Benefit Summary Guide

Transcription

1 Benefit Summary Guide Group Health Plan Information for Small Businesses with 2 to 50 Eligible Employees Effective January 1, 2007 blueshieldca.com

2 Health coverage that works for your business. With some of the state s largest provider networks, expanded choice to 25 plans including our lowest-rate PPO plans and increased flexibility, Blue Shield is making health coverage easy to choose and easy to use. A guide to Blue Shield products for small businesses This guide highlights the products available from Blue Shield, and provides you with the detailed benefit information needed to make informed choices about health coverage. Quick steps to selecting Blue Shield plans Review the health plan choices available to your business Review the optional and ancillary options that complement our health plan offerings Find out about legal information and plan limitations NEW: We ve added one HMO and one PPO plan and several new vision plans to our portfolio! You can find detailed information on these plans on the following pages: Access+ HMO Plan 30 see pages Shield Spectrum PPO Plan 750 Value,* see pages Vision plans, see pages * Underwritten by Blue Shield of California Life & Health Insurance Company. Learn more For questions about the information in this guide, please call your broker or visit us online at blueshieldca.com.

3 Table of Contents Health Plans HMO Health Plans The Access+ HMO Plans At A Glance... 2 Benefit Summaries... 4 PPO Health Plans The Shield Spectrum PPO Plans At A Glance Benefit Summaries PPO Savings Health Plans (HSA-eligible high-deductible health plans) The Shield Spectrum PPO Savings Plans At A Glance...52 Benefit Summaries Active Choice Health Plans The Active Choice Plans At A Glance Benefit Summaries Supplemental Coverage Supplemental Coverage At A Glance Additional Inpatient Substance Abuse Treatment Benefits Available by Plan Ancillary Products Dental Plans Group Term Life and Accidental Death and Dismemberment (AD&D) Plans Vision Plans General Plan Information Guaranteed Issue Pre-existing Condition Exclusion Principal Plan Exclusions Maximum Aggregate Payment Amount POS Health Plan Added Advantage POS Plan At A Glance Benefit Summary Access Baja Health Plans The Access Baja HMO Plans At A Glance Benefit Summaries CaliforniaChoice Program CaliforniaChoice Program At A Glance CaliforniaChoice Benefit Summaries Benefit Summary Guide 1

4 HMO Health Plans The Access+ HMO Plans At A Glance Access+ HMO plans are our most comprehensive plans, offering a wide range of benefits that include: No medical deductible No lifetime maximums Preventive care office visits at no charge Access to one of the largest provider networks in California Laboratory, X-ray, and diagnostic testing at no charge Inpatient physician services at no charge (including pregnancy and maternity care) Many plans with no drug deductible These plans also feature: Access+ Specialist SM Gives members the option to go directly to a participating Access+ Specialist in the same medical group or IPA as their Personal Physician without a referral, for a fixed office visit copayment. Access+ Satisfaction SM Gives members a voice through our groundbreaking member feedback program. If members are dissatisfied with the service they received during a covered office visit with an HMO network physician, they can request a refund of the standard office visit copayment. Out-of-area considerations Access+ HMO plans are not designed to provide coverage for employees who do not live or work within the Blue Shield of California HMO service area. Employers with employees who reside or work for more than six months outside the Blue Shield of California HMO service area should consider a PPO plan. With an HMO plan, employees and all eligible family members must live or work in an area served by the Blue Shield of California HMO and have a designated Personal Physician to enroll and maintain enrollment, except students, long-term travelers, and workers on extended outof-state assignments enrolled in the Away From Home Care program. The Blue Shield of California HMO service area is identified in the HMO Physician and Hospital Directory. Each eligible family member of an employee may select a different Personal Physician, as long as each provider is located adequately close to the member s home or work address to ensure access to care as determined by Blue Shield of California. Access to care and limitations Access+ HMO members must contact their Personal Physician for all covered services (except emergencies, mental health,* and substance abuse), including: Preventive services Routine health problems Consultation with plan specialists Urgent services within the service area Hospitalization * Members must pay in full for all services not authorized by their Personal Physician, except when choosing the Access+ Specialist option, OB/GYN services, emergency, and urgent care services or when accessing mental health and substance abuse services through the Mental Health Services Administrator (MHSA). Except for emergencies, members must contact the MHSA for all their mental health and substance abuse needs. 2 Benefit Summary Guide

5 Limitations on Access+ Specialist visits 1. To access this benefit, you must choose a Personal Physician in a medical group or IPA that participates in the Access+ program. The Access+ Specialist option applies to basic examinations and consultations provided by a physician (an M.D. or D.O.) in his or her office. It does not apply to: Any services that are not medically necessary or not a covered benefit Services that are not considered to be a physician office visit, such as outpatient or inpatient surgery Services provided by non-physicians, such as podiatrists or physical therapists Emergency or urgent care services (the copayment amounts shown in the plan s Evidence of Coverage will apply.) Services that members may already obtain without an authorized referral from their Personal Physician s medical group or IPA (for example, benefits already allow female members to go directly to an OB/GYN or family practice physician in the same medical group or IPA as their Personal Physician for OB/GYN services) Psychological testing and evaluation 2. During an Access+ Specialist visit, a physician may order conventional X-rays and laboratory services without prior authorization from his or her medical group or IPA. However, the following services still require prior authorization from a member s Personal Physician s medical group or IPA: Allergy testing Endoscopic procedures Diagnostic imaging, including CT, MRI, or bonedensity measurement Chemotherapy or other infusion drugs and injectables other than vaccines and antibiotics All infertility services 3. For mental health and chemical dependency Access+ Specialist visits, members must use MHSA participating providers. Please see the General Information section of this guide for more information on plan exclusions. Benefit Summary Guide 3 Health plans calchoice Program Supplemental Coverage Ancillary Products General PLan Information

6 Access + HMO Plan 5 Benefit Summary (Uniform Health Plan Benefits and Coverage Matrix) Effective January 1, 2007 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE GROUP HEALTH SERVICE AGREEMENT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. DEDUCTIBLES Calendar-Year Medical Deductibles Calendar-Year Copayment Maximum # (For many covered services) LIFETIME MAXIMUMS PROFESSIONAL SERVICES Physician services outpatient Physician and authorized specialist office visits (Note: A woman may self-refer to an OB/GYN or family practice physician in her Personal Physician s medical group or IPA for OB/GYN services.) None $1,500 per individual/$3,000 per family None $5/visit Allergy testing $5/visit Access+ Specialist SM (Self-referred office visits and consultations only) 1, # $30/visit Laboratory, X-ray and diagnostic tests Preventive care Routine physical exam, eye/ear screenings and immunizations according to age schedule Note: A woman may self-refer to an OB/GYN or family practice physician in her Personal Physician s medical group or IPA. OUTPATIENT SERVICES Non-emergency No charge No charge Outpatient surgery in hospital/facility No charge Outpatient treatment (except as described under Rehabilitative therapy services ), and necessary supplies No charge HOSPITALIZATION SERVICES Inpatient physician services, including pregnancy and maternity care No charge Semi-private room and board, medically necessary services and necessary supplies No charge Skilled nursing facility (SNF) services 2 No charge EMERGENCY HEALTH COVERAGE $100/visit (Waived if the member is directly admitted to the hospital for inpatient services) AMBULANCE SERVICES $50 PRESCRIPTION DRUG COVERAGE 3,4 (Includes oral contraceptives, diaphragms, and covered diabetic drugs and testing supplies) Pharmacy (For up to a 30-day supply)# Mail Service Prescriptions (For up to a 90-day supply)# Generic drugs $10/prescription $20/prescription Formulary brand-name drugs $25/prescription $50/prescription Non-Formulary brand-name drugs $45/prescription $90/prescription Home self-administered injectable medications (Medications may require prior authorization from Blue Shield Pharmacy Services; member pay up to $100 copayment maximum per prescription) DURABLE MEDICAL EQUIPMENT # Home medical equipment, prosthetics/orthotics, oxygen, colostomy/ostomy supplies (Orthosis benefits, except for services covered under diabetes care, are limited to a $2,000 max. per person per calendar-year) 20% of allowed charges 20% of allowed charges A a(1/07) 4 Benefit Summary Guide

7 MENTAL HEALTH SERVICES (PSYCHIATRIC) 5 Inpatient hospital facility services No charge Outpatient visits for severe mental health conditions $5/visit Outpatient visits for non-severe mental health conditions # (Up to 20 visits per calendar year combined with outpatient chemical dependency visits) $25/visit CHEMICAL DEPENDENCY SERVICES (SUBSTANCE ABUSE) 5 Please See Footnote 8 Inpatient services for medical acute detoxification No charge Outpatient visits # (Up to 20 visits per calendar year combined with outpatient non-severe mental health visits) HOME HEALTH SERVICES $25/visit Agency visits (Up to 100 visits per calendar year) $5/visit Medical supplies/iv (For home self-administratered injectable drugs, see Prescription Drug Coverage ) OTHER Hospice No charge Routine home care and inpatient respite care No charge 24 hour continuous home care and general inpatient care No charge Pregnancy and maternity care Prenatal and postnatal professional (physician) services No charge (For all necessary inpatient hospital services, see Hospitalization Services. ) Family planning and infertility services Family planning counseling $5/visit Diagnosis and treatment of causes of infertility 50% of allowed charges (Excludes in vitro fertilization, injectables for infertility, artificial insemination and GIFT) Tubal ligation 6,7 and elective abortion 7 $100 Vasectomy 7 $75 Rehabilitative therapy services Outpatient visits (Copayment applies to all place of services, including professional and facility settings) $5/visit Urgent care outside service area (BlueCard Program) $50/visit Diabetes care Equipment, devices and non-testing supplies (For testing supplies, see Prescription Drug Coverage. ) 20% of allowed charges Self-management training and education $5/visit Optional benefits # Optional dental, vision, chiropractic, chiropractic and acupuncture, or infertility benefit is available. If your employer purchased any of these benefits, a description of the benefit is provided separately. # Copayments marked with a (#) do not accrue to the calendar-year copayment maximum. Copayments and charges for services not accruing to the member s calendaryear copayment maximum continue to be the member s responsibility after the calendar-year copayment maximum is reached. Please refer to the Evidence of Coverage and the Group Health Service Agreement for exact terms and conditions of coverage. 1 To use this option, members must select a Personal Physician who is affiliated with a medical group or IPA that is an Access+ provider group, which offers the Access+ Specialist feature. Members should then select a specialist within that medical group or IPA. Access+ Specialist visits for mental health or substance abuse services must be provided by a MHSA network participating provider. Access+ Specialist visits for mental health services for non-severe mental illness, or non-serious emotional disturbances of a child or substance abuse will accrue toward the 20 visit per calendar year maximum. 2 Skilled nursing services are limited to 100 days during a calendar year except when received through a hospice program provided by a participating hospice agency. This 100-day maximum on skilled nursing services is a combined maximum between SNF in a hospital unit and skilled nursing facilities. 3 If the member requests a brand-name drug and a generic drug equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield of California of the brand-name drug and its generic drug equivalent, as well as the applicable generic drug copayment. Home self-administered injectable drugs are covered only when dispensed by select participating pharmacies in the Specialty Pharmacy Network. Drugs from non-participating pharmacies are not covered except in emergency and urgent situations. Please note that if you switch to another Blue Shield of California or Blue Shield of California Life & Health Insurance Company plan, your prescription drug deductible credit from the previous plan during the calendar year, if applicable, will not carry forward to your new plan. 4 This plan's prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal government for Medicare Part D (also called creditable coverage). Since this plan s prescription drug coverage is creditable, you do not have to enroll in Medicare Part D while you maintain this coverage; however, you should be aware that if you have a subsequent break in this coverage of 63 days or more before enrolling in Medicare Part D you could be subject to payment of higher Medicare Part D premiums. 5 Mental health and chemical dependency services, other than medical acute detoxification, are accessed through the mental health services administrator (MHSA) U.S. Behavioral Health Plan, California (USBHPC) using MHSA participating providers. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield HMO providers. For a listing of severe mental illnesses, including serious emotional disturbances of a child, and other benefit details, please refer to the Evidence of Coverage or Group Health Service Agreement 6 Copayment waived when procedure is performed in conjunction with delivery or abdominal surgery. 7 Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply 8 Optional inpatient substance abuse treatment benefits are available. If your employer purchased these benefits, a description of the benefit is attached hereto as Additional Substance Abuse Treatment Benefits. Benefits are subject to modification by Blue Shield for subsequently enacted state or federal legislation. Benefit Summary Guide 5 Health plans calchoice Program Supplemental Coverage Ancillary Products General PLan Information

8 Access + HMO Plan 10 Benefit Summary (Uniform Health Plan Benefits and Coverage Matrix) Effective January 1, 2007 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE GROUP HEALTH SERVICE AGREEMENT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. DEDUCTIBLES Calendar-Year Medical Deductibles Calendar-Year Copayment Maximum # (For many covered services) LIFETIME MAXIMUMS PROFESSIONAL SERVICES Physician services outpatient Physician and authorized specialist office visits (Note: A woman may self-refer to an OB/GYN or family practice physician in her Personal Physician s medical group or IPA for OB/GYN services.) None $2,000 per individual/$4,000 per family None $10/visit Allergy testing $10/visit Access+ Specialist SM (Self-referred office visits and consultations only) 1, # $30/visit Laboratory, X-ray and diagnostic tests Preventive care Routine physical exam, eye/ear screenings and immunizations according to age schedule Note: A woman may self-refer to an OB/GYN or family practice physician in her Personal Physician s medical group or IPA. OUTPATIENT SERVICES Non-emergency No charge No charge Outpatient surgery in hospital/facility $50/surgery Outpatient treatment (except as described under Rehabilitative therapy services ), and necessary supplies No charge HOSPITALIZATION SERVICES Inpatient physician services, including pregnancy and maternity care No charge Semi-private room and board, medically necessary services and necessary supplies $100/admission Skilled nursing facility (SNF) services 2 $75/day EMERGENCY HEALTH COVERAGE $100/visit (Waived if the member is directly admitted to the hospital for inpatient services) AMBULANCE SERVICES $50 PRESCRIPTION DRUG COVERAGE 3,4 (Includes oral contraceptives, diaphragms, and covered diabetic drugs and testing supplies) Pharmacy (For up to a 30-day supply)# Mail Service Prescriptions (For up to a 90-day supply)# Generic drugs $10/prescription $20/prescription Formulary brand-name drugs $25/prescription $50/prescription Non-Formulary brand-name drugs $45/prescription $90/prescription Home self-administered injectable medications (Medications may require prior authorization from Blue Shield Pharmacy Services; member pay up to $100 copayment maximum per prescription) DURABLE MEDICAL EQUIPMENT # Home medical equipment, prosthetics/orthotics, oxygen, colostomy/ostomy supplies (Orthosis benefits, except for services covered under diabetes care, are limited to a $2,000 max. per person per calendar-year) 20% of allowed charges 50% of allowed charges A a (1/07) 6 Benefit Summary Guide

9 MENTAL HEALTH SERVICES (PSYCHIATRIC) 5 Inpatient hospital facility services $100/admission Outpatient visits for severe mental health conditions $10/visit Outpatient visits for non-severe mental health conditions # (Up to 20 visits per calendar year combined with outpatient chemical dependency visits) $25/visit CHEMICAL DEPENDENCY SERVICES (SUBSTANCE ABUSE) 5 Please See Footnote 8 Inpatient services for medical acute detoxification $100/admission Outpatient visits # (Up to 20 visits per calendar year combined with outpatient non-severe mental health visits) HOME HEALTH SERVICES $25/visit Agency visits (Up to 100 visits per calendar year) $10/visit Medical supplies/iv (For home self-administratered injectable drugs, see Prescription Drug Coverage ) OTHER Hospice No charge Routine home care and inpatient respite care No charge 24 hour continuous home care and general inpatient care $75/day Pregnancy and maternity care Prenatal and postnatal professional (physician) services No charge (For all necessary inpatient hospital services, see Hospitalization Services. ) Family planning and infertility services Family planning counseling $10/visit Diagnosis and treatment of causes of infertility 50% of allowed charges (Excludes in vitro fertilization, injectables for infertility, artificial insemination and GIFT) Tubal ligation 6,7 and elective abortion 7 $100 Vasectomy 7 $75 Rehabilitative therapy services Outpatient visits (Copayment applies to all place of services, including professional and facility settings) $10/visit Urgent care outside service area (BlueCard Program) $50/visit Diabetes care Equipment, devices and non-testing supplies (For testing supplies, see Prescription Drug Coverage. ) 50% of allowed charges Self-management training and education $10/visit Optional benefits # Optional dental, vision, chiropractic, chiropractic and acupuncture, or infertility benefit is available. If your employer purchased any of these benefits, a description of the benefit is provided separately. # Copayments marked with a (#) do not accrue to the calendar-year copayment maximum. Copayments and charges for services not accruing to the member s calendaryear copayment maximum continue to be the member s responsibility after the calendar-year copayment maximum is reached. Please refer to the Evidence of Coverage and the Group Health Service Agreement for exact terms and conditions of coverage. 1 To use this option, members must select a Personal Physician who is affiliated with a medical group or IPA that is an Access+ provider group, which offers the Access+ Specialist feature. Members should then select a specialist within that medical group or IPA. Access+ Specialist visits for mental health or substance abuse services must be provided by a MHSA network participating provider. Access+ Specialist visits for mental health services for non-severe mental illness, or non-serious emotional disturbances of a child or substance abuse will accrue toward the 20 visit per calendar year maximum. 2 Skilled nursing services are limited to 100 days during a calendar year except when received through a hospice program provided by a participating hospice agency. This 100-day maximum on skilled nursing services is a combined maximum between SNF in a hospital unit and skilled nursing facilities. 3 If the member requests a brand-name drug and a generic drug equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield of California of the brand-name drug and its generic drug equivalent, as well as the applicable generic drug copayment. Home self-administered injectable drugs are covered only when dispensed by select participating pharmacies in the Specialty Pharmacy Network. Drugs from non-participating pharmacies are not covered except in emergency and urgent situations. Please note that if you switch to another Blue Shield of California or Blue Shield of California Life & Health Insurance Company plan, your prescription drug deductible credit from the previous plan during the calendar year, if applicable, will not carry forward to your new plan. 4 This plan's prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal government for Medicare Part D (also called creditable coverage). Since this plan s prescription drug coverage is creditable, you do not have to enroll in Medicare Part D while you maintain this coverage; however, you should be aware that if you have a subsequent break in this coverage of 63 days or more before enrolling in Medicare Part D you could be subject to payment of higher Medicare Part D premiums. 5 Mental health and chemical dependency services, other than medical acute detoxification, are accessed through the mental health services administrator (MHSA) U.S. Behavioral Health Plan, California (USBHPC) using MHSA participating providers. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield HMO providers. For a listing of severe mental illnesses, including serious emotional disturbances of a child, and other benefit details, please refer to the Evidence of Coverage or Group Health Service Agreement 6 Copayment waived when procedure is performed in conjunction with delivery or abdominal surgery. 7 Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply 8 Optional inpatient substance abuse treatment benefits are available. If your employer purchased these benefits, a description of the benefit is attached hereto as Additional Substance Abuse Treatment Benefits. Benefits are subject to modification by Blue Shield for subsequently enacted state or federal legislation. Benefit Summary Guide 7 Health plans calchoice Program Supplemental Coverage Ancillary Products General PLan Information

10 Access + HMO Plan 15 Benefit Summary (Uniform Health Plan Benefits and Coverage Matrix) Effective January 1, 2007 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE GROUP HEALTH SERVICE AGREEMENT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. DEDUCTIBLES Calendar-Year Medical Deductibles Calendar-Year Copayment Maximum # (For many covered services) LIFETIME MAXIMUMS PROFESSIONAL SERVICES Physician services outpatient Physician and authorized specialist office visits (Note: A woman may self-refer to an OB/GYN or family practice physician in her Personal Physician s medical group or IPA for OB/GYN services.) None $2,000 per individual/$4,000 per family None $15/visit Allergy testing $15/visit Access+ Specialist SM (Self-referred office visits and consultations only) 1, # $30/visit Laboratory, X-ray and diagnostic tests Preventive care Routine physical exam, eye/ear screenings and immunizations according to age schedule Note: A woman may self-refer to an OB/GYN or family practice physician in her Personal Physician s medical group or IPA. OUTPATIENT SERVICES Non-emergency No charge No charge Outpatient surgery in hospital/facility $250/surgery Outpatient treatment (except as described under Rehabilitative therapy services ), and necessary supplies No charge HOSPITALIZATION SERVICES Inpatient physician services, including pregnancy and maternity care No charge Semi-private room and board, medically necessary services and necessary supplies $300/admission Skilled nursing facility (SNF) services 2 $100/day EMERGENCY HEALTH COVERAGE $100/visit (Waived if the member is directly admitted to the hospital for inpatient services) AMBULANCE SERVICES $50 PRESCRIPTION DRUG COVERAGE 3,4 (Includes oral contraceptives, diaphragms, and covered diabetic drugs and testing supplies) Pharmacy (For up to a 30-day supply)# Mail Service Prescriptions (For up to a 90-day supply)# Generic drugs $15/prescription $30/prescription Formulary brand-name drugs $30/prescription $60/prescription Non-Formulary brand-name drugs $45/prescription $90/prescription Home self-administered injectable medications (Medications may require prior authorization from Blue Shield Pharmacy Services; member pay up to $100 copayment maximum per prescription) DURABLE MEDICAL EQUIPMENT # Home medical equipment, prosthetics/orthotics, oxygen, colostomy/ostomy supplies (Plan payment up to $2,000 max. per calendar - year) 20% of allowed charges 50% of allowed charges A (1/07) 8 Benefit Summary Guide

11 MENTAL HEALTH SERVICES (PSYCHIATRIC) 5 Inpatient hospital facility services $300/admission Outpatient visits for severe mental health conditions $15/visit Outpatient visits for non-severe mental health conditions # (Up to 20 visits per calendar year combined with outpatient chemical dependency visits) $25/visit CHEMICAL DEPENDENCY SERVICES (SUBSTANCE ABUSE) 5 Please See Footnote 8 Inpatient services for medical acute detoxification $300/admission Outpatient visits # (Up to 20 visits per calendar year combined with outpatient non-severe mental health visits) HOME HEALTH SERVICES $25/visit Agency visits (Up to 100 visits per calendar year) $15/visit Medical supplies/iv (For home self-administratered injectable drugs, see Prescription Drug Coverage ) OTHER Hospice No charge Routine home care and inpatient respite care No charge 24 hour continuous home care and general inpatient care $100/day Pregnancy and maternity care Prenatal and postnatal professional (physician) services No charge (For all necessary inpatient hospital services, see Hospitalization Services. ) Family planning and infertility services Family planning counseling $15/visit Diagnosis and treatment of causes of infertility 50% of allowed charges (Excludes in vitro fertilization, injectables for infertility, artificial insemination and GIFT) Tubal ligation 6,7 and elective abortion 7 $100 Vasectomy 7 $75 Rehabilitative therapy services Outpatient visits (Copayment applies to all place of services, including professional and facility settings) $15/visit Urgent care outside service area (BlueCard Program) $50/visit Diabetes care Equipment, devices and non-testing supplies (For testing supplies, see Prescription Drug Coverage. ) 50% of allowed charges Self-management training and education $15/visit Optional benefits # Optional dental, vision, chiropractic, chiropractic and acupuncture, or infertility benefit is available. If your employer purchased any of these benefits, a description of the benefit is provided separately. # Copayments marked with a (#) do not accrue to the calendar-year copayment maximum. Copayments and charges for services not accruing to the member s calendaryear copayment maximum continue to be the member s responsibility after the calendar-year copayment maximum is reached. Please refer to the Evidence of Coverage and the Group Health Service Agreement for exact terms and conditions of coverage. 1 To use this option, members must select a Personal Physician who is affiliated with a medical group or IPA that is an Access+ provider group, which offers the Access+ Specialist feature. Members should then select a specialist within that medical group or IPA. Access+ Specialist visits for mental health or substance abuse services must be provided by a MHSA network participating provider. Access+ Specialist visits for mental health services for non-severe mental illness, or non-serious emotional disturbances of a child or substance abuse will accrue toward the 20 visit per calendar year maximum. 2 Skilled nursing services are limited to 100 days during a calendar year except when received through a hospice program provided by a participating hospice agency. This 100-day maximum on skilled nursing services is a combined maximum between SNF in a hospital unit and skilled nursing facilities. 3 If the member requests a brand-name drug and a generic drug equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield of California of the brand-name drug and its generic drug equivalent, as well as the applicable generic drug copayment. Home self-administered injectable drugs are covered only when dispensed by select participating pharmacies in the Specialty Pharmacy Network. Drugs from non-participating pharmacies are not covered except in emergency and urgent situations. Please note that if you switch to another Blue Shield of California or Blue Shield of California Life & Health Insurance Company plan, your prescription drug deductible credit from the previous plan during the calendar year, if applicable, will not carry forward to your new plan. 4 This plan's prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal government for Medicare Part D (also called creditable coverage). Since this plan s prescription drug coverage is creditable, you do not have to enroll in Medicare Part D while you maintain this coverage; however, you should be aware that if you have a subsequent break in this coverage of 63 days or more before enrolling in Medicare Part D you could be subject to payment of higher Medicare Part D premiums. 5 Mental health and chemical dependency services, other than medical acute detoxification, are accessed through the mental health services administrator (MHSA) U.S. Behavioral Health Plan, California (USBHPC) using MHSA participating providers. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield HMO providers. For a listing of severe mental illnesses, including serious emotional disturbances of a child, and other benefit details, please refer to the Evidence of Coverage or Group Health Service Agreement 6 Copayment waived when procedure is performed in conjunction with delivery or abdominal surgery. 7 Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply 8 Optional inpatient substance abuse treatment benefits are available. If your employer purchased these benefits, a description of the benefit is attached hereto as Additional Substance Abuse Treatment Benefits. Benefits are subject to modification by Blue Shield for subsequently enacted state or federal legislation. Benefit Summary Guide 9 Health plans calchoice Program Supplemental Coverage Ancillary Products General PLan Information

12 Access + HMO Plan 20 Benefit Summary (Uniform Health Plan Benefits and Coverage Matrix) Effective January 1, 2007 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE GROUP HEALTH SERVICE AGREEMENT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. DEDUCTIBLES Calendar-Year Medical Deductibles Calendar-Year Copayment Maximum # (For many covered services) LIFETIME MAXIMUMS PROFESSIONAL SERVICES Physician services outpatient Physician and authorized specialist office visits (Note: A woman may self-refer to an OB/GYN or family practice physician in her Personal Physician s medical group or IPA for OB/GYN services.) None $2,500 per individual/$5,000 per family None $20/visit Allergy testing $20/visit Access+ Specialist SM (Self-referred office visits and consultations only) 1, # $40/visit Laboratory, X-ray and diagnostic tests Preventive care Routine physical exam, eye/ear screenings and immunizations according to age schedule (Note: A woman may self-refer to an OB/GYN or family practice physician in her Personal Physician s medical group or IPA.) OUTPATIENT SERVICES Non-emergency No charge No charge Outpatient surgery in hospital/facility $500/surgery Outpatient treatment (except as described under Rehabilitative therapy services ), and necessary supplies No charge HOSPITALIZATION SERVICES Inpatient physician services, including pregnancy and maternity care No charge Semi-private room and board, medically necessary services and necessary supplies $1,000/admission Skilled nursing facility (SNF) services 2 $150/day EMERGENCY HEALTH COVERAGE $100/visit (Waived if the member is directly admitted to the hospital for inpatient services) AMBULANCE SERVICES $50 PRESCRIPTION DRUG COVERAGE 3,4 (Includes oral contraceptives, diaphragms, and covered diabetic drugs and testing supplies) Pharmacy (For up to a 30-day supply)# Mail Service Prescriptions (For up to a 90-day supply)# Calendar-year brand-name drug deductible $150 per member per calendar-year, applied to all covered brand-name and home self-administered injectable drugs. Generic drugs $15/prescription $30/prescription Formulary brand-name drugs $30/prescription $60/prescription Non-Formulary brand-name drugs $45/prescription $90/prescription Home self-administered injectable medications (Medications may require prior authorization from Blue Shield Pharmacy Services; member pay up to $100 copayment maximum per prescription) DURABLE MEDICAL EQUIPMENT # Home medical equipment, prosthetics/orthotics, oxygen, colostomy/ostomy supplies (Plan payment up to $2,000 max. per calendar - year) 20% of allowed charges 50% of allowed charges A (1/07) 10 Benefit Summary Guide

13 MENTAL HEALTH SERVICES (PSYCHIATRIC) 5 Inpatient hospital facility services $1,000/admission Outpatient visits for severe mental health conditions $20/visit Outpatient visits for non-severe mental health conditions # (Up to 20 visits per calendar year combined with outpatient chemical dependency visits) $25/visit CHEMICAL DEPENDENCY SERVICES (SUBSTANCE ABUSE) 5 Please See Footnote 8 Inpatient services for medical acute detoxification $1,000/admission Outpatient visits # (Up to 20 visits per calendar year combined with outpatient non-severe mental health visits) HOME HEALTH SERVICES $25/visit Agency visits (Up to 100 visits per calendar year) $20/visit Medical supplies/iv (For home self-administratered injectable drugs, see Prescription Drug Coverage ) OTHER Hospice No charge Routine home care and inpatient respite care No charge 24 hour continuous home care and general inpatient care $150/day Pregnancy and maternity care Prenatal and postnatal professional (physician) services No charge (For all necessary inpatient hospital services, see Hospitalization Services. ) Family planning and infertility services Family planning counseling $20/visit Diagnosis and treatment of causes of infertility 50% of allowed charges (Excludes in vitro fertilization, injectables for infertility, artificial insemination and GIFT) Tubal ligation 6,7 and elective abortion 7 $100 Vasectomy 7 $75 Rehabilitative therapy services Outpatient visits (Copayment applies to all place of services, including professional and facility settings) $20/visit Urgent care outside service area (BlueCard Program) $50/visit Diabetes care Equipment, devices and non-testing supplies (For testing supplies, see Prescription Drug Coverage. ) 50% of allowed charges Self-management training and education $20/visit Optional benefits # Optional dental, vision, chiropractic, chiropractic and acupuncture, or infertility benefit is available. If your employer purchased any of these benefits, a description of the benefit is provided separately. # Copayments marked with a (#) do not accrue to the calendar-year copayment maximum. Copayments and charges for services not accruing to the member s calendaryear copayment maximum continue to be the member s responsibility after the calendar-year copayment maximum is reached. Please refer to the Evidence of Coverage and the Group Health Service Agreement for exact terms and conditions of coverage. 1 To use this option, members must select a Personal Physician who is affiliated with a medical group or IPA that is an Access+ provider group, which offers the Access+ Specialist feature. Members should then select a specialist within that medical group or IPA. Access+ Specialist visits for mental health or substance abuse services must be provided by a MHSA network participating provider. Access+ Specialist visits for mental health services for non-severe mental illness, or non-serious emotional disturbances of a child or substance abuse will accrue toward the 20 visit per calendar year maximum. 2 Skilled nursing services are limited to 100 days during a calendar year except when received through a hospice program provided by a participating hospice agency. This 100-day maximum on skilled nursing services is a combined maximum between SNF in a hospital unit and skilled nursing facilities. 3 If the member requests a brand-name drug and a generic drug equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield of California of the brand-name drug and its generic drug equivalent, as well as the applicable generic drug copayment. Home self-administered injectable drugs are covered only when dispensed by select participating pharmacies in the Specialty Pharmacy Network. Drugs from non-participating pharmacies are not covered except in emergency and urgent situations. Please note that if you switch to another Blue Shield of California or Blue Shield of California Life & Health Insurance Company plan, your prescription drug deductible credit from the previous plan during the calendar year, if applicable, will not carry forward to your new plan. 4 This plan's prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal government for Medicare Part D (also called creditable coverage). Since this plan s prescription drug coverage is creditable, you do not have to enroll in Medicare Part D while you maintain this coverage; however, you should be aware that if you have a subsequent break in this coverage of 63 days or more before enrolling in Medicare Part D you could be subject to payment of higher Medicare Part D premiums. 5 Mental health and chemical dependency services, other than medical acute detoxification, are accessed through the mental health services administrator (MHSA) U.S. Behavioral Health Plan, California (USBHPC) using MHSA participating providers. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield HMO providers. For a listing of severe mental illnesses, including serious emotional disturbances of a child, and other benefit details, please refer to the Evidence of Coverage or Group Health Service Agreement 6 Copayment waived when procedure is performed in conjunction with delivery or abdominal surgery. 7 Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply 8 Optional inpatient substance abuse treatment benefits are available. If your employer purchased these benefits, a description of the benefit is attached hereto as Additional Substance Abuse Treatment Benefits. Benefits are subject to modification by Blue Shield for subsequently enacted state or federal legislation. Benefit Summary Guide 11 Health plans calchoice Program Supplemental Coverage Ancillary Products General PLan Information

14 Access + HMO Plan 30 Benefit Summary (Uniform Health Plan Benefits and Coverage Matrix) Effective January 1, 2007 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE GROUP HEALTH SERVICE AGREEMENT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. DEDUCTIBLES Calendar-Year Medical Deductibles Calendar-Year Copayment Maximum # (For many covered services) LIFETIME MAXIMUMS PROFESSIONAL SERVICES Physician services outpatient Physician and authorized specialist office visits (Note: A woman may self-refer to an OB/GYN or family practice physician in her Personal Physician s medical group or IPA for OB/GYN services.) None $3,500 per individual/$7,000 per family None $30/visit Allergy testing $30/visit Access+ Specialist SM (Self-referred office visits and consultations only) 1, # $45/visit Laboratory, X-ray and diagnostic tests Preventive care Routine physical exam, eye/ear screenings and immunizations according to age schedule (Note: A woman may self-refer to an OB/GYN or family practice physician in her Personal Physician s medical group or IPA.) OUTPATIENT SERVICES Non-emergency No charge No charge Outpatient surgery in hospital/facility $500/surgery Outpatient treatment (except as described under Rehabilitative therapy services ), and necessary supplies No charge HOSPITALIZATION SERVICES Inpatient physician services, including pregnancy and maternity care No charge Semi-private room and board, medically necessary services and necessary supplies $500/day (up to 3 days max/admission) Skilled nursing facility (SNF) services 2 $150/day EMERGENCY HEALTH COVERAGE $150/visit (Waived if the member is directly admitted to the hospital for inpatient services) AMBULANCE SERVICES $100 PRESCRIPTION DRUG COVERAGE 3,4 (Includes oral contraceptives, diaphragms, and covered diabetic drugs and testing supplies) Pharmacy (For up to a 30-day supply)# Mail Service Prescriptions (For up to a 90-day supply)# Calendar-year brand-name drug deductible $150 per member per calendar-year, applied to all covered brand-name and home self-administered injectable drugs. Generic drugs $15/prescription $30/prescription Formulary brand-name drugs $30/prescription $60/prescription Non-Formulary brand-name drugs Home self-administered injectable medications (Medications may require prior authorization from Blue Shield Pharmacy Services; member pay up to $100 copayment maximum per prescription) DURABLE MEDICAL EQUIPMENT # Home medical equipment, prosthetics/orthotics, oxygen, colostomy/ostomy supplies (Plan payment up to $2,000 max. per calendar - year) 20% of allowed charges 50% of allowed charges A17527 (1/07) 12 Benefit Summary Guide

15 MENTAL HEALTH SERVICES (PSYCHIATRIC) 5 Inpatient hospital facility services $500/day (up to 3 days max/admission) Outpatient visits for severe mental health conditions $30/visit Outpatient visits for non-severe mental health conditions # (Up to 20 visits per calendar year combined with outpatient chemical dependency visits) $25/visit CHEMICAL DEPENDENCY SERVICES (SUBSTANCE ABUSE) 5 Please See Footnote 8 Inpatient services for medical acute detoxification $500/day (up to 3 days max/admission) Outpatient visits # (Up to 20 visits per calendar year combined with outpatient non-severe mental health visits) HOME HEALTH SERVICES $25/visit Agency visits (Up to 100 visits per calendar year) $30/visit Medical supplies/iv (For home self-administratered injectable drugs, see Prescription Drug Coverage ) OTHER Hospice No charge Routine home care and inpatient respite care No charge 24 hour continuous home care and general inpatient care $200/day Pregnancy and maternity care Prenatal and postnatal professional (physician) services No charge (For all necessary inpatient hospital services, see Hospitalization Services. ) Family planning and infertility services Family planning counseling $30/visit Diagnosis and treatment of causes of infertility 50% of allowed charges (Excludes in vitro fertilization, injectables for infertility, artificial insemination and GIFT) Tubal ligation 6,7 and elective abortion 7 $100 Vasectomy 7 $75 Rehabilitative therapy services Outpatient visits (Copayment applies to all place of services, including professional and facility settings) $30/visit Urgent care outside service area (BlueCard Program) $50/visit Diabetes care Equipment, devices and non-testing supplies (For testing supplies, see Prescription Drug Coverage. ) 50% of allowed charges Self-management training and education $30/visit Optional benefits # Optional dental, vision, chiropractic, chiropractic and acupuncture, or infertility benefit is available. If your employer purchased any of these benefits, a description of the benefit is provided separately. # Copayments marked with a (#) do not accrue to the calendar-year copayment maximum. Copayments and charges for services not accruing to the member s calendaryear copayment maximum continue to be the member s responsibility after the calendar-year copayment maximum is reached. Please refer to the Evidence of Coverage and the Group Health Service Agreement for exact terms and conditions of coverage. 1 To use this option, members must select a Personal Physician who is affiliated with a medical group or IPA that is an Access+ provider group, which offers the Access+ Specialist feature. Members should then select a specialist within that medical group or IPA. Access+ Specialist visits for mental health or substance abuse services must be provided by a MHSA network participating provider. Access+ Specialist visits for mental health services for non-severe mental illness, or non-serious emotional disturbances of a child or substance abuse will accrue toward the 20 visit per calendar year maximum. 2 Skilled nursing services are limited to 100 days during a calendar year except when received through a hospice program provided by a participating hospice agency. This 100-day maximum on skilled nursing services is a combined maximum between SNF in a hospital unit and skilled nursing facilities. 3 If the member requests a brand-name drug and a generic drug equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield of California of the brand-name drug and its generic drug equivalent, as well as the applicable generic drug copayment. Home self-administered injectable drugs are covered only when dispensed by select participating pharmacies in the Specialty Pharmacy Network. Drugs from non-participating pharmacies are not covered except in emergency and urgent situations. Please note that if you switch to another Blue Shield of California or Blue Shield of California Life & Health Insurance Company plan, your prescription drug deductible credit from the previous plan during the calendar year, if applicable, will not carry forward to your new plan. 4 This plan's prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal government for Medicare Part D (also called creditable coverage). Since this plan s prescription drug coverage is creditable, you do not have to enroll in Medicare Part D while you maintain this coverage; however, you should be aware that if you have a subsequent break in this coverage of 63 days or more before enrolling in Medicare Part D you could be subject to payment of higher Medicare Part D premiums. 5 Mental health and chemical dependency services, other than medical acute detoxification, are accessed through the mental health services administrator (MHSA) U.S. Behavioral Health Plan, California (USBHPC) using MHSA participating providers. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield HMO providers. For a listing of severe mental illnesses, including serious emotional disturbances of a child, and other benefit details, please refer to the Evidence of Coverage or Group Health Service Agreement 6 Copayment waived when procedure is performed in conjunction with delivery or abdominal surgery. 7 Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply 8 Optional inpatient substance abuse treatment benefits are available. If your employer purchased these benefits, a description of the benefit is attached hereto as Additional Substance Abuse Treatment Benefits. Benefits are subject to modification by Blue Shield for subsequently enacted state or federal legislation. Benefit Summary Guide 13 Health plans calchoice Program Supplemental Coverage Ancillary Products General PLan Information