	DEFERRALS AND CONTRIBUTIONS	  	 	8	  
	 4.01
	  	Salary and Compensation	  	 	8	  
	 4.02
	  	Bonus	  	 	9	  
	 4.03
	  	Newly Eligible Executives	  	 	10	  
	 4.04
	  	Matching Contributions	  	 	11	  
	 4.05
	  	Non-Elective Contributions	  	 	11	  
	 ARTICLE V
	  	SUPPLEMENTAL PENSION PLAN CONTRIBUTIONS	  	 	13	  
	 5.01
	  	Eligibility for Supplemental Pension Contribution	  	 	13	  
	 5.02
	  	In General	  	 	13	  
	 5.03
	  	Former DeCare Dental Pension Plan Participants	  	 	13	  
	 5.04
	  	QSERP	  	 	14	  
	 ARTICLE VI
	  	EARNINGS	  	 	14	  
	 6.01
	  	Investment Funds	  	 	14	  
	 6.02
	  	Conversion of Investments from Predecessor Plans and Merged Plans	  	 	14	  
	 ARTICLE VII
	  	VESTING	  	 	15	  
	 7.01
	  	Elective Deferrals under the Plan	  	 	15	  
	 7.02
	  	Supplemental Pension Plan Contributions	  	 	15	  
	 7.03
	  	Predecessor or Merged Plans	  	 	16	  
	 7.04
	  	Company and/or Make-Up Contributions	  	 	16	  
	 ARTICLE VIII
	  	DISTRIBUTIONS	  	 	16	  
	 8.01
	  	Annual Election	  	 	16	  
	 8.02
	  	Time for Distribution	  	 	16	  
	 8.03
	  	In-Service Payout	  	 	16	  
	 8.04
	  	Separation from Service	  	 	17	  
	 8.05
	  	Subsequent Changes in Elections	  	 	18	  
	 8.06
	  	Death	  	 	18	  
	 8.07
	  	Hardship Withdrawal	  	 	18	  

  
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	 8.08
	  	Valuation	  	 	19	  
	 8.09
	  	Tax Withholding	  	 	19	  
	 8.10
	  	Payment of Small Accounts	  	 	19	  
	 8.11
	  	Right of Offset	  	 	19	  
	 8.12
	  	Bona Fide Dispute	  	 	20	  
	 8.13
	  	Income Inclusion Under Code Section 409A	  	 	20	  
	 8.14
	  	Effect of Rehire	  	 	20	  
	 ARTICLE IX
	  	EFFECT ON PREDECESSOR AND MERGED PLANS	  	 	20	  
	 9.01
	  	Coordination With Predecessor Plans	  	 	20	  
	 9.02
	  	Predecessor Plan Accounts	  	 	20	  
	 9.03
	  	Merged Plans	  	 	20	  
	 ARTICLE X
	  	CLAIMS PROCEDURES	  	 	21	  
	 10.01
	  	Presentation of Claim	  	 	21	  
	 10.02
	  	Decision on Initial Claim	  	 	21	  
	 10.03
	  	Right to Review	  	 	22	  
	 10.04
	  	Decision on Review	  	 	22	  
	 10.05
	  	Form of Notice and Decision	  	 	23	  
	 10.06
	  	Legal Action	  	 	23	  
	 ARTICLE XI
	  	ADMINISTRATION	  	 	23	  
	 11.01
	  	Plan Administration	  	 	23	  
	 11.02
	  	Powers, Duties and Procedures	  	 	23	  
	 11.03
	  	Agents	  	 	23	  
	 11.04
	  	Binding Effect of Decisions	  	 	24	  
	 11.05
	  	Information	  	 	24	  
	 11.06
	  	Coordination with Other Benefits	  	 	24	  
	 ARTICLE XII
	  	MISCELLANEOUS	  	 	24	  
	 12.01
	  	Limitation of Rights	  	 	24	  
	 12.02
	  	Additional Restrictions	  	 	24	  
	 12.03
	  	Indemnification	  	 	24	  
	 12.04
	  	Assignment	  	 	25	  
	 12.05
	  	Inability to Locate Recipient	  	 	25	  
	 12.06
	  	Amendment and Termination	  	 	25	  
	 12.07
	  	Applicable Law	  	 	25	  
	 12.08
	  	No Funding	  	 	25	  
	 12.09
	  	Trust	  	 	26	  

  
 iii

 WELLPOINT, INC. 

COMPREHENSIVE NON-QUALIFIED DEFERRED 
 COMPENSATION PLAN 
 (AS AMENDED AND RESTATED EFFECTIVE 

JANUARY 1, 2011) 
 ARTICLE I 
 HISTORY AND PURPOSE 

1.01 History. WellPoint, Inc. (the “Company”) established the WellPoint, Inc. 2005 Comprehensive Executive Non-Qualified
Retirement Plan, originally effective January 1, 2005 (“WellPoint Plan”), as a new plan for certain types of deferred compensation subject to Section 409A of the Internal Revenue Code of 1986, as amended (the “Code”),
which governs nonqualified deferred compensation arrangements. The Company amended and restated the WellPoint Plan effective January 1, 2006, and renamed it the WellPoint, Inc. Comprehensive Non-Qualified Deferred Compensation Plan (the
“Plan”). The Company amended and restated the Plan effective as of November 1, 2006 and then again effective as of January 1, 2009 for compliance with the final regulations issued under Code Section 409A. The Company hereby
amends and restates the Plan effective as of January 1, 2011. 
 (a) Merged Plans. In
addition, effective January 1, 2005, the Company, one of its predecessors or entities related to the Company or a predecessor also established the following nonqualified deferred compensation plans applicable to amounts subject to Code
Section 409A. 
  

	 	(i)	the 2005 Anthem Supplemental Executive Retirement Plan; 

  

	 	(ii)	the 2005 Anthem Deferred Compensation Plan; 

  

	 	(iii)	the 2005 Trigon Insurance Company 401(k) Restoration Plan; and 

  

	 	(iv)	the 2005 Supplemental Retirement Plan for Certain Employees of Trigon Insurance Company. 

Each of the foregoing plans were separately maintained for the 2005 calendar year and cover deferred compensation that
related solely to the 2005 calendar year. The Company subsequently ceased accruals and merged each of the plans into the WellPoint Plan effective as of December 31, 2005 and are referred to herein as the Merged Plans (either alone or
collectively). 
 (b) Predecessor Plans. The Company or one of its predecessors separately maintained the
following nonqualified deferred compensation plans, which cover amounts earned and vested as of December 31, 2004 (including vested bonuses earned in 2004 and paid in 2005): 

 

	 	(i)	each pre-2005 Anthem Long-Term Incentive Plan; 

	 	(ii)	the WellPoint Health Networks Inc. Comprehensive Executive Non-Qualified Retirement Plan; 

 

	 	(iii)	the Anthem Supplemental Executive Retirement Plan; 

  

	 	(iv)	the Anthem Deferred Compensation Plan; 

  

	 	(v)	the Trigon Insurance Company 401(k) Restoration Plan; and 

  

	 	(vi)	the Supplemental Retirement Plan for Certain Employees of Trigon Insurance Company. 

Each of the foregoing plans are referred to as a “Predecessor Plan(s).” Benefits ceased to accrue under the
Predecessor Plans effective December 31, 2004 and, as such, are grandfathered for purposes of Code Section 409A. Solely for administrative purposes, Predecessor Plan Account balances, determined as of December 31, 2005, became
accounted for under the 2005 WellPoint Plan effective as of January 1, 2006. In all other respects, each Predecessor Plan Account remains subject exclusively to the terms of the Predecessor Plan to which it relates. 

1.02 Purpose. Except as otherwise provided herein, the Plan applies only to Participants to whose Account contributions are
credited under Article IV and Article V. The purpose of the Plan is to (1) restore to selected employees of the Company and its affiliates certain benefits that cannot be provided under the tax-qualified plans maintained by the Company and its
affiliates and (2) provide additional opportunities for certain management and highly compensated employees to defer one or more items of their compensation. 
 The Plan is intended to comply with Code Section 409A and shall be interpreted, administered and operated as necessary to comply with the requirements of Code Section 409A and applicable
Treasury Regulations. The Plan is further intended to be a plan that is unfunded and maintained by WellPoint, Inc. primarily for the purpose of providing deferred compensation for a select group of management or highly compensated employees within
the meaning of the Employee Retirement Income Security Act of 1974 (“ERISA”). 
 ARTICLE II 

DEFINITIONS 
 In this Plan, the following terms have the meanings indicated below: 
 2.01
“Account”means the account maintained under the Plan for each Participant which is credited with amounts under Article IV and Article V of the Plan and adjusted periodically for investment performance under Article VI of the Plan
and distributions or withdrawals in accordance with Article VIII. The Account of each Participant who is also a Predecessor Plan Participant shall also include the Predecessor Plan Account maintained on behalf of that Predecessor Plan Participant,
as adjusted periodically for investment performance under Article VI of the Plan and distributions or withdrawals in accordance with the terms of the Predecessor Plan to which it relates. Each Participant’s Account shall be divided into a
series of Plan Year subaccounts, one for each Plan Year for which the Participant defers any 

  
 2 

 
Compensation under the Plan. To the extent it considers necessary or appropriate, the Administrator may further divide each such Plan Year subaccount into a series of separate subaccounts so that
each category of deferred Compensation may be credited to its own separate subcategories within that particular Plan Year subaccount. 
 2.02 “Administrator”means the Executive Vice President and Chief Human Resources of the Company and, if the context requires, the Human Resources Department of the Company, in charge of
the day-to-day administration of the Plan. 
 2.03 “Affiliate”means an entity other than the Company whose
employees participate in the tax-qualified retirement plans of ATH Holding Company, LLC or National Government Services, Inc. or whose employees are authorized to participate in the Plan by the Committee. 

2.04 “Anthem LTIP”means each pre-2005 Anthem Long-Term Incentive Plan. 

2.05 “Anthem Plan”means the Anthem Deferred Compensation Plan. 

2.06 “Anthem SERP”means the Anthem Supplemental Executive Retirement Plan. 

2.07 “Anthem SERP Participant”means an individual who is eligible on or after January 1, 2006 to earn a benefit
under the 2005 Anthem SERP. 
 2.08 “Beneficiary”means the person or persons, trust or estate designated in
writing, to receive a Participant’s vested Account if the Participant dies before distribution of the entire vested balance credited to that Account. A Participant may designate one or more primary Beneficiaries and one or more secondary
Beneficiaries. A Participant’s Beneficiary designation must be made in writing pursuant to such procedures as the Administrator may establish and delivered to the Administrator before the Participant’s death. The Participant may revoke or
change this designation at any time before his or her death by following such procedures as the Administrator will establish. If the Administrator has not received a Participant’s Beneficiary designation before the Participant’s death or
if the Participant does not otherwise have an effective Beneficiary designation on file when he or she dies, the vested balance of such Participant’s Account will be distributed to his or her estate. 

2.09 “Bonus”means an amount awarded to an Eligible Employee or Eligible Executive under the Annual Incentive Plan
maintained by the Company. 
 2.10 “Bonus Deferral”means an election by a Participant to defer the receipt of a
Bonus in accordance with the requirements of Article IV. 
 2.11 “Code”means the Internal Revenue Code of 1986,
as amended from time to time. 
 2.12 “Committee”means the Compensation Committee of the Company’s Board
of Directors or a subcommittee of two or more members thereof. The Committee shall have full discretionary authority to administer and interpret the Plan, to determine eligibility for Plan benefits, to select employees for Plan participation, to
determine the benefit entitlement of each Participant and Beneficiary hereunder and to correct errors. The Committee may delegate any of its duties and responsibilities not otherwise delegated hereunder to the Executive Vice President

  
 3 

 
and Chief Human Resources as Administrator, and unless the Committee expressly provides to the contrary, any such delegation will carry with it the Committee’s full discretionary authority
with respect to the delegated duties and responsibilities. In no event, however, shall the Committee delegate its authority to amend or terminate the Plan pursuant to the provisions of Sections 12.02 and 12.06. Decisions of the Committee or its
delegate will be final and binding on all persons. 
 2.13 “Company”means WellPoint, Inc., an Indiana
corporation. 
 2.14 “Company Contribution”means, for any one Plan Year, the amount determined in accordance
with Section 4.05. 
 2.15 “Compensation”means the respective definitions of compensation as set forth in
the Savings Plan for elective deferrals and matching contributions, as constituted from time to time and as the context requires. In either case, the respective definition of compensation as set forth in the Savings Plan is determined without regard
to the application of the limitation under Code Section 401(a)(17). 
 2.16 “Compensation Deferral”means
an election by a Participant to defer the receipt of Compensation in accordance with the requirements of Article IV. 
 2.17
“Election Form”means the form or forms established from time to time by the Administrator that a Participant completes, signs and returns to the Administrator to make a deferral election, make or change a payment election, and/or
make or change an investment election. To the extent authorized by the Administrator, such form may be electronic or set forth in some other media or format. 
 2.18 “Eligible Employee”means each employee of the Company or an Affiliate who is not an Eligible Executive and whose Compensation is in excess of the Code Section 401(a)(17)
compensation limit in effect at the time the employee’s eligibility is determined in accordance with Section 3.01. 

2.19 “Eligible Executive”means each executive of the Company or an Affiliate at the level of Vice President or above.

 2.20 “In-Service Payout”means a complete distribution of a Participant’s vested Plan Year subaccount
(including the related Matching Contribution) as of a specified date elected by a Participant. 
 2.21 “Key
Employee”means for the period January 1 through December 31 each individual identified by the Administrator as of the immediately preceding September 30 as a “key employee,” as defined under Code
Section 416(i), disregarding Code Section 416(i)(5). 
 2.22 “Make-Up Contribution”means the
contribution described under Section 4.05. 
 2.23 “Matching Contribution”means a matching contribution
pursuant to Section 4.04. 

  
 4 

 2.24 “Merged Plan”means the 2005 Anthem SERP, the 2005 Anthem Plan, the
2005 Trigon Plan or the 2005 Trigon SERP. 
 2.25 “Participant”means a current or former Eligible Executive or
Eligible Employee for whom an Account (including one or more Plan Year subaccounts) is maintained. A Participant shall also include a Predecessor Plan Participant for the limited purposes set forth in the Plan. 

2.26 “Pension Benefit”means the benefit payable to an individual under the Pension Plan or the UGS Pension Plan, as the
context requires. 
 2.27 “Pension Plan” means the qualified pension plan maintained by ATH Holding Company,
LLC or its predecessors under which a Participant is actively accruing a benefit, which may include the WellPoint Cash Balance Pension Plan, as amended from time to time, and/or such other qualified pension plan maintained by ATH Holding Company,
LLC. 
 2.28 “Plan”means this WellPoint, Inc. Comprehensive Non-Qualified Deferred Compensation Plan, as
amended from time to time. 
 2.29 “Plan Year”means the calendar year. 

2.30 “Predecessor Plan”means any of the WellPoint Plan, the Anthem SERP, the Anthem Plan, the various Anthem LTIPs, the
Trigon Plan or the Trigon SERP, each of which cover grandfathered benefits not subject to Code Section 409A. 
 2.31
“Predecessor Plan Account”means a hypothetical or bookkeeping account reflecting a grandfathered benefit under a Predecessor Plan, the amount of which was transferred to the Plan on December 31, 2005. Such account is
credited with additional earnings pursuant to Article VI. 
 2.32 “Predecessor Plan Participant”means an
individual who was eligible to participate in one or more of the Predecessor Plans and who, as of December 31, 2005 (the date Predecessor Plan Accounts were transferred to the Plan), has a Predecessor Plan Account. 

2.33 “Regulations”mean Treasury Regulations issued under the Code. 

2.34 “Salary”means that portion of a Participant’s Compensation other than a Bonus. 

2.35 “Salary Deferral”means an election by a Participant to defer the receipt of Salary in accordance with the
requirements of Article IV. 
 2.36 “Savings Plan”means the WellPoint 401(k) Retirement Savings Plan, as
amended from time to time. 
 2.37 “Separation from Service”means termination of the Participant’s
employment relationship (within the meaning of Code Section 409A and Regulations issued thereunder) with the Company and its affiliates and any other service relationship defined in such applicable Regulations, other than by reason of death.
For purposes of the foregoing, whether an entity is 

  
 5 

 
affiliated with the Company shall be determined pursuant to the controlled group rules of Code Section 414, as modified by Code Section 409A. However, the Participant’s employment
relationship with the Employer shall be treated as continuing intact while the individual is on a military leave, sick leave or other bona fide leave of absence if the period of such leave does not exceed six months (or longer, if required by
statute or contract). If the period of the leave exceeds six months and the Participant’s right to reemployment is not provided either by statute or contract, the employment relationship is deemed to terminate on the first date immediately
following such six-month period for purposes of Code Section 409A only. 
 2.38 “Trigon Plan”means the
Trigon Insurance Company 401(k) Restoration Plan. 
 2.39 “Trigon SERP”means the Supplemental Retirement Plan
for Certain Employees of Trigon Insurance Company. 
 2.40 “UGS Pension Plan”means the UGS Pension Plan, as
amended from time to time, and any predecessor qualified pension plan maintained by National Government Services, Inc. 
 2.41
“WellPoint Plan”means the WellPoint Health Networks Inc. Comprehensive Executive Non-Qualified Retirement Plan. 
 2.42 “WellPoint SERP Participant”means an individual who is eligible on or after January 1, 2006 to earn a benefit under Section 4.01 of the 2005 WellPoint Plan. 

2.43 “2005 Anthem SERP”means the 2005 Anthem Supplemental Executive Retirement Plan. 

2.44 “2005 WellPoint Plan”means the WellPoint, Inc. 2005 Comprehensive Executive Non-Qualified Retirement Plan, as in
effect on December 31, 2005. 
 2.45 “2005 Anthem Plan”means the 2005 Anthem Deferred Compensation Plan.

 2.46 “2005 Trigon Plan”means the 2005 Trigon Insurance Company 401(k) Restoration Plan. 

2.47 “2005 Trigon SERP”means the 2005 Supplemental Retirement Plan for Certain Employees of Trigon Insurance Company.

 ARTICLE III 
 ELIGIBILITY AND PARTICIPATION 
 3.01 Eligibility. 

(a) Determination of an individual as an Eligible Executive is made each Plan Year. Once an individual is determined to be
an Eligible Executive, the individual will continue to be an Eligible Executive until Separation from Service. 

(b) Determination of an individual as an Eligible Employee is made on a Plan Year by Plan Year basis. The Administrator
may determine the individual is an Eligible 

  
 6 

 
Employee for the immediately following Plan Year pursuant to any such rules and requirements regarding the criteria for, and manner in, which individuals are determined to be an Eligible
Employee. Such rules and requirements do not need to be consistent from Plan Year to Plan Year or among individuals. An individual who is determined to be an Eligible Employee shall be permitted to make a Compensation Deferral election effective for
the Plan Year that begins immediately following the Administrator’s determination of the individual as an Eligible Employee. An individual who is determined to be an Eligible Employee shall not be permitted to make a Compensation Deferral with
respect to Compensation earned in the Plan Year in which he or she is determined to be an Eligible Employee. 
 Notwithstanding
any Plan provision to the contrary, the Committee may, in its sole discretion, place further requirements and/or limitations on an Eligible Employee or Eligible Executive’s participation in any portion of the Plan. 

3.02 Participation. To begin participation in the Plan, an Eligible Executive and Eligible Employee shall properly complete and
timely submit an Election Form to the Administrator in accordance with the Administrator’s rules. An Eligible Executive or Eligible Employee shall become a Participant on the first day on which a deferral of an elected amount or contribution is
first credited to his or her Account. The Administrator may establish from time to time such other enrollment requirements as it determines in its sole discretion are necessary. 

3.03 Enrollment Requirements. Election Forms shall be completed and filed with the Administrator by the time periods set forth in
Article IV for the particular type of compensation to be deferred or during such other enrollment period as the Administrator determines in accordance with such Article. Subject to Section 8.05, a Participant may change or revoke a deferral or
distribution election any time before such election becomes irrevocable, which shall occur as of the applicable deadline specified in Article IV unless the Administrator establishes an earlier deadline. Unless the Administrator determines otherwise,
a new Election Form shall be required for each Plan Year in which an Eligible Executive wants to defer his or her Salary or Bonus and an Eligible Employee wants to defer his or her Compensation. A Participant’s Election Form shall specify the
form of payment, which shall be paid at the times specified in Article VIII. Unless otherwise specified herein or determined by the Administrator, the election made by the Participant for each Plan Year shall apply to all amounts credited to the
Participant’s Plan Year subaccount for such Plan Year. 
 3.04 Cessation of Participation. 

(a) Loss of Eligibility. 
  

	 	(i)	 An individual who is an Eligible Executive as of the first day of the Plan Year and who thereafter remains employed but ceases to be an executive of
the Company or an Affiliate at the level of Vice President or above shall continue to be treated as an Eligible Executive during the course of that Plan Year and for each following Plan Year until the earliest of (A) the date the individual

  
 7 

	 	 
ceases to be employed by the Company or (B) the date the Plan is terminated. 

  

	 	(ii)	An individual who qualifies as an Eligible Employee for a particular Plan Year will automatically cease to be an Eligible Employee for an immediately following Plan
Year if the individual ceases to meet the qualification requirements set forth in Section 3.01. 

 Any individual who ceases to be an Eligible Executive or Eligible Employee shall continue to be a Participant with respect to amounts credited to his or her Account until such amounts are completely
distributed to him or her in accordance with the Plan. 
 (b) Committee Discretion. Notwithstanding any
Plan provision to the contrary, the Committee shall have the sole discretionary authority to exclude a Participant from making further deferrals under the Plan with such exclusion becoming effective as of the first day of the next succeeding Plan
Year. Such Participant shall remain a Participant in the Plan until his Account balance is paid in full. 
 (c)
Hardship Withdrawals. Elective or deemed deferrals made by a Participant who receives a hardship withdrawal shall be canceled pursuant to Section 8.07. The Participant shall remain a Participant in the Plan until his Account balance is
paid in full. 
 (d) Separation from Service or Death. Notwithstanding anything in the Plan to the
contrary, upon a Participant’s Separation from Service or death, if earlier, any outstanding distribution election shall be given effect to the extent any amounts covered by such election are paid after such event. 

ARTICLE IV 

DEFERRALS AND CONTRIBUTIONS 
 4.01 Salary and Compensation. 
 (a) Elections.
Subject to Article III, an Eligible Executive may make a Salary Deferral and an Eligible Employee may make a Compensation Deferral by filing an Election Form with the Administrator before the beginning of the Plan Year in which the Salary or
Compensation, as the case may be, is earned. All deferrals shall be made on a pre-tax basis. The Administrator may prescribe such rules and requirements regarding Salary and Compensation Deferral elections, including without limitation, the
requirement that an Eligible Executive’s Salary Deferral election be in the same percentage as his or her deferral election under the Savings Plan as in effect on the first day of the Plan Year to which the Salary Deferral election relates. In
such case, an Eligible Executive’s Savings Plan election cannot be changed during the Plan Year to which the Salary Deferral election relates. 
 (b) Amount. 

  
 8 

	 	(i)	Salary Deferral. For each Plan Year, an Eligible Executive may elect to make a Salary Deferral for each payroll period in a percentage (not to exceed 60%) of his
or her Salary net of any required taxes, Savings Plan deferrals and salary reduction amounts described in Code Section 125. Deferrals to the Plan shall begin after the Eligible Executive has made the maximum salary deferrals permitted under the
Savings Plan for the Plan Year under Code Section 402(g). For purposes of the preceding sentence, for any given Plan Year and for all Eligible Executives, the Administrator may determine whether such maximum salary deferral includes catch-up
contributions (within the meaning of Code Section 402(g)). 

  

	 	(ii)	Compensation Deferral. For each Plan Year in which an Eligible Employee participates in the Plan, he or she may elect to defer for each payroll period a
percentage of his or her Compensation in excess of the Code Section 401(a)(17) limit then in effect for the Plan Year, net of any required taxes, Savings Plan deferrals and salary reduction amounts described in Code Section 125. The
maximum deferral percentage of his or her Compensation that an Eligible Employee can elect is the maximum percentage of Compensation needed to defer under the Savings Plan to obtain the maximum match thereunder. However, deferrals to the Plan shall
begin as of the first payroll period after the Participant earns Compensation equal to the Code Section 401(a)(17) limit, whether or not the Participant has made the maximum salary deferrals under Code Section 402(g). For the Plan Year
beginning January 1, 2011 only, if an Eligible Employee elected to defer 6% of his or her Compensation, such election shall continue to apply to any Compensation Deferral applied to the Eligible Employee’s Annual Incentive Plan bonus, if
any, that is paid in 2011. 

 (c) No Changes. Subject to
Section 3.03, a Salary and Compensation Deferral election shall be irrevocable as of the first day of the Plan Year to which the Election Form relates, or if an election is filed under Section 4.03, the 31st day of the newly-eligible election period. 

(d) Crediting. Salary or Compensation Deferrals made by a Participant will be credited to his or her applicable
Plan Year subaccount as soon as practical after the date that the Salary or Compensation amount to which those Salary or Compensation Deferrals relate would have otherwise been paid. 

4.02 Bonus. 

  
 9 

 (a) Elections. The Administrator may prescribe such rules and
requirements regarding Bonus Deferral elections. 
  

	 	(i)	Generally. Subject to Article III, an Eligible Executive may make a Bonus Deferral by filing an Election Form with the Administrator before the beginning of the
Plan Year in which the Bonus is earned. All deferrals shall be made on a pre-tax basis. 

  

	 	(ii)	Performance-Based Compensation. Notwithstanding anything in the Plan to the contrary, to the extent the Committee determines that a Bonus constitutes
“performance-based compensation” (within the meaning of Code Section 409A and Regulations issued thereunder), the Committee may permit an Eligible Executive to file an Election Form with the Administrator on or before a date that
occurs no later than six months before the end of the performance period provided that (A) the Eligible Executive performs services continuously from the later of the beginning of the performance period or the date the criteria are established
through the date the Election Form is submitted and (B) the compensation is not readily ascertainable (within the meaning of Code Section 409A and Regulations issued thereunder) as of the date the Election Form is filed. If a Bonus
Deferral election is made pursuant to this paragraph after the beginning of the Plan Year in which the Bonus is earned, such election shall be void if the Bonus becomes payable as a result of the Eligible Executive’s death before the
satisfaction of the performance criteria. 

 (b) Amount. For each Plan Year, an Eligible
Executive may elect to make a Bonus Deferral with respect to any amount of his or her Bonus net of any required taxes, Savings Plan deferrals and salary reduction amounts described in Code Section 125. Further, the amount deferred will be equal
to the percentage elected for his or her Bonus Deferral plus the percentage elected for his Salary Deferral. The total amount of Salary Deferrals and Bonus Deferrals for a given Plan Year cannot exceed 80% of his or her Compensation. 

(c) No Changes. Subject to Section 3.03, such Bonus Deferral election shall be irrevocable as of the first day
of the Plan Year to which the Election Form relates or the deadline established by the Administrator for performance-based compensation, as the case may be. 
 (d) Crediting. Bonus Deferrals made by the Participant will be credited to his or her applicable Plan Year subaccount as soon as practical after the date that the Bonus amount to which those Bonus
Deferrals relate would have otherwise been paid. 
 4.03 Newly Eligible Executives. 

  
 10 

 (a) Notwithstanding anything in the Plan to the contrary, if an individual
first becomes an Eligible Executive after the start of a Plan Year (and is not already eligible to participate in any other “account balance plan” (as defined in Treasury Regulation Section 1.409A-1(c)(2)(i)(A)) of the Company or an
Affiliate), that individual may, within 30 days after he or she first becomes eligible to participate in the Plan, elect to make a Salary Deferral election. An election to participate shall only be effective with respect to Salary earned for
services performed by such individual in pay periods during that Plan Year beginning after the filing of his or her Election Form. An Eligible Executive who first becomes eligible during the Plan Year may only make a Bonus Deferral if he or she
first becomes eligible before June 30 of the Plan Year. 
 (b) Where a Participant who is an Eligible
Executive has ceased being eligible to participate in the Plan and he or she subsequently becomes eligible to participate in the Plan again, such individual may be treated as being initially eligible to participate in the Plan for purposes of
subsection (a) if he or she had not been eligible to participate in the Plan (or any other “account balance plan,” as defined in Treasury Regulation Section 1.409A-1(c)(2)(i)(A) of the Company or an Affiliate) (other than the
accrual of earnings) at any time during the 24-month period ending on the date the individual again becomes eligible to participate in the Plan. Such individual shall be permitted to make an election during the 30 day period described in subsection
(a). 
 4.04 Matching Contributions. 

(a) Eligibility. Participants shall be entitled to a Matching Contribution under the Plan only to the extent he or
she has satisfied the eligibility requirements for an employer matching contribution under the Savings Plan. 

(b) Amount. The amount of the Matching Contribution to which a Participant is entitled will be a percentage of
Compensation that he or she elects to defer under the Plan applied to the matching contribution formula then in effect under the Savings Plan less the amount of matching contribution made, if any, under the Savings Plan. 

(c) Crediting. The Matching Contributions to which the Participant is entitled will be credited to his or her
applicable Plan Year subaccount at such time and in such manner as determined by the Administrator and as applied uniformly to all Participants. 
 4.05 Non-Elective Contributions. 
 (a) Eligibility.
For each Plan Year, the Company or an Affiliate, in its sole discretion, may, but is not required to, credit any amount it desires as a Company Contribution and/or Make-Up Contribution to the Plan Year subaccount of one or more Participants, on such
terms as it determines, which need not be the same for each Participant. 
 (b) Company Contribution.

  

	 	(i)	 Form of Payment. Subject to Article III, a Participant who receives a Company Contribution may make a separate election as to the

  
 11 

	 	 
form of payment for such Amount. Any Election Form selecting a form of payment must be filed with the Administrator either: 

 

	 	(A)	During a period of at least 30 days, or as otherwise specified by the Administrator in its discretion, that occurs before the beginning of the Plan Year in which
the Company Contribution is earned or begins to be earned, as the case may be, or 

  

	 	(B)	Within 30 days after the Company Contribution is awarded, Contribution is subject to a vesting schedule of at least 12 months from the date the completed Election Form
is filed with the Administrator (taking into account any automatic vesting provisions that may be provided upon certain terminations from employment that may occur before such 12 month period). 

If no such Election Form is filed, then the Participant’s elected form of payment that applies to the Plan Year
subaccount in which the Company Contribution is credited shall apply. 
  

	 	(ii)	No Changes. Subject to Section 3.03, a Participant’s Election Form shall be irrevocable as of the first day of the Plan Year to which the Election Form
relates. 

  

	 	(iii)	Amount. The Company Contribution credited to a Participant shall be determined by the Committee or the Administrator, in their discretion. Such contribution may
be smaller or larger than the amount credited to any other Participant, and the amount credited to any Participant for a Plan Year may be zero, even though one or more other Participants receive a Company Contribution for that Plan Year. Crediting
of a Company Contribution for one Plan Year does not guarantee a Company Contribution for subsequent Plan Years. 

 (c) Make-Up Contribution. 
  

	 	(i)	Form of Payment. If a Participant is credited with a Make-Up Contribution, such contribution shall be paid in a lump sum at the earlier of the Participant’s
Separation from Service or death. 

  

	 	(ii)	Amount. The Make-Up Contribution credited to a Participant shall be determined by the Committee or the Administrator, in their discretion.

 (d) Crediting. Company and Make-Up Contributions will be credited to a Participant’s
applicable Plan Year subaccount as soon as practical after the date that the Company or Affiliate determines such contributions shall be made. 

  
 12 

 ARTICLE V 
 SUPPLEMENTAL PENSION PLAN CONTRIBUTIONS 
 5.01 Eligibility for
Supplemental Pension Contribution. For Plan Years beginning on and after January 1, 2006, a Participant whose benefit under the Pension Plan or UGS Pension Plan, as the case may be, is limited as a result of Code Section 401(a)(17) or
Code Section 415, shall be credited with a Supplemental Pension Contribution as described in this Article. 
 5.02 In
General. Except as otherwise provided in this Article, the Supplemental Pension Contribution shall be equal to the difference between the amount which was actually credited to his account under the Pension Plan or the UGS Pension Plan, as the
case may be, and the amount which would have been credited to his account had the amount not been limited as a result of Code Section 401(a)(17) or Code Section 415. The Supplemental Pension Contribution to which the Participant is
entitled will be credited to his applicable Plan Year subaccount as of the date that the Pension Benefit to which such Supplemental Pension Contribution relates would otherwise have been credited under the Pension Plan. 

5.03 Former DeCare Dental Pension Plan Participants. An individual who was a named participant in the DeCare Dental Deferred
Compensation Plan and/or the DeCare Dental Restoration Plan as of such plans’ termination on or about April 9, 2009, became a Participant under this Article as of April 9, 2009. Such Participant shall be eligible for a Supplemental
Pension Contribution if he previously participated in the DeCare Dental Pension Plan, met the Rule of 65 (as defined under the Pension Plan) as of December 31, 2009 and became a Participant in the Pension Plan on January 1, 2010. In such
circumstance, the Supplemental Pension Contribution will be equal to the “Supplemental Part A Benefit,” the “Supplemental A* Benefit,” if any, plus the “Supplemental Part B Benefit,” if any, each as further described
below. 
 (a) The Supplemental Part A Benefit will be equal to: 

 

	 	(i)	the Part A Benefit (as determined under and set forth in the Pension Plan) that would have been payable to the Participant without regard to Code
Section 401(a)(17) or Code Section 415, as of December 31, 2014 (or such earlier Separation from Service) less the Part A Benefit actually payable to the Participant under the Pension Plan and determined in an annuity, less

  

	 	(ii)	an annuity equivalent of any lump sum amount received by the Participant from (i) the DeCare Dental Deferred Compensation Plan and the DeCare Dental Restoration
Plan upon the respective plans’ termination, and (ii) if applicable, the non-qualified plans sponsored by BCBSM, Inc. (d/b/a Blue Cross Blue Shield of Minnesota) that provided benefits in excess of the benefits provided under such
entity’s qualified plans. 

 The Part A Benefit formula uses a Participant’s actual
“Salary” (as defined in Exhibit S of the Pension Plan), to determine the Part A Benefit. In the event a Participant has an individual agreement that provides for 

  
 13 

 
certain assumptions to apply in the determination of Salary, the terms of the agreement shall be given effect. 

The Supplemental Part A Benefit will be credited to a Plan Year subaccount as soon as administratively feasible after
December 31, 2014, or Separation from Service, as the case may be. 
 (b) If the Participant continues to be
eligible to participate in the Pension Plan after December 31, 2014, the Supplemental Part A* Benefit will be equal to the Benefit Transition Adjustment (as determined and defined under the Pension Plan) without regard to Code
Section 401(a)(17) less the actual Benefit Transition Adjustment payable to the Participant under the Pension Plan. Such Benefit Transition Adjustment will be determined each Plan Year. The Supplemental Part A* Benefit to which the Participant
is entitled will be credited to his applicable Plan Year subaccount as of the date that the Benefit Transition Adjustment to which such Supplemental Part A* Benefit relates would otherwise have been credited under the Pension Plan. 

(c) If the Participant continues to be eligible to participate in the Pension Plan after December 31, 2014, the
Supplemental Part B Benefit will be determined under, and credited pursuant to, Section 5.02 of this Article. 
 5.04
QSERP. Notwithstanding anything in this Article to the contrary and subject to Section 12.06, the Company reserves the discretion to credit some or all of a Participant’s Supplemental Pension Contributions including earnings on such
amounts, on a prospective or retroactive basis, to the Pension Plan or the UGS Pension Plan, as the case may be. Any such credit shall only be made if it is consistent with applicable rules governing the Pension Plan and/or the UGS Pension Plan and
Code Section 409A and Regulations issued thereunder. 
 ARTICLE VI 

EARNINGS 

6.01 Investment Funds. Amounts credited to a Participant’s Account under the Plan shall be credited with earnings, at
periodic intervals determined by the Administrator, at a rate equal to the actual rate of return for such period on the investment fund or funds or index or indices or vehicle or vehicles selected by that Participant. The investment options shall be
the same as those offered under the Savings Plan, from time to time, except for the option to invest in WellPoint common stock or the Vanguard brokerage option (or other self-managed account option that may be offered under the Savings Plan). The
Committee may offer other investment options in its discretion. The rate of return on such investment vehicles shall be tracked solely for the purpose of determining the phantom investment gain, earnings and losses to be credited to the
Participant’s Account during the deferral period. Neither the Company nor any of its affiliates shall be obligated to make any actual investment. 
 6.02 Conversion of Investments from Predecessor Plans and Merged Plans. Before January 1, 2006, amounts representing Predecessor Plan Account balances and account balances from Merged Plans
were credited with earnings based on investment options available under the Predecessor Plan or Merged Plan to which they related. Effective as of January 1, 2006, those 

  
 14 

 
Predecessor Plan Accounts (or accounts from Merged Plans) shall be credited with earnings in accordance with Section 6.01. Before January 1, 2006, the Committee shall prescribe rules
(that may vary among classes of Participants) that provide each Predecessor Plan Participant (and Participant with a Merged Plan account balance) an opportunity to select the investment fund or funds or index or indices to be used as the basis for
crediting his or her Predecessor Plan Account (or Merged Plan account) with earnings as of January 1, 2006. To the extent the Committee has not received investment direction from a Participant before December 15, 2005 with respect to his
or her Predecessor Plan Account or Merged Plan account, such Predecessor Plan Account or Merged Plan account shall be credited with earnings based upon a default investment option under the Savings Plan designated as such by the Committee or in
accordance with such other rules as may be adopted by the Committee and applied on a consistent, uniform basis. 
 ARTICLE VII

 VESTING 
 7.01 Elective Deferrals under the Plan. 
 (a) Each
Participant will be 100% vested in that portion of his or her Account attributable to Salary Deferrals, Compensation Deferrals and Bonus Deferrals made on or after January 1, 2006. 

(b) Deferrals made under the Plan before January 1, 2006 were 100% vested except as follows: 

 

	 	(i)	To the extent any item of Compensation deferred under the Plan before January 1, 2006 would have been subject to additional vesting requirements if not deferred,
then the portion of the Participant’s Plan Year subaccount attributable to that item shall be subject to those additional vesting requirements. 

  

	 	(ii)	Each Participant will vest in the portion of each Plan Year subaccount attributable to “Supplemental Pension Plan Contributions” and “Supplemental
Special Deferred Compensation Arrangements” (as those terms were defined in the Plan before January 1, 2006) in the same manner that he or she vests under the Pension Plan, as amended from time to time, and/or under any “Special
Deferred Compensation Arrangement” (as that term was defined in the Plan before January 1, 2006). 

7.02 Supplemental Pension Plan Contributions. 

(a) Contributions made on and after January 1, 2006 to a WellPoint SERP Participant’s Plan Year subaccount under
Article V shall vest in the same manner as benefits vest for such Participant under the Pension Plan and/or UGS Pension Plan, as the case may be, and as such plans may be amended from time to time. 

  
 15 

 (b) Contributions made on and after January 1, 2006 to an Anthem SERP
Participant’s Plan Year subaccount under Article V shall vest in accordance with the terms of the 2005 Anthem SERP. 
 (c) Contributions made on and after January 1, 2010 on behalf of a former DeCare Pension Plan Participant (as described in Section 5.02) shall vest in the same manner as benefits vest for such
Participant under the Pension Plan, as may be amended from time to time. 
 7.03 Predecessor or Merged Plans. Vesting of
a Participant’s Account attributable to deferrals made and accruals earned before January 1, 2006 under a Predecessor Plan or Merged Plan were governed by the terms of the Predecessor Plan or Merged Plan to which they relate. 

7.04 Company and/or Make-Up Contributions. Vesting of any Company Contributions and Make-Up Contributions shall be determined by
the Company or Affiliate, in its sole discretion, and need not be the same for all Participants. 
 ARTICLE VIII

 DISTRIBUTIONS 
 8.01 Annual Election. Participants must indicate on an Election Form which of the distribution options described below will govern payment of the Plan Year subaccount to which deferred amounts are
credited before the beginning of the Plan Year in which the compensation is earned or such earlier or later time as may be specified by the Administrator pursuant to Article III or Article IV. Unless otherwise specified in the Plan or permitted by
the Administrator, such distribution election applies to all amounts credited to the Plan Year subaccount, including, but not limited to, Matching Contributions and Supplemental Pension Contributions, provided such contributions or amounts are
vested at the time of distribution. Except as provided in 8.06, any unvested amounts at Separation from Service shall be forfeited. 
 8.02 Time for Distribution. Except as otherwise provided in Section 8.07, distribution of a Participant’s Account shall be made on the earliest to occur of: 

(a) The date elected by a Participant under Section 8.03 with respect to an In-Service Payout; 

(b) The date set forth in Section 8.03 with respect to the Participant’s Separation from Service; or 

(c) The date set forth in Section 8.06 with respect to the Participant’s death. 

8.03 In-Service Payout. A Participant may irrevocably select, on his or her Election Form, a specified date to
receive a lump sum In-Service Payout of all vested amounts credited to a Plan Year subaccount. Payment shall be made as soon as administratively feasible following the specified date and before the later of (i) December 31 of the calendar
year containing the specified date, or (ii) the 15th
day of the third month following the specified date. If any amounts are unvested at the time of the elected In-Service Payout date, but later become vested, such 

  
 16 

 
remaining amounts shall be paid at the earlier of the Participant’s Separation from Service or Death. 

8.04 Separation from Service. Upon a Participant’s Separation from Service for any reason other than
death, a Participant’s vested Plan Year subaccount shall be paid or begin to be paid as soon as administratively feasible following Separation from Service and before the later of (i) December 31 of the calendar year in which the
Participant’s Separation from Service occurs, or (ii) the 15th day of the third month following the Participant’s Separation from Service. Notwithstanding the foregoing, distributions made to a Key Employee upon such separation shall be paid or begin to be paid
no earlier than the first day following the six month anniversary of the Participant’s Separation from Service unless the Participant dies before or during such six-month period, in which case, such six-month delay shall not apply and payment
shall be made pursuant to Section 8.06. Subsequent installment payments shall be made thereafter on or about the anniversary of the first installment payment. 
 Payment shall be made to the Participant in such form as determined below. 
 (a) Lump Sum. A Participant’s Plan Year subaccount balance shall be paid in a lump sum if: 
  

	 	(i)	timely elected by the Participant pursuant to the Plan; or 

  

	 	(ii)	no valid payment election is in effect when distribution is to be made. 

(b) Annual Installments. A Participant may elect to receive payment of his or her Plan Year subaccount balance in
either: 
  

	 	(i)	five annual installments; or 

  

	 	(ii)	ten annual installments. 

 (c) Exceptions. Notwithstanding the foregoing provisions, the following shall apply: 
  

	 	(i)	If a Participant’s Account balance constituting contributions (other than Company and Make-Up Contributions) for all Plan Years at Separation from Service or
death, whichever is earlier, is equal to or less than the limit then in effect under Code Section 402(g)(1)(B), such balance shall be paid in a lump sum in lieu of any election to receive installments. 

 

	 	(ii)	A Participant who is entitled to receive a Supplemental Part A Benefit, as provided under Article V, shall receive such benefit in a lump sum. Payment of the
Supplemental Part A* Benefit, if any, and Supplemental Part B Benefit, if any, shall be made as otherwise specified in the Plan. 

  
 17 

 8.05 Subsequent Changes in Elections. 

(a) Participants who previously elected to receive an In-Service Payout pursuant to Section 8.03 shall be permitted
to change his or her election to delay the time for payment until the fifth anniversary of the date the lump sum distribution would otherwise have been made. However, no such change of election under this Section shall have any force or effect or
become effective until the expiration of the 12-month period measured from the filing date of such election. In addition, each such change of election with respect to an original election to receive an In-Service Payout shall be valid only if such
election is made at least 12 months before the date of the scheduled distribution. In no event, however, may any change to the time for payment in effect for the Plan Year subaccount result in any acceleration of the distribution of that subaccount.
Notwithstanding anything in this Section to the contrary, in the event of the Participant’s Separation from Service or death after a subsequent election is made but before the end of the five-year delay described above, payment shall instead be
made upon such Separation from Service or death, as the case may be. 
 (b) Notwithstanding any provision in the
Plan to the contrary, on or before December 31, 2008, Participants may make changes to distribution elections previously filed with respect to amounts deferred under the Plan that relate to Plan Years 2005 through 2008 consistent with
transition relief provided by the Department of the Treasury in Notice 2006-79, Notice 2007-86 and proposed regulations promulgated under Code Section 409A. 
 8.06 Death. If a Participant dies on or after January 1, 2011 with a vested balance credited to one or more of his or her Plan Year subaccounts, whether or not the Participant was receiving
payouts from those subaccounts at the time of his or her death, then the Participant’s Beneficiary will receive the vested balance of each of those Plan Year subaccounts in a lump sum. If a Participant has any unvested Matching Contributions or
Supplemental Pension Contributions credited to the Participant’s Account as of death, such amounts will become fully vested, nonforfeitable and distributed pursuant to this Section. 

8.07 Hardship Withdrawal. This Section shall only apply to amounts credited to a Participant’s Account that are subject to
Code Section 409A. Any hardship withdrawal right with respect to grandfathered amounts (within the meaning of Code Section 409A) shall be subject to rules, if any, of the Predecessor Plans. If a Participant (A) incurs a severe
financial hardship as a result of (i) an illness or accident involving the Participant, his or her spouse, Beneficiary or any dependent (as determined pursuant to Code Section 152(a)), (ii) a casualty loss involving the
Participant’s property or (iii) other similar extraordinary and unforeseeable event beyond the Participant’s control and (B) does not have any other resources available, whether through reimbursement or compensation (by insurance
or otherwise) or liquidation of existing assets (to the extent such liquidation would not itself result in financial hardship), to satisfy such financial emergency, then the Participant may apply to the Administrator for an immediate distribution
from the vested portion of his or her Account (but not the Predecessor Plan Account) in an amount necessary to satisfy such financial hardship and the tax liability attributable to such distribution. The Administrator shall have complete discretion
to accept or reject the request and shall in no event authorize a distribution in an amount in excess of that 

  
 18 

 
reasonably required to meet such financial hardship and the tax liability attributable to that distribution. 
 Any hardship withdrawal shall be made only to the extent permitted in accordance with Regulation Section 1.409A-3(i)(3). As a condition of the Administrator’s acceptance of a request for a
hardship withdrawal under this Section, the Participant’s election to make Salary Deferrals, Bonus Deferrals and/or Compensation Deferrals shall be terminated for the remainder of the Plan Year in which the hardship withdrawal is taken. In
addition, such Participant shall be suspended from making Salary Deferrals, Compensation Deferrals and Bonus Deferrals for the Plan Year immediately after the Plan Year in which the hardship withdrawal is taken. Such Participant, if then an Eligible
Employee or Executive, may make a deferral election that relates to the second Plan Year following the Plan Year in which the hardship withdrawal was made in accordance with Article III and Article IV. 

8.08 Valuation. The amount to be distributed from any Plan Year subaccount pursuant to this Article VIII shall be determined on
the basis of the vested balance credited to that subaccount as of the most recent practicable date (as determined by the Administrator or its delegate) preceding the date of the actual distribution. 

8.09 Tax Withholding. Income taxes and other taxes payable with respect to an Account shall be deducted from amounts payable under
the Plan. All federal, state or local taxes that the Administrator determines are required to be withheld from any payments made pursuant to this Article VIII shall be withheld. 

8.10 Payment of Small Accounts. The Administrator may, in its sole discretion which shall be evidenced in writing no later than
the date of payment, elect to pay the value of the Participant’s Account in a single lump sum if the balance of such Account is not greater than the applicable dollar amount under Code Section 402(g)(1)(B), provided the payment represents
the complete liquidation of the Participant’s interest in the Plan and all other account balance plans as determined pursuant to Regulation Section 1.409A-1(c)(2). 
 8.11 Right of Offset. The Company or an Affiliate shall have the right to offset any amounts payable to a Participant under the Plan to reimburse the Company or an Affiliate for liabilities or
obligations of the Participant to the Company or Affiliate if the following conditions are met: 
 (a) the
liabilities or obligations of the Participant to the Company or Affiliate were incurred in the ordinary course of the service relationship between the Participant and the Company or Affiliate; 

(b) the entire amount to be offset does not exceed $5,000 in any taxable year of the Participant; and 

(c) the offset is made at the same time and in the same amount as the liabilities or obligations otherwise would have been
due and collected from the Participant. 

  
 19 

 8.12 Bona Fide Dispute. The Committee or the Administrator shall have the discretion
to accelerate the time or schedule of payment under the Plan pursuant to Regulation Section 1.409A-3(j)(4)(xiv) where such payment occurs as part of an arm’s length settlement of a bona fide dispute between the Company or an Affiliate and
a Participant as to the Participant’s right to the deferred amount. 
 8.13 Income Inclusion Under Code
Section 409A. The Committee or the Administrator shall have the discretion to accelerate the time or schedule of payment under the Plan if the Plan fails to meet the requirements of Code Section 409A and Regulations issued thereunder,
provided that any such payment does not exceed the amount required to be included in income as a result of such failure. 
 8.14
Effect of Rehire. In the event a Participant experiences a Separation from Service, begins receiving payment of his or her Account and is subsequently rehired by the Company or an Affiliate, distributions shall continue as regularly
scheduled. 
 ARTICLE IX 
 EFFECT ON PREDECESSOR AND MERGED PLANS 
 9.01 Coordination With
Predecessor Plans. Solely for ease of administration, the Predecessor Plans may be attached as exhibits to the Plan and are incorporated by reference herein. Except as otherwise specifically provided in the Plan, eligibility for and entitlement
to benefits under the Predecessor Plans are governed solely by the terms of those Predecessor Plans. Effective January 1, 2005 (or such earlier date as may be provided in a Predecessor Plan), Participants ceased to accrue further benefits under
the Predecessor Plans; however, Predecessor Plan benefits continue to accrue earnings per the Predecessor Plan terms before January 1, 2006 and pursuant to the Plan effective as of January 1, 2006. A Predecessor Plan Participant who does
not meet the requirements of an Eligible Executive or Eligible Employee shall participate in the Plan (and have rights and obligations hereunder) solely with respect to the Predecessor Plan Account maintained under the Plan on his or her behalf.

 9.02 Predecessor Plan Accounts. Although benefits accrued under Predecessor Plans are grandfathered for purposes of
Code Section 409A to the extent such amounts were earned and vested as of December 31, 2004, for administrative purposes, the December 31, 2005 Predecessor Plan Account balance of any Predecessor Plan Participant became accounted for
under the Plan as of January 1, 2006 and shall be subject to Article VI. In all other respects, each Predecessor Plan Account shall remain subject exclusively to the terms of the Predecessor Plan to which it relates, including without
limitation the existing distribution election (commencement date and form of distribution) applicable to the Predecessor Participant’s Predecessor Plan Account. Any change in that distribution election must be made in compliance with the
applicable provisions of the applicable Predecessor Plan. 
 9.03 Merged Plans. The 2005 Anthem Plan, the 2005 Anthem
SERP, the 2005 Trigon Plan and the 2005 Trigon SERP were merged into the Plan effective as of December 31, 2005. All benefits accrued under such merged plans are subject to Code Section 409A. In conjunction with the merger, on and after
January 1, 2006, benefits ceased to accrue under the 2005 Anthem Plan, the 2005 Anthem SERP, the 2005 Trigon Plan, and the 2005 Trigon SERP except as 

  
 20 

 
otherwise provided in the Plan. The rights and obligations of participants in the Merged Plans before their effective dates of merger shall be governed solely by the terms of the Merged Plans;
provided, however, that to the extent minimally necessary to comply with the requirements of Section 409A of the Code, the requirements and restrictions of Sections 5.01(a)-(c) and 8.01(a)-(d) of the 2005 WellPoint Plan shall apply,
effective as of January 1, 2005, to the portion of the Participant’s Account attributable to the 2005 Anthem Plan. Distributions of amounts attributable to Merged Plan benefits are made pursuant to a Participant’s election in effect
under the applicable Merged Plan. If no such election is on file, amounts shall be distributed in a single lump sum payment. 

ARTICLE X 

CLAIMS PROCEDURES 
 10.01 Presentation of Claim. No application is required for the commencement of benefits under the Plan. However, if a Participant or Beneficiary (“Claimant”) believes that he or she is
entitled to a greater benefit under the Plan, the Claimant may submit a signed, written application to the Committee for such a greater benefit. If such a claim relates to the contents of a notice received by the Claimant, the claim must be made
within 90 days after such notice was received by the Claimant. All other claims shall be made within 180 days of the date on which the event that caused the claim to arise occurred. The claim shall state with particularity the determination desired
by the Claimant. A claim shall be considered to have been made when a written communication made by the Claimant or the Claimant’s representative is received by the Committee or its authorized delegate. References to the Committee in this
Article includes references to the Executive Vice President and Chief Human Resources and, if applicable, such officer’s delegate. The Executive Vice President and Chief Human Resources may further delegate, orally or in writing, authority to
decide certain claims under this Article. 
 10.02 Decision on Initial Claim. The Committee shall consider a
Claimant’s claim and provide written notice to the Claimant of any denial within a reasonable time, but no later than 90 days after receipt of the claim. If an extension of time beyond the initial 90-day period for processing is required,
written notice of the extension shall be provided to the Claimant before the initial 90-day period expires indicating the special circumstances requiring an extension of time and the date by which the Committee expects to render a final decision. In
no event shall the period, as extended, exceed 180 days. If the Committee denies, in whole or in part, the claim, the notice shall set forth in a manner calculated to be understood by the Claimant: 

(a) The specific reasons for the denial of the claim, or any part thereof; 

(b) Specific references to pertinent Plan provisions upon which such denial was based; 

(c) A description of any additional material or information necessary for the Claimant to perfect the claim, and an
explanation of why such material or information is necessary; and 

  
 21 

 (d) An explanation of the claim review procedure, which explanation shall
also include a statement of the Claimant’s right to bring a civil action under ERISA Section 502(a) following a denial of the claim upon review. 
 10.03 Right to Review. A Claimant is entitled to appeal any claim that has been denied in whole or in part. To do so, the Claimant must submit a signed, written request for review with the
Committee within 60 days after receiving a notice from the Committee that a claim has been denied, in whole or in part. Absent receipt by the Committee of a written request for review within such 60-day period, the claim shall be deemed to be
conclusively denied. The Claimant (or the Claimant’s duly authorized representative) may: 
 (a) Review
and/or receive copies of, upon request and free of charge, all documents, records, and other information relevant to the Claimant’s claim; and/or 
 (b) Submit written comments, documents, records or other information relating to her claim, which the Committee shall take into account in considering the claim on review, without regard to whether such
information was submitted or considered in the initial review of the claim. 
 If a Claimant requests to review and/or receive
copies of relevant information pursuant to subsection (a) above before filing a written request for review, the 60-day period for submitting the written request for review will be tolled during the period beginning on the date the Claimant
makes such request and ending on the date the Claimant reviews or receives such relevant information. 
 10.04 Decision on
Review. The Committee shall render its decision on review promptly, and not later than 60 days after it receives a written request for review of the denial, unless other special circumstances require additional time. In such case, the Committee
will notify the Claimant, before the expiration of the initial 60-day period and in writing, of the need for additional time, the reason the additional time is necessary, and the date (no later than 60 days after expiration of the initial 60-day
period) by which the Committee expects to render its decision on review. Notwithstanding the foregoing, if the Committee determines that an extension of the initial 60-day period is required due to the Claimant’s failure to submit information
necessary for the Committee to decide the claim, the time period by which the Committee must make its determination on review shall be tolled from the date on which the notification of the extension is sent to the Claimant until the date on which
the Claimant responds to the request for additional information. The decision on review shall be written in a manner calculated to be understood by the Claimant, and shall contain: 

(a) Specific reasons for the decision; 

(b) Specific references to the pertinent Plan provisions upon which the decision was based; 

(c) A statement that the Claimant is entitled to receive, upon request and free of charge, reasonable access to, and
copies of, all documents, records or other information relevant (within the meaning of Department of Labor Regulation Section 2560.503-1(m)(8)) to the Claimant’s claim; 
  

  
 22 

 (d) A statement of the Claimant’s right to bring a civil action under
ERISA Section 502(a) following a wholly or partially denied claim for benefits; and 
 (e) Such other
matters as the Committee deems relevant. 
 10.05 Form of Notice and Decision. Any notice or decision by the Committee
under this Article may be furnished electronically in accordance with Department of Labor Regulation Section 2520.104b-(1)(c)(i), (iii) and (iv). 
 10.06 Legal Action. Any final decision by the Committee shall be binding on all parties. A Claimant’s compliance with the foregoing provisions of this Article is a mandatory prerequisite to a
Claimant’s right to commence any legal action with respect to any claim for benefits under the Plan. Any such legal action must be initiated no later than 180 days after the Committee renders its final decision. If a final determination of
the Committee is challenged in court, such determination shall not be subject to de novo review and shall not be overturned unless proven to be arbitrary and capricious based on the evidence considered by the Committee at the time of such
determination. 
 ARTICLE XI 
 ADMINISTRATION 
 11.01 Plan Administration. The Committee has
overall responsibility for the Plan, but the Administrator shall have responsibility for the day-to-day administration of the Plan, as specified herein and as otherwise delegated by the Committee. The Administrator and members of the Committee may
be Participants under this Plan. Any individual serving on the Committee who is a Participant shall not vote or act on any matter relating solely to himself or herself. The Chief Executive Officer, Executive Vice President and Chief Human Resources
or any other individual charged with administrative authority may not act on any matter involving such individual’s own participation in the Plan. 
 11.02 Powers, Duties and Procedures. The Committee shall have full and complete discretionary authority to (i) make, amend, interpret and enforce all appropriate rules and regulations for the
administration of the Plan, including any rules relating to trading restrictions as it determines necessary, and (ii) decide or resolve any and all questions including interpretations of the Plan, as may arise in connection with the claims
procedures set forth in Article X or otherwise with regard to the Plan. The Committee shall have complete control and authority to determine the rights and benefits of all claims, demands and actions arising out of the provisions of the Plan of any
Participant or Beneficiary or other person having or claiming to have any interest under the Plan. When making a determination or calculation, the Committee may rely on information furnished by a Participant or the Company, an Affiliate or other
related entity. Benefits under the Plan shall be paid only if the Committee decides in its sole discretion that the Participant or Beneficiary is entitled to them. The Committee may delegate such powers and duties as it determines for the efficient
administration of the Plan. 
 11.03 Agents. In the administration of this Plan, the Committee or the Administrator may,
from time to time, employ agents and delegate to them such administrative duties as it sees 

  
 23 

 
fit (including acting through a duly appointed representative) and may from time to time consult with counsel who may be counsel to the Company, an Affiliate or other related entity. 

11.04 Binding Effect of Decisions. Notwithstanding any other provision of the Plan to the contrary, the Committee or its delegate
shall have complete discretion to interpret the Plan and to decide all matters under the Plan. Any such interpretation shall be final, conclusive and binding on all Participants, Beneficiaries and any person claiming under or through any
Participant, in the absence of clear and convincing evidence that the Committee or its delegate acted arbitrarily and capriciously. 
 11.05 Information. To enable the Committee and the Administrator to perform its functions, the Company, an Affiliate or other related entity shall supply full and timely information to the
Committee or the Administrator, as the case may be, on all matters relating to the compensation of its Participants, the dates of the death or Separation from Service and such other pertinent information as the Committee or Administrator may
reasonably require. 
 11.06 Coordination with Other Benefits. The benefits provided to a Participant and the Beneficiary
under the Plan are in addition to any other benefits available to such Participant under any other plan or program for employees of the Company, an Affiliate or other related entity. The Plan shall supplement and shall not supersede, modify or amend
any other such plan or program except as may otherwise be expressly provided. 
 ARTICLE XII 

MISCELLANEOUS 
 12.01 Limitation of Rights. Participation in the Plan does not give any individual the right to be retained in the service of the Company, any Affiliate or other related entity, or to interfere
with the right of the Company, any Affiliate or other related entity to discipline or discharge the individual at any time, with or without cause, or to modify the Salary, Compensation or Bonus of such individual at any time. 

12.02 Additional Restrictions. If the Administrator determines that additional restrictions or limitations must be placed on the
investment vehicles utilized for measuring the return on the amounts credited to Participant Accounts, the right of Participants to make investment elections with respect to their Accounts, their ability to make or change distribution elections,
their ability to defer distributions or to change the commencement date for the distribution of their benefits or the method of such distribution or their rights or status as creditors under the Plan in order to avoid current income taxation of
amounts deferred under the Plan, the Administrator may, in its sole discretion, amend the Plan to impose such restrictions or limitations, cease deferrals under the Plan and/or defer distribution dates under the Plan. 

12.03 Indemnification. The Company will indemnify and hold harmless the Directors, the members of the Committee and any delegate
of the Committee, and employees of the Company and its Affiliates, from and against any and all liabilities, claims, costs and expenses, including attorneys’ fees, arising out of an alleged breach in the performance of their fiduciary duties
under the Plan, other than such liabilities, claims, costs and expenses as may result from the gross negligence or willful misconduct of such persons. The Company shall have the right, 

  
 24 

 
but not the obligation, to conduct the defense of such persons in any proceeding to which this Section applies. 
 12.04 Assignment. To the fullest extent permitted by law, benefits under the Plan and rights thereto are not subject in any manner to anticipation, alienation, sale, transfer, assignment, pledge,
encumbrance, attachment, or garnishment by creditors of a Participant or a Beneficiary. 
 12.05 Inability to Locate
Recipient. If a benefit under the Plan remains unpaid for two (2) years from the date it becomes payable, solely by reason of the inability of the Administrator to locate the Participant or Beneficiary entitled to the payment, the benefit
shall be treated as forfeited. Any amount forfeited in this manner shall be restored without interest upon presentation of an authenticated written claim by the person entitled to the benefit. 

12.06 Amendment and Termination. 
 (a) The Committee may, at any time, amend or terminate the Plan. Any amendment must be made in writing; no oral amendment will be effective. Except to the limited extent authorized pursuant to
Section 12.02, no amendment may, without the consent of an affected Participant (or, if the Participant is deceased, the Participant’s Beneficiary), adversely affect the Participant’s or the Beneficiary’s rights and obligations
under the Plan with respect to amounts already credited to a Participant’s Account, and all amounts deferred under the Plan before the date of any such amendment or termination of the Plan shall continue to become due and payable in accordance
with the distribution provisions of Article VIII as in effect immediately before such amendment or termination. 

(b) Notwithstanding subsection (a), if the Company exercises its discretion under Article V and determines an amendment is
necessary to the Plan, participant consent shall only be required if the amendment impacts Supplemental Contributions and earnings credited through December 31, 2008. 

(c) Upon termination of the Plan, the Committee reserves the discretion to accelerate distribution of the Accounts of
Participants in accordance with regulations promulgated by the Department of Treasury under Code Section 409A. 
 12.07
Applicable Law. To the extent not governed by Federal law, the laws of the State of Indiana shall govern the Plan. If any provision of the Plan is held to be invalid or unenforceable, the remaining provisions of the Plan will continue to be
fully effective. 
 12.08 No Funding. The obligation to pay the vested balance of each Participant’s Account shall
at all times be an unfunded and unsecured obligation of the Company or its Affiliates, as the case may be, and Participants and Beneficiaries shall have the status of general unsecured creditors of the Company or applicable Affiliate. Except to the
extent provided below in Section 12.09, Plan benefits will be paid from the general assets of the Company, and nothing in the Plan will be construed to give any Participant or any other person rights to any specific assets of the Company or its
Affiliates. In all events, it is the intention of the Company and its Affiliates and all Participants that the Plan be treated as unfunded for tax purposes and for purposes of Title I of ERISA. 

  
 25 

 12.09 Trust. The benefits under the Plan will be paid from the assets of a grantor
trust (the “Trust”) established by the Company to assist it and its Affiliates in meeting their obligations hereunder and, to the extent that such assets are not sufficient, by the Company or the applicable Affiliate out of their general
assets. The Trust shall conform to the terms of the Internal Revenue Service Model Trust in Internal Revenue Service Procedure 92-64 (or any successor procedure). 
 *            *            * 

IN WITNESS WHEREOF, WellPoint, Inc. has caused the Plan to be executed by its duly authorized representative as of the date
indicated above. 
  

			
	WELLPOINT, INC.
		
	By:	 	 
		 	Angela F. Braly
		 	Chair, President & CEO

  
 26Blue Cross License Agreement

 Exhibit 10.14 
 BLUE CROSS LICENSE AGREEMENT 
 (Includes revisions, if any, adopted by
Member Plans through their November 18, 2010 meeting) 
 This agreement by and between Blue Cross and Blue Shield
Association (“BCBSA”) and The Blue Cross Plan, known as ________________ (the “Plan”). 
 Preamble

 WHEREAS, the Plan and/or its predecessor(s) in interest (collectively the “Plan”) had the right to use the
BLUE CROSS and BLUE CROSS Design service marks (collectively the “Licensed Marks”) for health care plans in its service area, which was essentially local in nature; 
 WHEREAS, the Plan was desirous of assuring nationwide protection of the Licensed Marks, maintaining uniform quality controls among Plans, facilitating the provision of cost effective health care services
to the public and otherwise benefiting the public; 
 WHEREAS, to better attain such ends, the Plan and the predecessor of BCBSA
in 1972 simultaneously executed the BCA License Agreement (s) and the Ownership Agreement; and 
 WHEREAS, BCBSA and the
Plan desire to supercede said Agreement(s) to reflect their current practices and to assure the continued integrity of the Licensed Marks and of the BLUE CROSS system; 
 NOW, THEREFORE, in consideration of the foregoing and the mutual agreements hereinafter set forth and for other good and valuable consideration, the receipt and sufficiency of which are hereby
acknowledged, the parties agree as follows: 

 Agreement 

1. BCBSA hereby grants to the Plan, upon the terms and conditions of this License Agreement, the right to use BLUE CROSS in its trade
and/or corporate name (the “Licensed Name”), and the right to use the Licensed Marks, in the sale, marketing and administration of health care plans and related services in the Service Area set forth and defined in paragraph 5 below. As
used herein, health care plans and related services shall include acting as a nonprofit health care plan, a for-profit health care plan, or mutual health insurer operating on a not-for-profit or for-profit basis, under state law; financing access to
health care services; when working with a bank that holds the relevant license to use the Licensed Name and Marks, offering: (i) tax- favored savings accounts for medical expenses and means for accessing such accounts, such as debit cards or
checks, that are provided solely to support access to such tax-favored savings accounts, all pursuant to such license, or (ii) prepaid rewards cards that are provided for completion of a wellness program, all pursuant to such license; providing
health care management and administration; administering, but not underwriting, non-health portions of Worker’s Compensation insurance; delivering health care services, except hospital services (as defined in the Guidelines to Membership
Standards Applicable to Regular Members); and performing the Eligibility and Enrollment functions of HR administration for all benefit plans offered by a group account to its members, including benefit plans not provided by the Plan, provided that
the Plan has contracted to provide Health Coverage under the Licensed Marks to the account (as the terms “Health Coverage,” “Eligibility” and “Enrollment” are defined in Exhibit 4, Paragraph 2.t.). 

2. The Plan may use the Licensed Marks and Name in connection with the offering of: a) health care plans and related services in the
Service Area through Controlled Affiliates, provided that each such Controlled Affiliate is separately licensed to use the Licensed Marks and Name under the terms and conditions contained in the Agreement attached as Exhibit 1 hereto (the
“Controlled Affiliate License Agreement”); and: b) insurance coverages offered by life insurers under the applicable law in the Service Area, other than those which the Plan may offer in its own name, provided through Controlled
Affiliates, provided that each such Controlled Affiliate is separately licensed to use the Licensed Marks and Name under the terms and conditions contained in the Agreement attached as Exhibit 1A hereto (the “Controlled Affiliate License
Agreement Applicable to Life Insurance Companies”) or the Agreement attached as Exhibit 1A1 hereto (the “Controlled Affiliate Trademark License Agreement for Life and Disability Insurance Products”) and further provided that the
offering of such services does not and will not dilute or tarnish the unique value of the Licensed Marks and Name; and c) administration and underwriting of Workers’ Compensation Insurance Controlled Affiliates, provided that each such
Controlled Affiliate is separately licensed to use the Licensed Marks and Name under the terms and conditions contained in the Agreement attached as Exhibit 1 hereto (the “Controlled Affiliate License.”); and d) regional Medicare Advantage
PPO products in cooperation with one or more other Plans through jointly-held Controlled Affiliates, provided that each such Controlled Affiliate is separately licensed to use the Licensed Marks and Name under the terms and conditions contained in
the Agreement attached as Exhibit 1B hereto (the “Controlled Affiliate License Agreement Applicable to Regional Medicare Advantage PPO Products”); and e) regional Medicare Part D Prescription Drug Plan products in cooperation with one or
more other Plans through jointly-held Controlled Affiliates, provided that each such Controlled Affiliate is separately licensed to use the Licensed Marks and Name under the terms and conditions contained in the Agreement attached as Exhibit 1C
hereto (the “Controlled Affiliate License Agreement Applicable to Regional Medicare Part D Prescription Drug Plan Products”). As used herein, a Controlled Affiliate is defined as an entity organized and operated in such a manner that it is
subject to the bona fide control of a Plan or Plans and, if the entity meets the standards of subparagraph B but not subparagraph A of this paragraph, the 

  

					
		  		  	Amended as of November 18, 2010
		  		  	

 
entity, its owners, and persons with authority to select or appoint members or board members, other than a Plan or Plans, have received written approval of BCBSA. Absent written approval by BCBSA
of an alternative method of control, bona fide control with respect to the Controlled Affiliate Licenses authorized in clauses a) through c) of this Paragraph 2 shall mean that a Plan or Plans authorized to use the Licensed Marks in the Service Area
of the Controlled Affiliate pursuant to this License Agreement(s) with BCBSA, other than such Controlled Affiliate’s License Agreement(s), (for purposes of subparagraphs 2.A. and 2.B., the “Controlling Plan(s)”), must have:

  

	 	A.	The legal authority, directly or indirectly through wholly-owned subsidiaries: (a) to select members of the Controlled Affiliate’s governing body having more
than 50% voting control thereof; (b) to exercise control over the policy and operations of the Controlled Affiliate; (c) to prevent any change in the articles of incorporation, bylaws or other establishing or governing documents of the
Controlled Affiliate with which the Controlling Plan(s) do(es) not concur. In addition, a Plan or Plans directly or indirectly through wholly-owned subsidiaries shall own more than 50% of any for-profit Controlled Affiliate; or

  

	 	B.	The legal authority directly or indirectly through wholly-owned subsidiaries (a) to select members of the Controlled Affiliate’s governing body having not
less than 50% voting control thereof; (b) to prevent any change in the articles of incorporation, bylaws or other establishing or governing documents of the Controlled Affiliate with which the Controlling Plan(s) do(es) not concur; (c) to
exercise control over the policy and operations of the Controlled Affiliate at least equal to that exercised by persons or entities (jointly or individually) other than the Controlling Plan(s). Notwithstanding anything to the contrary in
(a) through (c) hereof, the Controlled Affiliate’s establishing or governing documents must also require written approval by the Controlling Plan(s) before the Controlled Affiliate can: 

 

	 	1.	Change its legal and/or trade name; 

  

	 	2.	Change the geographic area in which it operates; 

  

	 	3.	Change any of the types of businesses in which it engages; 

  

	 	4.	Create, or become liable for by way of guarantee, any indebtedness, other than indebtedness arising in the ordinary course of business; 

 

	 	5.	Sell any assets, except for sales in the ordinary course of business or sales of equipment no longer useful or being replaced; 

 

	 	6.	Make any loans or advances except in the ordinary course of business; 

  

					
		  		  	Amended as of June 11, 1998
		  	-2-	  	

	 	7.	Enter into any arrangement or agreement with any party directly or indirectly affiliated with any of the owners of the Controlled Affiliate or persons or entities with
the authority to select or appoint members or board members of the Controlled Affiliate, other than the Plan or Plans (excluding owners of stock holdings of under 5% in a publicly traded Controlled Affiliate); 

 

	 	8.	Conduct any business other than under the Licensed Marks and Name; 

  

	 	9.	Take any action that any Controlling Plan or BCBSA reasonably believes will adversely affect the Licensed Marks or Names. 

In addition, a Plan or Plans directly or indirectly through wholly owned subsidiaries shall own at least 50% of any for-profit Controlled
Affiliate. With respect to the Controlled Affiliate License Agreements authorized in clauses d) and e) of this Paragraph 2, and absent written approval by BCBSA of an alternative method of control, bona fide control shall mean that the Controlled
Affiliate is organized and operated in such a manner that it meets the following requirements: 
  

	 	C.	The Controlled Affiliate is owned or controlled by two or more Plans authorized to use the Licensed Marks pursuant to this License Agreement with BCBSA (for purposes of
this subparagraph 2.C. through subparagraph 2.E., the “Controlling Plans”); 

  

	 	D.	Each Controlling Plan is authorized pursuant to this Agreement to use the Licensed Marks in a geographic area in the Region (as that term is defined in such Controlled
Affiliate License Agreements) and every geographic area in the Region is so licensed to at least one of the Controlling Plans; and 

  

	 	E.	The Controlling Plans must have the legal authority directly or indirectly through wholly-owned subsidiaries (a) to select members of the Controlled
Affiliate’s governing body having not less than 100% voting control thereof; (b) to prevent any change in the articles of incorporation, bylaws or other establishing or governing documents of the Controlled Affiliate with which the
Controlling Plans do not concur; and (c) to exercise control over the policy and operations of the Controlled Affiliate. Notwithstanding anything to the contrary in (a) through (c) of this subparagraph E., the Controlled
Affiliate’s establishing or governing documents must also require written approval by each of the Controlling Plans before the Controlled Affiliate can: 

 

	 	1.	Change its legal and/or trade names; 

  

					
		  		  	 Amended as of March 17, 2005

 
 (The next page is page 3)

		  	-2a-	  	

	 	2.	Change the geographic area in which it operates (except such approval shall not be required with respect to business of the Controlled Affiliate conducted under the
Licensed Marks within the Service Area of one of the Controlling Plans pursuant to a separate controlled affiliate license agreement with BCBSA sponsored by such Controlling Plan); 

 

	 	3.	Change any of the type(s) of businesses in which it engages (except such approval shall not be required with respect to business of the Controlled Affiliate conducted
under the Licensed Marks within the Service Area of one of the Controlling Plans pursuant to a separate controlled affiliate license agreement with BCBSA sponsored by such Controlling Plan); 

 

	 	4.	Take any action that any Controlling Plan or BCBSA reasonably believes will adversely affect the Licensed Marks and Name. 

In addition, the Controlling Plans directly or indirectly through wholly-owned subsidiaries shall own 100% of any for-profit Controlled
Affiliate. 
 3. The Plan may engage in activities not required by BCBSA to be directly licensed through Controlled Affiliates
and may indicate its relationship thereto by use of the Licensed Name as a tag line, provided that the engaging in such activities does not and will not dilute or tarnish the unique value of the Licensed Marks and Name and further provided that such
tag line use is not in a manner likely to cause confusion or mistake. Consistent with the avoidance of confusion or mistake, each tag line use of the Plan’s Licensed Name: (a) shall be in the style and manner specified by BCBSA from
time-to-time; (b) shall not include the design service marks; (c) shall not be in a manner to import more than the Plan’s mere ownership of the Controlled Affiliate; and (d) shall be restricted to the Service Area. No rights are
hereby created in any Controlled Affiliate to use the Licensed Name in its own name or otherwise. At least annually, the Plan shall provide BCBSA with representative samples of each such use of its Licensed Name pursuant to the foregoing conditions.

 4. The Plan recognizes the importance of a comprehensive national network of independent BCBSA licensees which are committed
to strengthening the Licensed Marks and Name. The Plan further recognizes that its actions within its Service Area may affect the value of the Licensed Marks and Name nationwide. The Plan agrees (a) to maintain in good standing its membership
in BCBSA; (b) promptly to pay its dues to BCBSA, said dues to represent the royalties for this License Agreement; (c) materially to comply with all applicable laws; (d) to comply with the Membership Standards Applicable to Regular
Members of BCBSA, a current copy of which is attached as Exhibit 2 hereto; and (e) reasonably to permit BCBSA, upon a written, good faith request and during reasonable business hours, to inspect the Plan’s books and records necessary to
ascertain compliance herewith. As to other Plans and third parties, BCBSA shall maintain the confidentiality of all documents and information furnished by the Plan pursuant hereto, or pursuant to the Membership Standards, and clearly designated by
the Plan as containing proprietary information of the Plan. 

  

					
		  		  	Amended as of March 17, 2005
		  	-3-	  	

 5. The rights hereby granted are exclusive to the Plan within the geographical area(s)
served by the Plan on June 30, 1972, and/or as to which the Plan has been granted a subsequent license, which is hereby defined as the “Service Area,” except that BCBSA reserves the right to use the Licensed Marks in said Service
Area, and except to the extent that said Service Area may overlap areas served by one or more other licensed Blue Cross Plans as of said date or subsequent license, as to which overlapping areas the rights hereby granted are nonexclusive as to such
other Plan or Plans only. 
 6. Except as expressly provided by BCBSA with respect to National Accounts, Government Programs and
certain other necessary and collateral uses, the current rules and regulations governing which are attached as Exhibit 3 and Exhibit 4 hereto, and are contained in other documents referenced herein, or as expressly provided herein, the Plan may not
use the Licensed Marks and Name outside the Service Area or in connection with other goods and services, nor may the Plan use the Licensed Marks or Name in a manner which is intended to transfer in the Service Area the goodwill associated therewith
to another mark or name. Nothing herein shall be construed to prevent the Plan from engaging in lawful activity anywhere under other marks and names not confusingly similar to the Licensed Marks and Name, provided that engaging in such activity does
and will not dilute or tarnish the unique value of the Licensed Marks and Name. In addition to any and all remedies available hereunder, BCBSA may impose monetary fines on the Plan for the Plan’s use of the Licensed Marks and Names outside the
Service Area, and provided that the procedure used in imposing a fine is consistent with procedures specifically prescribed by BCBSA from time to time in regulations of general application. In the case of regional Medicare Advantage PPO and regional
Medicare Part D Prescription Drug Plan products offered by consenting and participating Plans in a region that includes the Service Areas, or portions thereof, of more than one Plan, such fine may be imposed jointly on the consenting and
participating Plans for use of the Licensed Marks and Name in any geographic area of the region in which a Plan having exclusive rights to the Licensed Marks and Name does not consent to and particitpate in such offering, provided that the basis for
imposition of such fine is consistent with rules specifically prescribed by BCBSA from time to time in regulations of general application. 
 7. The Plan agrees that it will display the Licensed Marks and Name only in such form, style and manner as shall be specifically prescribed by BCBSA from time-to-time in regulations of general application
in order to prevent impairment of the distinctiveness of the Licensed Marks and Name and the goodwill pertaining thereto. The Plan shall cause to appear on all materials on or in connection with which the Licensed Marks or Name are used such
legends, markings and notices as BCBSA may reasonably request in order to give appropriate notice of service mark or other proprietary rights therein or pertaining thereto. 

  

					
		  		  	Amended as of November 16, 2006
		  	-3a-	  	

 8. BCBSA agrees that: (a) it will not grant any other license effective during the term
of this License Agreement for the use of the Licensed Marks or Name which is inconsistent with the rights granted to the Plan hereunder; and (b) it will not itself use the Licensed Marks in derogation of the rights of the Plan or in a manner to
deprive the Plan of the full benefits of this License Agreement, provided that BCBSA shall have the right to use the Licensed Marks in conjunction with any national offering under the Federal Employees Health Benefits Program in the manner set forth
in Exhibit 4, Paragraph 4 (including subparagraphs) to this License Agreement. The Plan agrees that it will not attack the title of BCBSA in and to the Licensed Marks or Name or attack the validity of the Licensed Marks or of this License Agreement.
The Plan further agrees that all use by it of the Licensed Marks and Name or any similar mark or name shall inure to the benefit of BCBSA, and the Plan shall cooperate with BCBSA in effectuating the assignment to BCBSA of any service mark or
trademark registrations of the Licensed Marks or any similar mark or name held by the Plan or a Controlled Affiliate of the Plan, all or any portion of which registration consists of the Licensed Marks. 

9. (a). Should the Plan fail to comply with the provisions of paragraphs 2-4, 6, 7 and/or 12, and not cure such failure within thirty
(30) days of receiving written notice thereof (or commence curing such failure within such thirty day period and continue diligent efforts to complete the curing of such failure if such curing cannot reasonably be completed within such thirty
day period), BCBSA shall have the right to issue a notice that the Plan is in a state of noncompliance. Except as to the termination of a Plan’s License Agreement or the merger of two or more Plans, disputes as to noncompliance, and all other
disputes between or among BCBSA, the Plan, other Plans and/or Controlled Affiliates, shall be submitted promptly to mediation and mandatory dispute resolution pursuant to the rules and regulations of BCBSA, a current copy of which is attached as
Exhibit 5 hereto, and shall be timely presented and resolved. The mandatory dispute resolution panel shall have authority to issue orders for specific performance and assess monetary penalties. If a state of noncompliance as aforesaid is undisputed
by the Plan or is found to exist by a mandatory dispute resolution panel and is uncured as provided above, BCBSA shall have the right to seek judicial enforcement of the License Agreement. Except, however, as provided in paragraphs 9(d)(iii),
15(a)(i)-(viii), and 15(a)(x) below, no Plan’s license to use the Licensed Marks and Name may be finally terminated for any reason without the affirmative vote of three-fourths of the Plans and three-fourths of the total then current weighted
vote of all the Plans. 

  

					
		  		  	Amended as of March 16, 2006
		  	-4-	  	

 (b). Notwithstanding any other provision of this License Agreement, a
Plan’s license to use the Licensed Marks and Name may be forthwith terminated by the affirmative vote of three-fourths of the Plans and three-fourths of the total then current weighted vote of all the Plans at a special meeting expressly called
by BCBSA for the purpose on ten (10) days written notice to the Plan advising of the specific matters at issue and granting the Plan an opportunity to be heard and to present its response to Member Plans for: (i) failure to comply with any
minimum capital or liquidity requirement under the Membership Standard on Financial Responsibility; or (ii) impending financial insolvency; or (iii) the pendency of any action instituted against the Plan seeking its dissolution or
liquidation or its assets or seeking appointment of a trustee, interim trustee, receiver or other custodian for any of its property or business or seeking the declaration or establishment of a trust for any of its property of business, unless this
License Agreement has been earlier terminated under paragraph 15(a); or (iv) such other reason as is determined in good faith immediately and irreparably to threaten the integrity and reputation of BCBSA, the Plans and/or the Licensed Marks.

 (c). To the extent not otherwise provided therein, neither: (i) the Membership Standards Applicable to
Regular Members of BCBSA; nor (ii) the rules and regulations governing Government Programs and certain other uses; nor (iii) the rules and regulations governing mediation and mandatory dispute resolution, may be amended unless and until
each such amendment is first adopted by the affirmative vote of three-fourths of the Plans and of three-fourths of the total then current weighted vote of all the Plans. The rules and regulations governing National Accounts and other national
programs required by the Membership Standards Applicable to Regular Members of BCBSA (Exhibit 2) are contained, in addition to those set forth in Exhibit 3, in the following documents, as amended from time to time: (1) the Transfer Program
Policies and Provisions; (2) the Inter-Plan Programs Policies and Provisions; (3) Inter-Plan Medicare Advantage Program Policies and Provisions. The voting requirements specified in rules and regulations governing such national programs
may not be amended unless and until each such amendment is first adopted by the affirmative vote of three-fourths of the Plans and of three-fourths of the total then current weighted vote of all the Plans. 

  

					
		  		  	Amended as of November 15, 2007
		  	-4a-	  	

 (d). The Plan may operate as a for-profit company on the following
conditions: 
 (i) The Plan shall discharge all responsibilities which it has to the Association and to other
Plans by virtue of this Agreement and the Plan’s membership in BCBSA. 
 (ii) The Plan shall not use the
licensed Marks and Name, or any derivative thereof, as part of its legal name or any symbol used to identify the Plan in any securities market. The Plan shall use the licensed Marks and Name as part of its trade name within its service area for the
sale, marketing and administration of health care and related services in the service area. 
 (iii) The
Plan’s license to use the Licensed Marks and Name shall automatically terminate effective: (a) thirty days after the Plan knows, or there is an SEC filing indicating that, any Institutional Investor, has become the Beneficial Owner of
securities representing 10% or more of the voting power of the Plan (“Excess Institutional Voter”), unless such Excess Institutional Voter shall cease to be an Excess Institutional Voter prior to such automatic termination becoming
effective; (b) thirty days after the Plan knows, or there is an SEC filing indicating that, any Noninstitutional Investor has become the Beneficial Owner of securities representing 5% or more of the voting power of the Plan (“Excess
Noninstitutional Voter”) unless such Excess Noninstitutional Voter shall cease to be an Excess Noninstitutional Voter prior to such automatic termination becoming effective; (c) thirty days after the Plan knows, or there is an SEC filing
indicating that, any Person has become the Beneficial Owner of 20% or more of the Plan’s then outstanding common stock or other equity securities which (either by themselves or in combination) represent an ownership interest of 20% or more
pursuant to determinations made under paragraph 9(d)(iv) below (“Excess Owner”), unless such Excess Owner shall cease to be an Excess Owner prior to such automatic termination becoming effective; (d) ten business days after
individuals who at the time the Plan went public constituted the Board of Directors of the Plan (together with any new directors whose election to the Board was approved by a vote of 2/3 of the directors then still in office who were directors at
the time the Plan went public or whose election or nomination was previously so approved) (the “Continuing Directors”) cease for any reason to constitute a majority of the Board of Directors; or (e) ten business days after the Plan
consolidates with or merges with or into any person or conveys, assigns, transfers or sells all or substantially all of its assets to any person other than a merger in which the Plan is the surviving entity and immediately after which merger, no
person is an Excess Institutional Voter, an Excess Noninstitutional Voter or an Excess Owner: provided that, if requested by the affected Plan in a writing received by BCBSA prior to such automatic termination becoming effective, the provisions of
this paragraph 9(d)(iii) may be waived, in whole or in part, 

  

					
		  		  	Amended as of September 17, 1997
		  	-5-	  	

 
upon the affirmative vote of a majority of the disinterested Plans and a majority of the total then current weighted vote of the disinterested Plans. Any waiver so granted may be conditioned upon
such additional requirements (including but not limited to imposing new and independent grounds for termination of this License) as shall be approved by the affirmative vote of a majority of the disinterested Plans and a majority of the total then
current weighted vote of the disinterested Plans. If a timely waiver request is received, no automatic termination shall become effective until the later of: (1) the conclusion of the applicable time period specified in paragraphs
9(d)(iii)(a)-(d) above, or (2) the conclusion of the first Member Plan meeting after receipt of such a waiver request. 
 In the event
that the Plan’s license to use the Licensed Marks and Name is terminated pursuant to this Paragraph 9(d)(iii), the license may be reinstated in BCBSA’s sole discretion if, within 30 days of the date of such termination, the Plan
demonstrates that the Person referred to in clause (a), (b) or (c) of the preceding paragraph is no longer an Excess Institutional Voter, an Excess Noninstitutional Voter or an Excess Owner. 

(iv) The Plan shall not issue any class or series of security other than (i) shares of common stock having identical
terms or options or derivatives of such common stock, (ii) non-voting, non-convertible debt securities or (iii) such other securities as the Plan may approve, provided that BCBSA receives notice at least thirty days prior to the issuance
of such securities, including a description of the terms for such securities, and BCBSA shall have the authority to determine how such other securities will be counted in determining whether any Person is an Excess Institutional Voter, Excess
Noninstitutional Voter or an Excess Owner. 
 (v) For purposes of paragraph 9(d)(iii), the following definitions
shall apply: 
 (a) “Affiliate” and “Associate” shall have the respective meanings ascribed
to such terms in Rule 12b-2 of the General Rules and Regulations under the Securities Exchange Act of 1934, as amended and in effect on November 17, 1993 (the “Exchange Act”). 

(b) A Person shall be deemed the “Beneficial Owner” of and shall be deemed to “beneficially own” any
securities: 
 (i) which such Person or any of such Person’s Affiliates or Associates beneficially owns,
directly or indirectly; 

  

					
		  		  	Amended as of September 17, 1997
		  	-5a-	  	

 (ii) which such Person or any of such Person’s Affiliates or Associates
has (A) the right to acquire (whether such right is exercisable immediately or only after the passage of time) pursuant to any agreement, arrangement or understanding, or upon the exercise of conversion rights, exchange rights, warrants or
options, or otherwise; or (B) the right to vote pursuant to any agreement, arrangement or understanding; provided, however, that a Person shall not be deemed the Beneficial Owner of, or to beneficially own, any security if the agreement,
arrangement or understanding to vote such security (1) arises solely from a revocable proxy or consent given to such Person in response to a public proxy or consent solicitation made pursuant to, and in accordance with, the applicable rules and
regulations promulgated under the Exchange Act and (2) is not also then reportable on Schedule 13D under the Exchange Act (or any comparable or successor report); or 

(iii) which are beneficially owned, directly or indirectly, by any other Person (or any Affiliate or Associate thereof)
with which such Person (or any of such Person’s Affiliates or Associates) has any agreement, arrangement or understanding (other than customary agreements with and between underwriters and selling group members with respect to a bona fide
public offering of securities) relating to the acquisition, holding, voting (except to the extent contemplated by the proviso to (b)(ii)(B) above) or disposing of any securities of the Plan. 

Notwithstanding anything in this definition of Beneficial Ownership to the contrary, the phrase “then outstanding,” when used
with reference to a Person’s Beneficial Ownership of securities of the Plan, shall mean the number of such securities then issued and outstanding together with the number of such securities not then actually issued and outstanding which such
Person would be deemed to own beneficially hereunder. 
 (c) A Person shall be deemed an “Institutional
Investor” if (but only if) such Person (i) is an entity or group identified in the SEC’s Rule 13d-1(b)(1)(ii) as constituted on June 1, 1997, and (ii) every filing made by such Person with the SEC under Regulation 13D-G (or
any successor Regulation) with respect to such Person’s Beneficial Ownership of Plan securities shall have contained a certification identical to the one required by item 10 of SEC Schedule 13G as constituted on June 1, 1997. 

(d) “Noninstitutional Investor” means any Person who is not an Institutional Investor. 

(e) “Person” shall mean any individual, firm, partnership, corporation, trust, association, joint venture or
other entity, and shall include any successor (by merger or otherwise) of such entity. 

  

					
		  		  	Amended as of September 17, 1997
		  		  	
		  	-5b-	  	(The next page is page 6)

 10. This License Agreement shall remain in effect: (a) until terminated as provided
herein; or (b) until this and all such other License Agreements are terminated by the affirmative vote of three-fourths of the Plans and three-fourths of the total then current weighted vote of all the Plans; or (c) until termination of
aforesaid Ownership Agreement; or (d) until terminated by the Plan upon eighteen (18) months written notice to BCBSA or upon a shorter notice period approved by BCBSA in writing at its sole discretion. 

11. Except as otherwise provided in paragraph 15 below or by the affirmative vote of three-fourths of the Plans and three-fourths of the
total then current weighted vote of all the Plans, or unless this and all such other License Agreements are simultaneously terminated by force of law, the termination of this License Agreement for any reason whatsoever shall cause the reversion to
BCBSA of all rights in and to the Licensed Marks and Name, and the Plan agrees that it will promptly discontinue all use of the Licensed Marks and Name, will not use them thereafter, and will promptly, upon written notice from BCBSA, change its
corporate name so as to eliminate the Licensed Name therefrom. 
 12. The license hereby granted to Plan to use the Licensed
Marks and Name is and shall be personal to the Plan so licensed and shall not be assignable by any act of the Plan, directly or indirectly, without the written consent of BCBSA. Said license shall not be assignable by operation of law, nor shall
Plan mortgage or part with possession or control of this license or any right hereunder, and the Plan shall have no right to grant any sublicense to use the Licensed Marks and Name. 

13. BCBSA shall maintain appropriate service mark registrations of the Licensed Marks and BCBSA shall take such lawful steps and
proceedings as may be necessary or proper to prevent use of the Licensed Marks by any person who is not authorized to use the same. Any actions or proceedings undertaken by BCBSA under the provisions of this paragraph shall be at BCBSA’s sole
cost and expense. BCBSA shall have the sole right to determine whether or not any legal action shall be taken on account of unauthorized use of the Licensed Marks, such right not to be unreasonably exercised. The Plan shall report any unlawful usage
of the Licensed Marks to BCBSA in writing and agrees, free of charge, to cooperate fully with BCBSA’s program of enforcing and protecting the service mark rights, trade name rights and other rights in the Licensed Marks. 

14. The Plan hereby agrees to save, defend, indemnify and hold BCBSA and any other Plan(s) harmless from and against all claims, damages,
liabilities and costs of every kind, nature and description which may arise exclusively and directly as a result of the activities of the Plan. BCBSA hereby agrees to save, defend, indemnify and hold the Plan and any other Plan(s) harmless from and
against all claims, damages, liabilities and costs of every kind, nature and description which may arise exclusively and directly as a result of the activities of BCBSA. 

  

					
		  		  	Amended as of June 16, 2005
		  	-6-	  	

 15. (a). This Agreement shall automatically terminate upon the occurrence of any of the
following events: (i) a voluntary petition shall be filed by the Plan or by BCBSA seeking bankruptcy, reorganization, arrangement with creditors or other relief under the bankruptcy laws of the United States or any other law governing
insolvency or debtor relief, or (ii) an involuntary petition or proceeding shall be filed against the Plan or BCBSA seeking bankruptcy, reorganization, arrangement with creditors or other relief under the bankruptcy laws of the United States or
any other law governing insolvency or debtor relief and such petition or proceeding is consented to or acquiesced in by the Plan or BCBSA or is not dismissed within sixty (60) days of the date upon which the petition or other document
commencing the proceeding is served upon the Plan or BCBSA respectively, or (iii) an order for relief is entered against the Plan or BCBSA in any case under the bankruptcy laws of the United States, or the Plan or BCBSA is adjudged bankrupt or
insolvent (as that term is defined in the Uniform Commercial Code as enacted in the state of Illinois) by any court of competent jurisdiction, or (iv) the Plan or BCBSA makes a general assignment of its assets for the benefit of creditors, or
(v) any government or any government official, office, agency, branch, or unit assumes control of the Plan or delinquency proceedings (voluntary or involuntary) are instituted, or (vi) an action is brought by the Plan or BCBSA seeking its
dissolution or liquidation of its assets or seeking the appointment of a trustee, interim trustee, receiver or other custodian for any of its property or business, or (vii) an action is instituted by any governmental entity or officer against
the Plan or BCBSA seeking its dissolution or liquidation of its assets or seeking appointment of a trustee, interim trustee, receiver or other custodian for any of its property or business and such action is consented to or acquiesced in by the Plan
or BCBSA or is not dismissed within one hundred thirty (130) days of the date upon which the pleading or other document commencing the action is served upon the Plan or BCBSA respectively, provided that if the action is stayed or its
prosecution is enjoined, the one hundred thirty (130) day period is tolled for the duration of the stay or injunction, and provided further, that the Association’s Board of Directors may toll or extend the 130 day period at any time prior
to its expiration, or (viii) a trustee, interim trustee, receiver or other custodian for any of the Plan’s or BCBSA’s property or business is appointed, or the Plan or BCBSA is ordered dissolved or liquidated, or (ix) the Plan
shall fail to pay its dues and shall not cure such failure within thirty (30) days of receiving written notice thereof, or (x) if, due to regulatory action, the Plan together with any applicable Controlled Affiliate becomes unable to do
business using the Names and Marks in any State or portion thereof included in its Service Area, provided that: (i) automatic termination shall not occur prior to the exhaustion by any such Plan of its rights to appeal or challenge such
regulatory action; and (ii) in the event the Plan is licensed to do business using the Names and Marks in multiple States or portions of States, the termination of its License Agreement shall be solely limited to the State(s) or portions
thereof in which the regulatory action applies. By not appealing or challenging such regulatory action within the time prescribed by law or regulation, and in any event no later than 120 days after such action is taken, a Plan shall be deemed to
have exhausted its rights to appeal or challenge, and automatic termination shall proceed. 

  
 -7-

 Notwithstanding any other provision of this Agreement, a declaration or a request for declaration of the
existence of a trust over any of the Plan’s or BCBSA’s property or business shall not in itself be deemed to constitute or seek appointment of a trustee, interim trustee, receiver or other custodian for purposes of subparagraphs 15(a)(vii)
and (viii) of this Agreement. 

  

					
		  		  	Amended as of September 14, 2004
		  	-7a-	  	

 (b). BCBSA, or the Plans (as provided and in addition to the rights
conferred in Paragraph 10(b) above), may terminate this Agreement immediately upon written notice upon the occurrence of either of the following events: (a) the Plan or BCBSA becomes insolvent (as that term is defined in the Uniform
Commercial Code enacted in the state of Illinois), or (b) any final judgment against the Plan or BCBSA remains unsatisfied or unbonded of record for a period of sixty (60) days or longer. 

(c). If this License Agreement is terminated as to BCBSA for any reason stated in subparagraphs 15(a) and (b) above,
the ownership of the Licensed Marks shall revert to each of the Plans. 
 (d). Upon termination of this License
Agreement or any Controlled Affiliate License Agreement of a Larger Controlled Affiliate, as defined in Exhibit 1 to this License Agreement, the following conditions shall apply, except that, in the event of a partial termination of this Agreement
pursuant to Paragraph 15 (a)(x)(ii) of this Agreement, the notices, national account listing, payment and audit right listed below shall be applicable solely with respect to the geographic area for which the Plan’s license to use the Licensed
Names and Marks is terminated: 
  

	 	(i)	The terminated entity shall send a notice through the U.S. mails, with first class postage affixed, to all individual and group customers, providers, brokers and agents
of products or services sold, marketed, underwritten or administered by the terminated entity or its Controlled Affiliates under the Licensed Marks and Name. The form and content of the notice shall be specified by BCBSA and shall, at a minimum,
notify the recipient of the termination of the license, the consequences thereof, and instructions for obtaining alternate products or services licensed by BCBSA, subject to any conflicting state law and state regulatory requirements. This notice
shall be mailed within 15 days after termination or, if termination is pursuant to paragraph 10(d) of this Agreement, within 15 days after the written notice to BCBSA described in paragraph 10(d). 

 

	 	(ii)	The terminated entity shall deliver to BCBSA within five days of a request by BCBSA a listing of national accounts in which the terminated entity is involved (in a
Control, Participating or Servicing capacity), identifying the national account and the terminated entity’s role therein. For those accounts where the terminated entity is the Control Plan, the Plan must also indicate the Participating and
Servicing Plans in the national account syndicate. 

  

					
		  		  	Amended as of June 16, 2005
		  	-8-	  	

	 	(iii)	 Unless the cause of termination is an event stated in paragraph 15(a) or (b) above respecting BCBSA, the Plan and its Licensed Controlled
Affiliates shall be jointly liable for payment to BCBSA of an amount equal to the Re-Establishment Fee (described below) multiplied by the number of Licensed Enrollees of the terminated entity and its Licensed Controlled Affiliates; provided that if
any other Plan is permitted by BCBSA to use marks or names licensed by BCBSA in the Service Area established by this Agreement, the Re-Establishment Fee shall be multiplied by a fraction, the numerator of which is the number of Licensed Enrollees of
the terminated entity and its Licensed Controlled Affiliates and the denominator of which is the total number of Licensed Enrollees in the Service Area. The Re-Establishment Fee shall be indexed to a base fee of $80. The Re-Establishment Fee through
December 31, 2005 shall be $80. The Re-Establishment Fee for calendar years after December 31, 2005 shall be adjusted on January 1 of each calendar year up to and including January 1, 2010 and shall be the base fee multiplied by
100% plus the cumulative percentage increase or decrease in the Plans’ gross administrative expense (standard BCBSA definition) per Licensed Enrollee since December 31, 2004. The adjustment shall end on January 1, 2011, at which time
the Re-Establishment Fee shall be fixed at the then-current amount and no longer automatically adjusted. For example, if the Plans’ gross administrative expense per Licensed Enrollee was $278.60, $285.00 and $290.00 for calendar year end 2004,
2005 and 2006, respectively, the January 1, 2007 Re-Establishment Fee would be $83.27 (100% of the base fee plus $1.84 for calendar year 2005 and $1.43 for calendar year 2006). Licensed Enrollee means each and every person and covered dependent
who is enrolled as an individual or member of a group receiving products or services sold, marketed or administered under marks or names licensed by BCBSA as determined at the earlier of (a) the end of the last fiscal year of the terminated
entity which ended prior to termination or (b) the fiscal year which ended before any transactions causing the termination began. Notwithstanding the foregoing, the amount payable pursuant to this subparagraph (d)(iii) shall be due only to the
extent that, in BCBSA’s 

  

					
		  		  	Amended as of June 16, 2005
		  	-8a-	  	

	 	 
opinion, it does not cause the net worth of the Plan to fall below 100% of the Health Risk-Based Capital formula or its equivalent under any successor formula, as set forth in the applicable
financial responsibility standards established by BCBSA (provided such equivalent is approved for purposes of this sub paragraph by the affirmative vote of three-fourths of the Plans and three-fourths of the total then current weighted vote of all
the Plans), measured as of the date of termination and adjusted for the value of any transactions not made in the ordinary course of business. This payment shall not be due in connection with transactions exclusively by or among Plan or their
affiliates, including reorganizations, combinations or mergers, where the BCBSA Board of Directors determines that the license termination does not result in a material diminution in the number of Licensed Enrollees or the extent of their coverage.
At least 50% of the Re-Establishment Fee shall be awarded to the Plan (or Plans) that receive the new license(s) for the service area(s) at issue; provided, however, that such award shall not become due or payable until all disputes, if any,
regarding the amount of and BCBSA’s right to such Re-Establishment Fee have been finally resolved; and provided further that the award shall be based on the final amount actually received by BCBSA. The Board of Directors shall adopt a
resolution which it may amend from time to time that shall govern BCBSA’s use of its portion of the award. In the event that the terminated entity’s license is reinstated by BCBSA or is deemed to have remained in effect without
interruption by a court of competent jurisdiction, BCBSA shall reimburse the Plan (and/or its Licensed Controlled Affiliates, as the case may be) for payments made under this subparagraph only to the extent that such payments exceed the amounts due
to BCBSA pursuant to subparagraph 15(d)(vi) and any costs associated with reestablishing the Service Area, including any payments made by BCBSA to a Plan or Plans (or their Licensed Controlled Affiliates) for purposes of replacing the terminated
entity. 

  

	 	(iv)	 The terminated entity shall comply with all financial settlement procedures set forth in BCBSA’s License Termination Contingency Plan, as amended
from time 

  

					
		  		  	Amended as of June 16, 2005
		  	-8b-	  	

	 	 
to time and shall work diligently and in good faith with BCBSA, any Alternative Control Licensee or Replacement Licensee and any existing or potential new account for Blue-branded products and
services to minimize the disruption of termination, and honor, to the fullest extent possible, the desire of accounts to continue to receive or obtain Blue-branded products and services through a new Licensee (“Transition”). Such diligence
and good faith on the part of the terminated entity shall include, but not be limited to: (a) working cooperatively with BCBSA to protect the Names and Marks from potential harm; (b) cooperating with BCBSA’s use of the Names and Marks
in the terminated entity’s former service area during the termination and Transition; (c) transmitting, upon the request of an existing Blue account or of BCBSA with consent and on behalf of an existing Blue account, all member and
account-data relating to the Federal Employee Program to BCBSA, and all member and account data relating to other programs to an Alternative Control Licensee or Replacement Licensee; (d) working with BCBSA and the Alternative Control or
Replacement Licensee with respect to potential new Blue accounts headquartered in the terminated entity’s former service area; (e) continuing to service Blue accounts during the Transition; (f) continuing to comply with National
Programs, Federal Employee Program and NASCO policies and procedures and all voluntary BCBSA programs, policies and performance standards, such as Away From Home Care, including being responsible for payment of all penalties for non-compliance duly
levied in conformity with the License Agreements, Membership Standards, or the Federal Employee Program agreements, that may arise during the Transition; (g) maintaining and providing access to its provider networks, as defined by Federal
Employee Program agreements and National Account Program Policies and Provisions, and Inter-Plan Programs Policies and Provisions, and making those networks and discounts available to members and providers who participate in National Programs and
the Federal Employee Program during the Transition; (h) maintaining its technical connections and processing capabilities during the Transition; and (i) working diligently to conclude all financial settlements and account reconciliations
as negotiated in the termination transition agreement. 

  

					
		  		  	Amended as of November 16, 2006
		  	-8c-	  	

	 	(v)	Notwithstanding any other provision in this Agreement, BCBSA shall have the right, with the approval of its Board of Directors, to assess additional fines against the
terminated entity during the Transition in the event it fails to maintain and provide access to provider networks as defined by Federal Employee Program agreements, National Account Program Policies and Provisions, and Inter-Plan Programs Policies
and Provisions, and/or pass on applicable discounts. Such fines shall be in addition to any other assessments, fees or liquidated damages payable herein, or under existing policies and programs and shall be imposed to make whole BCBSA and/or the
Plans. Terminated entity shall pay any such fines to BCBSA no later than 30 days after they are approved by the Board of Directors. 

  

	 	(vi)	BCBSA shall have the right to examine and audit and/or hire at terminated entity’s expense a third-party auditor to examine and audit the books and records of the
terminated entity and its Licensed Controlled Affiliates to verify compliance with the terms and requirements this paragraph 15(d). 

  

	 	(vii)	Subsequent to termination of this Agreement, the terminated entity and its affiliates, agents, and employees shall have an ongoing and continuing obligation to protect
all BCBSA and Blue Licensee data that was acquired or accessed during the period this Agreement was in force, including but not limited to all confidential processes, pricing, provider, discount and other strategic and competitively sensitive
information (“Blue Information”) from disclosure, and shall not, either alone or with another entity, disclose such Blue Information or use it in any manner to compete without the express written permission of BCBSA.

  

	 	(viii)	As to a breach of 15 (d) (i), (ii), (iii), (iv), (vi), or (vii) the parties agree that the obligations are immediately enforceable in a court of competent
jurisdiction. As to a breach of 15 (d) (i), (ii), (iv), (vi), or (vii) by the Plan, the parties agree there is no adequate remedy at law and BCBSA is entitled to obtain specific performance. 

  

					
		  		  	Amended as of November 16, 2006
		  	-8d-	  	

	 	(ix)	In the event that the terminated entity’s license is reinstated by BCBSA or is deemed to have remained in effect without interruption by a court of competent
jurisdiction, the Plan and its Licensed Controlled Affiliates shall be jointly liable for reimbursing BCBSA the reasonable costs incurred by BCBSA in connection with the termination and the reinstatement or court action, and any associated legal
proceedings, including but not limited to: outside legal fees, consulting fees, public relations fees, advertising costs, and costs incurred to develop, lease or establish an interim provider network. Any amount due to BCBSA under this subparagraph
may be waived in whole or in part by the BCBSA Board of Directors in its sole discretion. 

 (e).
BCBSA shall be entitled to enjoin the Plan or any related party in a court of competent jurisdiction from entry into any transaction which would result in a termination of this License Agreement unless the License Agreement has been terminated
pursuant to paragraph 10 (d) of this Agreement upon the required six (6) month written notice. 
 (f).
BCBSA acknowledges that it is not the owner of assets of the Plan. 

  

					
		  		  	Amended as of June 16, 2005
		  	-8e-	  	

 16. This Agreement supersedes any and all other agreements between the parties with respect
to the subject matter herein, and contains all of the covenants and agreements of the parties as to the licensing of the Licensed Marks and Name. This Agreement may be amended only by the affirmative vote of three-fourths of the Plans and
three-fourths of the total then current weighted vote of all the Plans as officially recorded by the BCBSA Corporate Secretary. 

17. If any provision or any part of any provision of this Agreement is judicially declared unlawful, each and every other provision, or
any part of any provision, shall continue in full force and effect notwithstanding such judicial declaration. 
 18. No waiver
by BCBSA or the Plan of any breach or default in performance on the part of BCBSA or the Plan or any other licensee of any of the terms, covenants or conditions of this Agreement shall constitute a waiver of any subsequent breach or default in
performance of said terms, covenants or conditions. 
 19a. All notices provided for hereunder shall be in writing and shall be
sent in duplicate by regular mail to BCBSA or the Plan at the address currently published for each by BCBSA and shall be marked respectively to the attention of the President and, if any, the General Counsel, of BCBSA or the Plan. 

  

					
		  		  	Amended as of November 20, 1997
		  	-8f-	  	

 19b. Except as provided in paragraphs 9(b), 9(d)(iii), 15(a), and 15(b) above, this
Agreement may be terminated for a breach only upon at least 30 days’ written notice to the Plan advising of the specific matters at issue and granting the Plan an opportunity to be heard and to present its response to the Member Plans.

 19c. For all provisions of this Agreement referring to voting, the term ‘Plans’ shall mean all entities licensed
under the Blue Cross License Agreement and/or the Blue Shield License Agreement, and in all votes of the Plans under this Agreement the Plans shall vote together. For weighted votes of the Plans, the Plan shall have a number of votes equal to the
number of weighted votes (if any) that it holds as a Blue Cross Plan plus the number of weighted votes (if any) that it holds as a Blue Shield Plan. For all other votes of the Plans, the Plan shall have one vote. For all questions requiring an
affirmative three-fourths weighted vote of the Plans, the requirement shall be deemed satisfied with a lesser weighted vote unless the greater of: (i) 6/52 or more of the Plans (rounded to the nearest whole number, with 0.5 or multiples thereof
being rounded to the next higher whole number) fail to cast weighted votes in favor of the question; or (ii) three (3) of the Plans fail to cast weighted votes in favor of the question. Notwithstanding the foregoing provision, if there are
thirty-nine (39) Plans, the requirement of an affirmative three-fourths weighted vote shall be deemed satisfied with a lesser weighted vote unless four (4) or more Plans fail to cast weighted votes in favor of the question. 

  

					
		  		  	Amended as of June 16, 2005
			
		  	-8g-	  	(The next page is page 9)

 20. Nothing herein contained shall be construed to constitute the parties hereto as partners
or joint venturers, or either as the agent of the other, and Plan shall have no right to bind or obligate BCBSA in any way, nor shall it represent that it has any right to do so. BCBSA shall have no liability to third parties with respect to any
aspect of the business, activities, operations, products, or services of the Plan. 
 21. This Agreement shall be governed,
construed and interpreted in accordance with the laws of the State of Illinois. 
 IN WITNESS WHEREOF, the parties have caused this License
Agreement to be executed, effective as of the date of last signature written below. 
  

			
	BLUE CROSS AND BLUE SHIELD ASSOCIATION
		
	By	 	 
		
	Title	 	 
		
	Date	 	 
	
	PLAN:
		
	By	 	 
		
	Title	 	 
		
	Date	 	 

  
 -9-

 EXHIBIT 1 
 BLUE CROSS 
 CONTROLLED AFFILIATE LICENSE AGREEMENT 

(Includes revisions adopted by Member Plans through their November 18, 2010 meeting) 

This Agreement by and among Blue Cross and Blue Shield Association (“BCBSA”) and
                 (“Controlled Affiliate”), a Controlled Affiliate of the Blue Cross Plan(s), known as
                 (“Plan”), which is also a Party signatory hereto. 
 WHEREAS, BCBSA is the owner of the BLUE CROSS and BLUE CROSS Design service marks; 

WHEREAS, Plan and Controlled Affiliate desire that the latter be entitled to use the BLUE CROSS and BLUE CROSS Design service marks
(collectively the “Licensed Marks”) as service marks and be entitled to use the term BLUE CROSS in a trade name (“Licensed Name”); 
 NOW THEREFORE, in consideration of the foregoing and the mutual agreements hereinafter set forth and for other good and valuable consideration, the receipt and sufficiency of which are hereby
acknowledged, the parties hereby agree as follows: 
  

	 	1.	GRANT OF LICENSE 

Subject to the terms and conditions of this Agreement, BCBSA hereby grants to Controlled Affiliate the right to use the Licensed Marks and
Name in connection with, and only in connection with: (i) health care plans and related services, as defined in BCBSA’s License Agreement with Plan, and administering the non-health portion of workers’ compensation insurance, and
(ii) underwriting the indemnity portion of workers’ compensation insurance, provided that Controlled Affiliate’s total premium revenue comprises less than 15 percent of the sponsoring Plan’s net subscription revenue. 

This grant of rights is non-exclusive and is limited to the Service Area served by the Plan. Controlled Affiliate may use the Licensed Marks and Name in
its legal name on the following conditions: (i) the legal name must be approved in advance, in writing, by BCBSA; (ii) Controlled Affiliate shall not do business outside the Service Area under any name or mark; and (iii) Controlled
Affiliate shall not use the Licensed Marks and Name, or any derivative thereof, as part of any name or symbol used to identify itself in any securities market. Controlled Affiliate may use the Licensed Marks and Name in its Trade Name only with the
prior, written, consent of BCBSA. 
  

	 	2.	QUALITY CONTROL 

A. Controlled Affiliate agrees to use the Licensed Marks and Name only in connection with the licensed services and further agrees to be
bound by the conditions regarding quality control shown in attached Exhibit A as they may be amended by BCBSA from time-to-time. 

  

					
		  		  	Amended as of November 16, 2000
		  		  	

 B. Controlled Affiliate agrees to comply with all applicable federal, state and local laws.

 C. Controlled Affiliate agrees that it will provide on an annual basis (or more often if reasonably required by Plan or by
BCBSA) a report or reports to Plan and BCBSA demonstrating Controlled Affiliate’s compliance with the requirements of this Agreement including but not limited to the quality control provisions of this paragraph and the attached Exhibit A.

 D. Controlled Affiliate agrees that Plan and/or BCBSA may, from time-to-time, upon reasonable notice, review and inspect the
manner and method of Controlled Affiliate’s rendering of service and use of the Licensed Marks and Name. 
 E. As used
herein, a Controlled Affiliate is defined as an entity organized and operated in such a manner, that it meets the following requirements: 
 (1)
A Plan or Plans authorized to use the Licensed Marks in the Service Area of the Controlled Affiliate pursuant to separate License Agreement(s) with BCBSA, other than such Controlled Affiliate’s License Agreement(s), (the “Controlling
Plan(s)”), must have the legal authority directly or indirectly through wholly-owned subsidiaries to select members of the Controlled Affiliate’s governing body having not less than 50% voting control thereof and to: 

(a) prevent any change in the articles of incorporation, bylaws or other establishing or governing documents of the Controlled Affiliate
with which the Controlling Plan(s) do(es) not concur; 
 (b) exercise control over the policy and operations of the Controlled
Affiliate at least equal to that exercised by persons or entities (jointly or individually) other than the Controlling Plan(s); and 

Notwithstanding anything to the contrary in (a) through (b) hereof, the Controlled Affiliate’s establishing or governing documents must
also require written approval by the Controlling Plan(s) before the Controlled Affiliate can: 
  

	 	(i)	change its legal and/or trade names; 

  

	 	(ii)	change the geographic area in which it operates; 

  

	 	(iii)	change any of the type(s) of businesses in which it engages; 

  
 2 

	 	(iv)	create, or become liable for by way of guarantee, any indebtedness, other than indebtedness arising in the ordinary course of business; 

 

	 	(v)	sell any assets, except for sales in the ordinary course of business or sales of equipment no longer useful or being replaced; 

 

	 	(vi)	make any loans or advances except in the ordinary course of business; 

  

	 	(vii)	enter into any arrangement or agreement with any party directly or indirectly affiliated with any of the owners or persons or entities with the authority to select or
appoint members or board members of the Controlled Affiliate, other than the Plan or Plans (excluding owners of stock holdings of under 5% in a publicly traded Controlled Affiliate); 

 

	 	(viii)	conduct any business other than under the Licensed Marks and Name; 

  

	 	(ix)	take any action that any Controlling Plan or BCBSA reasonably believes will adversely affect the Licensed Marks and Name. 

In addition, a Plan or Plans directly or indirectly through wholly owned subsidiaries shall own at least 50% of any for-profit Controlled Affiliate.

 Or 
 (2) A Plan or
Plans authorized to use the Licensed Marks in the Service Area of the Controlled Affiliate pursuant to separate License Agreement(s) with BCBSA, other than such Controlled Affiliate’s License Agreement(s), (the “Controlling Plan(s)”),
have the legal authority directly or indirectly through wholly-owned subsidiaries to select members of the Controlled Affiliate’s governing body having more than 50% voting control thereof and to: 

 

	 	(a)	prevent any change in the articles of incorporation, bylaws or other establishing or governing documents of the Controlled Affiliate with which the Controlling Plan(s)
do(es) not concur; 

  

	 	(b)	exercise control over the policy and operations of the Controlled Affiliate. 

 In addition, a Plan or Plans directly or indirectly through wholly-owned subsidiaries shall own more than 50% of any for-profit Controlled Affiliate. 

  
 3 

	 	3.	SERVICE MARK USE 

A. Controlled Affiliate recognizes the importance of a comprehensive national network of independent BCBSA licensees which are committed
to strengthening the Licensed Marks and Name. The Controlled Affiliate further recognizes that its actions within its Service Area may affect the value of the Licensed Marks and Name nationwide. 

B. Controlled Affiliate shall at all times make proper service mark use of the Licensed Marks and Name, including but not limited to use
of such symbols or words as BCBSA shall specify to protect the Licensed Marks and Name and shall comply with such rules (generally applicable to Controlled Affiliates licensed to use the Licensed Marks and Name) relative to service mark use, as are
issued from time-to-time by BCBSA. Controlled Affiliate recognizes and agrees that all use of the Licensed Marks and Name by Controlled Affiliate shall inure to the benefit of BCBSA. 

C. Controlled Affiliate may not directly or indirectly use the Licensed Marks and Name in a manner that transfers or is intended to
transfer in the Service Area the goodwill associated therewith to another mark or name, nor may Controlled Affiliate engage in activity that may dilute or tarnish the unique value of the Licensed Marks and Name. 

D. If Controlled Affiliate meets the standards of 2E(1) but not 2E(2) above and any of Controlled Affiliate’s advertising or
promotional material is reasonably determined by BCBSA and/or the Plan to be in contravention of rules and regulations governing the use of the Licensed Marks and Name, Controlled Affiliate shall for ninety (90) days thereafter obtain prior
approval from BCBSA of advertising and promotional efforts using the Licensed Marks and Name, approval or disapproval thereof to be forthcoming within five (5) business days of receipt of same by BCBSA or its designee. In all advertising and
promotional efforts, Controlled Affiliate shall observe the Service Area limitations applicable to Plan. 
 E. Notwithstanding
any other provision in the Plan’s License Agreement with BCBSA or in this Agreement, Controlled Affiliate shall use its best efforts to promote and build the value of the Licensed Marks and Name. 

  

					
		  		  	Amended as of June 16, 2005
		  	4	  	

	 	4.	SUBLICENSING AND ASSIGNMENT 

 Controlled Affiliate shall not, directly or indirectly, sublicense, transfer, hypothecate, sell, encumber or mortgage, by operation of law or otherwise, the rights granted hereunder and any such act shall
be voidable at the sole option of Plan or BCBSA. This Agreement and all rights and duties hereunder are personal to Controlled Affiliate. 
  

	 	5.	INFRINGEMENT 

Controlled Affiliate shall promptly notify Plan and Plan shall promptly notify BCBSA of any suspected acts of infringement, unfair
competition or passing off that may occur in relation to the Licensed Marks and Name. Controlled Affiliate shall not be entitled to require Plan or BCBSA to take any actions or institute any proceedings to prevent infringement, unfair competition or
passing off by third parties. Controlled Affiliate agrees to render to Plan and BCBSA, without charge, all reasonable assistance in connection with any matter pertaining to the protection of the Licensed Marks and Name by BCBSA. 

 

	 	6.	LIABILITY INDEMNIFICATION 

 Controlled Affiliate and Plan hereby agree to save, defend, indemnify and hold BCBSA harmless from and against all claims, damages, liabilities and costs of every kind, nature and description (except
those arising solely as a result of BCBSA’s negligence) that may arise as a result of or related to Controlled Affiliate’s rendering of services under the Licensed Marks and Name. 

 

	 	7.	LICENSE TERM 

 A.
Except as otherwise provided herein, the license granted by this Agreement shall remain in effect for a period of one (1) year and shall be automatically extended for additional one (1) year periods unless terminated pursuant to the
provisions herein. 
 B. This Agreement and all of Controlled Affiliate’s rights hereunder shall immediately terminate
without any further action by any party or entity in the event that: (i) the Plan ceases to be authorized to use the Licensed Marks and Name; or (ii) pursuant to Paragraph 15(a)(x) of the Blue Cross License Agreement the Plan ceases to be
authorized to use the Licensed Names and Marks in the geographic area served by the Controlled Affiliate provided, however, that if the Controlled Affiliate is serving more than one State or portions thereof, the termination of this Agreement shall
be limited to the State(s) or portions thereof in which the Plan’s license to use the Licensed Marks and Names is terminated. By not appealing or challenging such regulatory action within the time prescribed by law or regulation, and in any
event no later than 120 days after such action is taken, a Plan shall be deemed to have exhausted its rights to appeal or challenge, and automatic termination shall proceed. 

  

					
		  		  	Amended as of September 14, 2004
		  	5	  	

 C. Notwithstanding any other provision of this Agreement, this license to use the Licensed
Marks and Name may be forthwith terminated by the Plan or the affirmative vote of the majority of the Board of Directors of BCBSA present and voting at a special meeting expressly called by BCBSA for the purpose on ten (10) days written notice
to the Plan advising of the specific matters at issue and granting the Plan an opportunity to be heard and to present its response to the Board for: (1) failure to comply with any applicable minimum capital or liquidity requirement under the
quality control standards of this Agreement; or (2) failure to comply with the “Organization and Governance” quality control standard of this Agreement; or (3) impending financial insolvency; or (4) for a Smaller Controlled
Affiliate (as defined in Exhibit A), failure to comply with any of the applicable requirements of Standards 2, 3, 4, 5 or 7 of attached Exhibit A; or (5) the pendency of any action instituted against the Controlled Affiliate seeking its
dissolution or liquidation of its assets or seeking appointment of a trustee, interim trustee, receiver or other custodian for any of its property or business or seeking the declaration or establishment of a trust for any of its property or
business, unless this Controlled Affiliate License Agreement has been earlier terminated under paragraph 7(e); or (6) failure by a Controlled Affiliate that meets the standards of 2E(1) but not 2E(2) above to obtain BCBSA’s written consent
to a change in the identity of any owner, in the extent of ownership, or in the identity of any person or entity with the authority to select or appoint members or board members, provided that as to publicly traded Controlled Affiliates this
provision shall apply only if the change affects a person or entity that owns at least 5% of the Controlled Affiliate’s stock before or after the change; or (7) such other reason as is determined in good faith immediately and irreparably
to threaten the integrity and reputation of BCBSA, the Plans, any other licensee including Controlled Affiliate and/or the Licensed Marks and Name. 
 D. Except as otherwise provided in Paragraphs 7(B), 7(C) or 7(E) herein, should Controlled Affiliate fail to comply with the provisions of this Agreement and not cure such failure within thirty
(30) days of receiving written notice thereof (or commence a cure within such thirty day period and continue diligent efforts to complete the cure if such curing cannot reasonably be completed within such thirty day period) BCBSA or the Plan
shall have the right to issue a notice that the Controlled Affiliate is in a state of noncompliance. If a state of noncompliance as aforesaid is undisputed by the Controlled Affiliate or is found to exist by a mandatory dispute resolution panel and
is uncured as provided above, BCBSA shall have the right to seek judicial enforcement of the Agreement or to issue a notice of termination thereof. Notwithstanding any other provisions of this Agreement, any disputes as to the termination of this
License pursuant to Paragraphs 7(B), 7(C) or 7(E) of this Agreement shall not be subject to mediation and mandatory dispute resolution. All other disputes between BCBSA, the Plan and/or Controlled Affiliate shall be submitted promptly to mediation
and mandatory dispute resolution. The mandatory dispute resolution panel shall have authority to issue orders for specific performance and assess monetary penalties. Except, however, as provided in Paragraphs 7(B) and 7(E) of this Agreement, this
license to use the Licensed Marks and Name may not be finally terminated for any reason without the affirmative vote of a majority of the present and voting members of the Board of Directors of BCBSA. 

  
 6 

 E. This Agreement and all of Controlled Affiliate’s rights hereunder shall immediately
terminate without any further action by any party or entity in the event that: 
 (1) Controlled Affiliate shall no longer
comply with item 2(E) above; 
 (2) Appropriate dues, royalties and other payments for Controlled Affiliate pursuant to
paragraph 9 hereof, which are the royalties for this License Agreement, are more than sixty (60) days in arrears to BCBSA; or 
 (3) Any of the following events occur: (i) a voluntary petition shall be filed by Controlled Affiliate seeking bankruptcy, reorganization, arrangement with creditors or other relief under the
bankruptcy laws of the United States or any other law governing insolvency or debtor relief, or (ii) an involuntary petition or proceeding shall be filed against Controlled Affiliate seeking bankruptcy, reorganization, arrangement with
creditors or other relief under the bankruptcy laws of the United States or any other law governing insolvency or debtor relief and such petition or proceeding is consented to or acquiesced in by Controlled Affiliate or is not dismissed within sixty
(60) days of the date upon which the petition or other document commencing the proceeding is served upon the Controlled Affiliate, or (iii) an order for relief is entered against Controlled Affiliate in any case under the bankruptcy laws
of the United States, or Controlled Affiliate is adjudged bankrupt or insolvent as those terms are defined in the Uniform Commercial Code as enacted in the State of Illinois by any court of competent jurisdiction, or (iv) Controlled Affiliate
makes a general assignment of its assets for the benefit of creditors, or (v) any government or any government official, office, agency, branch, or unit assumes control of Controlled Affiliate or delinquency proceedings (voluntary or
involuntary) are instituted, or (vi) an action is brought by Controlled Affiliate seeking its dissolution or liquidation of its assets or seeking the appointment of a trustee, interim trustee, receiver or other custodian for any of its property
or business, or (vii) an action is instituted by any governmental entity or officer against Controlled Affiliate seeking its dissolution or liquidation of its assets or seeking the appointment of a trustee, interim trustee, receiver or other
custodian for any of its property or business and such action is consented to or acquiesced in by Controlled Affiliate or is not dismissed within one hundred thirty (130) days of the date upon which the pleading or other document commencing the
action is served upon the Controlled Affiliate, provided that if the action is stayed or its prosecution is enjoined, the one hundred thirty (130) day period is tolled for the duration of the stay or injunction, and provided further, that the
Association’s Board of Directors may toll or extend the 130 day period at any time prior to its expiration, or (viii) a trustee, interim trustee, receiver or other custodian for any of Controlled Affiliate’s property or business is
appointed or the Controlled Affiliate is ordered dissolved or liquidated. Notwithstanding any other provision of this Agreement, a declaration or a request for declaration of the existence of a trust over any of the Controlled Affiliate’s
property or business shall not in itself be deemed to constitute or seek appointment of a trustee, interim trustee, receiver or other custodian for purposes of subparagraphs 7(e)(3)(vii) and (viii) of this Agreement 

  

					
		  		  	Amended as of March 18, 2004
		  	7	  	

 F. Upon termination of this Agreement for cause or otherwise, Controlled Affiliate agrees
that it shall immediately discontinue all use of the Licensed Marks and Name, including any use in its trade name. 
 G. Upon
termination of this Agreement, Controlled Affiliate shall immediately notify all of its customers that it is no longer a licensee of BCBSA and, if directed by the Association’s Board of Directors, shall provide instruction on how the customer
can contact BCBSA or a designated licensee to obtain further information on securing coverage. The notification required by this paragraph shall be in writing and in a form approved by BCBSA. The BCBSA shall have the right to audit the terminated
entity’s books and records to verify compliance with this paragraph. 
 H. In the event this Agreement terminates pursuant
to 7(b) hereof, or in the event the Controlled Affiliate is a Larger Controlled Affiliate (as defined in Exhibit A), upon termination of this Agreement, the provisions of Paragraph 7.G. shall not apply and the following provisions shall apply,
except that, in the event of a partial termination of this Agreement pursuant to Paragraph 7(B)(ii) of this Agreement, the notices, national account listing, payment, and audit right listed below shall be applicable solely with respect to the
geographic area for which the Plan’s license to use the Licensed Names and Marks is terminated: 
 (1) The Controlled
Affiliate shall send a notice through the U.S. mails, with first class postage affixed, to all individual and group customers, providers, brokers and agents of products or services sold, marketed, underwritten or administered by the Controlled
Affiliate under the Licensed Marks and Name. The form and content of the notice shall be specified by BCBSA and shall, at a minimum, notify the recipient of the termination of the license, the consequences thereof, and instructions for obtaining
alternate products or services licensed by BCBSA, subject to any conflicting state law and state regulatory requirements. This notice shall be mailed within 15 days after termination. 

(2) The Controlled Affiliate shall deliver to BCBSA within five days of a request by BCBSA a listing of national accounts in which the
Controlled Affiliate is involved (in a control, participating or servicing capacity), identifying the national account and the Controlled Affiliate’s role therein. 
 (3) Unless the cause of termination is an event respecting BCBSA stated in paragraph 15(a) or (b) of the Plan’s license agreement with BCBSA to use the Licensed Marks and Name, the Controlled
Affiliate, the Plan, and any other Licensed Controlled Affiliates of the Plan shall be jointly liable for payment to BCBSA of an amount equal to the Re-Establishment Fee (desribed below) multiplied by the number of Licensed Enrollees of the
Controlled Affiliate; provided that if any other Plan is permitted by BCBSA to use marks or names licensed by BCBSA in the Service Area established by this Agreement, the Re-Establishment Fee shall be multiplied by a fraction, the numerator of which
is the number of Licensed Enrollees of the Controlled Affiliate, the Plan, and any other Licensed Controlled Affiliates and the denominator of which is the total number of Licensed Enrollees in the Service Area. 

  

					
		  		  	Amended as of June 16, 2005
		  	8	  	

 The Re-Establishment Fee shall be indexed to a base fee of $80. The Re-Establishment Fee
through December 31, 2005 shall be $80. The Re-establishment Fee for calendar years after December 31, 2005 shall be adjusted on January 1 of each calendar year up to and including January 1, 2010 and shall be the base fee
multiplied by 100% plus the cumulative percentage increase or decrease in the Plans’ gross administrative expense (standard BCBSA definition) per Licensed Enrollee since December 31, 2004. The adjustment shall end on January 1, 2011,
at which time the Re-Establishment Fee shall be fixed at the then-current amount and no longer automatically adjusted. For example, if the Plans’ gross administrative expense per Licensed Enrollee was $278.60, $285.00 and $290.00 for calendar
year end 2004, 2005 and 2006, respectively, the January 1, 2007 Re-Establishment Fee would be $83.27 (100% of base fee plus $1.84 for calendar year 2005 and $1.43 for calendar year 2006). Licensed Enrollee means each and every person and
covered dependent who is enrolled as an individual or member of a group receiving products or services sold, marketed or administered under marks or names licensed by BCBSA as determined at the earlier of (i) the end of the last fiscal year of
the terminated entity which ended prior to termination or (ii) the fiscal year which ended before any transactions causing the termination began. Notwithstanding the foregoing, the amount payable pursuant to this subparagraph H. (3) shall
be due only to the extent that, in BCBSA’s opinion, it does not cause the net worth of the Controlled Affiliate, the Plan or any other Licensed Controlled Affiliates of the Plan to fall below 100% of the Health Risk-Based Capital formula, or
its equivalent under any successor formula, as set forth in the applicable financial responsibility standards established by BCBSA (provided such equivalent is approved for purposes of this sub paragraph by the affirmative vote of three-fourths of
the Plans and three-fourths of the total then current weighted vote of all the Plans); measured as of the date of termination, and adjusted for the value of any transactions not made in the ordinary course of business. This payment shall not be due
in connection with transactions exclusively by or among Plans or their affiliates, including reorganizations, combinations or mergers, where the BCBSA Board of Directors determines that the license termination does not result in a material
diminution in the number of Licensed Enrollees or the extent of their coverage. At least 50% of the Re-Establishment Fee shall be awarded to the Plan (or Plans) that receive the new license(s) for the service area(s) at issue; provided, however,
that such award shall not become due or payable until all disputes, if any, regarding the amount of and BCBSA’s right to such Re-Establishment Fee have been finally resolved; and provided further that the award shall be based on the final
amount actually received by BCBSA. The Board of Directors shall adopt a resolution which it may amend from time to time that shall govern BCBSA’s use of its portion of the award. In the event that the Controlled Affiliate’s license is
reinstated by BCBSA or is deemed to have remained in effect without interruption by a court of competent jurisdiction, BCBSA shall reimburse the Controlled Affiliate (and/or the Plan or its other Licensed Controlled Affiliates, as the case may be)
for payments made under this subparagraph 7.H.(3) only to the extent that such payments exceed the amounts due to BCBSA pursuant to paragraph 7.M. and 

  

					
		  		  	Amended as of June 16, 2005
		  	9	  	

 
any costs associated with reestablishing the Service Area, including payments made by BCBSA to a Plan or Plans (or their Licensed Controlled Affiliates) for purposes of replacing the Controlled
Affiliate. 
 (4) BCBSA shall have the right to examine and audit and/or hire at terminated entity’s expense a third party
auditor to examine and audit the books and records of the Controlled Affiliate, the Plan, and any other Licensed Controlled Affiliates of the Plan to verify compliance with this paragraph 7.H. 

(5) Subsequent to termination of this Agreement, the terminated entity and its affiliates, agents, and employees shall have an ongoing
and continuing obligation to protect all BCBSA and Blue Licensee data that was acquired or accessed during the period this Agreement was in force, including but not limited to all confidential processes, pricing, provider, discount and other
strategic and competitively sensitive information (“Blue Information”) from disclosure, and shall not, either alone or with another entity, disclose such Blue Information or use it in any manner to compete without the express written
permission of BCBSA. 
 (6) As to a breach of 7.H.(1), (2), (3), (4) or (5) the parties agree that the obligations are
immediately enforceable in a court of competent jurisdiction. As to a breach of 7.H.(1), (2) or (4) by the Controlled Affiliate, the parties agree there is no adequate remedy at law and BCBSA is entitled to obtain specific performance.

 I. This Agreement shall remain in effect until terminated by the Controlled Affiliate upon not less than eighteen
(18) months written notice to the Association or upon a shorter notice period approved by BCBSA in writing at its sole discretion, or until terminated as otherwise provided herein. 

J. In the event the Controlled Affiliate is a Smaller Controlled Affiliate (as defined in Exhibit A), the Controlled Affiliate agrees to
be jointly liable for the amount described in H.3. and M. hereof upon termination of the BCBSA license agreement of any Larger Controlled Affiliate of the Plan. 
 K. BCBSA shall be entitled to enjoin the Controlled Affiliate or any related party in a court of competent jurisdiction from entry into any transaction which would result in a termination of this
Agreement unless the Plan’s license from BCBSA to use the Licensed Marks and Names has been terminated pursuant to 10(d) of the Plan’s license agreement upon the required 6 month written notice. 

L. BCBSA acknowledges that it is not the owner of assets of the Controlled Affiliate. 

M. In the event that the Plan has more than 50 percent voting control of the Controlled Affiliate under Paragraph 2(E)(2) above and is a
Larger Controlled Affiliate (as defined in Exhibit A), then the vote called for in Paragraphs 7(C) and 7(D) above shall require the affirmative vote of three-fourths of the Plans and three-fourths of the total then current weighted vote of all the
Plans. 

  

					
		  		  	Amended as of June 16, 2005
		  	10	  	

 N. In the event this Agreement terminates and is subsequently reinstated by BCBSA or is
deemed to have remained in effect without interruption by a court of competent jurisdiction, the Controlled Affiliate, the Plan, and any other Licensed Controlled Affiliates of the Plan shall be jointly liable for reimbursing BCBSA the reasonable
costs incurred by BCBSA in connection with the termination and the reinstatement or court action, and any associated legal proceedings, including but not limited to: outside legal fees, consulting fees, public relations fees, advertising costs, and
costs incurred to develop, lease or establish an interim provider network. Any amount due to BCBSA under this subparagraph may be waived in whole or in part by the BCBSA Board of Directors in its sole discretion. 

 

	 	8.	DISPUTE RESOLUTION 

The parties agree that any disputes between them or between or among either of them and one or more Plans or Controlled Affiliates of
Plans that use in any manner the Blue Cross and Blue Cross Marks and Name are subject to the Mediation and Mandatory Dispute Resolution process attached to and made a part of Plan’s License from BCBSA to use the Licensed Marks and Name as
Exhibit 5 as amended from time-to-time, which documents are incorporated herein by reference as though fully set forth herein. 
  

	 	9.	LICENSE FEE 

Controlled Affiliate will pay to BCBSA a fee for this License determined pursuant to the formula(s) set forth in Exhibit B. 

 

	 	10.	JOINT VENTURE 

Nothing contained in the Agreement shall be construed as creating a joint venture, partnership, agency or employment relationship between
Plan and Controlled Affiliate or between either and BCBSA. 

  

					
		  		  	Amended as of September 20, 2007
		  	11	  	

	 	11.	NOTICES AND CORRESPONDENCE 

 Notices regarding the subject matter of this Agreement or breach or termination thereof shall be in writing and shall be addressed in duplicate to the last known address of each other party, marked
respectively to the attention of its President and, if any, its General Counsel. 
  

	 	12.	COMPLETE AGREEMENT 

This Agreement contains the complete understandings of the parties in relation to the subject matter hereof. This Agreement may only be
amended by the affirmative vote of three-fourths of the Plans and three-fourths of the total then current weighted vote of all the Plans as officially recorded by the BCBSA Corporate Secretary. 

 

	 	13.	SEVERABILITY 

 If
any term of this Agreement is held to be unlawful by a court of competent jurisdiction, such findings shall in no way affect the remaining obligations of the parties hereunder and the court may substitute a lawful term or condition for any unlawful
term or condition so long as the effect of such substitution is to provide the parties with the benefits of this Agreement. 
  

	 	14.	NONWAIVER 

 No
waiver by BCBSA of any breach or default in performance on the part of Controlled Affiliate or any other licensee of any of the terms, covenants or conditions of this Agreement shall constitute a waiver of any subsequent breach or default in
performance of said terms, covenants or conditions. 
  

	 	14A.	VOTING 

 For all provisions of this
Agreement referring to voting, the term ‘Plans’ shall mean all entities licensed under the Blue Cross License Agreement and/or the Blue Shield License Agreement, and in all votes of the Plans under this Agreement the Plans shall vote
together. For weighted votes of the Plans, the Plan shall have a number of votes equal to the number of weighted votes (if any) that it holds as a Blue Cross Plan plus the number of weighted votes (if any) that it holds as a Blue Shield Plan. For
all other votes of the Plans, the Plan shall have one vote. For all questions requiring an affirmative three-fourths weighted vote of the Plans, the requirement shall be deemed satisfied with a lesser weighted vote unless the greater of:
(i) 6/52 or more of the Plans (rounded to the nearest whole number, with 0.5 or multiples thereof being rounded to the next higher whole number) fail to cast weighted votes in favor of the question; or (ii) three (3) of the Plans fail
to cast weighted votes in favor of the question. Notwithstanding the foregoing provision, if there are thirty-nine (39) Plans, the requirement of an affirmative three-fourths weighted vote shall be deemed satisfied with a lesser weighted vote
unless four (4) or more Plans fail to cast weighted votes in favor of the question. 

  

					
		  		  	Amended as of June 16, 2005
		  	12	  	

 THIS PAGE IS INTENTIONALLY BLANK. 

  
 13 

	 	15.	GOVERNING LAW 

This Agreement shall be governed by, and construed and interpreted in accordance with, the laws of the State of Illinois. 

 

	 	16.	HEADINGS 

 The
headings inserted in this agreement are for convenience only and shall have no bearing on the interpretation hereof. 
 IN
WITNESS WHEREOF, the parties have caused this License Agreement to be executed and effective as of the date of last signature written below. 
  

			
	Controlled Affiliate:
		
	By:	 	 
		
	Date:	 	 

  

			
	Plan:
		
	By:	 	 
		
	Date:	 	 

  

			
	BLUE CROSS AND BLUE SHIELD ASSOCIATION
		
	By:	 	 
		
	Date:	 	 

  

					
		  		  	
		  	14	  	

 EXHIBIT A 
 CONTROLLED AFFILIATE LICENSE STANDARDS 
 June 2010 

PREAMBLE 
 The standards for licensing
Controlled Affiliates are established by BCBSA and are subject to change from time-to-time upon the affirmative vote of three-fourths (3/4) of the Plans and three-fourths (3/4) of the total weighted vote. Each licensed Plan is required to
use a standard Controlled Affiliate license form provided by BCBSA and to cooperate fully in assuring that the licensed Controlled Affiliate maintains compliance with the license standards. 
 The Controlled Affiliate License provides a flexible vehicle to accommodate the potential range of health and workers’ compensation related products and services Plan Controlled Affiliates provide.
The Controlled Affiliate License collapses former health Controlled Affiliate licenses (HCC, HMO, PPO, TPA, and IDS) into a single license using the following business-based criteria to provide a framework for license standards: 

 

	 	•	 	 Percent of Controlled Affiliate controlled by parent: Greater than 50 percent or 50 percent? 

 

	 	•	 	 Risk assumption: yes or no? 

  

	 	•	 	 Medical care delivery: yes or no? 

  

	 	•	 	 Size of the Controlled Affiliate: If the Controlled Affiliate has health or workers’ compensation administration business, does such business
constitute 15 percent or more of the parent’s and other licensed health subsidiaries’ member enrollment? 

  

					
		  		  	Amended as of September 19, 2002
		  	15	  	

 EXHIBIT A (continued) 
 For purposes of definition: 
  

	 	•	 	 A “smaller Controlled Affiliate:” (1) comprises less than fifteen percent (15%) of Plan’s and its licensed Controlled
Affiliates’ total member enrollment (as reported on the BCBSA Quarterly Enrollment Report, excluding rider and freestanding coverage, and treating an entity seeking licensure as licensed);* or (2) underwrites the indemnity portion of
workers’ compensation insurance and has total premium revenue less than 15 percent of the sponsoring Plan’s net subscription revenue. 

  

	 	•	 	 A “larger Controlled Affiliate” comprises fifteen percent (15%) or more of Plan’s and its licensed Controlled Affiliates’
total member enrollment (as reported on the BCBSA Quarterly Enrollment Report, excluding rider and freestanding coverage, and treating an entity seeking licensure as licensed.)* 

Changes in Controlled Affiliate status: 
 If
any Controlled Affiliate’s status changes regarding: its Plan ownership level, its risk acceptance or direct delivery of medical care, the Controlled Affiliate shall notify BCBSA within thirty (30) days of such occurrence in writing
and come into compliance with the applicable standards within six (6) months. 
 If a smaller Controlled Affiliate’s health and
workers’ compensation administration business reaches or surpasses fifteen percent (15%) of the total member enrollment of the Plan and licensed Controlled Affiliates, the Controlled Affiliate shall: 

  

					
		  		  	Amended as of September 19, 2002
		  	16	  	

 EXHIBIT A (continued) 

 

	1.	Within thirty (30) days, notify BCBSA of this fact in writing, including evidence that the Controlled Affiliate meets the minimum liquidity and capital (BCBSA
“Health Risk-Based Capital (HRBC)” as defined by the NAIC and state-established minimum reserve) requirements of the larger Controlled Affiliate Financial Responsibility standard; and 

 

	2.	Within six (6) months after reaching or surpassing the fifteen percent (15%) threshold, demonstrate compliance with all license requirements for a larger
Controlled Affiliate. 

 If a Controlled Affiliate that underwrites the indemnity portion of workers’ compensation insurance
receives a change in rating or proposed change in rating, the Controlled Affiliate shall notify BCBSA within 30 days of notification by the external rating agency. 
 *For purposes of this calculation, 
 The numerator equals: 

Applicant Controlled Affiliate’s member enrollment, as defined in BCBSA’s Quarterly Enrollment Report (excluding rider and freestanding
coverage). 
 The denominator equals: 

Numerator PLUS Plan and all other licensed Controlled Affiliates’ member enrollment, as reported in BCBSA’s Quarterly Enrollment Report
(excluding rider and freestanding coverage). 

  

					
		  		  	Amended as of September 19, 2002
		  	17	  	

 EXHIBIT A (continued) 

 

 STANDARDS FOR LICENSED CONTROLLED AFFILIATES 

As described in Preamble section of Exhibit A to the Affiliate License Agreement, each controlled affiliate seeking licensure must answer four questions.
Depending on the controlled affiliate’s answers, certain standards apply: 
 1. What percent of the controlled affiliate is controlled by
the parent Plan? 
  

					
	More than 50%	  	50%	  	 100% and
Primary Business is
 Government Non-Risk

	ò	  	ò	  	ò

	Standard 1A, 4	  	Standard 1B, 4	  	Standard 4*, 10A

 

	*	Applicable only if using the names and marks. 

 IN ADDITION, 
 2. Is risk being assumed? 

 

											
	 	 	Yes	 	 	 	 	 	No	 	 
	

	 	ò
	 	

	 	

	 	ò
	 	

	 Controlled Affiliate underwrites any indemnity portion of workers’
compensation insurance

ò
 Standards 7A-7E, 12
	 	 Controlled Affiliate comprises < 15% of total member enrollment of Plan and its licensed affiliates, and does

not underwrite the indemnity portion of workers’ compensation insurance
 ò
	 	 Controlled Affiliate comprises > 15% of total member enrollment of Plan and its licensed affiliates, and does not underwrite
the indemnity portion of workers’ compensation insurance
 ò
	 	 Controlled Affiliate comprises < 15% of total member enrollment of Plan and its licensed affiliates

ò
	 	 Controlled Affiliate comprises > 15% of total member enrollment of Plan and its licensed affiliates

ò
 Standard 6H
	 	 Controlled Affiliate’s Primary Business is Government Non-
Risk
 ò
 Standard 10B

	 	 	Standard 2 (Guidelines 1.1,1.2) and Standard 11	 	Standard 6H	 	 Standard 2
 (Guidelines 1.1,1.3)
 and Standard 11
	 	 	 	 

 IN ADDITION, 
 3. Is medical care being directly provided? 

 

			
	Yes	  	No
	ò	  	ò

	Standard 3A	  	Standard 3B

IN ADDITION, 
 4. If the
controlled affiliate has health or workers’ compensation administration business, does such business comprise 15% or more of the total member enrollment of Plan and its licensed controlled affiliates? 

 

									
	 Yes
 ò
 Standards
6A-6J
	 	
 

 Controlled Affiliate is not a former primary licensee and elects to participate in BCBSA national
programs
 ò
 Standards 5,8,9B,12
	 	
 

 Controlled Affiliate is a former primary licensee

ò
 Standards 5,8,9A,11, 12
	 	 No

ò
 Controlled Affiliate is not a former primary licensee and does not elect to
participate in BCBSA national programs
 ò
 Standards
5,8,12
	 	
 

 Controlled Affiliate’s Primary Business is Government Non-Risk

ò
 Standards 8, 10(C), 12

  
 18 

 EXHIBIT A (continued) 
 Standard 1 - Organization and Governance 
  

	1A.)	The Standard for more than 50% Plan control is: 

A Controlled Affiliate shall be organized and operated in such a manner that a licensed Plan or Plans authorized to use the Licensed Marks in the Service
Area of the Controlled Affiliate pursuant to separate License Agreement(s) with BCBSA, other than such Controlled Affiliate’s License Agreement(s), (the “Controlling Plan(s)”), have the legal authority, directly or indirectly through
wholly-owned subsidiaries: 1) to select members of the Controlled Affiliate’s governing body having more than 50% voting control thereof; and 2) to prevent any change in the articles of incorporation, bylaws or other establishing or governing
documents of the Controlled Affiliate with which the Controlling Plan(s) do(es) not concur; and 3) to exercise control over the policy and operations of the Controlled Affiliate. In addition, a Plan or Plans directly or indirectly through
wholly-owned subsidiaries shall own more than 50% of any for-profit Controlled Affiliate. 
  

	1B.)	The Standard for 50% Plan control is: 

 A
Controlled Affiliate shall be organized and operated in such a manner that a licensed Plan or Plans authorized to use the Licensed Marks in the Service Area of the Controlled Affiliate pursuant to separate License Agreement(s) with BCBSA, other than
such Controlled Affiliate’s License Agreement(s), (the “Controlling Plan(s)”), have the legal authority, directly or indirectly through wholly-owned subsidiaries: 

 

	1)	to select members of the Controlled Affiliate’s governing body having not less than 50% voting control thereof; and 

 

	2)	to prevent any change in the articles of incorporation, bylaws or other establishing or governing documents of the Controlled Affiliate with which the Controlling
Plan(s) do(es) not concur; and 

  

	3)	to exercise control over the policy and operations of the Controlled Affiliate at least equal to that exercised by persons or entities (jointly or individually) other
than the Controlling Plan(s). 

  
 19 

 EXHIBIT A (continued) 
 Notwithstanding anything to the contrary in 1) through 3) hereof, the Controlled Affiliate’s establishing or governing documents must also require written approval by the Controlling Plan(s) before
the Controlled Affiliate can: 
  

	 	•	 	 change the geographic area in which it operates 

  

	 	•	 	 change its legal and/or trade names 

  

	 	•	 	 change any of the types of businesses in which it engages 

 

	 	•	 	 create, or become liable for by way of guarantee, any indebtedness, other than indebtedness arising in the ordinary course of business

  

	 	•	 	 sell any assets, except for sales in the ordinary course of business or sales of equipment no longer useful or being replaced

  

	 	•	 	 make any loans or advances except in the ordinary course of business 

 

	 	•	 	 enter into any arrangement or agreement with any party directly or indirectly affiliated with any of the owners or persons or entities with the
authority to select or appoint members or board members of the Controlled Affiliate, other than the Plan or Plans (excluding owners of stock holdings of under 5% in a publicly traded Controlled Affiliate) 

 

	 	•	 	 conduct any business other than under the Licensed Marks and Name 

 

	 	•	 	 take any action that any Controlling Plan or BCBSA reasonably believes will adversely affect the Licensed Marks and Name. 

In addition, a Plan or Plans directly or indirectly through wholly-owned subsidiaries shall own at least 50% of any for-profit Controlled Affiliate.

  
 20 

 EXHIBIT A (continued) 
 Standard 2 - Financial Responsibility 
 A Controlled Affiliate shall be operated in a manner
that provides reasonable financial assurance that it can fulfill all of its contractual obligations to its customers. If a risk-assuming Controlled Affiliate ceases operations for any reason, Blue Cross and/or Blue Cross Plan coverage will be
offered to all Controlled Affiliate subscribers without exclusions, limitations or conditions based on health status. If a nonrisk-assuming Controlled Affiliate ceases operations for any reason, sponsoring Plan(s) will provide for services to its
(their) customers. The requirements of the preceding two sentences shall apply to all lines of business unless a line of business is specially exempted from the requirement(s) by the BCBSA Board of Directors. 

Standard 3 - State Licensure/Certification 
  

	3A.)	The Standard for a Controlled Affiliate that employs, owns or contracts on a substantially exclusive basis for medical services is: 

A Controlled Affiliate shall maintain unimpaired licensure or certification for its medical care providers to operate under applicable state laws.

  

	3B.)	The Standard for a Controlled Affiliate that does not employ, own or contract on a substantially exclusive basis for medical services is: 

A Controlled Affiliate shall maintain unimpaired licensure or certification to operate under applicable state laws. 

Standard 4 - Certain Disclosures 
 A
Controlled Affiliate shall make adequate disclosure in contracting with third parties and in disseminating public statements of 1) the structure of the Blue Cross and Blue Shield System; and 2) the independent nature of every licensee; and 3) the
Controlled Affiliate’s financial condition. 
 Standard 5 - Reports and Records for Certain Smaller Controlled Affiliates

 For a smaller Controlled Affiliate that does not underwrite the indemnity portion of workers’ compensation insurance, the Standard
is: 

  

					
		  		  	Amended as of June 16, 2005
		  	21	  	

 EXHIBIT A (continued) 
 A Controlled Affiliate and/or its licensed Plan(s) shall furnish, on a timely and accurate basis, reports and records relating to these Standards and the License Agreements between BCBSA and Controlled
Affiliate. 
 Standard 6 - Other Standards for Larger Controlled Affiliates 
 Standards 6(A) - (I) that follow apply to larger Controlled Affiliates. 
 Standard 6(A): Board of
Directors 
 A Controlled Affiliate Governing Board shall act in the interest of its Corporation in providing cost-effective health care
services to its customers. A Controlled Affiliate shall maintain a governing Board, which shall control the Controlled Affiliate, composed of a majority of persons other than providers of health care services, who shall be known as public members. A
public member shall not be an employee of or have a financial interest in a health care provider, nor be a member of a profession which provides health care services. 
 Standard 6(B): Responsiveness to Customers 
 A Controlled Affiliate shall be operated in a manner
responsive to customer needs and requirements. 
 Standard 6(C): Participation in National Programs 

A Controlled Affiliate shall effectively and efficiently participate in each national program as from time to time may be adopted by the Member Plans for
the purposes of providing portability of membership between the licensees and ease of claims processing for customers receiving benefits outside of the Controlled Affiliate’s Service Area. 

Such programs are applicable to licensees, and include: 
  

	1.	Transfer Program; 

  

	2.	BlueCard Program; 

  
 22 

 EXHIBIT A (continued) 

 

	3.	Inter-Plan Teleprocessing System (ITS); 

  

	4.	National Account Programs; 

  

	5.	Business Associate Agreement for Blue Cross and Blue Shield Licensees, effective April 14, 2003; and 

 

	6.	Inter-Plan Medicare Advantage Program. 

Standard 6(D): Financial Performance Requirements 
 In addition to requirements under the national programs listed in Standard 6C: Participation in National Programs, a Controlled Affiliate shall take such action as required to ensure its financial
performance in programs and contracts of an inter-licensee nature or where BCBSA is a party. 
 Standard 6(E): Cooperation with Plan Performance
Response Process 
 A Controlled Affiliate shall cooperate with BCBSA’s Board of Directors and its Plan Performance and Financial Standards
Committee in the administration of the Plan Performance Response Process and in addressing Controlled Affiliate performance problems identified thereunder. 
 Standard 6(F): Independent Financial Rating 
 A Controlled Affiliate shall obtain a rating of its
financial strength from an independent rating agency approved by BCBSA’s Board of Directors for such purpose. 
 Standard 6(G): Local and
National Best Efforts 
 Notwithstanding any other provision in the Plan’s License Agreement with BCBSA or in this License Agreement,
during each year, a Controlled Affiliate shall use its best efforts to promote and build the value of the Blue Cross Mark. 
 Standard 6(H):
Financial Responsibility 
 A Controlled Affiliate shall be operated in a manner that provides reasonable financial assurance that it can
fulfill all of its contractual obligations to its customers. 

  

					
		  		  	Amended as of November 15, 2007
		  	23	  	

 EXHIBIT A (continued) 
 Standard 6(I): Reports and Records 
 A Controlled Affiliate shall furnish to BCBSA on a timely and
accurate basis reports and records relating to compliance with these Standards and the License Agreements between BCBSA and Controlled Affiliate. Such reports and records are the following: 

 

	A)	BCBSA Controlled Affiliate Licensure Information Request; and 

  

	B)	Biennial trade name and service mark usage material, including disclosure material; and 

 

	C)	Changes in the ownership and governance of the Controlled Affiliate, including changes in its charter, articles of incorporation, or bylaws, changes in a Controlled
Affiliate’s Board composition, or changes in the identity of the Controlled Affiliate’s Principal Officers, and changes in risk acceptance, contract growth, or direct delivery of medical care; and 

 

	D)	 Quarterly Financial Report, Semi-annual “Health Risk-Based Capital (HRBC) Report”as defined by the NAIC, Annual Financial Forecast, Annual Certified Audit Report, Insurance Department Examination
Report, Annual Statement filed with State Insurance Department (with all attachments), and 

  

	E)	Quarterly Enrollment Report. 

  

					
		  		  	Amended as of March 14, 2002
		  	24	  	

 EXHIBIT A (continued) 
 Standard 6(J): Control by Unlicensed Entities Prohibited 
 No Controlled Affiliate shall cause or
permit an entity other than a Plan or a Licensed Controlled Affiliate thereof to obtain control of the Controlled Affiliate or to acquire a substantial portion of its assets related to licensable services. 

Standard 7 - Other Standards for Risk-Assuming Workers’ Compensation Controlled Affiliates 

Standards 7(A) - (E) that follow apply to Controlled Affiliates that underwrite the indemnity portion of workers’ compensation insurance. 

Standard 7 (A): Financial Responsibility 
 A
Controlled Affiliate shall be operated in a manner that provides reasonable financial assurance that it can fulfill all of its contractual obligations to its customers. 
 Standard 7(B): Reports and Records 
 A Controlled Affiliate shall furnish, on a timely and
accurate basis, reports and records relating to compliance with these Standards and the License Agreements between BCBSA and the Controlled Affiliate. Such reports and records are the following: 

 

	A.	BCBSA Controlled Affiliate Licensure Information Request; and 

  

	B.	Biennial trade name and service mark usage materials, including disclosure materials; and 

 

	C.	Annual Certified Audit Report, Annual Statement as filed with the State Insurance Department (with all attachments), Annual NAIC’s Risk-Based Capital Worksheets
for Property and Casualty Insurers, Annual Financial Forecast; and 

  

	D.	Quarterly Financial Report, Quarterly Estimated Risk-Based Capital for Property and Casualty Insurers, Insurance Department Examination Report, Quarterly Enrollment
Report; and 

  

					
		  		  	Amended as of September 19, 2002
		  	25	  	

 EXHIBIT A (continued) 

 

	E.	Notification of all changes and proposed changes to independent ratings within 30 days of receipt and submission of a copy of all rating reports; and

  

	F.	Changes in the ownership and governance of the Controlled Affiliate including changes in its charter, articles of incorporation, or bylaws, changes in a Controlled
Affiliate’s Board composition, Plan control, state license status, operating area, the Controlled Affiliate’s Principal Officers or direct delivery of medical care. 

 Standard 7(C): Loss Prevention 
 A Controlled Affiliate shall apply loss prevention protocol to
both new and existing business. 
 Standard 7(D): Claims Administration 
 A Controlled Affiliate shall maintain an effective claims administration process that includes all the necessary functions to assure prompt and proper resolution of medical and indemnity claims.

 Standard 7(E): Disability and Provider Management 
 A Controlled Affiliate shall arrange for the provision of appropriate and necessary medical and rehabilitative services to facilitate early intervention by medical professionals and timely and appropriate
return to work. 

  

					
		  		  	Amended as of November 16, 2000
		  	26	  	

 EXHIBIT A (continued) 
 Standard 8 - Cooperation with Controlled Affiliate License Performance Response Process Protocol 
 A Controlled Affiliate and its Sponsoring Plan(s) shall cooperate with BCBSA’s Board of Directors and its Plan Performance and Financial Standards Committee in the administration of the Controlled
Affiliate License Performance Response Process Protocol (ALPRPP) and in addressing Controlled Affiliate compliance problems identified thereunder. 
 Standard 9(A) - Participation in National Programs by Smaller Controlled Affiliates that were former Primary Licensees 
 A smaller controlled affiliate that formerly was a Primary Licensee shall effectively and efficiently participate in certain national programs from time to time as may be adopted by Member Plans for the
purposes of providing ease of claims processing for customers receiving benefits outside of the Controlled Affiliate’s service area and be subject to certain relevant financial and reporting requirements. 

 

	A.	National program requirements include: 

  

	 	•	 	 BlueCard Program; 

  

	 	•	 	 Inter-Plan Teleprocessing System (ITS); 

  

	 	•	 	 Transfer Program; 

  

	 	•	 	 National Account Programs. 

  

	B.	Financial Requirements include: 

  

	 	•	 	 Standard 6(D): Financial Performance Requirements and Standard 6(H): Financial Responsibility; or 

 

	 	•	 	 A financial guarantee covering the Controlled Affiliate’s Inter-Plan Programs obligations in a form, and from a guarantor, acceptable to BCBSA.

  

					
		  		  	Amended as of November 15, 2007
		  	27	  	

 EXHIBIT A (continued) 
 Standard 9(A) - Participation in National Programs by Smaller Controlled Affiliates that were former Primary Licensees 

 

	C.	Reporting requirements include: 

  

	 	•	 	 The Semi-annual Health Risk-Based Captial (HRBC) Report. 

  

					
		  		  	Amended as of June 13, 2002
		  	28	  	

 EXHIBIT A (continued) 
 Standard 9(B) - Participation in National Programs by Smaller Controlled Affiliates 
 A
smaller controlled affiliate that voluntarily elects to participate in national programs in accordance with BlueCard and other relevant Policies and Provisions shall effectively and efficiently participate in national programs from time to time as
may be adopted by Member Plans for the purposes of providing ease of claims processing for customers receiving benefits outside of the controlled affiliate’s service area and be subject to certain relevant financial and reporting requirements.

  

	A.	National program requirements include: 

  

	 	•	 	 BlueCard Program; 

  

	 	•	 	 Inter-Plan Teleprocessing System (ITS); 

  

	 	•	 	 National Account Programs. 

  

	B.	Financial Requirements include: 

  

	 	•	 	 Standard 6(D): Financial Performance Requirements and Standard 6(H): Financial Responsibility; or 

 

	 	•	 	 A financial guarantee covering the Controlled Affiliate’s Inter-Plan Programs obligations in a form, and from a guarantor, acceptable to BCBSA.

  

					
		  		  	Amended as of November 15, 2007
		  	29	  	

 EXHIBIT A (continued) 
 Standard 10 - Other Standards for Controlled Affiliates Whose Primary Business is Government Non-Risk 
 Standards 10(A) - (C) that follow apply to Controlled Affiliates whose primary business is government non-risk. 
 Standard 10(A) - Organization and Governance 
 A Controlled Affiliate shall be organized and
operated in such a manner that it is 1) wholly owned by a licensed Plan or Plans and 2) the sponsoring licensed Plan or Plans have the legal ability to prevent any change in the articles of incorporation, bylaws or other establishing or governing
documents of the Controlled Affiliate with which it does not concur. 

  
 30 

 EXHIBIT A (continued) 
 Standard 10(B) - Financial Responsibility 
 A Controlled Affiliate shall be operated in a manner
that provides reasonable financial assurance that it can fulfill all of its contractual obligations to its customers. 
 Standard 10(C):-
Reports and Records 
 A Controlled Affiliate shall furnish, on a timely and accurate basis, reports and records relating to compliance with
these Standards and the License Agreements between BCBSA and the Controlled Affiliate. Such reports and records are the following: 
  

	A.	BCBSA Affiliate Licensure Information Request; and 

  

	B.	Biennial trade name and service mark usage materials, including disclosure material; and 

 

	C.	Annual Certified Audit Report, Annual Statement (if required) as filed with the State Insurance Department (with all attachments), Annual NAIC Risk-Based Capital
Worksheets (if required) as filed with the State Insurance Department (with all attachments), and Insurance Department Examination Report (if applicable)*; and 

 

	D.	Changes in the ownership and governance of the Controlled Affiliate, including changes in its charter, articles of incorporation, or bylaws, changes in the Controlled
Affiliate’s Board composition, Plan control, state license status, operating area, the Controlled Affiliate’s Principal Officers or direct delivery of medical care. 

  
 31 

 EXHIBIT A (continued) 
 Standard 11- Participation in Inter-Plan Medicare Advantage Program 
 A smaller controlled
affiliate for which this standard applies pursuant to the Preamble section of Exihibit A of the Controlled Affiliate License Agreement shall effectively and efficiently participate in certain national programs from time to time as may be adopted by
Member Plans for the purposes of providing ease of claims processing for customers receiving benefits outside of the controlled affiliate’s service area. 
 National program requirements include: 
  

	A.	Inter-Plan Medicare Advantage Program. 

  

					
		  		  	Amended as of November 15, 2007
		  	32	  	

 EXHIBIT A (continued) 
 Standard 12: Participation in Master Business Associate Agreement by Smaller Controlled Affiliate Licensees 
 Effective April 14, 2003, all smaller controlled affiliates shall comply with the terms of the Business Associate Agreement for Blue Cross and Blue Shield Licensees to the extent they perform the
functions of a business associate or subcontractor to a business associate, as defined by the Business Associate Agreement. 

  

					
		  		  	Amended as of September 19, 2002
		  	33	  	

 EXHIBIT B 
 ROYALTY FORMULA FOR SECTION 9 OF THE 
 CONTROLLED AFFILIATE LICENSE AGREEMENT 

Controlled Affiliate will pay BCBSA a fee for this license in accordance with the following formula: 

FOR RISK AND GOVERNMENT NON-RISK PRODUCTS: 
 For Controlled Affiliates not underwriting the indemnity portion of workers’ compensation insurance: 
 An amount equal to its pro rata share of each sponsoring Plan’s dues payable to BCBSA computed with the addition of the Controlled Affiliate’s members using the Marks on health care plans and
related services as reported on the Quarterly Enrollment Report with BCBSA. The payment by each sponsoring Plan of its dues to BCBSA, including that portion described in this paragraph, will satisfy the requirement of this paragraph, and no separate
payment will be necessary. 
 For Controlled Affiliates underwriting the indemnity portion of workers’ compensation insurance: 

An amount equal to 0.35 percent of the gross revenue per annum of Controlled Affiliate arising from products using the marks; plus, an annual fee of
$5,000 per license for a Controlled Affiliate subject to Standard 7. 
 For Controlled Affiliates whose primary business is government non-risk:

 An amount equal to its pro-rata share of each sponsoring Plan’s dues payable to BCBSA computed with the addition of the Controlled
Affiliate’s government non-risk beneficiaries. 

  

					
		  		  	Amended as of June 14, 2007
		  	34	  	

 EXHIBIT B (continued) 
 FOR NONRISK PRODUCTS: 
 For third-party administrative business, an amount equal to its pro
rata share of each sponsoring Plan’s dues payable to BCBSA computed with the addition of the Controlled Affiliate’s members using the Marks on health care plans and related services as reported on the Quarterly Enrollment Report with
BCBSA. The payment by each sponsoring Plan of its dues to BCBSA, including that portion described in this paragraph, will satisfy the requirement of this paragraph, and no separate payment will be necessary. 

For non-third party administrative business (e.g., case management, provider networks, etc.), an amount equal to 0.24 percent of the gross revenue per
annum of Controlled Affiliate arising from products using the marks; plus: 
  

	1)	An annual fee of $5,000 per license for a Controlled Affiliate subject to Standard 6 D. 

 

	2)	An annual fee of $2,000 per license for all other Controlled Affiliates. 

 The foregoing shall be reduced by one-half where both a BLUE CROSS®
and BLUE SHIELD® License are issued to the same Controlled Affiliate. In the event that any license period is
greater or less than one (1) year, any amounts due shall be prorated. Royalties under this formula will be calculated, billed and paid in arrears. 

  

					
		  		  	Amended as of June 14, 2007
		  	35	  	

 EXHIBIT 1A 
 CONTROLLED AFFILIATE LICENSE AGREEMENT 
 APPLICABLE TO LIFE INSURANCE
COMPANIES 
 (Includes revisions adopted by Member Plans through their November 18, 2010 meeting) 

This agreement by and among Blue Cross and Blue Shield Association (“BCBSA”)
                                         
        (“Controlled Affiliate”), a Controlled Affiliate of the Blue Cross Plan(s), known as
                                         
                (“Plan”). 
 WHEREAS, BCBSA is the owner
of the BLUE CROSS and BLUE CROSS Design service marks; 
 WHEREAS, the Plan and the Controlled Affiliate desire that the latter be entitled to
use the BLUE CROSS and BLUE CROSS Design service marks (collectively the “Licensed Marks”) as service marks and be entitled to use the term BLUE CROSS in a trade name (“Licensed Name”); 

NOW, THEREFORE, in consideration of the foregoing and the mutual agreements hereinafter set forth and for other good and valuable consideration, the
receipt and sufficiency of which are hereby acknowledged, the parties hereby agree as follows: 
 1. GRANT OF LICENSE

 Subject to the terms and conditions of this Agreement, BCBSA hereby grants to the Controlled Affiliate the exclusive right
to use the licensed Marks and Names in connection with and only in connection with those life insurance and related services authorized by applicable state law, other than health care plans and related services (as defined in the Plan’s License
Agreements with BCBSA) which services are not separately licensed to Controlled Affiliate by BCBSA, in the Service Area served by the Plan, except that BCBSA reserves the right to use the Licensed Marks and Name in said Service Area, and except to
the extent that said Service Area may overlap the area or areas served by one or more other licensed Blue Cross Plans as of the date of this License as to which overlapping areas the rights hereby granted are non-exclusive as to such other Plan or
Plans and their respective Licensed Controlled Affiliates only. Controlled Affiliate cannot use the Licensed Marks or Name outside the Service Area or in its legal or trade name; provided, however, that if and only for so long as Controlled
Affiliate also holds a Blue Cross Controlled Affiliate License Agreement applicable to health care plans and related services, Controlled Affiliate may use the Licensed Marks and Name in its legal and trade name according to the terms of such
license agreement. 

  

					
		  		  	Amended as of June 12, 2003
		  	-1-	  	

 2. QUALITY CONTROL 

A. Controlled Affiliate agrees to use the Licensed Marks and Name only in relation to the sale, marketing and rendering of authorized
products and further agrees to be bound by the conditions regarding quality control shown in Exhibit A as it may be amended by BCBSA from time-to-time. 
 B. Controlled Affiliate agrees that Plan and/or BCBSA may, from time-to-time, upon reasonable notice, review and inspect the manner and method of Controlled Affiliate’s rendering of service and use
of the Licensed Marks and Name. 
 C. Controlled Affiliate agrees that it will provide on an annual basis (or more often if
reasonably required by Plan or by BCBSA) a report to Plan and BCBSA demonstrating Controlled Affiliate’s compliance with the requirements of this Agreement including but not limited to the quality control provisions of Exhibit A. 

D. As used herein, a Controlled Affiliate is defined as an entity organized and operated in such a manner that it is subject to the bona
fide control of a Plan or Plans. Absent written approval by BCBSA of an alternative method of control, bona fide control shall mean the legal authority, directly or indirectly through wholly-owned subsidiaries: (a) to select members of the
Controlled Affiliate’s governing body having not less than 51% voting control thereof; (b) to exercise operational control with respect to the governance thereof; and (c) to prevent any change in its articles of incorporation, bylaws
or other governing documents deemed inappropriate. In addition, a Plan or Plans shall own at least 51 % of any for-profit Controlled Affiliate. If the Controlled Affiliate is a mutual company, the Plan or its designee(s) shall have and
maintain, in lieu of the requirements of items (a) and (c) above, proxies representing 51% of the votes at any meeting of the policyholders and shall demonstrate that there is no reason to believe this such proxies shall be revoked by
sufficient policyholders to reduce such percentage below 51%. 
 3. SERVICE MARK USE 

Controlled Affiliate shall at all times make proper service mark use of the Licensed Marks, including but not limited to use of such
symbols or words as BCBSA shall specify to protect the Licensed Marks, and shall comply with such rules (applicable to all Controlled Affiliates licensed to use the Marks) relative to service mark use, as are issued from time-to-time by BCBSA. If
there is any public reference to the affiliation between the Plan and the Controlled Affiliate, all of the Controlled Affiliate’s licensed services in the Service Area of the Plan shall be rendered under the Licensed Marks. Controlled Affiliate
recognizes and agrees that all use of the Licensed Marks by Controlled Affiliate shall inure to the benefit of BCBSA. 

  
 -2-

 4. SUBLICENSING AND ASSIGNMENT 

Controlled Affiliate shall not sublicense, transfer, hypothecate, sell, encumber or mortgage, by operation of law or otherwise, the rights
granted hereunder and any such act shall be voidable at the option of Plan or BCBSA. This Agreement and all rights and duties hereunder are personal to Controlled Affiliate. 
 5. INFRINGEMENTS 
 Controlled Affiliate shall promptly notify Plan
and BCBSA of any suspected acts of infringement, unfair competition or passing off which may occur in relation to the Licensed Marks. Controlled Affiliate shall not be entitled to require Plan or BCBSA to take any actions or institute any
proceedings to prevent infringement, unfair competition or passing off by third parties. Controlled Affiliate agrees to render to Plan and BCBSA, free of charge, all reasonable assistance in connection with any matter pertaining to the protection of
the Licensed Marks by BCBSA. 
 6. LIABILITY INDEMNIFICATION 

Controlled Affiliate hereby agrees to save, defend, indemnify and hold Plan and BCBSA harmless from and against all claims, damages,
liabilities and costs of every kind, nature and description which may arise as a result of Controlled Affiliate’s rendering of health care services under the Licensed Marks. 

7. LICENSE TERM 
 The license granted by this Agreement shall remain in effect for a period of one (1) year and shall be automatically extended for additional one (1) year periods upon evidence satisfactory to
the Plan and BCBSA that Controlled Affiliate meets the then applicable quality control standards, unless one of the parties hereto notifies the other party of the termination hereof at least sixty (60) days prior to expiration of any license
period. 
 This Agreement may be terminated by the Plan or by BCBSA for cause at any time provided that Controlled Affiliate has
been given a reasonable opportunity to cure and shall not effect such a cure within thirty (30) days of receiving written notice of the intent to terminate (or commence a cure within such thirty day period and continue diligent efforts to
complete the cure if such curing cannot reasonably be completed within such thirty day period). By way of example and not for purposes of limitation, Controlled Affiliate’s failure to abide by the quality control provisions of Paragraph 2,
above, shall be considered a proper ground for cancellation of this Agreement. 

  
 -3-

 This Agreement and all of Controlled Affiliate’s rights hereunder shall immediately
terminate without any further action by any party or entity in the event that: 
 A. Controlled Affiliate shall no longer comply
with Standard No. 1 (Organization and Governance) of Exhibit A or, following an opportunity to cure, with the remaining quality control provisions of Exhibit A, as it may be amended from time-to-time; or 

B. Plan ceases to be authorized to use the Licensed Marks; or 
 C. Appropriate dues for Controlled Affiliate pursuant to item 8 hereof, which are the royalties for this License Agreement are more than sixty (60) days in arrears to BCBSA. 

Upon termination of this Agreement for cause or otherwise, Controlled Affiliate agrees that it shall immediately discontinue all use of
the Licensed Marks including any use in its trade name. 
 In the event of any disagreement between Plan and BCBSA as to whether
grounds exist for termination or as to any other term or condition hereof, the decision of BCBSA shall control, subject to provisions for mediation or mandatory dispute resolution in effect between the parties. 

Upon termination of this Agreement, Licensed Controlled Affiliate shall immediately notify all of its customers that it is no longer a
licensee of the Blue Cross and Blue Shield Association and provide instruction on how the customer can contact the Blue Cross and Blue Shield Association or a designated licensee to obtain further information on securing coverage. The written
notification required by this paragraph shall be in writing and in a form approved by the Association. The Association shall have the right to audit the terminated entity’s books and records to verify compliance with this paragraph. 

  
 -4a-

 8. DUES 

Controlled Affiliate will pay to BCBSA a fee for this license in accordance with the following formula: 

 

	 	•	 	 An annual fee of five thousand dollars ($5,000) per license, plus 

 

	 	•	 	 05% of gross revenue per year from branded group products, plus 

 

	 	•	 	 5% of gross revenue per year from branded individual products plus 

 

	 	•	 	 14% of gross revenue per year from branded individual annuity products. 

The foregoing percentages shall be reduced by one-half where both a BLUE CROSS® and BLUE SHIELD® license are issued to the same entity. In the event that any License period is greater or less than one (1) year, any amounts due shall be prorated. Royalties
under this formula will be calculated, billed and paid in arrears. 
 Plan will promptly and timely transmit to BCBSA all dues
owed by Controlled Affiliate as determined by the above formula and if Plan shall fail to do so, Controlled Affiliate shall pay such dues directly. 

  

					
		  		  	Amended as of November 20, 1997
		  	-4b-	  	

 9. JOINT VENTURE 

Nothing contained in this Agreement shall be construed as creating a joint venture, partnership, agency or employment relationship between
Plan and Controlled Affiliate or between either and BCBSA. 
 9A. VOTING 

For all provisions of this Agreement referring to voting, the term ‘Plans’ shall mean all entities licensed under the Blue Cross
License Agreement and/or the Blue Shield License Agreement, and in all votes of the Plans under this Agreement the Plans shall vote together. For weighted votes of the Plans, the Plan shall have a number of votes equal to the number of weighted
votes (if any) that it holds as a Blue Cross Plan plus the number of weighted votes (if any) that it holds as a Blue Shield Plan. For all other votes of the Plans, the Plan shall have one vote. For all questions requiring an affirmative
three-fourths weighted vote of the Plans, the requirement shall be deemed satisfied with a lesser weighted vote unless the greater of: (i) 6/52 or more of the Plans (rounded to the nearest whole number, with 0.5 or multiples thereof being
rounded to the next higher whole number) fail to cast weighted votes in favor of the question; or (ii) three (3) of the Plans fail to cast weighted votes in favor of the question. Notwithstanding the foregoing provision, if there are
thirty-nine (39) Plans, the requirement of an affirmative three-fourths weighted vote shall be deemed satisfied with a lesser weighted vote unless four (4) or more Plans fail to cast weighted votes in favor of the question. 

10. NOTICES AND CORRESPONDENCE 
 Notices regarding the subject matter of this Agreement or breach or termination thereof shall be in writing and shall be addressed in duplicate to the last known address of each other party, marked
respectively to the attention of its President and, if any, its General Counsel. 

  

					
		  		  	Amended as of June 16, 2005
		  	-4c-	  	
		  		  	(The next page is page 5)

 11. COMPLETE AGREEMENT 

This Agreement contains the complete understandings of the parties in relation to the subject matter hereof. This Agreement may only be
amended by a writing executed by all parties. 
 12. SEVERABILITY 

If any term of this Agreement is held to be unlawful by a court of competent jurisdiction, such finding shall in no way effect the
remaining obligations of the parties hereunder and the court may substitute a lawful term or condition for any unlawful term or condition so long as the effect of such substitution is to provide the parties with the benefits of this Agreement.

 13. NONWAIVER 
 No waiver by BCBSA of any breach or default in performance on the part of the Controlled Affiliate or any other licensee of any of the terms, covenants or conditions of this Agreement shall constitute a
waiver of any subsequent breach or default in performance of said terms, covenants or conditions. 
 14. GOVERNING LAW

 This Agreement shall be governed by, and construed and interpreted in accordance with, the laws of the State of Illinois.

  

					
		  		  	
		  	-5-	  	

 IN WITNESS WHEREOF, the parties have caused this License Agreement to be executed, effective as of the date
of last signature written below. 
  

			
	BLUE CROSS AND BLUE SHIELD ASSOCIATION
		
	By:	 	 
		
	Date:	 	 

  

			
	Controlled Affiliate:
		
	By:	 	 
		
	Date:	 	 

  

			
	Plan:
		
	By:	 	 
		
	Date:	 	 

  

					
		  		  	
		  	-6-	  	

 EXHIBIT A 
 CONTROLLED AFFILIATE LICENSE STANDARDS 
 LIFE INSURANCE COMPANIES 

Page 1 of 2 
 PREAMBLE 

The standards for licensing Life Insurance Companies (Life and Health Insurance companies, as defined by state statute) are established by BCBSA and are
subject to change from time-to-time upon the affirmative vote of three-fourths (3/4) of the Plans and three-fourths (3/4) of the total weighted vote of all Plans. Each Licensed Plan is required to use a standard controlled affiliate
license form provided by BCBSA and to cooperate fully in assuring that the licensed Life Insurance Company maintains compliance with the license standards. 
 An organization meeting the following standards shall be eligible for a license to use the Licensed Marks within the service area of its sponsoring Licensed Plan to the extent and the manner authorized
under the Controlled Affiliate License applicable to Life Insurance Companies and the principal license to the Plan. 
 Standard 1 -
Organization and Governance 
 The LIC shall be organized and operated in such a manner that it is controlled by a licensed Plan or Plans
which have, directly or indirectly: 1) not less than 51% of the voting control of the LIC; and 2) the legal ability to prevent any change in the articles of incorporation, bylaws or other establishing or governing documents of the LIC with which it
does not concur; and 3) operational control of the LIC. 
 If the LIC is a mutual company, the Plan or its designee(s) shall have and maintain,
in lieu of the requirements of items 1 and 2 above, proxies representing at least 51% of the votes at any policyholder meeting and shall demonstrate that there is no reason to believe such proxies shall be revoked by sufficient policyholders to
reduce such percentage below 51%. 
 Standard 2 - State Licensure 
 The LIC must maintain unimpaired licensure or certificate of authority to operate under applicable state laws as a life and health insurance company in each state in which the LIC does business.

  

					
		  		  	
		  	-1-	  	

 EXHIBIT A 
 CONTROLLED AFFILIATE LICENSE STANDARDS 
 LIFE INSURANCE COMPANIES 

Page 2 of 2 
 Standard 3 - Records and
Examination 
 The LIC and its sponsoring licensed Plan(s) shall maintain and furnish, on a timely and accurate basis, such records and
reports regarding the LIC as may be required in order to establish compliance with the license agreement. The LIC and its sponsoring licensed Plan(s) shall permit BCBSA to examine the affairs of the LIC and shall agree that BCBSA’s board may
submit a written report to the chief executive officer(s) and the board(s) of directors of the sponsoring Plan(s). 
 Standard 4 - Mediation

 The LIC and its sponsoring Plan(s) shall agree to use the then-current BCBSA mediation and mandatory dispute resolution processes, in lieu
of a legal action between or among another licensed controlled affiliate, a licensed Plan or BCBSA. 
 Standard 5 - Financial Responsibility

 The LIC shall maintain adequate financial resources to protect its customers and meet its business obligations. 

Standard 6 - Cooperation with Affiliate License Performance Response Process Protocol 
 The LIC and its Sponsoring Plan(s) shall cooperate with BCBSA’s Board of Directors and its Plan Performance and Financial Standards Committee in the administration of the Affiliate License
Performance Response Process Protocol (ALPRPP) and in addressing LIC compliance problems identified thereunder. 

  

					
		  		  	
		  	-2-	  	

 Exhibit 1B 
 BLUE CROSS 
 CONTROLLED AFFILIATE LICENSE AGREEMENT 

APPLICABLE TO REGIONAL MEDICARE ADVANTAGE PPO PRODUCTS 
 (Adopted by Member Plans at their November 18, 2010 meeting) 
 This
Agreement by and among Blue Cross and Blue Shield Association (“BCBSA”) and              (“Controlled Affiliate”), a Controlled Affiliate of the Blue Cross
Plan(s), known as                      (“Controlling Plans”), each of which is also a 

Party signatory hereto. 

WHEREAS, BCBSA is the owner of the BLUE CROSS and BLUE CROSS Design service marks; 

WHEREAS, under the Medicare Modernization Act, companies may apply to and be awarded a contract by the Centers for Medicare and Medicaid
Services (“CMS”) to offer Medicare Advantage PPO products in geographic regions designated by CMS (hereafter “regional MAPPO products”). 
 WHEREAS, some of the CMS-designated regions include the Service Areas, or portions thereof, of more than one Plan. 
 WHEREAS, the Controlling Plans and Controlled Affiliate desire that the latter be entitled to use the BLUE CROSS and BLUE CROSS Design service marks (collectively the “Licensed Marks”) as
service marks and be entitled to use the term BLUE CROSS in a trade name (“Licensed Name”) to offer regional MAPPO products in a region that includes the Service Areas, or portions thereof, of more than one Controlling Plan; 

NOW THEREFORE, in consideration of the foregoing and the mutual agreements hereinafter set forth and for other good and valuable
consideration, the receipt and sufficiency of which are hereby acknowledged, the parties hereby agree as follows: 
  

	 	1.	GRANT OF LICENSE 

Subject to the terms and conditions of this Agreement, BCBSA hereby grants to Controlled Affiliate the right to use the Licensed Marks and
Name in connection with, and only in connection with the sale, marketing and administration of regional MAPPO products and related services. 
 This grant of rights is non-exclusive and is limited to the following states:                    
(the “Region”). Controlled Affiliate may use the Licensed 

  

					
		  		  	
		  	-1-	  	

 
Marks and Name in its legal name on the following conditions: (i) the legal name must be approved in advance, in writing, by BCBSA; (ii) Controlled Affiliate shall not do business
outside the Region under any name or mark except business conducted in the Service Area of a Controlling Plan provided that Controlled Affiliate is separately licensed by BCBSA to use the Licensed Marks and Name in connection with health care plans
and related services in the Service Area of such Controlling Plan; and (iii) Controlled Affiliate shall not use the Licensed Marks and Name, or any derivative thereof, as part of any name or symbol used to identify itself in any securities
market. Controlled Affiliate may use the Licensed Marks and Name in its Trade Name only with the prior, written, consent of BCBSA. 
  

	 	2.	QUALITY CONTROL 

A. Controlled Affiliate agrees to use the Licensed Marks and Name only in connection with the licensed services and further agrees to be
bound by the conditions regarding quality control shown in attached Exhibit A as they may be amended by BCBSA from time-to-time. 
 B. Controlled Affiliate agrees to comply with all applicable federal, state and local laws. 
 C. Controlled Affiliate agrees that it will provide on an annual basis (or more often if reasonably required by the Controlling Plans or by BCBSA) a report or reports to the Controlling Plans and BCBSA
demonstrating Controlled Affiliate’s compliance with the requirements of this Agreement including but not limited to the quality control provisions of this paragraph and the attached Exhibit A. 

D. Controlled Affiliate agrees that the Controlling Plans and/or BCBSA may, from time-to-time, upon reasonable notice, review and inspect
the manner and method of Controlled Affiliate’s rendering of service and use of the Licensed Marks and Name. 
 E. As used
herein, a Controlled Affiliate is defined as an entity organized and operated in such a manner, that it meets the following requirements: 
 (1) Controlled Affiliate is owned or controlled by two or more Controlling Plans; 

(2) Each Controlling Plan is authorized pursuant to a separate Blue Cross License Agreement to use the Licensed Marks in a geographic
area in the Region and every geographic area in the Region is so licensed to at least one of the Controlling Plans; and 

  

					
		  		  	
		  	-2-	  	

 (3) The Controlling Plans must have the legal authority directly or indirectly through
wholly-owned subsidiaries: 
 (a) to select members of the Controlled Affiliate’s governing body having not less than 100%
voting control thereof; 
 (b) to prevent any change in the articles of incorporation, bylaws or other establishing or governing
documents of the Controlled Affiliate with which the Controlling Plans do not concur; 
 (c) to exercise control over the policy
and operations of the Controlled Affiliate; and 
 Notwithstanding anything to the contrary in (a) through (c) hereof, the Controlled
Affiliate’s establishing or governing documents must also require written approval by each of the Controlling Plans before the Controlled Affiliate can: 
  

	 	(i)	change its legal and/or trade names; 

  

	 	(ii)	change the geographic area in which it operates (except such approval shall not be required with respect to business of the Controlled Affiliate conducted under the
Licensed Marks within the Service Area of one of the Controlling Plans pursuant to a separate controlled affiliate license agreement with BCBSA sponsored by such Controlling Plan); 

 

	 	(iii)	change any of the type(s) of businesses in which it engages (except such approval shall not be required with respect to business of the Controlled Affiliate conducted
under the Licensed Marks within the Service Area of one of the Controlling Plans pursuant to a separate controlled affiliate license agreement with BCBSA sponsored by such Controlling Plan); 

 

	 	(iv)	take any action that any Controlling Plan or BCBSA reasonably believes will adversely affect the Licensed Marks and Name. 

In addition, the Controlling Plans directly or indirectly through wholly owned subsidiaries shall own 100% of any for-profit Controlled Affiliate.

  

					
		  		  	
		  	-3-	  	

	 	3.	SERVICE MARK USE 

A. Controlled Affiliate recognizes the importance of a comprehensive national network of independent BCBSA licensees which are committed
to strengthening the Licensed Marks and Name. The Controlled Affiliate further recognizes that its actions within the Region may affect the value of the Licensed Marks and Name nationwide. 

B. Controlled Affiliate shall at all times make proper service mark use of the Licensed Marks and Name, including but not limited to use
of such symbols or words as BCBSA shall specify to protect the Licensed Marks and Name and shall comply with such rules (generally applicable to Controlled Affiliates licensed to use the Licensed Marks and Name) relative to service mark use, as are
issued from time-to-time by BCBSA. Controlled Affiliate recognizes and agrees that all use of the Licensed Marks and Name by Controlled Affiliate shall inure to the benefit of BCBSA. 

C. Controlled Affiliate may not directly or indirectly use the Licensed Marks and Name in a manner that transfers or is intended to
transfer in the Region the goodwill associated therewith to another mark or name, nor may Controlled Affiliate engage in activity that may dilute or tarnish the unique value of the Licensed Marks and Name. 

D. Controlled Affiliate shall use its best efforts to promote and build the value of the Licensed Marks and Name in connection with the
sale, marketing and administration of regional MAPPO products and related services. 
  

	 	4.	SUBLICENSING AND ASSIGNMENT 

 Controlled Affiliate shall not, directly or indirectly, sublicense, transfer, hypothecate, sell, encumber or mortgage, by operation of law or otherwise, the rights granted hereunder and any such act shall
be voidable at the sole option of any Controlling Plan or BCBSA. This Agreement and all rights and duties hereunder are personal to Controlled Affiliate. 

  

					
		  		  	
		  	-4-	  	

	 	5.	INFRINGEMENT 

Controlled Affiliate shall promptly notify the Controlling Plans and the Controlling Plans shall promptly notify BCBSA of any suspected
acts of infringement, unfair competition or passing off that may occur in relation to the Licensed Marks and Name. Controlled Affiliate shall not be entitled to require the Controlling Plans or BCBSA to take any actions or institute any proceedings
to prevent infringement, unfair competition or passing off by third parties. Controlled Affiliate agrees to render to the Controlling Plans and BCBSA, without charge, all reasonable assistance in connection with any matter pertaining to the
protection of the Licensed Marks and Name by BCBSA. 
  

	 	6.	LIABILITY INDEMNIFICATION 

 Controlled Affiliate and the Controlling Plans hereby agree to save, defend, indemnify and hold BCBSA harmless from and against all claims, damages, liabilities and costs of every kind, nature and
description (except those arising solely as a result of BCBSA’s negligence) that may arise as a result of or related to Controlled Affiliate’s rendering of services under the Licensed Marks and Name. 

 

	 	7.	LICENSE TERM 

 A.
Except as otherwise provided herein, the license granted by this Agreement shall remain in effect for a period of one (1) year and shall be automatically extended for additional one (1) year periods unless terminated pursuant to the
provisions herein. 
 B. This Agreement and all of Controlled Affiliate’s rights hereunder shall immediately terminate
without any further action by any party or entity in the event that: (i) any one of the Controlling Plans ceases to be authorized to use the Licensed Marks and Name; or (ii) pursuant to Paragraph 15(a)(x) of the Blue Cross License
Agreement any one of the Controlling Plans ceases to be authorized to use the Licensed Names and Marks in the Region. 
 C.
Notwithstanding any other provision of this Agreement, this license to use the Licensed Marks and Name may be forthwith terminated by the Controlling Plans or the affirmative vote of the majority of the Board of Directors of BCBSA present and voting
at a special meeting expressly called by BCBSA for the purpose on ten (10) days written notice to the Controlling Plans advising of the specific matters at issue and granting the Controlling Plans an opportunity to be heard and to present their
response to the Board for: (1) failure to comply with any applicable minimum capital or liquidity requirement under the quality control standards of this 

  
 -5-

 
Agreement; or (2) failure to comply with the “Organization and Governance” quality control standard of this Agreement; or (3) impending financial insolvency; or
(4) failure to comply with any of the applicable requirements of Standards 2, 3, 4, or 5 of attached Exhibit A; or (5) the pendency of any action instituted against the Controlled Affiliate seeking its dissolution or liquidation of its
assets or seeking appointment of a trustee, interim trustee, receiver or other custodian for any of its property or business or seeking the declaration or establishment of a trust for any of its property or business, unless this Controlled Affiliate
License Agreement has been earlier terminated under paragraph 7(E); or (6) such other reason as is determined in good faith immediately and irreparably to threaten the integrity and reputation of BCBSA, the Plans (including the Controlling
Plans), any other licensee including Controlled Affiliate and/or the Licensed Marks and Name. 
 D. Except as otherwise provided
in Paragraphs 7(B), 7(C) or 7(E) herein, should Controlled Affiliate fail to comply with the provisions of this Agreement and not cure such failure within thirty (30) days of receiving written notice thereof (or commence a cure within such
thirty day period and continue diligent efforts to complete the cure if such curing cannot reasonably be completed within such thirty day period) BCBSA or the Controlling Plans shall have the right to issue a notice that the Controlled Affiliate is
in a state of noncompliance. If a state of noncompliance as aforesaid is undisputed by the Controlled Affiliate or is found to exist by a mandatory dispute resolution panel and is uncured as provided above, BCBSA shall have the right to seek
judicial enforcement of the Agreement or to issue a notice of termination thereof. Notwithstanding any other provisions of this Agreement, any disputes as to the termination of this License pursuant to Paragraphs 7(B), 7(C) or 7(E) of this Agreement
shall not be subject to mediation and mandatory dispute resolution. All other disputes between or among BCBSA, any of the Controlling Plans and/or Controlled Affiliate shall be submitted promptly to mediation and mandatory dispute resolution. The
mandatory dispute resolution panel shall have authority to issue orders for specific performance and assess monetary penalties. Except, however, as provided in Paragraphs 7(B) and 7(E) of this Agreement, this license to use the Licensed Marks and
Name may not be finally terminated for any reason without the affirmative vote of a majority of the present and voting members of the Board of Directors of BCBSA. 
 E. This Agreement and all of Controlled Affiliate’s rights hereunder shall immediately terminate without any further action by any party or entity in the event that: 

(1) Controlled Affiliate shall no longer comply with item 2(E) above; 

(2) Appropriate dues, royalties and other payments for Controlled Affiliate pursuant to paragraph 9 hereof, which are the royalties for
this License Agreement, are more than sixty (60) days in arrears to BCBSA; or 

  
 -6-

 (3) Any of the following events occur: (i) a voluntary petition shall be filed by
Controlled Affiliate seeking bankruptcy, reorganization, arrangement with creditors or other relief under the bankruptcy laws of the United States or any other law governing insolvency or debtor relief, or (ii) an involuntary petition or
proceeding shall be filed against Controlled Affiliate seeking bankruptcy, reorganization, arrangement with creditors or other relief under the bankruptcy laws of the United States or any other law governing insolvency or debtor relief and such
petition or proceeding is consented to or acquiesced in by Controlled Affiliate or is not dismissed within sixty (60) days of the date upon which the petition or other document commencing the proceeding is served upon the Controlled Affiliate,
or (iii) an order for relief is entered against Controlled Affiliate in any case under the bankruptcy laws of the United States, or Controlled Affiliate is adjudged bankrupt or insolvent as those terms are defined in the Uniform Commercial Code
as enacted in the State of Illinois by any court of competent jurisdiction, or (iv) Controlled Affiliate makes a general assignment of its assets for the benefit of creditors, or (v) any government or any government official, office,
agency, branch, or unit assumes control of Controlled Affiliate or delinquency proceedings (voluntary or involuntary) are instituted, or (vi) an action is brought by Controlled Affiliate seeking its dissolution or liquidation of its assets or
seeking the appointment of a trustee, interim trustee, receiver or other custodian for any of its property or business, or (vii) an action is instituted by any governmental entity or officer against Controlled Affiliate seeking its dissolution
or liquidation of its assets or seeking the appointment of a trustee, interim trustee, receiver or other custodian for any of its property or business and such action is consented to or acquiesced in by Controlled Affiliate or is not dismissed
within one hundred thirty (130) days of the date upon which the pleading or other document commencing the action is served upon the Controlled Affiliate, provided that if the action is stayed or its prosecution is enjoined, the one hundred
thirty (130) day period is tolled for the duration of the stay or injunction, and provided further, that the Association’s Board of Directors may toll or extend the 130 day period at any time prior to its expiration, or (viii) a
trustee, interim trustee, receiver or other custodian for any of Controlled Affiliate’s property or business is appointed or the Controlled Affiliate is ordered dissolved or liquidated. Notwithstanding any other provision of this Agreement, a
declaration or a request for declaration of the existence of a trust over any of the Controlled Affiliate’s property or business shall not in itself be deemed to constitute or seek appointment of a trustee, interim trustee, receiver or other
custodian for purposes of subparagraphs 7(E)(3)(vii) and (viii) of this Agreement. 
 F. Upon termination of this Agreement
for cause or otherwise, Controlled Affiliate agrees that it shall immediately discontinue all use of the Licensed Marks and Name, including any use in its trade name, except to the extent that it continues to be authorized to use the Licensed Marks
within the Service Area of one of the Controlling Plans pursuant to a separate controlled affiliate license agreement with BCBSA sponsored by such Controlling Plan. 

  
 -7-

 G. Upon termination of this Agreement, Controlled Affiliate shall immediately notify all of
its customers to whom it provides products or services under the Licensed Marks pursuant to this Agreement that it is no longer a licensee of BCBSA and, if directed by the Association’s Board of Directors, shall provide instruction on how the
customer can contact BCBSA or a designated licensee to obtain further information on securing coverage. The notification required by this paragraph shall be in writing and in a form approved by BCBSA. The BCBSA shall have the right to audit the
terminated entity’s books and records to verify compliance with this paragraph. 
 H. In the event this Agreement
terminates pursuant to 7(B) hereof, upon termination of this Agreement the provisions of Paragraph 7(G) shall not apply and the following provisions shall apply, except that, in the event that Controlled Affiliate is separately licensed by BCBSA to
use the Licensed Marks in the Service Area of a Controlling Plan and termination of this Agreement is due to a partial termination of such Controlling Plan’s license pursuant to Paragraph 15(a)(x)(ii) of the Blue Cross License Agreement, the
notices, national account listing, payment, and audit right listed below shall be applicable solely with respect to the Region and the geographic area for which the Controlling Plan’s license to use the Licensed Names and Marks is terminated:

 (1) The Controlled Affiliate shall send a notice through the U.S. mails, with first class postage affixed, to all individual
and group customers, providers, brokers and agents of products or services sold, marketed, underwritten or administered by the Controlled Affiliate under the Licensed Marks and Name. The form and content of the notice shall be specified by BCBSA and
shall, at a minimum, notify the recipient of the termination of the license, the consequences thereof, and instructions for obtaining alternate products or services licensed by BCBSA. This notice shall be mailed within 15 days after termination.

 (2) The Controlled Affiliate shall deliver to BCBSA within five days of a request by BCBSA a listing of national accounts in
which the Controlled Affiliate is involved (in a control, participating or servicing capacity), identifying the national account and the Controlled Affiliate’s role therein. 

(3) Unless the cause of termination is an event respecting BCBSA stated in paragraph 15(a) or (b) of the Plan’s license
agreement with BCBSA to use the Licensed Marks and Name, the Controlled Affiliate, the Controlling Plans, and any other Licensed Controlled Affiliates of the Controlling Plans shall be jointly liable for payment to BCBSA of an amount equal to $25
multiplied by the number of Licensed Enrollees of the Controlled Affiliate; provided that if any Plan other than a Controlling Plan is permitted by BCBSA to use marks or names licensed by BCBSA in a geographic area in the Region, the payment for
Licensed Enrollees in such 

  
 -8-

 
geographic area shall be multiplied by a fraction, the numerator of which is the number of Licensed Enrollees of the Controlled Affiliate, the Controlling Plans, and any other Licensed Controlled
Affiliates of the Controlling Plans in such geographic area and the denominator of which is the total number of Licensed Enrollees in such geographic area. Licensed Enrollee means each and every person and covered dependent who is enrolled as an
individual or member of a group receiving products or services sold, marketed or administered under marks or names licensed by BCBSA as determined at the earlier of (i) the end of the last fiscal year of the terminated entity which ended prior
to termination or (ii) the fiscal year which ended before any transactions causing the termination began. Notwithstanding the foregoing, the amount payable pursuant to this subparagraph H. (3) shall be due only to the extent that, in
BCBSA’s opinion, it does not cause the net worth of the Controlled Affiliate, the Controlling Plans or any other Licensed Controlled Affiliates of the Controlling Plans to fall below 100% of the Health Risk-Based Capital formula, or its
equivalent under any successor formula, as set forth in the applicable financial responsibility standards established by BCBSA (provided such equivalent is approved for purposes of this subparagraph by the affirmative vote of three-fourths of the
Plans and three-fourths of the total then current weighted vote of all the Plans); measured as of the date of termination, and adjusted for the value of any transactions not made in the ordinary course of business. This payment shall not be due in
connection with transactions exclusively by or among Plans (including the Controlling Plans) or their affiliates, including reorganizations, combinations or mergers, where the BCBSA Board of Directors determines that the license termination does not
result in a material diminution in the number of Licensed Enrollees or the extent of their coverage. In the event that the Controlled Affiliate’s license is reinstated by BCBSA or is deemed to have remained in effect without interruption by a
court of competent jurisdiction, BCBSA shall reimburse the Controlled Affiliate (and/or the Controlling Plans or their other Licensed Controlled Affiliates, as the case may be) for payments made under this subparagraph 7.H.(3) only to the extent
that such payments exceed the amounts due to BCBSA pursuant to paragraph 7.K. and any costs associated with reestablishing the terminated Controlling Plan’s Service Area or the Region, including any payments made by BCBSA to a Plan or Plans
(including the other Controlling Plans), or their Licensed Controlled Affiliates, for purposes of replacing the Controlled Affiliate. 
 (4) BCBSA shall have the right to audit the books and records of the Controlled Affiliate, the Controlling Plans, and any other Licensed Controlled Affiliates of the Controlling Plans to verify compliance
with this paragraph 7.H. 
 (5) As to a breach of 7.H.(1), (2), (3) or (4), the parties agree that the obligations are
immediately enforceable in a court of competent jurisdiction. As to a breach of 7.H.(1), (2) or (4) by the Controlled Affiliate, the parties agree there is no adequate remedy at law and BCBSA is entitled to obtain specific performance.

  
 -9-

 I. BCBSA shall be entitled to enjoin the Controlled Affiliate or any related party in a
court of competent jurisdiction from entry into any transaction which would result in a termination of this Agreement unless a Controlling Plan’s license from BCBSA to use the Licensed Marks and Names has been terminated pursuant to 10(d) of
such Controlling Plan’s license agreement upon the required 6 month written notice. 
 J. BCBSA acknowledges that it is not
the owner of assets of the Controlled Affiliate. 
 K. In the event this Agreement terminates and is subsequently reinstated by
BCBSA or is deemed to have remained in effect without interruption by a court of competent jurisdiction, the Controlled Affiliate, the Controlling Plans, and any other Licensed Controlled Affiliates of the Controlling Plans shall be jointly liable
for reimbursing BCBSA the reasonable costs incurred by BCBSA in connection with the termination and the reinstatement or court action, and any associated legal proceedings, including but not limited to: outside legal fees, consulting fees, public
relations fees, advertising costs, and costs incurred to develop, lease or establish an interim provider network. Any amount due to BCBSA under this subparagraph may be waived in whole or in part by the BCBSA Board of Directors in its sole
discretion. 
  

	 	8.	DISPUTE RESOLUTION 

The parties agree that any disputes between or among them or between or among any of them and one or more Plans or Controlled Affiliates
of Plans that use in any manner the Blue Cross and Blue Cross Marks and Name are subject to the Mediation and Mandatory Dispute Resolution process attached to and made a part of each Controlling Plan’s License from BCBSA to use the Licensed
Marks and Name as Exhibit 5 as amended from time-to-time, which documents are incorporated herein by reference as though fully set forth herein. 
  

	 	9.	LICENSE FEE 

Controlled Affiliate will pay to BCBSA a fee for this License determined pursuant to the formula(s) set forth in Exhibit B. 

 

	 	10.	JOINT VENTURE 

Nothing contained in this Agreement shall be construed as creating a joint venture, partnership, agency or employment relationship between
the Controlling Plans and Controlled Affiliate or between either and BCBSA. 

  
 -10-

	 	11.	NOTICES AND CORRESPONDENCE 

 Notices regarding the subject matter of this Agreement or breach or termination thereof shall be in writing and shall be addressed in duplicate to the last known address of each other party, marked
respectively to the attention of its President and, if any, its General Counsel. 
  

	 	12.	COMPLETE AGREEMENT 

This Agreement contains the complete understandings of the parties in relation to the subject matter hereof. This Agreement may only be
amended by the affirmative vote of three-fourths of the Plans and three-fourths of the total then current weighted vote of all the Plans as officially recorded by the BCBSA Corporate Secretary. 

 

	 	13.	SEVERABILITY 

 If
any term of this Agreement is held to be unlawful by a court of competent jurisdiction, such findings shall in no way affect the remaining obligations of the parties hereunder and the court may substitute a lawful term or condition for any unlawful
term or condition so long as the effect of such substitution is to provide the parties with the benefits of this Agreement. 
  

	 	14.	NONWAIVER 

 No
waiver by BCBSA of any breach or default in performance on the part of Controlled Affiliate or any other licensee of any of the terms, covenants or conditions of this Agreement shall constitute a waiver of any subsequent breach or default in
performance of said terms, covenants or conditions. 
  

	 	14A.	VOTING 

 For all
provisions of this Agreement referring to voting, the term ‘Plans’ shall mean all entities licensed under the Blue Cross License Agreement and/or the Blue Shield License Agreement, and in all votes of the Plans under this Agreement the
Plans shall vote together. For weighted votes of the Plans, the Plan shall have a number of votes equal to the number of weighted votes (if any) that it holds as a Blue Cross Plan plus the number of weighted votes (if any) that it holds as a Blue
Shield Plan. For all other votes of the Plans, the Plan shall have one vote. For all questions requiring an affirmative three-fourths weighted vote of the Plans, the requirement shall be deemed satisfied with a lesser weighted vote unless the
greater of: (i) 6/52 or more of the Plans (rounded to the nearest whole number, with 

  
 -11-

 
0.5 or multiples thereof being rounded to the next higher whole number) fail to cast weighted votes in favor of the question; or (ii) three (3) of the Plans fail to cast weighted votes
in favor of the question. Notwithstanding the foregoing provision, if there are thirty-nine (39) Plans, the requirement of an affirmative three-fourths weighted vote shall be deemed satisfied with a lesser weighted vote unless four (4) or
more Plans fail to cast weighted votes in favor of the question. 
  

	 	15.	GOVERNING LAW 

This Agreement shall be governed by, and construed and interpreted in accordance with, the laws of the State of Illinois. 

 

	 	16.	HEADINGS 

 The
headings inserted in this agreement are for convenience only and shall have no bearing on the interpretation hereof. 

  
 -12-

 IN WITNESS WHEREOF, the parties have caused this License Agreement to be executed and effective as of the
date of last signature written below. 
  

			
	Controlled Affiliate:
		
	By:	 	 
	Date:	 	 
	
	Controlling Plan:
		
	By:	 	 
	Date:	 	 
	
	Controlling Plan:
		
	By:	 	 
	Date:	 	 
	
	BLUE CROSS AND BLUE SHIELD ASSOCIATION
		
	By:	 	 
	Date:	 	 

  
 -13-

 EXHIBIT A 
 CONTROLLED AFFILIATE LICENSE STANDARDS 
 APPLICABLE TO REGIONAL MEDICARE 

ADVANTAGE PPO PRODUCTS 
 November 2010

 PREAMBLE 
 The standards for
licensing Controlled Affiliates for Medicare Advantage PPO Products are established by BCBSA and are subject to change from time-to-time upon the affirmative vote of three-fourths (3/4) of the Plans and three-fourths (3/4) of the total
weighted vote. Each Controlling Plan is required to use a standard Controlled Affiliate license form provided by BCBSA and to cooperate fully in assuring that the licensed Controlled Affiliate maintains compliance with the license standards.

 Standard 1 - Organization and Governance 
 A Controlled Affiliate is defined as an entity organized and operated in such a manner, that it meets the following requirements: 
 (1) Controlled Affiliate is owned or controlled by two or more Controlling Plans; 

(2) Each Controlling Plan is authorized pursuant to a separate Blue Cross License Agreement to use the Licensed Marks in a geographic area
in the Region and every geographic area in the Region is so licensed to at least one of the Controlling Plans; and 
 (3) The
Controlling Plans must have the legal authority directly or indirectly through wholly-owned subsidiaries: 
 (a)
to select members of the Controlled Affiliate’s governing body having not less than 100% voting control thereof; 
 (b) prevent any change in the articles of incorporation, bylaws or other establishing or governing documents of the Controlled Affiliate with which the Controlling Plans do not concur; 

(c) exercise control over the policy and operations of the Controlled Affiliate; and 

  
 -14-

 EXHIBIT A (continued) 
 Notwithstanding anything to the contrary in (a) through (c) hereof, the Controlled Affiliate’s establishing or governing documents must also require written approval by each of the
Controlling Plans before the Controlled Affiliate can: 
  

	 	(i)	change its legal and/or trade names; 

  

	 	(ii)	change the geographic area in which it operates (except such approval shall not be required with respect to business of the Controlled Affiliate conducted under the
Licensed Marks within the Service Area of one of the Controlling Plans pursuant to a separate controlled affiliate license agreement with BCBSA sponsored by such Controlling Plan); 

 

	 	(iii)	change any of the type(s) of businesses in which it engages (except such approval shall not be required with respect to business of the Controlled Affiliate conducted
under the Licensed Marks within the Service Area of one of the Controlling Plans pursuant to a separate controlled affiliate license agreement with BCBSA sponsored by such Controlling Plan); 

 

	 	(iv)	take any action that any Controlling Plan or BCBSA reasonably believes will adversely affect the Licensed Marks and Name. 

In addition, the Controlling Plans directly or indirectly through wholly owned subsidiaries shall own 100% of any for-profit Controlled Affiliate.

 Standard 2 - Financial Responsibility 
 A Controlled Affiliate shall be operated in a manner that provides reasonable financial assurance that it can fulfill all of its contractual obligations to its customers. 

Standard 3 - State Licensure/Certification 
 A Controlled Affiliate shall maintain appropriate and unimpaired licensure and certifications. 

  
 -15-

 EXHIBIT A (continued) 
 Standard 4 - Certain Disclosures 
 A Controlled Affiliate shall make adequate disclosure in
contracting with third parties and in disseminating public statements of: 
  

	 	a.	the structure of the Blue Cross and Blue Shield System; and 

  

	 	b.	the independent nature of every licensee. 

Standard 5 - Reports and Records for Controlled Affiliates 
 A Controlled Affiliate and/or its Controlling Plans shall furnish, on a timely and accurate basis, reports and records relating to these Standards and the License Agreements between BCBSA and Controlled
Affiliate. 
 Standard 6 - Best Efforts 
 During each year, a Controlled Affiliate shall use its best efforts to promote and build the value of the Blue Cross Marks. 
 Standard 7 - Participation in Certain National Programs 
 A Controlled Affiliate shall
effectively and efficiently participate in certain national programs from time to time as may be adopted by Member Plans for the purposes of providing ease of claims processing for customers receiving benefits outside of the Controlled
Affiliate’s service area. 
 National program requirements include: 

 

	 	a.	Inter-Plan Teleprocessing System (ITS); and 

  

	 	b.	Inter-Plan Medicare Advantage Program. 

Standard 8 - Participation in Master Business Associate Agreement 
 Controlled Affiliates shall comply with the terms of the Business Associate Agreement for Blue Cross and Blue Shield Licensees to the extent they perform the functions of a business associate or
subcontractor to a business associate, as defined by the Business Associate Agreement. 

  

					
		  		  	Amended as of November 15, 2007
		  	-16-	  	

 EXHIBIT B 
 ROYALTY FORMULA FOR SECTION 9 OF THE 
 CONTROLLED AFFILIATE LICENSE AGREEMENTS

 APPLICABLE TO REGIONAL MEDICARE ADVANTAGE PPO PRODUCTS 
 Controlled Affiliate will pay BCBSA a fee for this license in accordance with the following formula: 
 An amount equal to its pro rata share of each Controlling Plan dues payable to BCBSA computed with the addition of the Controlled Affiliate’s members using the Marks on regional MAPPO products and
related services as reported on the Quarterly Enrollment Report with BCBSA. The payment by each Controlling Plan of its dues to BCBSA, including that portion described in this paragraph, will satisfy the requirement of this paragraph, and no
separate payment will be necessary. 

  

					
		  		  	Amended as of June 14, 2007
		  	-17-	  	

 Exhibit 1C 
 BLUE CROSS 
 CONTROLLED AFFILIATE LICENSE AGREEMENT 

APPLICABLE TO REGIONAL MEDICARE PART D PRESCRIPTION DRUG PLAN 

PRODUCTS 

(Adopted by Member Plans at their November 18, 2010 meeting) 

This Agreement by and among Blue Cross and Blue Shield Association (“BCBSA”) and
                 (“Controlled Affiliate”), a Controlled Affiliate of the Blue Cross Plan(s), known as
                 (“Controlling Plans”), each of which is also a Party signatory hereto. 

WHEREAS, BCBSA is the owner of the BLUE CROSS and BLUE CROSS Design service marks; 

WHEREAS, under the Medicare Modernization Act, companies may apply to and be awarded a contract by the Centers for Medicare and Medicaid
Services (“CMS”) to offer Medicare Part D Prescription Drug Plan products in geographic regions designated by CMS (hereafter “regional PDP products).” 
 WHEREAS, some of the CMS-designated regions include the Service Areas, or portions thereof, of more than one Plan. 
 WHEREAS, the Controlling Plans and Controlled Affiliate desire that the latter be entitled to use the BLUE CROSS and BLUE CROSS Design service marks (collectively the “Licensed Marks”) as
service marks and be entitled to use the term BLUE CROSS in a trade name (“Licensed Name”) to offer regional PDP products in a region that includes the Service Areas, or portions thereof, of more than one Controlling Plan; 

NOW THEREFORE, in consideration of the foregoing and the mutual agreements hereinafter set forth and for other good and valuable
consideration, the receipt and sufficiency of which are hereby acknowledged, the parties hereby agree as follows: 
  

	 	1.	GRANT OF LICENSE 

Subject to the terms and conditions of this Agreement, BCBSA hereby grants to Controlled Affiliate the right to use the Licensed Marks and
Name in connection with, and only in connection with the sale, marketing and administration of regional PDP products and related services. 
 This grant of rights is non-exclusive and is limited to the following states:
                                 (the “Region”). Controlled Affiliate
may use the Licensed 

  
 -1-

 
Marks and Name in its legal name on the following conditions: (i) the legal name must be approved in advance, in writing, by BCBSA; (ii) Controlled Affiliate shall not do business
outside the Region under any name or mark except business conducted in the Service Area of a Controlling Plan provided that Controlled Affiliate is separately licensed by BCBSA to use the Licensed Marks and Name in connection with health care plans
and related services in the Service Area of such Controlling Plan; and (iii) Controlled Affiliate shall not use the Licensed Marks and Name, or any derivative thereof, as part of any name or symbol used to identify itself in any securities
market. Controlled Affiliate may use the Licensed Marks and Name in its Trade Name only with the prior, written, consent of BCBSA. 
  

	 	2.	QUALITY CONTROL 

A. Controlled Affiliate agrees to use the Licensed Marks and Name only in connection with the licensed services and further agrees to be
bound by the conditions regarding quality control shown in attached Exhibit A as they may be amended by BCBSA from time-to-time. 
 B. Controlled Affiliate agrees to comply with all applicable federal, state and local laws. 
 C. Controlled Affiliate agrees that it will provide on an annual basis (or more often if reasonably required by the Controlling Plans or by BCBSA) a report or reports to the Controlling Plans and BCBSA
demonstrating Controlled Affiliate’s compliance with the requirements of this Agreement including but not limited to the quality control provisions of this paragraph and the attached Exhibit A. 

D. Controlled Affiliate agrees that the Controlling Plans and/or BCBSA may, from time-to-time, upon reasonable notice, review and inspect
the manner and method of Controlled Affiliate’s rendering of service and use of the Licensed Marks and Name. 
 E. As used
herein, a Controlled Affiliate is defined as an entity organized and operated in such a manner, that it meets the following requirements: 
 (1) Controlled Affiliate is owned or controlled by two or more Controlling Plans; 

(2) Each Controlling Plan is authorized pursuant to a separate Blue Cross License Agreement to use the Licensed Marks in a geographic
area in the Region and every geographic area in the Region is so licensed to at least one of the Controlling Plans; and 

  
 -2-

 (3) The Controlling Plans must have the legal authority directly or indirectly through
wholly-owned subsidiaries: 
 (a) to select members of the Controlled Affiliate’s governing body having not less than 100%
voting control thereof; 
 (b) to prevent any change in the articles of incorporation, bylaws or other establishing or governing
documents of the Controlled Affiliate with which the Controlling Plans do not concur; 
 (c) to exercise control over the policy
and operations of the Controlled Affiliate; and 
 Notwithstanding anything to the contrary in (a) through (c) hereof, the Controlled
Affiliate’s establishing or governing documents must also require written approval by each of the Controlling Plans before the Controlled Affiliate can: 
  

	 	(i)	change its legal and/or trade names; 

  

	 	(ii)	change the geographic area in which it operates (except such approval shall not be required with respect to business of the Controlled Affiliate conducted under the
Licensed Marks within the Service Area of one of the Controlling Plans pursuant to a separate controlled affiliate license agreement with BCBSA sponsored by such Controlling Plan); 

 

	 	(iii)	change any of the type(s) of businesses in which it engages (except such approval shall not be required with respect to business of the Controlled Affiliate conducted
under the Licensed Marks within the Service Area of one of the Controlling Plans pursuant to a separate controlled affiliate license agreement with BCBSA sponsored by such Controlling Plan); 

 

	 	(iv)	take any action that any Controlling Plan or BCBSA reasonably believes will adversely affect the Licensed Marks and Name. 

In addition, the Controlling Plans directly or indirectly through wholly-owned subsidiaries shall own 100% of any for-profit Controlled Affiliate.

  
 -3-

	 	3.	SERVICE MARK USE 

A. Controlled Affiliate recognizes the importance of a comprehensive national network of independent BCBSA licensees which are committed
to strengthening the Licensed Marks and Name. The Controlled Affiliate further recognizes that its actions within the Region may affect the value of the Licensed Marks and Name nationwide. 

B. Controlled Affiliate shall at all times make proper service mark use of the Licensed Marks and Name, including but not limited to use
of such symbols or words as BCBSA shall specify to protect the Licensed Marks and Name and shall comply with such rules (generally applicable to Controlled Affiliates licensed to use the Licensed Marks and Name) relative to service mark use, as are
issued from time-to-time by BCBSA. Controlled Affiliate recognizes and agrees that all use of the Licensed Marks and Name by Controlled Affiliate shall inure to the benefit of BCBSA. 

C. Controlled Affiliate may not directly or indirectly use the Licensed Marks and Name in a manner that transfers or is intended to
transfer in the Region the goodwill associated therewith to another mark or name, nor may Controlled Affiliate engage in activity that may dilute or tarnish the unique value of the Licensed Marks and Name. 

D. Controlled Affiliate shall use its best efforts to promote and build the value of the Licensed Marks and Name in connection with the
sale, marketing and administration of regional PDP products and related services. 
  

	 	4.	SUBLICENSING AND ASSIGNMENT 

 Controlled Affiliate shall not, directly or indirectly, sublicense, transfer, hypothecate, sell, encumber or mortgage, by operation of law or otherwise, the rights granted hereunder and any such act shall
be voidable at the sole option of any Controlling Plan or BCBSA. This Agreement and all rights and duties hereunder are personal to Controlled Affiliate. 

  
 -4-

	 	5.	INFRINGEMENT 

Controlled Affiliate shall promptly notify the Controlling Plans and the Controlling Plans shall promptly notify BCBSA of any suspected
acts of infringement, unfair competition or passing off that may occur in relation to the Licensed Marks and Name. Controlled Affiliate shall not be entitled to require the Controlling Plans or BCBSA to take any actions or institute any proceedings
to prevent infringement, unfair competition or passing off by third parties. Controlled Affiliate agrees to render to the Controlling Plans and BCBSA, without charge, all reasonable assistance in connection with any matter pertaining to the
protection of the Licensed Marks and Name by BCBSA. 
  

	 	6.	LIABILITY INDEMNIFICATION 

 Controlled Affiliate and the Controlling Plans hereby agree to save, defend, indemnify and hold BCBSA harmless from and against all claims, damages, liabilities and costs of every kind, nature and
description (except those arising solely as a result of BCBSA’s negligence) that may arise as a result of or related to Controlled Affiliate’s rendering of services under the Licensed Marks and Name. 

 

	 	7.	LICENSE TERM 

 A.
Except as otherwise provided herein, the license granted by this Agreement shall remain in effect for a period of one (1) year and shall be automatically extended for additional one (1) year periods unless terminated pursuant to the
provisions herein. 
 B. This Agreement and all of Controlled Affiliate’s rights hereunder shall immediately terminate
without any further action by any party or entity in the event that: (i) any one of the Controlling Plans ceases to be authorized to use the Licensed Marks and Name; or (ii) pursuant to Paragraph 15(a)(x) of the Blue Cross License
Agreement any one of the Controlling Plans ceases to be authorized to use the Licensed Names and Marks in the Region. 
 C.
Notwithstanding any other provision of this Agreement, this license to use the Licensed Marks and Name may be forthwith terminated by the Controlling Plans or the affirmative vote of the majority of the Board of Directors of BCBSA present and voting
at a special meeting expressly called by BCBSA for the purpose on ten (10) days written notice to the Controlling Plans advising of the specific matters at issue and granting the Controlling Plans an opportunity to be heard and to present their
response to the Board for: (1) failure to comply with any applicable minimum capital or liquidity requirement under the quality control standards of this 

  
 -5-

 
Agreement; or (2) failure to comply with the “Organization and Governance” quality control standard of this Agreement; or (3) impending financial insolvency; or
(4) failure to comply with any of the applicable requirements of Standards 2, 3, 4, or 5 of attached Exhibit A; or (5) the pendency of any action instituted against the Controlled Affiliate seeking its dissolution or liquidation of its
assets or seeking appointment of a trustee, interim trustee, receiver or other custodian for any of its property or business or seeking the declaration or establishment of a trust for any of its property or business, unless this Controlled Affiliate
License Agreement has been earlier terminated under paragraph 7(E); or (6) such other reason as is determined in good faith immediately and irreparably to threaten the integrity and reputation of BCBSA, the Plans (including the Controlling
Plans), any other licensee including Controlled Affiliate and/or the Licensed Marks and Name. 
 D. Except as otherwise provided
in Paragraphs 7(B), 7(C) or 7(E) herein, should Controlled Affiliate fail to comply with the provisions of this Agreement and not cure such failure within thirty (30) days of receiving written notice thereof (or commence a cure within such
thirty day period and continue diligent efforts to complete the cure if such curing cannot reasonably be completed within such thirty day period) BCBSA or the Controlling Plans shall have the right to issue a notice that the Controlled Affiliate is
in a state of noncompliance. If a state of noncompliance as aforesaid is undisputed by the Controlled Affiliate or is found to exist by a mandatory dispute resolution panel and is uncured as provided above, BCBSA shall have the right to seek
judicial enforcement of the Agreement or to issue a notice of termination thereof. Notwithstanding any other provisions of this Agreement, any disputes as to the termination of this License pursuant to Paragraphs 7(B), 7(C) or 7(E) of this Agreement
shall not be subject to mediation and mandatory dispute resolution. All other disputes between or among BCBSA, any of the Controlling Plans and/or Controlled Affiliate shall be submitted promptly to mediation and mandatory dispute resolution. The
mandatory dispute resolution panel shall have authority to issue orders for specific performance and assess monetary penalties. Except, however, as provided in Paragraphs 7(B) and 7(E) of this Agreement, this license to use the Licensed Marks and
Name may not be finally terminated for any reason without the affirmative vote of a majority of the present and voting members of the Board of Directors of BCBSA. 
 E. This Agreement and all of Controlled Affiliate’s rights hereunder shall immediately terminate without any further action by any party or entity in the event that: 

(1) Controlled Affiliate shall no longer comply with item 2(E) above; 

(2) Appropriate dues, royalties and other payments for Controlled Affiliate pursuant to paragraph 9 hereof, which are the royalties for
this License Agreement, are more than sixty (60) days in arrears to BCBSA; or 

  
 -6-

 (3) Any of the following events occur: (i) a voluntary petition shall be filed by
Controlled Affiliate seeking bankruptcy, reorganization, arrangement with creditors or other relief under the bankruptcy laws of the United States or any other law governing insolvency or debtor relief, or (ii) an involuntary petition or
proceeding shall be filed against Controlled Affiliate seeking bankruptcy, reorganization, arrangement with creditors or other relief under the bankruptcy laws of the United States or any other law governing insolvency or debtor relief and such
petition or proceeding is consented to or acquiesced in by Controlled Affiliate or is not dismissed within sixty (60) days of the date upon which the petition or other document commencing the proceeding is served upon the Controlled Affiliate,
or (iii) an order for relief is entered against Controlled Affiliate in any case under the bankruptcy laws of the United States, or Controlled Affiliate is adjudged bankrupt or insolvent as those terms are defined in the Uniform Commercial Code
as enacted in the State of Illinois by any court of competent jurisdiction, or (iv) Controlled Affiliate makes a general assignment of its assets for the benefit of creditors, or (v) any government or any government official, office,
agency, branch, or unit assumes control of Controlled Affiliate or delinquency proceedings (voluntary or involuntary) are instituted, or (vi) an action is brought by Controlled Affiliate seeking its dissolution or liquidation of its assets or
seeking the appointment of a trustee, interim trustee, receiver or other custodian for any of its property or business, or (vii) an action is instituted by any governmental entity or officer against Controlled Affiliate seeking its dissolution
or liquidation of its assets or seeking the appointment of a trustee, interim trustee, receiver or other custodian for any of its property or business and such action is consented to or acquiesced in by Controlled Affiliate or is not dismissed
within one hundred thirty (130) days of the date upon which the pleading or other document commencing the action is served upon the Controlled Affiliate, provided that if the action is stayed or its prosecution is enjoined, the one hundred
thirty (130) day period is tolled for the duration of the stay or injunction, and provided further, that the Association’s Board of Directors may toll or extend the 130 day period at any time prior to its expiration, or (viii) a
trustee, interim trustee, receiver or other custodian for any of Controlled Affiliate’s property or business is appointed or the Controlled Affiliate is ordered dissolved or liquidated. Notwithstanding any other provision of this Agreement, a
declaration or a request for declaration of the existence of a trust over any of the Controlled Affiliate’s property or business shall not in itself be deemed to constitute or seek appointment of a trustee, interim trustee, receiver or other
custodian for purposes of subparagraphs 7(E)(3)(vii) and (viii) of this Agreement. 
 F. Upon termination of this Agreement
for cause or otherwise, Controlled Affiliate agrees that it shall immediately discontinue all use of the Licensed Marks and Name, including any use in its trade name, except to the extent that it continues to be authorized to use the Licensed Marks
within the Service Area of one of the Controlling Plans pursuant to a separate controlled affiliate license agreement with BCBSA sponsored by such Controlling Plan. 

  
 -7-

 G. Upon termination of this Agreement, Controlled Affiliate shall immediately notify all of
its customers to whom it provides products or services under the Licensed Marks pursuant to this Agreement that it is no longer a licensee of BCBSA and, if directed by the Association’s Board of Directors, shall provide instruction on how the
customer can contact BCBSA or a designated licensee to obtain further information on securing coverage. The notification required by this paragraph shall be in writing and in a form approved by BCBSA. The BCBSA shall have the right to audit the
terminated entity’s books and records to verify compliance with this paragraph. 
 H. In the event this Agreement
terminates pursuant to 7(B) hereof, upon termination of this Agreement the provisions of Paragraph 7(G) shall not apply and the following provisions shall apply, except that, in the event that Controlled Affiliate is separately licensed by BCBSA to
use the Licensed Marks in the Service Area of a Controlling Plan and termination of this Agreement is due to a partial termination of such Controlling Plan’s license pursuant to Paragraph 15(a)(x)(ii) of the Blue Cross License Agreement, the
notices, national account listing, payment, and audit right listed below shall be applicable solely with respect to the Region and the geographic area for which the Controlling Plan’s license to use the Licensed Names and Marks is terminated:

 (1) The Controlled Affiliate shall send a notice through the U.S. mails, with first class postage affixed, to all individual
and group customers, providers, brokers and agents of products or services sold, marketed, underwritten or administered by the Controlled Affiliate under the Licensed Marks and Name. The form and content of the notice shall be specified by BCBSA and
shall, at a minimum, notify the recipient of the termination of the license, the consequences thereof, and instructions for obtaining alternate products or services licensed by BCBSA. This notice shall be mailed within 15 days after termination.

 (2) The Controlled Affiliate shall deliver to BCBSA within five days of a request by BCBSA a listing of national accounts in
which the Controlled Affiliate is involved (in a control, participating or servicing capacity), identifying the national account and the Controlled Affiliate’s role therein. 

(3) Unless the cause of termination is an event respecting BCBSA stated in paragraph 15(a) or (b) of the Plan’s license
agreement with BCBSA to use the Licensed Marks and Name, the Controlled Affiliate, the Controlling Plans, and any other Licensed Controlled Affiliates of the Controlling Plans shall be jointly liable for payment to BCBSA of an amount equal to $25
multiplied by the number of Licensed Enrollees of the Controlled Affiliate; provided that if any Plan other than a Controlling Plan is permitted by BCBSA to use marks or names licensed by BCBSA in a geographic area in the Region, the payment for
Licensed Enrollees in such 

  

					
		  		  	
		  	-8-	  	

 
geographic area shall be multiplied by a fraction, the numerator of which is the number of Licensed Enrollees of the Controlled Affiliate, the Controlling Plans, and any other Licensed Controlled
Affiliates of the Controlling Plans in such geographic area and the denominator of which is the total number of Licensed Enrollees in such geographic area. Licensed Enrollee means each and every person and covered dependent who is enrolled as an
individual or member of a group receiving products or services sold, marketed or administered under marks or names licensed by BCBSA as determined at the earlier of (i) the end of the last fiscal year of the terminated entity which ended prior
to termination or (ii) the fiscal year which ended before any transactions causing the termination began. Notwithstanding the foregoing, the amount payable pursuant to this subparagraph H. (3) shall be due only to the extent that, in
BCBSA’s opinion, it does not cause the net worth of the Controlled Affiliate, the Controlling Plans or any other Licensed Controlled Affiliates of the Controlling Plans to fall below 100% of the Health Risk-Based Capital formula, or its
equivalent under any successor formula, as set forth in the applicable financial responsibility standards established by BCBSA (provided such equivalent is approved for purposes of this subparagraph by the affirmative vote of three-fourths of the
Plans and three-fourths of the total then current weighted vote of all the Plans); measured as of the date of termination, and adjusted for the value of any transactions not made in the ordinary course of business. This payment shall not be due in
connection with transactions exclusively by or among Plans (including the Controlling Plans) or their affiliates, including reorganizations, combinations or mergers, where the BCBSA Board of Directors determines that the license termination does not
result in a material diminution in the number of Licensed Enrollees or the extent of their coverage. In the event that the Controlled Affiliate’s license is reinstated by BCBSA or is deemed to have remained in effect without interruption by a
court of competent jurisdiction, BCBSA shall reimburse the Controlled Affiliate (and/or the Controlling Plans or their other Licensed Controlled Affiliates, as the case may be) for payments made under this subparagraph 7.H.(3) only to the extent
that such payments exceed the amounts due to BCBSA pursuant to paragraph 7.K. and any costs associated with reestablishing the terminated Controlling Plan’s Service Area or the Region, including any payments made by BCBSA to a Plan or Plans
(including the other Controlling Plans), or their Licensed Controlled Affiliates, for purposes of replacing the Controlled Affiliate. 
 (4) BCBSA shall have the right to audit the books and records of the Controlled Affiliate, the Controlling Plans, and any other Licensed Controlled Affiliates of the Controlling Plans to verify compliance
with this paragraph 7.H. 
 (5) As to a breach of 7.H.(1), (2), (3) or (4), the parties agree that the obligations are
immediately enforceable in a court of competent jurisdiction. As to a breach of 7.H.(1), (2) or (4) by the Controlled Affiliate, the parties agree there is no adequate remedy at law and BCBSA is entitled to obtain specific performance.

  

					
		  		  	
		  	-9-	  	

 I. BCBSA shall be entitled to enjoin the Controlled Affiliate or any related party in a
court of competent jurisdiction from entry into any transaction which would result in a termination of this Agreement unless a Controlling Plan’s license from BCBSA to use the Licensed Marks and Names has been terminated pursuant to 10(d) of
such Controlling Plan’s license agreement upon the required 6 month written notice. 
 J. BCBSA acknowledges that it is not
the owner of assets of the Controlled Affiliate. 
 K. In the event this Agreement terminates and is subsequently reinstated by
BCBSA or is deemed to have remained in effect without interruption by a court of competent jurisdiction, the Controlled Affiliate, the Controlling Plans, and any other Licensed Controlled Affiliates of the Controlling Plans shall be jointly liable
for reimbursing BCBSA the reasonable costs incurred by BCBSA in connection with the termination and the reinstatement or court action, and any associated legal proceedings, including but not limited to: outside legal fees, consulting fees, public
relations fees, advertising costs, and costs incurred to develop, lease or establish an interim provider network. Any amount due to BCBSA under this subparagraph may be waived in whole or in part by the BCBSA Board of Directors in its sole
discretion. 
  

	 	8.	DISPUTE RESOLUTION 

The parties agree that any disputes between or among them or between or among any of them and one or more Plans or Controlled Affiliates
of Plans that use in any manner the Blue Cross and Blue Cross Marks and Name are subject to the Mediation and Mandatory Dispute Resolution process attached to and made a part of each Controlling Plan’s License from BCBSA to use the Licensed
Marks and Name as Exhibit 5 as amended from time-to-time, which documents are incorporated herein by reference as though fully set forth herein. 
  

	 	9.	LICENSE FEE 

Controlled Affiliate will pay to BCBSA a fee for this License determined pursuant to the formula(s) set forth in Exhibit B. 

 

	 	10.	JOINT VENTURE 

Nothing contained in this Agreement shall be construed as creating a joint venture, partnership, agency or employment relationship between
the Controlling Plans and Controlled Affiliate or between either and BCBSA. 

  

					
		  		  	
		  	-10-	  	

	 	11.	NOTICES AND CORRESPONDENCE 

 Notices regarding the subject matter of this Agreement or breach or termination thereof shall be in writing and shall be addressed in duplicate to the last known address of each other party, marked
respectively to the attention of its President and, if any, its General Counsel. 
  

	 	12.	COMPLETE AGREEMENT 

This Agreement contains the complete understandings of the parties in relation to the subject matter hereof. This Agreement may only be
amended by the affirmative vote of three-fourths of the Plans and three-fourths of the total then current weighted vote of all the Plans as officially recorded by the BCBSA Corporate Secretary. 

 

	 	13.	SEVERABILITY 

 If
any term of this Agreement is held to be unlawful by a court of competent jurisdiction, such findings shall in no way affect the remaining obligations of the parties hereunder and the court may substitute a lawful term or condition for any unlawful
term or condition so long as the effect of such substitution is to provide the parties with the benefits of this Agreement. 
  

	 	14.	NONWAIVER 

 No
waiver by BCBSA of any breach or default in performance on the part of Controlled Affiliate or any other licensee of any of the terms, covenants or conditions of this Agreement shall constitute a waiver of any subsequent breach or default in
performance of said terms, covenants or conditions. 
  

	 	14A.  	VOTING 

 For all
provisions of this Agreement referring to voting, the term ‘Plans’ shall mean all entities licensed under the Blue Cross License Agreement and/or the Blue Shield License Agreement, and in all votes of the Plans under this Agreement the
Plans shall vote together. For weighted votes of the Plans, the Plan shall have a number of votes equal to the number of weighted votes (if any) that it holds as a Blue Cross Plan plus the number of weighted votes (if any) that it holds as a Blue
Shield Plan. For all other votes of the Plans, the Plan shall have one vote. For all questions requiring an affirmative three-fourths weighted vote of the Plans, the requirement shall be deemed satisfied with a lesser weighted vote unless the
greater of: (i) 6/52 or more of the Plans (rounded to the nearest whole number, with 

  

					
		  		  	
		  	-11-	  	

 
0.5 or multiples thereof being rounded to the next higher whole number) fail to cast weighted votes in favor of the question; or (ii) three (3) of the Plans fail to cast weighted votes
in favor of the question. Notwithstanding the foregoing provision, if there are thirty-nine (39) Plans, the requirement of an affirmative three-fourths weighted vote shall be deemed satisfied with a lesser weighted vote unless four (4) or
more Plans fail to cast weighted votes in favor of the question. 
  

	 	15.	GOVERNING LAW 

This Agreement shall be governed by, and construed and interpreted in accordance with, the laws of the State of Illinois. 

 

	 	16.	HEADINGS 

 The
headings inserted in this agreement are for convenience only and shall have no bearing on the interpretation hereof. 

  

					
		  		  	
		  	-12-	  	

 IN WITNESS WHEREOF, the parties have caused this License Agreement to be executed and effective as of the
date of last signature written below. 
  

			
	Controlled Affiliate:
		
	By:	 	 
		
	Date:	 	 

  

			
	Controlling Plan:
		
	By:	 	 
		
	Date:	 	 

  

			
	Controlling Plan:
		
	By:	 	 
		
	Date:	 	 

  

			
	BLUE CROSS AND BLUE SHIELD ASSOCIATION
		
	By:	 	 
		
	Date:	 	 

  

					
		  		  	
		  	-13-	  	

 EXHIBIT A 
 CONTROLLED AFFILIATE LICENSE STANDARDS 
 APPLICABLE TO REGIONAL MEDICARE 

PART D PRESCRIPTION DRUG PLAN PRODUCTS 

November 2010 
 PREAMBLE

 The standards for licensing Controlled Affiliates for Medicare Part D Prescription Drug Plan Products are established by BCBSA and are
subject to change from time-to-time upon the affirmative vote of three-fourths (3/4) of the Plans and three-fourths (3/4) of the total weighted vote. Each Controlling Plan is required to use a standard Controlled Affiliate license form
provided by BCBSA and to cooperate fully in assuring that the licensed Controlled Affiliate maintains compliance with the license standards. 

Standard 1 - Organization and Governance 

A Controlled Affiliate is defined as an entity organized and operated in such a manner, that it meets the following requirements: 

(1) Controlled Affiliate is owned or controlled by two or more Controlling Plans; 

(2) Each Controlling Plan is authorized pursuant to a separate Blue Cross License Agreement to use the Licensed Marks in a geographic
area in the Region and every geographic area in the Region is so licensed to at least one of the Controlling Plans; and 
 (3)
The Controlling Plans must have the legal authority directly or indirectly through wholly-owned subsidiaries: 

(a) to select members of the Controlled Affiliate’s governing body having not less than 100% voting control thereof;

 (b) prevent any change in the articles of incorporation, bylaws or other establishing or governing documents
of the Controlled Affiliate with which the Controlling Plans do not concur; 
 (c) exercise control over the
policy and operations of the Controlled Affiliate; and 

  

					
		  		  	
		  	-14-	  	

 EXHIBIT A (continued) 
 Notwithstanding anything to the contrary in (a) through (c) hereof, the Controlled Affiliate’s establishing or governing documents must also require written approval by each of the
Controlling Plans before the Controlled Affiliate can: 
  

	 	(i)	change its legal and/or trade names; 

  

	 	(ii)	change the geographic area in which it operates (except such approval shall not be required with respect to business of the Controlled Affiliate conducted under the
Licensed Marks within the Service Area of one of the Controlling Plans pursuant to a separate controlled affiliate license agreement with BCBSA sponsored by such Controlling Plan); 

 

	 	(iii)	change any of the type(s) of businesses in which it engages (except such approval shall not be required with respect to business of the Controlled Affiliate conducted
under the Licensed Marks within the Service Area of one of the Controlling Plans pursuant to a separate controlled affiliate license agreement with BCBSA sponsored by such Controlling Plan); 

 

	 	(iv)	take any action that any Controlling Plan or BCBSA reasonably believes will adversely affect the Licensed Marks and Name. 

In addition, the Controlling Plans directly or indirectly through wholly-owned subsidiaries shall own 100% of any for-profit Controlled Affiliate.

 Standard 2 - Financial Responsibility 
 A Controlled Affiliate shall be operated in a manner that provides reasonable financial assurance that it can fulfill all of its contractual obligations to its customers. 

Standard 3 - State Licensure/Certification 
 A Controlled Affiliate shall maintain appropriate and unimpaired licensure and certifications. 

  

					
		  		  	
		  	-15-	  	

 EXHIBIT A (continued) 
 Standard 4 - Certain Disclosures 
 A Controlled Affiliate shall make adequate disclosure in
contracting with third parties and in disseminating public statements of: 
  

	 	a.	the structure of the Blue Cross and Blue Shield System; and 

  

	 	b.	the independent nature of every licensee. 

Standard 5 - Reports and Records for Controlled Affiliates 
 A Controlled Affiliate and/or its Controlling Plans shall furnish, on a timely and accurate basis, reports and records relating to these Standards and the License Agreements between BCBSA and Controlled
Affiliate. 
 Standard 6 - Best Efforts 
 During each year, a Controlled Affiliate shall use its best efforts to promote and build the value of the Blue Cross Marks. 
 Standard 7 - Participation in Master Business Associate Agreement 
 Controlled Affiliates
shall comply with the terms of the Business Associate Agreement for Blue Cross and Blue Shield Licensees to the extent they perform the functions of a business associate or subcontractor to a business associate, as defined by the Business Associate
Agreement. 

  
 -16-

 EXHIBIT B 
 ROYALTY FORMULA FOR SECTION 9 OF THE 
 CONTROLLED AFFILIATE LICENSE AGREEMENTS

 APPLICABLE TO REGIONAL MEDICARE PART D PRESCRIPTION DRUG PLAN 
 PRODUCTS 
 Controlled Affiliate will pay BCBSA a fee for this license in accordance with the
following formula: 
 An amount equal to its pro rata share of each Controlling Plan dues payable to BCBSA computed with the addition of the
Controlled Affiliate’s members using the Marks on regional PDP products and related services as reported on the Quarterly Enrollment Report with BCBSA. The payment by each Controlling Plan of its dues to BCBSA, including that portion described
in this paragraph, will satisfy the requirement of this paragraph, and no separate payment will be necessary. 

  

					
		  		  	Amended as of June 14, 2007
		  	-17-	  	

 EXHIBIT 2 
 Membership Standards 
 Page 1 of 5 
 Preamble 
 The Membership Standards apply to all organizations seeking to become or to continue as
Regular Members of the Blue Cross and Blue Shield Association. Any organization seeking to become a Regular Member must be found to be in substantial compliance with all Membership Standards at the time membership is granted and the organization
must be found to be in substantial compliance with all Membership Standards for a period of two (2) years preceding the date of its application. If Membership is sought by an entity which controls or is controlled by one or more Plans, such
compliance shall be determined on the basis of compliance by such Plan or Plans. 
 The Regular Member Plans shall have authority to interpret
these Standards. 
 A Regular Member Plan that operates as a “Shell Holding Company” is defined as an entity that assumes no
underwriting risk and has less than 1% of the consolidated enterprise assets (excludes investments in subsidiaries) and less than 5% of the consolidated enterprise net general and administrative expenses. 

A Regular Member Plan that operates as a “Hybrid Holding Company” is defined as an entity that assumes no underwriting risk and has either more
than 1% of the consolidated enterprise assets (excludes investments in subsidiaries) or more than 5% of the consolidated enterprise net general and administrative expenses. 

 

			
	 Standard 1:
	  	A Plan shall maintain a governing Board, which shall control the Plan and ensure that the Plan follows appropriate practices of corporate governance. A Plan’s Board shall
not be controlled by any special interest group, shall make an annual determination that a majority of its directors are independent, and shall act in the best interest of its Corporation and its customers. The Board shall be composed of a majority
of persons other than providers of health care services, who shall be known as public members. A public member shall not be an employee of or have a financial interest in a health care provider, nor be a member of a profession which provides health
care services.

  

					
		  		  	Amended as of March 15, 2007
		  		  	

 EXHIBIT 2 
 Membership Standards 
 Page 2 of 5 

 

			
	 Standard 2:
	 	A Plan shall furnish to the Association on a timely and accurate basis reports and records relating to compliance with these Standards and the License Agreements between the
Association and the Plans. Such reports and records are the following:
		
		 	 A.     BCBSA Membership Information Request;

		
		 	 B.     Biennial trade name and service mark usage material, including disclosure material under Standard
7;

		
		 	 C.     Changes in the governance of the Plan, including changes in a Plan’s Charter, Articles of
Incorporation, or Bylaws, changes in a Plan’s Board composition, or changes in the identity of the Plan’s Principal Officers;

		
		 	 D.     Quarterly Financial Report, Semi-annual “Health Risk-Based Capital (HRBC) Report” as
defined by the NAIC, Annual Financial Forecast, Annual Certified Audit Report, Insurance Department Examination Report, Annual Statement filed with State Insurance Department (with all attachments), Plan, Subsidiary and Affiliate Report;
and

		
		 	 •        Plans that are a Shell Holding Company as defined in the Preamble hereto
are required to furnish only a calendar year-end “Health Risk-Based Capital (HRBC) Report” as defined by the NAIC.

  

					
		  		  	Amended as of November 15, 2001
		  		  	

 EXHIBIT 2 
 Membership Standards 
 Page 3 of 5 

 

			
		  	 E.     Quarterly Enrollment Report, Member Touchpoint Measures Index (MTM) (current version) through
12/31/2010, MTM Index (first revised version) starting 1/1/2011 through 12/31/2011, and MTM Index (second revised version) starting 1/1/2012 and thereafter.

		
		  	 •        Plans that are a Shell Holding Company as defined in the Preamble hereto
are not required to furnish a Quarterly Enrollment Report

		
		  	 •        For purposes of MTM reporting only, a Plan shall file a separate MTM
report for each Geographic Market.

		
	 Standard 3:
	  	 A Plan shall be operated in a manner that provides reasonable financial assurance that it can fulfill its contractual obligations to its
customers.

		
	 Standard 4:
	  	 A Plan shall be operated in a manner responsive to customer needs and requirements.

		
	 Standard 5:
	  	 A Plan shall effectively and efficiently participate in each national program as from time to time may be adopted by the Member Plans for the
purposes of providing portability of membership between the Plans and ease of claims processing for customers receiving benefits outside of the Plan’s Service Area.

		
		  	 Such programs are applicable to Blue Cross and Blue Shield Plans, and include:

		
		  	 A.     Transfer Program;

		
		  	 B.     Inter-Plan Teleprocessing System (ITS);

		
		  	 C.     BlueCard Program;

		
		  	 D.     National Account Programs;

		
		  	 E.     Business Associate Agreement for Blue Cross and Blue

		
		  	 Shield Licensees, effective April 14, 2003; and

		
		  	 F.      Inter-Plan Medicare Advantage Program.

  

					
		  		  	Amended as of November 18, 2010
		  		  	

 EXHIBIT 2 
 Membership Standards 
 Page 4 of 5 

 

			
	 Standard 6:
	  	In addition to requirements under the national programs listed in Standard 5: Participation in National Programs, a Plan shall take such action as required to ensure its
financial performance in programs and contracts of an inter-Plan nature or where the Association is a party.
		
	 Standard 7:
	  	A Plan shall make adequate disclosure in contracting with third parties and in disseminating public statements of (i) the structure of the Blue Cross and Blue Shield System, (ii)
the independent nature of every Plan, and (iii) the Plan’s financial condition.
		
	 Standard 8:
	  	A Plan shall cooperate with the Association’s Board of Directors and its Plan Performance and Financial Standards Committee in the administration of the Plan Performance
Response Process and in addressing Plan performance problems identified thereunder.
		
	 Standard 9:
	  	A Plan shall obtain a rating of its financial strength from an independent rating agency approved by the Association’s Board of Directors for such purpose.
		
	 Standard 10:
	  	Notwithstanding any other provision in this License Agreement, during each year, a Plan and its Controlled Affiliate(s) engaged in providing licensable services (excluding Life
Insurance and Charitable Foundation Services) shall use their best efforts to promote and build the value of the Blue Cross Marks.
		
	 Standard 11:
	  	Neither a Plan nor any Larger Controlled Affiliate shall cause or permit an entity other than a Plan or a Licensed Controlled Affiliate thereof to obtain control of the Plan or
Larger Controlled Affiliate or to acquire a substantial portion of its assets related to licensable services.

  

					
		  		  	Amended as of June 16, 2005
		  		  	

 EXHIBIT 2 
 Membership Standards 
 Page 5 of 5 

 

			
	 Standard 12:
	  	No provider network, or portion thereof, shall be rented or otherwise made available to a National Competitor if the Licensed Marks or Names are used in any way with such
network.
		
		  	A provider network may be rented or otherwise made available, provided there is no use of the Licensed Marks or Names with respect to the network being
rented.

  

					
		  		  	Amended as of March 18, 2004
		  		  	

 EXHIBIT 3 
 GUIDELINES WITH RESPECT TO USE OF 
 LICENSED NAME AND MARKS IN CONNECTION WITH NATIONAL
ACCOUNTS 
 Page 1 of 3 
 1. The
strength of the Blue Cross/Blue Cross National Accounts mechanism, and the continued provision of cost effective, quality health care benefits to National Accounts, are predicated on locally managed provider networks coordinated on a national scale
in a manner consistent with effective service to National Account customers and consistent with the preservation of the integrity of the Blue Cross/Blue Shield system and the Licensed Marks. These guidelines shall be interpreted in keeping with such
ends. 
 2. A National Account is an entity with employee and/or retiree locations in more than one Plan’s Service Area. Unless otherwise
agreed, a National Account is deemed located in the Service Area in which the corporate headquarters of the National Account is located. A local plant, office or division headquarters of an entity may be deemed a separate National Account when that
local plant, office or division headquarters 1) has employee locations in more than one Service Area, and 2) has independent health benefit decision-making authority for the employees working at such local plant, office or division headquarters and
for employees working at other locations outside the Service Area. In such a case, the local plant, office or division headquarters is a National Account that is deemed located in the Service Area in which such local plant, office or division
headquarters is located. The Control Plan of a National Account is the Plan in whose Service Area the National Account is located. A participating (“Par”) Plan is a Plan in whose Service Area the National Account has employee and/or
retiree locations, but in which the National Account is not located. In the event that a National Account parent company consolidates health benefit-decision making for itself and its wholly- owned subsidiary companies, the parent company and the
subsidiary companies shall be considered one National Account. The Control Plan for such a National Account shall be the Plan in whose Service Area the parent company headquarters is located. 
 3. The National Account Guidelines enunciated herein below shall be applicable only with respect to the business of new National Accounts acquired after January 1, 1991. 

4. Control Plans shall utilize National Account identification cards complying with then currently effective BCBSA graphic standards in connection with
all National Accounts business to facilitate administration thereof, to minimize subscriber and provider confusion, and to reflect a commitment to cooperation among Plans. 

  

					
		  		  	Amended as of June 12, 2003
		  		  	

 EXHIBIT 3 
 Page 2 of 3 
 5. Disputes among Plans and/or BCBSA as to the interpretation or implementation of
these Guidelines or as to other National Accounts issues shall be submitted to mediation and mandatory dispute resolution as provided in the License Agreement. For two years from the effective date of the License Agreement, however, such disputes
shall be subject to mediation only, with the results of such mediation to be collected and reported in order to establish more definitive operating parameters for National Accounts business and to serve as ground rules for future binding dispute
resolution. 
 6. The Control Plan may use the BlueCard Program (as defined by IPPC) to deliver benefits to employees and non-Medicare eligible
retirees in a Participating Plan’s service area if an alternative arrangement with the Participating Plan cannot be negotiated. The Participating Plan’s minimum servicing requirement for those employees and non-Medicare retirees in its
service area is to deliver benefits using the BlueCard Program. Account delivery is subject to the policies, provisions and procedures of the BlueCard Program. 
 7. For provider payments in a Participating Plan’s area (on non-BlueCard claims), payment to the provider may be made by the Participating Plan or the Control Plan at the Participating Plan’s
option. If the Participating Plan elects to pay the provider, it may not withhold payment of a claim verified by the Control Plan or its designated processor, and payment must be in conformity with service criteria established by the Board of
Directors of BCBSA (or an authorized committee thereof) to assure prompt payment, good service and minimum confusion with providers and subscribers. The Control Plan, at the Participating Plan’s request, will also assure that measures are taken
to protect the confidentiality of the data pertaining to provider reimbursement levels and profiles. 
  

  

					
		  		  	Amended as of June 14, 1996
		  		  	

 EXHIBIT 3 
 Page 3 of 3 
 8. The Control Plan, in its financial agreements with a National Account, is
expected to reasonably reflect the aggregate amount of differentials passed along to the Control Plan by all Participating Plans in a National Account. 
 9. Other than in contracting with health care providers or soliciting such contracts in areas contiguous to a Plan’s Service Area in order to serve its subscribers or those of its licensed Controlled
Affiliate residing or working in its Service Area, a Control Plan may not use the Licensed Marks and/or Name, as a tag line or otherwise, to negotiate directly with providers outside its Service Area. 

  

					
		  		  	Amended as of March 13, 2003
		  		  	

 EXHIBIT 4 
 GOVERNMENT PROGRAMS AND CERTAIN OTHER USES 
 Page 1 of 13 

1. A Plan and its licensed Controlled Affiliate may use the Licensed Marks and Name in bidding on and executing a contract to serve a Government Program,
and in thereafter communicating with the Government concerning the Program. With respect, however, to such contracts entered into after the 1st day of January, 1991, the Licensed Marks and Name will not be used in communications or transactions with
beneficiaries or providers in the Government Program located outside a Plan’s Service Area, unless the Plan can demonstrate to the satisfaction of BCBSA’s governing body that such a restriction on use of the Licensed Marks and Name will
jeopardize its ability to procure the contract for the Government Program. As to both existing and future contracts for Government Programs, Plans will discontinue use of the Licensed Marks and Name as to beneficiaries and Providers outside their
Service Area as expenditiously as circumstances reasonably permit. Effective January 1, 1995, except as provided in the first sentence above, all use by a Plan of the Licensed Marks and Name in Government Programs outside of the Plan’s
Service Area shall be discontinued. Incidental communications outside a Plan’s Service Area with resident or former resident beneficiaries of the Plan, and other categories of necessary incidental communications approved by BCBSA, are not
prohibited. For purposes of this Paragraph 1, the term “Government Programs” shall mean Medicare Part A, Medicare Part B and other non-risk government programs. 
 2. In connection with activity otherwise in furtherance of the License Agreement, a Plan and its Controlled Affiliates that are licensed to use the Licensed Marks and Name in its Service Area pursuant to
the Controlled Affiliate License Agreements authorized in clauses a) through c) of Paragraph 2 of the Plan’s License Agreement with BCBSA may use the Licensed Marks and Name outside the Plan’s Service Area in the following circumstances
which are deemed legitimate and necessary and not likely to cause consumer confusion: 
  

	 	a.	sending letterhead, envelopes, and similar items solely for administrative purposes (e.g., not for purposes of marketing, advertising, promoting, selling or soliciting
the sale of health care plans and related services); 

  

	 	b.	distributing business cards other than in marketing and selling; 

  

	 	c.	contracting with health care providers or soliciting such contracts in areas contiguous to the Plan’s Service Area in order to serve its subscribers or those of
such licensed Controlled Affiliates residing or working in its service area; 

  

					
		  		  	Amended as of March 17, 2005
		  		  	

 EXHIBIT 4 
 Page 2 of 13 
  

	 	d.	issuing a small sign containing the legal name or trade name of the Plan or such licensed Controlled Affiliates for display by a provider to identify the latter as a
participating provider of the Plan or Controlled Affiliate; 

  

	 	e.	advertising in publications or electronic media solely to persons for employment; 

 

	 	f.	advertising in print, electronic or other media which serve, as a substantial market, the Service Area of the Plan or licensed Controlled Affiliate, provided that no
Plan or Controlled Affiliate may advertise outside its Service Area on the national broadcast and cable networks and that advertisements in national print media are limited to the smallest regional edition encompassing the Service Area;

  

	 	g.	advertising by direct mail where the addressee’s zip code plus 4 includes, at least in part, the Plan’s Service Area or that of a licensed Controlled
Affiliate. 

  

	 	h.	negotiating rates with a health care provider for services to a specific member, provided that all of the following conditions are met: 

 

	 	(1)	the health care provider does not have a contract, applicable to the services rendered or to be rendered, with the Licensee (or any of the Licensees in the case of
overlapping Service Areas) in whose Service Area the health care provider is located; and 

  

	 	(2)	the Plan or Controlled Affiliate reasonably determines that the member did/does not have a reasonable opportunity to access a participating provider whose contract
applies to the services rendered or to be rendered; and 

  

	 	(3)	at least one of the following circumstances exists: 

  

	 	(i)	the member received emergency services and the Plan or Controlled Affiliate knows or reasonably anticipates that the charges on the claim will meet or exceed $5,000; or

  

					
		  		  	Amended as of June 19, 2008
		  		  	

 EXHIBIT 4 
 Page 3 of 13 
  

	 	(ii)	a provider, in consultation pre- or post- treatment with the Plan or Controlled Affiliate, makes/made a treatment recommendation or referral to a non-par provider or to
a par provider whose contract does not apply to the services to be rendered; or 

  

	 	(iii)	the member inadvertently accessed a non-par provider or non-contracted services in the course of receiving services from a par provider (e.g., the member sees a non-par
consulting specialist in a participating hospital); and 

  

	 	(4)	the Licensee (and in the case of overlapping Service Areas, all of the Licensees) in whose Service Area the health care provider is located consent(s) in advance.

  

					
		  		  	Amended as of June 19, 2008
		  		  	

 EXHIBIT 4 
 Page 4 of 13 
  

	 	i.	contracting with a pharmacy management organization (“Pharmacy Intermediary”) to gain access to a national or regional pharmacy network to provide
self-administered prescription drugs to deliver a pharmacy benefit for all of the Plan’s or licensed Controlled Affiliate’s members nationwide, provided, however, that the Pharmacy Intermediary may not use the Licensed Marks or Name in
contracting with the pharmacy providers in such network; 

  

	 	j.	contracting with the corporate owner of a national or regional retail pharmacy chain to gain access to the pharmacies in the chain to provide self-administered
prescription drugs to deliver a pharmacy benefit for all of the Plan’s or licensed Controlled Affiliate’s members nationwide, provided that (1) the Plan and the Controlled Affiliate may not contract directly with pharmacists or
pharmacy stores outside the Plan’s Service Area, and (2) neither the Plan’s or the Controlled Affiliate’s name nor the Licensed Marks or Name may be posted or otherwise displayed at or by any pharmacy store outside the
Plan’s Service Area; 

  

	 	k.	contracting with a dental management organization (“Dental Intermediary”) to gain access to a national or regional dental network to deliver a routine dental
benefit for all of the Plan’s or licensed Controlled Affiliate’s members nationwide, provided, however, that the Dental Intermediary may not use the Licensed Marks or Name in contracting with the dental providers in such network;

  

	 	l.	contracting with a vision management organization (“Vision Intermediary”) to gain access to a national or regional vision network to deliver a routine vision
benefit for all of the Plan’s or licensed Controlled Affiliate’s members nationwide, provided, however, that the Vision Intermediary may not use the Licensed Marks or Name in contracting with the vision providers in such network;

  

	 	m.	contracting with an independent clinical laboratory for analysis and clinical assessment of specimens that are collected within the Plan’s Service Area;

  

					
		  		  	Amended as of March 17, 2005
		  		  	

 EXHIBIT 4 
 Page 5 of 13 
  

	 	n.	contracting with a durable medical equipment or home medical equipment company for durable medical equipment and supplies and home medical equipment and supplies that
are shipped to a location within the Plan’s Service Area; 

  

	 	o.	contracting with a speciality pharmaceutical company for non-routine biological therapeutics that are ordered by a health care professional located within the
Plan’s Service Area; 

  

	 	p.	contracting with a company that operates provider sites in the Plan’s Service Area, provided that the contract is solely for services rendered at a site (e.g.,
hospital, mobile van) that is within the Plan’s Service Area; 

  

	 	q.	contracting with a company that makes health care professionals available in the Plan’s Service Area (e.g., traveling home health nurse), provided that the
contract is solely for services rendered by health care professionals who are located within the Plan’s Service Area. 

  

	 	r.	entering into a license agreement between and among BCBSA, the Plan and a debit card issuer located outside the Plan’s Service Area, and entering into a
corresponding operating agreement or agreements, in order to offer a debit card bearing the Licensed Marks and Name to eligible persons as defined by the aforementioned license agreement. 

 

	 	s.	in conjunction with contracting with a National Account as Control Licensee or Alternate Control Licensee (as those terms are defined in the Inter-Plan Programs
Policies and Provisions (“IP Policies”)) to offer Blue-branded Health Coverage to the National Account, offering Blue-branded Health and Wellness Programs to all members of the National Account, including members who have not enrolled in
the Blue-branded Health Coverage (“non-Blue Health Coverage members”), provided that: 

  

	 	(i)	the Plan and/or licensed Controlled Affiliate has no contact or interaction with providers outside of the Plan’s Service Area regarding such non-Blue Health
Coverage members, except as specifically provided in the IP Policies; and 

  

					
		  		  	Amended as of March 19, 2009
		  		  	

 EXHIBIT 4 
 Page 6 of 13 
  

	 	(ii)	if in accordance with IP Policies another Licensee is soliciting or servicing under the Brands a local plant, office or division of the account that is outside of the
Plan’s Service Area, the Plan and/or licensed Controlled Affiliate may not offer Blue-branded Health and Wellness Programs to any employees working at such local plant, office or division without the consent of such other Licensee; and

  

	 	(iii)	if the Plan and/or licensed Controlled Affiliate provides an information card to the non-Blue Health Coverage members, the card may not display the Symbols in the
masthead, must contain a prominent disclosure conveying that it is not a health insurance card, and otherwise must be designed so that it is dissimilar to a Blue member identification card. 

For purposes of this subparagraph s, the following definitions apply: 

“Health and Wellness Program” shall mean a program that includes at least one of the following elements or a related
element: 
  

	 	•	 	 Health Risk Assessment and/or Preventive Screenings 

  

	 	•	 	 Exercise and Fitness Programs 

  

	 	•	 	 Health and Wellness Events (e.g., attendance at a health fair, a 5K walk) 

 

	 	•	 	 Nutrition and Weight Management 

  

	 	•	 	 Health Education (e.g., smoking cessation classes) 

  

	 	•	 	 Prenatal and Parenting Education 

  

	 	•	 	 Disease or Chronic Condition Management 

 The above listing is intended to represent examples of the types of programs that may be offered, and other programs, including those offered through different media such as the internet or
telephonically, may also be deemed Health and Wellness programs. 
 “Health Coverage” shall mean providing or
administering medical, surgical, hospital, major medical, or catastrophic coverage, or any HMO, PPO, POS or other managed care plan for the foregoing services. 

  

					
		  		  	Amended as of November 13, 2008
		  		  	

 EXHIBIT 4 
 Page 7 of 13 
  

	 	t.	in conjunction with contracting with a National Account as Control Licensee or Alternate Control Licensee to offer Blue-branded Health Coverage to the National Account,
performing the Eligibility and Enrollment functions of HR administration for all benefit plans offered by the National Account to its members, including benefit plans that are not underwritten or administered by the Plan, provided that:

  

	 	(i)	in performing such functions, the Plan and/or licensed Controlled Affiliate does not use the Brands in any communications with health care providers outside of the
Plan’s Service Area, and otherwise limits its use of the Brands outside of the Service Area to communications with the account’s members, the other benefit plan providers with which the account has contracted and other reasonably necessary
communications to perform such functions; and 

  

	 	(ii)	if in accordance with IP Policies another Licensee is soliciting or servicing under the Brands a local plant, office or division of the account that is outside of the
Plan’s Service Area, the Plan and/or licensed Controlled Affiliate may not perform Eligibility and Enrollment functions for employees working at such local plant, office or division without the consent of such other Licensee;

 For purposes of this subparagraph t, the following definitions apply: 

“Health Coverage” has the meaning set forth in subparagraph s. 

“Eligibility” means services that manage the account’s eligibility data and determine or process determinations relating to
eligibility for benefit plans offered by the account to its employees, including such services as: 
  

	 	•	 	 monitoring and auditing data to ensure that only entitled individuals are enrolled in each such benefit plan; 

 

	 	•	 	 review of eligibility documentation (e.g. marriage licenses, birth certificates, student status verification letters, employment records);

  

	 	•	 	 identification of key member segments such as over-age dependents, part-time employees, employees reaching certain milestones (e.g. Medicare-eligible,
retirees); 

  

					
		  		  	Amended November 18, 2010
		  		  	

 EXHIBIT 4 
 Page 8 of 13 
  

	 	•	 	 termination of coverage for those individuals found to be ineligible for coverage under a benefit plan, and, if applicable, generation of a COBRA
event; and 

  

	 	•	 	 management of “hour-banking” for union environments in which union members can bank hours to remain eligible for benefits.

 “Enrollment” means services that enroll eligible individuals and their spouses/dependents or
terminate or change their enrollment in the account’s benefit plans on an ongoing basis and during open enrollment periods, including such services as: 

	 	•	 	 the coordination of each step in open enrollment process from project planning and system set-up to the generation of confirmation statements;

  

	 	•	 	 ongoing enrollment support for new hires and changes due to life events and work status adjustments; 

 

	 	•	 	 evidence of insurability (EOI) administration for life and disability coverage; 

 

	 	•	 	 transmission of eligibility/enrollment information to the account’s benefit plan providers; 

 

	 	•	 	 review and reconciliation of error reports received from the account’s benefit plan providers; and 

 

	 	•	 	 transmission of information to the account’s payroll system (e.g., benefit deductions, employee demographic data). 

  

					
		  		  	Amended November 18, 2010
		  		  	

 EXHIBIT 4 
 Page 9 of 13 
 3. In connection with activity otherwise in furtherance of the License Agreement, a
Controlled Affiliate that is licensed to use the Licensed Marks and Name pursuant to a Controlled Affiliate License Agreement authorized in clauses d) or e) of Paragraph 2 of the Plan’s License Agreement with BCBSA may use the Licensed Marks
and Name outside the Region (as that term is defined in such respective Controlled Affiliate License Agreements) in the following circumstances which are deemed legitimate and necessary and not likely to cause consumer confusion: 

 

	 	a.	sending letterhead, envelopes, and similar items solely for administrative purposes (e.g., not for purposes of marketing, advertising, promoting, selling or soliciting
the sale of health care plans and related services); 

  

	 	b.	distributing business cards other than in marketing and selling; 

  

	 	c.	contracting with health care providers or soliciting such contracts in areas contiguous to the Region in order to serve its subscribers residing in the Region, provided
that the Controlled Affiliate may not use the names of any of its Controlling Plans in connection with such contracting unless the provider is located in a geographic area that is also contiguous to such Controlling Plan’s Service Area;

  

	 	d.	issuing a small sign containing the legal name or trade name of the Controlled Affiliate for display by a provider to identify the latter as a participating provider of
the Controlled Affiliate, provided that the Controlled Affiliate may not use the names of any of its Controlling Plans on such signs unless the provider is located in a geographic area that is also contiguous to such Controlling Plan’s Service
Area; 

  

	 	e.	advertising in publications or electronic media solely to persons for employment; 

  

					
		  		  	Amended as of March 17, 2005
		  		  	

 EXHIBIT 4 
 Page 10 of 13 
  

	 	f.	advertising in print, electronic or other media which serve, as a substantial market, the Region, provided that the Controlled Affiliate may not advertise outside its
Region on the national broadcast and cable networks and that advertisements in national print media are limited to the smallest regional edition encompassing the Region, and provided further that any such advertising by the Controlled Affiliate may
not reference the name of any of its Controlling Plans unless the respective Controlling Plan is authorized under paragraph 2 of this Exhibit 4 to advertise in such media; 

 

	 	g.	advertising by direct mail where the addressee’s zip code plus 4 includes, at least in part, the Region, provided that such advertising by the Controlled Affiliate
may not reference the name of any of its Controlling Plans unless the respective Controlling Plan is authorized under paragraph 2 of this Exhibit 4 to send direct mail to such zip code plus 4. 

 

	 	h.	[Intentionally left blank, pending review by the Inter-Plan Programs Committee of the applicability of the case management rule to such Controlled Affiliates.]

  

	 	i.	contracting with a pharmacy management organization (“Pharmacy Intermediary”) to gain access to a national or regional pharmacy network to provide
self-administered prescription drugs to deliver a pharmacy benefit for the Controlled Affiliate’s regional Medicare Advantage PPO or regional Medicare Part D Prescription Drug members enrolled under the Licensed Marks pursuant to such
respective Controlled Affiliate License Agreements, provided, however, that the Pharmacy Intermediary may not use the Licensed Marks or Name in contracting with the pharmacy providers in such network; 

 

	 	j.	contracting with the corporate owner of a national or regional retail pharmacy chain to gain access to the pharmacies in the chain to provide self-administered
prescription drugs to deliver a pharmacy benefit to the Controlled Affiliate’s regional Medicare Advantage PPO or regional Medicare Part D Prescription Drug members 

  

					
		  		  	Amended as of March 17, 2005
		  		  	

 EXHIBIT 4 
 Page 11 of 13 
 enrolled under the Licensed Marks pursuant to such respective
Controlled Affiliate License Agreements, provided that (1) the Controlled Affiliate may not contract directly with pharmacists or pharmacy stores outside the Region, and (2) neither the Controlled Affiliate’s name nor the Licensed
Marks or Name may be posted or otherwise displayed at or by any pharmacy store outside the Region; 
  

	 	k.	contracting with a dental management organization (“Dental Intermediary”) to gain access to a national or regional dental network to deliver a routine dental
benefit for the Controlled Affiliate’s regional Medicare Advantage PPO members enrolled under the Licensed Marks pursuant to such Controlled Affiliate License Agreement, provided, however, that the Dental Intermediary may not use the Licensed
Marks or Name in contracting with the dental providers in such network; 

  

	 	l.	contracting with a vision management organization (“Vision Intermediary”) to gain access to a national or regional vision network to deliver a routine vision
benefit for the Controlled Affiliate’s regional Medicare Advantage members enrolled under the Licensed Marks pursuant to such Controlled Affiliate License Agreement, provided, however, that the Vision Intermediary may not use the Licensed Marks
or Name in contracting with the vision providers in such network; 

  

	 	m.	contracting with an independent clinical laboratory for analysis and clinical assessment of specimens that are collected within the Controlled Affiliate’s Region;

  

	 	n.	contracting with a durable medical equipment or home medical equipment company for durable medical equipment and supplies and home medical equipment and supplies that
are shipped to a location within the Controlled Affiliate’s Region; 

  

	 	o.	contracting with a specialty pharmaceutical company for non-routine biological therapeutics that are ordered by a health care professional located within the Region;

  

					
		  		  	Amended as of March 17, 2005
		  		  	

 EXHIBIT 4 
 Page 12 of 13 
  

	 	p.	contracting with a company that operates provider sites in the Region, provided that the contract is solely for services rendered at a site (e.g., hospital, mobile van)
that is within the Region; 

  

	 	q.	contracting with a company that makes health care professionals available in the Region (e.g., traveling home health nurse), provided that the contract is solely for
services rendered by health care professionals who are located within the Region. 

 4. BCBSA shall retain the right to use the
Licensed Marks in conjunction with the Federal Employee Program and with any other national offering made to federal employees pursuant to the Federal Employees Health Benefits Program (FEHBP), including the right to license such use to its vendors,
but only in the following manner. 
  

	 	a.	the Licensed Marks may only be used by BCBSA with the term “Federal Employee Program”, “Federal”, “FEP”, or similar language identifying
the program as a benefit program for federal employees; 

  

	 	b.	the Licensed Marks may not be used by BCBSA with the name(s) of a specific Plan or Plans and; 

 

	 	c.	any use by BCBSA in conjunction with a new national FEHBP program proposed after the enactment of this amendment will require the approval of the BCBSA Board of
Directors. 

  

					
		  		  	Amended as of March 16, 2006
		  		  	

 EXHIBIT 4 
 Page 13 of 13 
 5. Where required by applicable state or local law or regulation, a Plan may
submit documents that contain the Brands to, and file forms that contain the Brands with, state or local regulators in a state not included in its Service Area, provided that it gives reasonable advance notice to the local Plan of its intent to
submit such documents or file such forms. Notwithstanding, in no event may a Plan use the Brands to register, or to obtain or maintain a license, a certificate of authority, or an equivalent document authorizing it to act as a risk-bearing entity or
third party administrator in a state not included in its Service Area. If the local Plan advises BCBSA that it believes its License Agreement has been or would be violated by any submission or filing, BCBSA shall determine whether such submission or
filing is required by state or local law or regulation and violates the License Agreement, subject to the Plan’s rights to obtain an independent review of such determination under Paragraph 9(a) and Exhibit 5 of its License Agreement. For
purposes of this paragraph, “local Plan” is defined as each Plan whose Service Area includes all or part of the state in which the foregoing applicable state or local law or regulation has been enacted. 

  

					
		  		  	Amended November 18, 2010
		  		  	

 EXHIBIT 5 
 MEDIATION AND MANDATORY DISPUTE RESOLUTION (MMDR) RULES 
 Page 1 of 23 

The Blue Cross and Blue Shield Plans (“Plans”) and the Blue Cross Blue Shield Association (“BCBSA”) recognize and
acknowledge that the Blue Cross and Blue Shield system is a unique nonprofit and for-profit system offering cost effective health care financing and services. The Plans and BCBSA desire to utilize Mediation and Mandatory Dispute Resolution
(“MMDR”) to avoid expensive and time-consuming litigation that may otherwise occur in the federal and state judicial systems. Even MMDR should be viewed, however, as methods of last resort, all other procedures for dispute resolution
having failed. Except as otherwise provided in the License Agreements, the Plans, their Controlled Affiliates and BCBSA agree to submit all disputes to MMDR pursuant to these Rules and in lieu of litigation. 

 

	1.	Initiation of Proceedings 

  

	 	A.	Pre-MMDR Efforts 

 Before
filing a Complaint to invoke the MMDR process, the CEO of a complaining party, or his/her designated representative, shall undertake good faith efforts with the other side(s) to try to resolve any dispute. 

 

	 	B.	Complaint 

 To commence a
proceeding, the complaining party (or parties) shall provide by certified mail, return receipt requested, a written Complaint to the BCBSA Corporate Secretary (which shall also constitute service on BCBSA if it is a respondent) and to any Plan(s)
and/or Controlled Affiliate(s) named therein. The Complaint shall contain: 
  

	 	i.	identification of the complaining party (or parties) requesting the proceeding; 

 

	 	ii.	identification of the respondent(s); 

  

	 	iii.	identification of any other persons or entities who are interested in a resolution of the dispute; 

 

	 	iv.	a full statement describing the nature of the dispute; 

  

	 	v.	identification of all of the issues that are being submitted for resolution; 

  

					
		  		  	Amended as of November 21, 1996
		  		  	

 EXHIBIT 5 
 Page 2 of 23 
  

	 	vi.	the remedy sought; 

  

	 	vii.	a statement as to whether the complaining party (or parties) elect(s) first to pursue Mediation; 

 

	 	viii.	any request, if applicable, that the matter be handled on an expedited basis and the reasons therefor; and 

 

	 	ix.	a statement signed by the CEO of the complaining party affirming that the CEO has undertaken efforts, or has directed efforts to be undertaken, to resolve the dispute
before resorting to the MMDR process. 

 The complaining party (or parties) shall file and serve with the Complaint copies of all
documents which the party (or parties) intend(s) to offer at the Arbitration Hearing and a statement identifying the witnesses the party (or parties) intend(s) to present at the Hearing, along with a summary of each witness’ expected testimony.

  

	 	C.	Answer 

 Within twenty
(20) days after receipt of the Complaint, each respondent shall serve on BCBSA and on the complaining party (or parties); 
  

	 	i.	a full Answer to the aforesaid Complaint; 

  

	 	ii.	a statement of any Counterclaims against the complaining party (or parties), providing with respect thereto the information specified in Paragraph 1.B., above;

  

	 	iii.	a statement as to whether the respondent elects to first pursue Mediation; and 

 

	 	iv.	any request, if applicable, that the matter be handled on an expedited basis and the reasons therefor. 

The respondent(s) shall file and serve with the Answer or by the date of the Initial Conference set forth in Paragraph 3.C., below, copies of all
documents which the respondent(s) intend(s) to offer at the Arbitration Hearing and a statement identifying the witnesses the party (or parties) intend(s) to present at the Hearing, along with a summary of each witness’ expected testimony.

  

					
		  		  	Amended as of September 20, 2007
		  		  	

 EXHIBIT 5 
 Page 3 of 23 
  

	 	D.	Reply To Counterclaim 

Within ten (10) days after receipt of any Counterclaim, the complaining party (or parties) shall serve on BCBSA and on the responding
party (or parties), a Reply to the Counterclaim. Such Reply must provide the same information required by Paragraph 1.C., above. 
  

	2.	Mediation 

 To
facilitate the mediation of disputes between or among BCBSA, the Plans and/or their Controlled Affiliates, the BCBSA Board has provided for Mediation under these Rules. Mediation may be pursued in lieu of or in an effort to obviate the Mandatory
Dispute Resolution process, and all parties are strongly urged, but not required, to exhaust the mediation procedure provided for herein. In the event any party refuses to proceed with Mediation, the parties shall proceed immediately to Mandatory
Dispute Resolution, as provided in Section 3. 
  

	 	A.	Selection of Mediators 

If all parties agree to pursue Mediation, they shall promptly attempt to agree upon: (i) the number of mediators desired, not to
exceed three mediators; and (ii) the selection of experienced mediator(s) from an independent entity to mediate all disputes set forth in the Complaint and Answer (and Counterclaim and Reply, if any). In the event the parties are unable to
agree upon the selection or number of mediators, both within five (5) days of the service of the Answer or Reply to Counterclaim, whichever is later, the BCBSA Corporate Secretary shall immediately refer the matter to a nationally recognized
professional ADR organization (such as CPR or JAMS) for mediation by a single mediator to be selected by the ADR organization. 
  

	 	B.	Binding Decision 

 Before
the Mediation Hearing described below, the BCBSA Corporate Secretary shall contact the parties to determine whether they wish to be bound by any recommendation of the selected mediator(s) for resolution of the disputes. If all wish to be bound, the
Corporate Secretary will send appropriate documentation to them for their signatures before the Mediation Hearing begins. 

  

					
		  		  	Amended as of September 20, 2007
		  		  	

 EXHIBIT 5 
 Page 4 of 23 
  

	 	C.	Mediation Procedure 

 The
Mediator(s) shall apply the mediation procedures and processes provided for herein (not the rules of the ADR organization with which they are affiliated) and shall promptly advise the parties of a scheduled Mediation Hearing date. Unless a party
requests an expedited procedure, or unless all parties to the proceeding agree to one or more extensions of time, the Mediation Hearing set forth below shall be completed within forty (40) days of BCBSA’s receipt of the Complaint. The
selected mediator(s), unless the parties otherwise agree, shall adhere to the following procedure: 
  

	 	i.	Each party must be represented by its CEO or other representative who has been delegated full authority to resolve the dispute. However, parties may send additional
representatives as they see fit. 

  

	 	ii.	Each party will be given one-half hour to present its case, beginning with the complaining party (or parties), followed by the other party or parties. The parties are
free to structure their presentations as they see fit, using oral statements or direct examination of witnesses. However, neither cross-examination nor questioning of opposing representatives will be permitted. At the close of each presentation, the
selected mediator(s) will be given an opportunity to ask questions of the presenters and witnesses. All parties must be present throughout the Mediation Hearing. The selected mediator(s) may extend the time allowed for each party’s presentation
at the Mediation Hearing. The selected mediator(s) may meet in executive session, outside the presence of the parties, or may meet with the parties separately, to discuss the controversy. 

 

	 	iii.	After the close of the presentations, the parties will attempt to negotiate a settlement of the dispute. If the parties desire, the selected mediator(s), or any one or
more of the selected mediators, will sit in on the negotiations. 

  

					
		  		  	Amended as of September 20, 2007
		  		  	

 EXHIBIT 5 
 Page 5 of 23 
  

	 	iv.	After the close of the presentations, the selected mediator(s) may meet privately to agree upon a recommendation for resolution of the dispute which would be submitted
to the parties for their consideration and approval. If the parties have previously agreed to be bound by the results of this procedure, this recommendation shall be binding upon the parties. 

 

	 	v.	The purpose of the Mediation Hearing is to assist the parties to settle their grievances short of mandatory dispute resolution. As a result, the Mediation Hearing has
been designed to be as informal as possible. Rules of evidence shall not apply. There will be no transcript of the proceedings, and no party may make a tape recording of the Mediation Hearing. 

 

	 	vi.	In order to facilitate a free and open discussion, the Mediation proceeding shall remain confidential. A “Stipulation to Confidentiality” which prohibits
future use of settlement offers, all position papers or other statements furnished to the selected mediator(s), and decisions or recommendations in any Mediation proceeding shall be executed by each party. 

 

	 	vii.	Upon request of the selected mediator(s), or one of the parties, BCBSA staff may also submit documentation at any time during the proceedings. 

 

	 	D.	Notice of Termination of Mediation 

 If the Mediation cannot be completed within the prescribed or agreed time period due to the lack of cooperation of any party, as determined by the selected mediator(s), or if the Mediation does not result
in a final resolution of all disputes at the Mediation Hearing or within ten (10) days after the Mediation Hearing, any party or any one of the selected mediators shall so notify the BCBSA Corporate Secretary, who shall promptly issue a Notice
of Termination of Mediation to all parties, to the selected mediator(s), and to the MDR Administrator. Such notice shall serve to bring the Mediation to an end and to initiate Mandatory Dispute Resolution. Upon agreement of all parties and the
mediator(s), the Mediation process may continue at the same time the MDR process is invoked. In such case, the Notice of Termination of Mediation described above serves to initiate the MDR proceeding, but does not terminate mediation proceedings,
which may proceed simultaneous with the MDR proceeding. 

  

					
		  		  	Amended as of September 20, 2007
		  		  	

 EXHIBIT 5 
 Page 6 of 23 
  

	3.	Mandatory Dispute Resolution (MDR) 

 If any party elects not to first pursue Mediation, or if a Notice of Termination of Mediation is issued as set forth in Paragraph 2.D., above, then the unresolved disputes set forth in any Complaint and
Answer (and Counterclaim and Reply, if any) shall be subject to mandatory binding arbitration (herein referred to as “MDR”). 
  

	 	A.	MDR Administrator 

 The
Administrator for purposes of Mandatory Arbitration shall be an independent nationally recognized entity such as CPR or JAMS, specializing in alternative dispute resolution. In the event the parties pursued Mediation with CPR, JAMS or a similar
organization, that organization also shall serve as the MDR Administrator, unless all parties notify the BCBSA Corporate Secretary in writing within two (2) days of receiving the Notice of Termination of Mediation that they wish to pursue MDR
with another nationally recognized organization serving as MDR Administrator. 
 In the event the parties (i) did not
pursue Mediation, (ii) pursued mediation with a Mediator not affiliated with an ADR organization that offers a panel of arbitrators, or (iii) all parties that pursued Mediation notified the BCBSA Corporate Secretary that they wish to have
an MDR Administrator that is different from the organization with which their mediator was affiliated, they shall promptly attempt to agree on a nationally recognized ADR entity that supplies a panel of arbitrators. If they reach such agreement
within five (5) days of the Notice of Termination of Mediation or receipt of the Answer or Reply to Counterclaim (whichever is later), the parties shall promptly inform the BCBSA Corporate Secretary of their agreed upon ADR organization. In the
event the parties are unable to reach agreement on an MDR Administrator within that timeframe, the BCBSA Corporate Secretary shall immediately refer the matter to CPR, JAMS or a similar organization for MDR. 

Any person who served as a Mediator shall not serve as an arbitrator for the same or similar dispute for purposes of MDR. 

 

	 	B.	Rules for MDR 

 The rules
controlling all aspects of MDR shall be exclusively those provided for herein. The rules promulgated or otherwise used by the MDR Administrator organization shall not apply. 

  
 Amended as
of September 20, 2007 

 EXHIBIT 5 
 Page 7 of 23 
  

	 	C.	Initial Conference 

Within seven (7) days after a Notice of Termination has issued or the matter has otherwise been referred to an MDR Administrator, or
within five (5) days after the time for filing and serving the Answer or Reply to any Counterclaim (whichever is later) if the parties elect first not to mediate, the parties shall confer with the Administrator to discuss selecting a dispute
resolution panel (“the Panel”). This conference (the “Initial Conference”) may be by telephone. The parties are encouraged to agree to the composition of the Panel and to present that agreement to the Administrator at the Initial
Conference. If the parties do not agree on the composition of the Panel by the time of the Initial Conference, or by any extension thereof agreed to by all parties and the Administrator, then the Panel Selection Process set forth in subparagraph D,
below, shall be followed. 
  

	 	D.	Panel Selection Process 

The Administrator shall designate, prior to the Initial Conference, at least seven potential arbitrators. Each party shall be permitted to
strike any designee for cause and the Administrator shall determine the sufficiency thereof in its sole discretion. The Administrator will designate a replacement for any designee so stricken. Each party shall then be permitted one peremptory strike
from the list of designees. The Administrator shall set the dates for exercising all strikes, which shall be set to encourage the prompt selection of arbitrators. 
 After the parties exercise any designee strikes for cause and their peremptory strike against any designee of their choice, the parties shall each rank the remaining panel members in order of preference
and provide the Administrator, without serving on any other party, their ranked list. The Administrator shall not disclose any party’s ranked list to members of the panel or to other parties. 

From the remaining designees, and after considering opportunities to maximize, so far as possible, the collectively stated arbitrator
preferences provided by the parties on their ranked lists, the Administrator shall select a three member Panel. The Panel Selection Process shall be completed no later than ten (10) days after the Initial Conference. 

Each Arbitrator shall be compensated at his or her normal hourly rate or, in the absence of an established rate, at a reasonable hourly
rate to be promptly fixed by the Administrator for all time spent in connection with the proceedings and shall be reimbursed for any travel and other reasonable expenses. 

  
 Amended as
of September 20, 2007 

 EXHIBIT 5 
 Page 8 of 23 
  

	 	E.	Duties Of The Arbitrators 

The Panel shall promptly designate a Presiding Arbitrator for the purposes reflected below, but shall retain the power to review and
modify any ruling or other action of said Presiding Arbitrator. Each Arbitrator shall be an independent Arbitrator, shall be governed by the Code of Ethics for Arbitrators in Commercial Disputes and shall at or prior to the commencement of any
Arbitration Hearing take an oath to that effect. Each Arbitrator shall promptly disclose in writing to the Panel and to the parties any circumstances, whenever arising, that might cause doubt as to such Arbitrator’s compliance, or ability to
comply, with said Code of Ethics, and, absent resignation by such Arbitrator, the remaining Arbitrators shall determine in their sole discretion whether the circumstances so disclosed constitute grounds for disqualification and for replacement. With
respect to such circumstances arising or coming to the attention of a party after an Arbitrator’s selection, a party may likewise request the Arbitrator’s resignation or a determination as to disqualification by the remaining Arbitrators.
With respect to a sole Arbitrator, the determination as to disqualification shall be made by the Administrator. 
 There shall
be no ex parte communication between the parties or their counsel and any member of the Panel. 
  

	 	F.	Panel’s Jurisdiction And Authority 

 The Panel’s jurisdiction and authority shall extend to all disputes between or among the Plans, their Controlled Affiliates, and/or BCBSA, except for those disputes excepted from these MMDR
procedures as set forth in the License Agreements. 
 With the exception of punitive or treble damages, the Panel shall have
full authority to award the relief it deems appropriate to resolve the parties’ disputes, including monetary awards and injunctions, mandatory or prohibitory. The Panel has no authority to award punitive or treble damages except that the Panel
may allocate or assess responsibility for punitive or treble damages assessed by another tribunal. Subject to the above limitations, the Panel may, by way of example, but not of limitation: 

  
 Amended as
of September 20, 2007 

 EXHIBIT 5 
 Page 9 of 23 
  

	 	i.	 interpret or construe the meaning of any terms, phrase or provision in any license between BCBSA and a Plan or a Controlled Affiliate relating to the
use of the BLUE CROSS® or BLUE SHIELD® service marks. 

  

	 	ii.	 determine whether BCBSA, a Plan or a Controlled Affiliate has violated the terms or conditions of any license between the BCBSA and a Plan or a
Controlled Affiliate relating to the use of the BLUE CROSS® or BLUE SHIELD® service marks. 

  

	 	iii.	decide challenges as to its own jurisdiction. 

  

	 	iv.	issue such orders for interim relief as it deems appropriate pending Hearing and Award in any Arbitration. 

It is understood that the Panel is expected to resolve issues based on governing principles of law, preserving to the maximum extent
legally possible the continued integrity of the Licensed Marks and the BLUE CROSS/BLUE SHIELD system. The Panel shall apply federal law to all issues which, if asserted in the United States District Court, would give rise to federal question
jurisdiction, 28 U.S.C. § 1331. The Panel shall apply Illinois law to all issues involving interpretation, performance or construction of any License Agreement or Controlled Affiliate License Agreement unless the agreement otherwise provides.
As to other issues, the Panel shall choose the applicable law based on conflicts of law principles of the State of Illinois. 
  

	 	G.	Administrative Conference 

Within five (5) days of the Panel being selected, the Presiding Arbitrator shall confer with the parties and the other members of the
Panel and shall schedule, in writing, a conference in which the parties and the Panel shall participate (the “Administrative Conference”). The Administrative Conference shall take place no later than fifteen (15) days after the Panel
is selected. At the Administrative Conference the parties and the Panel shall discuss the scheduling of the Arbitration Hearing and any other matter appropriate to be considered, including but not limited to: any written discovery in the form of
requests for production of documents or requests to admit facts; the identity of any witness whose deposition a party may desire and a showing of exceptional good cause for the taking of any such deposition; the desirability of bifurcation or other
separation of the issues; the need for and the type of record of conferences and hearings, including the need for transcripts; the need for expert witnesses and 

  
 Amended as
of September 20, 2007 

 EXHIBIT 5 
 Page 10 of 23 
  

 
how expert testimony should be presented; the appropriateness of motions to dismiss and/or for full or partial summary judgment; consideration of stipulations; the desirability of presenting any
direct testimony in writing; and the necessity for any on-site inspection by the Panel. If the parties agree, the Administrative Conference may be by telephone. 
  

	 	H.	Discovery 

  

	 	i.	 Requests for Production of Documents: All requests for the production of documents must be
served no later than five (5) days after the date of the Initial Conference. Within twenty (20) days after receipt of a request for production of documents, a party shall (a) serve responses and objections to the request,
(b) produce all responsive, non-privileged documents to the requesting party, and (c) to the extent any responsive documents are withheld on the grounds of attorney-client privilege or work product, produce a log identifying such documents
in the manner specified in Fed. R. Civ. P. 26(b)(5). If, after reviewing a privilege log, the requesting party believes attorney-client privilege or work product protection was improperly claimed by the producing party with respect to any document,
the requesting party may ask the Presiding Arbitrator to conduct an in-camera inspection of the same. With respect to documentary and other discovery produced in any MDR proceeding by BCBSA, the fact that a party’s CEO or other senior officers
may serve on the BCBSA Board of Directors, BCBSA Board Committees or other BCBSA work groups, task forces and the like, shall not be a basis for defeating an otherwise valid claim of attorney-client privilege or work product protection over such
documentary or other discovery materials by BCBSA. 

  

	 	ii.	 Requests for
Admissions: Requests for Admissions may be served up to twenty-one (21) days prior to the discovery cut-off set by the Presiding Arbitrator. A party served with Requests For Admissions must respond within twenty
(20) days of receipt of said request. The good faith use of and response to Requests for Admissions is encouraged, and the Panel shall have full discretion, with reference to the Federal Rules of Civil Procedure, in awarding appropriate
sanctions with respect to abuse of the procedure. 

  
 Amended as
of September 20, 2007 

 EXHIBIT 5 
 Page 11 of 23 
  

	 	iii.	Depositions: As a general rule, the parties will not be permitted to take party or non-party deposition testimony for discovery purposes. The Presiding
Arbitrator, in his or her sole discretion, shall have the authority to permit a party to take such deposition testimony upon a showing of exceptional good cause. The parties will be permitted to take de bene esse deposition1 testimony to the fullest extent permitted by law of any witness who
cannot be compelled to testify at the Arbitration Hearing. No deposition, for discovery purposes or otherwise, shall exceed three (3) hours, excluding objections and colloquy of counsel. Depositions may be recorded in any manner recognized by
the Federal Rules of Civil Procedure and the parties shall specify in each notice of deposition or request for permission to take deposition testimony the manner in which such deposition shall be recorded. 

 

	 	iv.	 Expert
witness(es): If a party intends to present the testimony of an expert witness during the oral hearing, it shall provide all other parties with a written statement setting forth the information required to be provided
by Fed. R. Civ. P. 26(a)(2) (B) ten (10) days prior to the discovery cut-off set by the Presiding Arbitrator. If a party intends to present the testimony of a rebuttal expert witness during the Arbitration Hearing, it shall provide all
other parties with a written statement setting forth the information required to be provided by Fed. R. Civ. P. 26(a)(2)(B) within twenty (20) days after the date on which the written statement of the expert witness whose testimony is to be
rebutted was produced. 

  

	 	v.	Discovery cut-off: The Presiding Arbitrator shall determine the date on which the discovery period will end, but the discovery period shall not exceed
thirty (30) days from the date of the Administrative Conference without the agreement of all parties. 

  

	1	As used in these Rules, “de bene esse deposition” means a deposition that is not taken for discovery purposes, but is taken for the purpose of reading part or
all of the deposition transcript into the record at the Arbitration Hearing, to the extent permitted by the Panel, because the witness cannot be compelled to testify at the Arbitration Hearing or has exercised a right provided under these Rules to
provide deposition testimony in lieu of testimony at the Arbitration Hearing. 

  
 Amended as
of September 20, 2007 

 EXHIBIT 5 
 Page 12 of 23 
  

	 	vi.	Additional discovery: Any additional discovery will be at the discretion of the Presiding Arbitrator. 

 

	 	vii.	Discovery Disputes: Any discovery disputes shall be raised by motion to the Presiding Arbitrator, who is authorized to resolve all such disputes, and
whose resolution will be binding on the parties unless modified by the Arbitration Panel. Prior to raising any discovery dispute with the Presiding Arbitrator, the parties shall meet and confer, telephonically or in person, in an attempt to resolve
or narrow the dispute. If a party refuses to comply with a decision resolving a discovery dispute, the Panel, in keeping with Fed. R. Civ. P. 37, may refuse to allow that party to support or oppose designated claims or defenses, prohibit that party
from introducing designated matters into evidence or, in extreme cases, decide an issue submitted for resolution adversely to that party. 

  

	 	viii.	Extensions: The time for responding to discovery requests may be extended by the Presiding Arbitrator for good and sufficient cause shown. Any request for
such an extension shall be made in writing. 

  

	 	I.	Panel Suggested Settlement/Mediation 

 At any point during the proceedings, the Panel at the request of any party or on its own initiative, may suggest that the parties explore settlement and that they do so at or before the conclusion of the
Arbitration Hearing, and the Panel shall give such assistance in settlement negotiations as the parties may request and the Panel may deem appropriate. Alternatively, the Panel may direct the parties to endeavor to mediate their disputes as provided
above, or to explore a mini-trial proceeding, or to have an independent party render a neutral evaluation of the parties’ respective positions. The Panel shall enter such sanctions as it deems appropriate with respect to any party failing to
pursue in good faith such Mediation or other alternate dispute resolution methods. 

  
 Amended as
of September 20, 2007 

 EXHIBIT 5 
 Page 13 of 23 
  

	 	J.	Subpoenas on Third Parties 

Pursuant to, and consistent with, the Federal Arbitration Act, 9 U.S.C. § 9 et seq., and subject to Paragraph 3.G(iii) above,
a party may request the issuance of a subpoena on any third party, including but not limited to any third party Blue Plan or any officer, employee or director of a third party Blue Plan, to compel deposition testimony or the production of documents,
and, if good and sufficient cause is shown, the Panel shall issue such a subpoena. 
  

	 	K.	Arbitration Hearing 

 An
Arbitration Hearing will be held within thirty (30) days after the Administrative Conference if no discovery is taken, or within thirty (30) days after the close of discovery, unless all parties and the Panel agree to extend the
Arbitration Hearing date, or unless the parties agree in writing to waive the Arbitration Hearing. The parties may mutually agree on the location of the Arbitration Hearing. If the parties fail to agree, the Arbitration Hearing shall be held in
Chicago, Illinois, or at such other location determined by the Presiding Arbitrator to be most convenient to the participants. The Panel will determine the date(s) and time(s) of the Arbitration Hearing(s) after consultation with all parties and
shall provide reasonable notice thereof to all parties or their representatives. 
  

	 	L.	Arbitration Hearing Memoranda 

 Twenty (20) days prior to the Arbitration Hearing, each party shall submit to the other party (or parties) and to the Panel an Arbitration Hearing Memorandum which sets forth the applicable law and
any argument as to any relevant issue. The Arbitration Hearing Memorandum will supplement, and not repeat, the allegations, information and documents contained in or with the Complaint, Answer, Counterclaim and Reply, if any. Ten (10) days
prior to the Arbitration Hearing, each party shall submit to each other party a list of all expert and fact witnesses (but not including rebuttal fact witness) that such party intends to have testify at the Arbitration Hearing and a brief summary of
the testimony each such witness is expected to give. In addition, no later than five (5) days prior to the Arbitration, each party may submit to each other party and to the Panel a Response Arbitration Hearing Memorandum which sets forth any
response to another party’s Arbitration Hearing Memorandum. 

  
 Amended as
of September 20, 2007 

 EXHIBIT 5 
 Page 14 of 23 
  

	 	M.	Notice For Testimony 

 Ten
(10) days prior to the Arbitration Hearing, any party may serve a Notice on any other party (or parties) requesting the attendance at the Arbitration Hearing of any officer, employee or director of the other party (or parties) for the purpose
of providing noncumulative testimony. If a party fails to produce one of its officers, employees or directors whose noncumulative testimony during the Arbitration Hearing is reasonably requested by an adverse party, the Panel may refuse to allow
that party to support or oppose designated claims or defenses, prohibit that party from introducing designated matters into evidence or, in extreme cases, decide an issue submitted for mandatory dispute resolution adversely to that party; provided,
however, that a party may refuse to produce a director to testify if, within two (2) days of receiving a notice requesting the attendance of such director at the Arbitration Hearing, the party agrees to make the director available for a de bene
esse deposition at a mutually convenient time at any location within fifty (50) miles of the director’s primary residence chosen by the party requesting the director’s testimony. This Rule may not be used for the purpose of burdening
or harassing any party, and the Presiding Arbitrator may impose such orders as are appropriate so as to prevent or remedy any such burden or harassment. 
 Pursuant to, and consistent with, the Federal Arbitration Act, 9 U.S.C. § 9 et seq., twenty (20) days or more prior to the Arbitration Hearing, a party may request the issuance of a
subpoena on any third party, including but not limited to any third party Blue Plan, BCBSA or any officer, employee or director of a third party Blue Plan or BCBSA for the purpose of providing noncummulative testimony at the Arbitration Hearing,
and, if good and sufficient cause is shown, the Panel shall issue such a subpoena; provided however, that a director of a third party Blue Plan or BCBSA may refuse to testify if, within two (2) days of receiving a subpoena requesting the
attendance of such director at the Arbitration Hearing, the director agrees to make him/herself available for a de bene esse deposition at a mutually convenient time at any location within fifty (50) miles of the director’s primary
residence chosen by the party requesting the director’s testimony. Each Blue Plan agrees to waive, on its own behalf and on behalf of its directors and officers, any objection it otherwise might have to any such subpoena based on service, venue
or extraterritoriality. 

  
 Amended as
of September 20, 2007 

 EXHIBIT 5 
 Page 15 of 23 
  

	 	N.	Arbitration Hearing Procedures 

  

	 	i.	Attendance at Arbitration Hearing: Any person having a direct interest in the proceeding is entitled to attend the Arbitration Hearing. The Presiding
Arbitrator shall otherwise have the power to require the exclusion of any witness, other than a party or other essential person, during the testimony of any other witness. It shall be discretionary with the Presiding Arbitrator to determine the
propriety of the attendance of any other person. 

  

	 	ii.	Confidentiality: The Panel and all parties shall maintain the privacy of the Arbitration Proceeding. The parties and the Panel shall treat
the Arbitration Hearing and any discovery or other proceedings or events related thereto, including any award resulting therefrom, as confidential except as otherwise necessary in connection with a judicial challenge to or enforcement of an award or
unless otherwise required by law. 

  

	 	iii.	Stenographic Record: Any party, or if the parties do not object, the Panel, may request that a stenographic or other record be made of any
Arbitration Hearing or portion thereof. The costs of the recording and/or of preparing the transcript shall be borne by the requesting party and by any party who receives a copy thereof. If the Panel requests a recording and/or a transcript, the
costs thereof shall be borne equally by the parties. 

  

	 	iv.	Oaths: The Panel may require witnesses to testify under oath or affirmation administered by any duly qualified person and, if requested by
any party, shall do so. 

  

	 	v.	Order of Arbitration Hearing: An Arbitration Hearing shall be opened by the recording of the date, time, and place of the Arbitration
Hearing, and the presence of the Panel, the parties, and their representatives, if any. The Panel may, at the beginning of the Arbitration Hearing, ask for statements clarifying the issues involved. 

  
 Amended as
of September 20, 2007 

 EXHIBIT 5 
 Page 16 of 23 
  

 Unless otherwise agreed, the complaining party (or parties) shall then present evidence
to support their claim(s). The respondent(s) shall then present evidence supporting their defenses and Counterclaims, if any. The complaining party (or parties) shall then present evidence supporting defenses to the Counterclaims, if any, and
rebuttal. 
 Witnesses for each party shall submit to questions by adverse parties and/or the Panel. 

The Panel has the discretion to vary these procedures, but shall afford a full and equal opportunity to all parties for the presentation
of any material and relevant evidence. 
  

	 	vi.	Evidence: The parties may offer such evidence as is relevant and material to the dispute and shall produce such evidence as the Panel may
deem necessary to an understanding and resolution of the dispute. Unless good cause is shown, as determined by the Panel or agreed to by all other parties, no party shall be permitted to offer evidence at the Arbitration Hearing which was not
disclosed prior to the Arbitration Hearing by that party. The Panel may receive and consider the evidence of witnesses by affidavit upon such terms as the Panel deems appropriate. 

The Panel shall be the judge of the relevance and materiality of the evidence offered, and conformity to legal rules of evidence, other
than enforcement of the attorney-client privilege and the work product protection, shall not be necessary. The Federal Rules of Evidence shall be considered by the Panel in conducting the Arbitration Hearing but those rules shall not be controlling.
All evidence shall be taken in the presence of the Panel and all of the parties, except where any party is in default or has waived the right to be present. 
 Settlement offers by any party in connection with Mediation or MDR proceedings, decisions or recommendations of the selected mediators, and a party’s position papers or statements furnished to the
selected mediators shall not be admissible evidence or considered by the Panel without the consent of all parties. 

  

 EXHIBIT 5 
 Page 17 of 23 
  

	 	vii.	Closing of Arbitration Hearing: The Presiding Arbitrator shall specifically inquire of all parties whether they have any further proofs to
offer or witnesses to be heard. Upon receiving negative replies or if he or she is satisfied that the record is complete, the Presiding Arbitrator shall declare the Arbitration Hearing closed with an appropriate notation made on the record. Subject
to being reopened as provided below, the time within which the Panel is required to make the award shall commence to run, in the absence of contrary agreement by the parties, upon the closing of the Arbitration Hearing. 

With respect to complex disputes, the Panel may, in its sole discretion, defer the closing of the Arbitration Hearing for a period of up
to thirty (30) days after the presentation of proofs in order to permit the parties to submit post-hearing briefs and argument, as the Panel deems appropriate, prior to making an award. 

For good cause, the Arbitration Hearing may be reopened for up to thirty (30) days on the Panel’s initiative, or upon
application of a party, at any time before the award is made 
  

	 	O.	Awards 

 An Award must be
in writing and shall be made promptly by the Panel and, unless otherwise agreed by the parties or specified by law, no later than thirty (30) days from the date of closing the Arbitration Hearing. If all parties so request, the Award shall
contain findings of fact and conclusions of law. The Award, and all other rulings and determinations by the Panel, may be by a majority vote. 
 Parties shall accept as legal delivery of the Award the placing of the Award or a true copy thereof in the mail addressed to a party or its representative at its last known address or personal service of
the Award on a party or its representative. 
 Awards are binding only on the parties to the Arbitration and are not binding on
any non-parties to the Arbitration and may not be used or cited as precedent in any other proceeding. 

  
 Amended as
of September 20, 2007 

 EXHIBIT 5 
 Page 18 of 23 
  

 After the expiration of twenty (20) days from initial delivery, the Award (with
corrections, if any) shall be final and binding on the parties, and the parties shall undertake to carry out the Award without delay. 
 Proceedings to confirm, modify or vacate an Award shall be conducted in conformity with and controlled by the Federal Arbitration Act. 9 U.S.C. § 1, et seq. 

 

	 	P.	Return of Documents 

Within sixty (60) days after the Award and the conclusion of any judicial proceedings with respect thereto, each party and the Panel
shall return any documents produced by any other party, including all copies thereof. If a party receives a discovery request in any other proceeding which would require it to produce any documents produced to it by any other party in a proceeding
hereunder, it shall not produce such documents without first notifying the producing party and giving said party reasonable time to respond, if appropriate, to the discovery request. 

 

	4.	Miscellaneous 

  

	 	A.	Expedited Procedures 

 Any
party to a Mediation may direct a request for an expedited Mediation Hearing to the Chairman of the Mediation Committee, to the selected Mediators, and to all other parties at any time. The Chairman of the Mediation Committee, or at his or her
direction, the then selected Mediators, shall grant any request which is supported by good and sufficient reasons. If such a request is granted, the Mediation shall be completed within as short a period as practicable, as determined by the Chairman
of the Mediation Committee or, at his or her direction, the then selected Mediators. 
 Any party to an Arbitration may direct a
request for expedited proceedings to the Administrator, to the Panel, and to all other parties at any time. The Administrator, or the Presiding Arbitrator if the Panel has been selected, shall grant any such request which is supported by good and
sufficient reasons. If such a request is granted, the Arbitration shall be completed within as short a time as practicable, as determined by the Administrator and/or the Presiding Arbitrator. 

  
 Amended as
of September 20, 2007 

 EXHIBIT 5 
 Page 19 of 23 
  

	 	B.	Temporary or Preliminary Injunctive Relief 

 Any party may seek temporary or preliminary injunctive relief with the filing of a Complaint or at any time thereafter. If such relief is sought prior to the time that an Arbitration Panel has been
selected, then the Administrator shall select a single Arbitrator who is a lawyer who has no interest in the subject matter of the dispute, and no connection to any of the parties, to hear and determine the request for temporary or preliminary
injunction. If such relief is sought after the time that an Arbitration Panel has been selected, then the Arbitration Panel will hear and determine the request. The request for temporary or preliminary injunctive relief will be determined with
reference to the temporary or preliminary injunction standards set forth in Fed. R. Civ. P. 65. 
  

	 	C.	Defaults and Proceedings in the Absence of a Party 

 Whenever a party fails to comply with the MDR Rules in a manner deemed material by the Panel, the Panel shall fix a reasonable time for compliance and, if the party does not comply within said period, the
Panel may enter an Order of default or afford such other relief as it deems appropriate. Arbitration may proceed in the event of a default or in the absence of any party who, after due notice, fails to be present or fails to obtain an extension. An
Award shall not be made solely on the default or absence of a party, but the Panel shall require the party who is present to submit such evidence as the Panel may require for the making of findings, determinations, conclusions, and Awards.

  

	 	D.	Notice 

 Each party shall
be deemed to have consented that any papers, notices, or process necessary or proper for the initiation or continuation of a proceeding under these rules or for any court action in connection therewith may be served on a party by mail addressed to
the party or its representative at its last known address or by personal service, in or outside the state where the MDR proceeding is to be held. 
 The Corporate Secretary and the parties may also use facsimile transmission, telex, telegram, or other written forms of electronic communication to give the notices required by these rules. 

  

 EXHIBIT 5 
 Page 20 of 23 
  

	 	E.	Expenses 

 The expenses of
witnesses shall be paid by the party causing or requesting the appearance of such witnesses. All expenses of the MDR proceeding, including compensation, required travel and other reasonable expenses of the Panel, and the cost of any proof produced
at the direct request of the Panel, shall be borne equally by the parties and shall be paid periodically on a timely basis, unless they agree otherwise or unless the Panel in the Award assesses such expenses, or any part thereof against any party
(or parties). In exceptional cases, the Panel may award reasonable attorneys’ fees as an item of expense, and the Panel shall promptly determine the amount of such fees based on affidavits or such other proofs as the Panel deems sufficient.

  

	 	F.	Disqualification or Disability of A Panel Member 

 In the event that any Arbitrator of a Panel with more than one Arbitrator should become disqualified, resign, die, or refuse or be unable to perform or discharge his or her duties after the commencement
of MDR but prior to the rendition of an Award, and the parties are unable to agree upon a replacement, the remaining Panel member(s): 
  

	 	i.	shall designate a replacement, subject to the right of any party to challenge such replacement for cause. 

 

	 	ii.	shall decide the extent to which previously held hearings shall be repeated. 

 If the remaining Panel members consider the proceedings to have progressed to a stage as to make replacement impracticable, the parties may agree, as an alternative to the recommencement of the Mandatory
Dispute Resolution process, to resolution of the dispute by the remaining Panel members. 
 In the event that a single
Arbitrator should become disqualified, resign, die, or refuse or be unable to perform or discharge his or her duties after the commencement of MDR but prior to the rendition of an Award, and the parties are unable to agree upon a replacement, the
Administrator shall appoint a successor, subject to the right of any party to challenge such successor for cause, and the successor shall decide the extent to which previously held proceedings shall be repeated. 

  

 EXHIBIT 5 
 Page 21 of 23 
  

	 	G.	Extensions of Time 

Subject to the provisions of Paragraph 3.H.(viii.), any time limit set forth in these Rules may be extended upon agreement of the parties
and approval of: (1) the Mediator if the proceeding is then in Mediation; (2) the Administrator if the proceeding is in Arbitration, but no Arbitration Panel has been selected; or (3) the Arbitration Panel, if the proceeding is in
Arbitration and the Arbitration Panel has been selected. 
  

	 	H.	Intervention 

 The Plans,
their Controlled Affiliates, and BCBSA, to the extent subject to MMDR pursuant to their License Agreements, shall have the right to move to intervene in any pending Arbitration. A written motion for intervention shall be made to: (1) the
Administrator, if the proceeding is in Arbitration, but no Arbitration Panel has been selected; or (2) the Arbitration Panel, if the proceeding is in Arbitration and the Arbitration Panel has been selected. The written motion for intervention
shall be delivered to the BCBSA Corporate Secretary (which shall also constitute service on the BCBSA if it is a respondent) and to any Plan(s) and/or Controlled Affiliate(s) which are parties to the proceeding. Any party to the proceeding can
submit written objections to the motion to intervene. The motion for intervention shall be granted upon good cause shown. Intervention also may be allowed by stipulation of the parties to the Arbitration proceeding. Intervention shall be allowed
upon such terms as the Arbitration Panel decides. 
  

	 	I.	BCBSA Assistance in Resolution of Disputes 

 The resources and personnel of the BCBSA may be requested by any member Plan at any time to try to resolve disputes with another Plan. 

 

	 	J.	Neutral Evaluation 

 The
parties can voluntarily agree at any time to have an independent party render a neutral evaluation of the parties’ respective positions. 

  
 Amended as
of September 20, 2007 

 EXHIBIT 5 
 Page 22 of 23 
  

	 	K.	Recovery of Attorney Fees and Expenses  

  

	 	i.	Motions to Compel 

Nothwithstanding any other provisions of these Rules, any Party subject to the License Agreements (for purposes of this Section K and all
of its sub-sections only hereinafter referred to collectively and individually as a “Party”) that initiates a court action or administrative proceeding solely to compel adherence to these Rules shall not be determined to have violated
these Rules by initiating such action or proceeding. 
  

	 	ii	Recovery of Fees, Expenses and Costs 

 The Arbitration Panel may, in its sole discretion, award a Party its reasonable attorneys’ fees, expenses and costs associated with a filing to compel adherence to these Rules and/or reasonable
attorneys’ fees, expenses and costs incurred in responding to an action filed in violation of these Rules; provided, however, that neither fees, expenses, nor costs shall be awarded by the Arbitration Panel if the Party from which the award is
sought can demonstrate to the Arbitration panel, in its sole discretion, that it did not violate these Rules or that it had reasonable grounds for believing that its action did not violate these Rules. 

 

	 	iii	Requests for Reimbursement 

 For
purposes of this Section K, any Party may request reimbursement of fees, expenses and/or costs by submitting said request in writing to the Arbitration Panel at any time before an award is delivered pursuant Paragraph to 3.O above with a copy to the
Party from which reimbursement is sought, explaining why it is entitled to such reimbursement. The Party from which reimbursement is sought shall have twenty (20) days to submit a response to such request to the Arbitration Panel with a copy to
the Party seeking reimbursement. 

  
 Amended as
of September 20, 2007 

 EXHIBIT 5 
 Page 23 of 23 
  

	 	L.	Calculation of Time and Deadlines 

In computing any period of time prescribed or allowed under these rules, the day of the act or event from which the designated period of
time begins to run shall not be included. The last day of the period so computed shall be included, unless it is a Saturday, a Sunday, or a legal holiday, in which event the period runs until the end of the next day which is not one of the
aforementioned days. When the period of time prescribed is less than six (6) days, intermediate Saturdays, Sundays and legal holidays shall be excluded in the computation. As used in this rule, “legal holiday” includes New Year’s
Day, Martin Luther King, Jr. Day, Washington’s Birthday, Memorial Day, Independence Day, Labor Day, Columbus Day, Veterans Day, Thanksgiving Day, Christmas Day and any other day appointed as a holiday by the President or the Congress of the
United States. 

  
 Amended as
of September 20, 2007

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